A N.S. Technologists Experiences

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June Harrell
5 years ago
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1 A N.S. Technologists Experiences

2 I have nothing to disclose

3 What does appropriate imaging mean For radiologists? For technologists? How does this affect patients and technologists? Discuss ordering trends In general Specifically in N.S. Discuss the relevance of Choosing Wisely Canada. Can we improve?

4 Appropriate utilization of medical imaging consists of the physician requesting the right test, at the right time and for the right reason to suit their patient s healthcare needs. Any request for medical imaging procedures should be based on the patient s symptoms and potentially alter the patient s management or outcomes. The Medical Imaging Team Website partnered with the CAR, CAMRT and COMP

5 Modality Is this the right test for the patients clinical presentation? Effectiveness Will doing this test improve or change the course of treatment for this patient? Timing Is follow up within the correct time interval?

Diagnostic Imaging referral guidelines to help physicians order the most appropriate and effective diagnostic imaging procedure for specific clinical circumstances

6 Diagnostic Imaging referral guidelines to help physicians order the most appropriate and effective diagnostic imaging procedure for specific clinical circumstances Unfortunately, these processes can be highly influenced by wait times specifically MRI vs. CT X-rays are more accessible; although CT may now be considered the standard

7 Modality shift: x-ray to CT 1 Sinus, skull, TMJ s, facial bones, Mandible, orbits How is this working in your hospital setting? Are we doing both x-rays and CT? General x-ray requisitions are not screened by radiologists so who is educating the requesting clinicians that these radiographs are no longer appropriate?

8 Seeing the patient gives us a much different perspective. Dissection Story It is some of the following issues that make us question whether some x-rays are necessary for our patients History not pertinent to request Multiple body parts with minor trauma CT and X-ray on the same request No clinical exam

9 The MRT assesses 2 : Completeness of requisition Patient condition Patient History Previous exams Alternative choices Patient position/immobilization Technique to be used

10 Cost Medical Imaging Costs estimated to exceed $2.2 billion annually₃ Evidence indicates that 10-20% of medical imaging studies are unnecessary or clinically inappropriate₃ Does absence of a film cost mean we are ignoring what is happening with general imaging

11 Wait Times More orders means longer waiting Same order multiple bookings, multiple sites Incidentals Often benign but lead to more tests, more radiation and lots of stress for patients ACR even has Incidental finding committee with recommendations ₄

12 Radiation Exposure All medical imaging procedures involve some risk the most appropriate medical imaging examination should be the first time and every time. We must remember that children and adolescents are more sensitive to radiation exposure

13 Angry Unqualified Apathetic Helpless

14 Really? What does that mean? ALARA everyday!!! But Fewer clinical exams: patients fully dressed or in waiting room More multiple exams: ankle, foot and tib-fib just in case, failure to use proven clinical rules (OAR, C-spine, knee) X-rays are ordered as a response to long wait times This way of thinking is spreading from low exposure exams to higher dose exams

15 The risk to the individual patient from a single radiographic examination is very low. However, the risk to a population is increased by increasing the frequency of radiographic examinations and by increasing the number of persons undergoing such examinations. For this reason, it is important to reduce the number of radiographs taken, the number of persons examined radiographically, and the doses associated with the examinations

16 Canada Million CT (1.6 Million MRI) MRI s of the spine increased significantly No reduction in the use of spine x-ray or CT 9 referring patients with spine-related complaints for surgical assessment in Canada appears to generate a substantial amount of unnecessary imaging. 9 A study of Ontario patients with degenerative spine disease referred for surgical consult found 100% of CT and 60% of MRI were unnecessary; COST 24 million 9

17 Evidence indicates that between 10 and 20 per cent of medical imaging studies are unnecessary or clinically inappropriate. 10 Emergency medicine residents do not show significant improvement over the course of their residency in their ability to choose appropriate imaging studies. This finding suggests that there is a role for more-rigorous focused instruction to better familiarize residents with appropriateness guidelines for diagnostic imaging selection. 11 UK study shows that although knowledge regarding imaging guidelines was limited, vetting of CT and MRI requisitions with amendment or return made the best use of clinical radiology 12

18 The number of professionals who can order x-ray imaging has broadened Physicians Nurse Practitioners Nurses Chiropractors Physiotherapists Research has established that triage initiated x-rays can improve efficiency Problem: If we have appropriateness issues with physician led orders..

19 Started with conversations with others about their concerns Technologists were asked to keep/record any requests that they issues with These issues were brought to our QA Technical meeting Asked to do a report on the findings Please note these are just the negatives

20 Bilateral Knees Pain to left knee x 4 days, no redness, able to ambulate, denies injury Shoulder, humerus, elbow, forearm Ambulatory, fell 2 days ago, good ROM, swelling noted Flat plate abdomen, CXR, shoulder, clavicle, ankle, foot, calcaneus Ambulatory: pt states he got thrown around by police last night and has pain in ankle (prev surgery), left collarbone, both elbows, swelling and redness to ear

21 CXR, abdomen series Experiencing generalized abdominal cramping across abdomen for past 3-5 days. Denies NVD, no change in bladder, pt is currently on menstrual period and had similar pain while on period in past but this time it is lasting longer Hand, thumb, scaphoid, wrist 8 yr old? broken thumb, smacked thumb on gym floor bent back, swelling and bruising, pain less than earlier

22 CXR Pt brought by EHS for depression, does not feel safe at home since husband died 2 years ago, suicidal ideations, appears calm, paranoid CXR FB in eye, grinding steel, no visual changes Abdomen series Headache, progressively worse, photophobia, alert and oriented, vomited earlier also earache

23 Orders by nurses (outside the medical directive) and physicians Variety of exams Chests, extremities, abdomen, hips Patients are in main waiting room with minimal exam (triage) knee vs. pant leg Some patients discharged before DI requests them

24 Error Multiple request error 2 No Physicians Name 19 No exam indicated 21 No change in history made for repeat imaging (ET tubes, post reduction etc) Number 11 X-rays requested through ER because patient has a requisition 2 Wrong side 8 Wrong exam 8 Wrong patient 2

27 Choosing Wisely Canada (CWC) is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high-quality care. Unnecessary tests and treatments do not add value to care. In fact, they take away from care by potentially exposing patients to harm, leading to more testing to investigate false positives and contributing to stress for patients. And of course unnecessary tests and treatments put increased strain on the resources of our health care system. The Lists

28 Updated list of 10: 6 deal with DI 1. NO CT in Minor Trauma 2. NO Lumbar spine imaging in non-traumatic back pain unless red flags or pathological injury present 3. Do not order C-spine imaging with out following the Canadian C-spine rule 4. Follow OAR before ordering foot and ankle 5. No Head CT in simple syncope 6. No VQ or PE CT without risk stratification decision rules

29 1. Don t do imaging for lower back pain unless red flags are present 2. Don t do imaging for minor head trauma unless red flags are present 3. Don t do imaging for the uncomplicated headache unless red flags are present. 4. Don t do CT for appendicitis in children until after an U/S has been considered. 5. Don t do ankle x-rays in adults for minor injuries

30 The CAMRT have been asked to formulate a list of top 5 for the Choosing wisely campaign This gives me hope that our education and role as patient advocates is being seen as important as it pertains to appropriateness.

Can radiologists alone transform the system effectively? Perceived Conflict? Support: committees, educators We are good at making rules/policies just not following them Buy in Government Involvement?

31 Can radiologists alone transform the system effectively? Perceived Conflict? Support: committees, educators We are good at making rules/policies just not following them Buy in Government Involvement? Will limits on provincial healthcare payments make a difference in the exams performed? Ontario: Provincial Low-Back Pain Strategy Alberta: Towards Optimal Practice Guidelines Choose Wisely Newfoundland

32 DI and Emergency meeting Collaborative multiple order audit Pilot project for Technologists Assessment and ordering of x-rays in the acutely injured extremity

33 33

1. CAR: diagnostic referral guidelines CAR website 2. Www.Camrt.Ca :quality of care (evaluation of appropriateness) 3. Www//ncbi.Nlm.Nih.Gov/pubmed/18697720 4.

Ionizing radiation effects and their risk to humans: image wisely 2017 website 7. MSI: NS MSI physician s manual 8. Medical imaging team website 9.

34 1. CAR: diagnostic referral guidelines CAR website 2. :quality of care (evaluation of appropriateness) 3. Www//ncbi.Nlm.Nih.Gov/pubmed/ Incidental findings: A retrospective analysis of management june 23, 2015 ACR publication 5. FDA: what are the radiation risks from CT? 6. Ionizing radiation effects and their risk to humans: image wisely 2017 website 7. MSI: NS MSI physician s manual 8. Medical imaging team website 9. Appropriateness of spinal imaging use in canada busse et al, april 25/13, CIHR 10. G appropriate utilization of advanced diagnostic imaging procedures: CT, MRI, and PET/CT published on: january 23, 2013 product line: environmental scans issue: 39 CADTH 11. Appropriateness of imaging studies ordered by emergency medicine residents: results of an online survey R. Joshua dym 1, judah burns 1 and benjamin H. Taragin 1 AJR october 2013, volume 201, read more: National audit on appropriate imaging: D. Remedios, K. Drinkwater, R. Warwick; clinical radiology may 27,

Pediatric Imaging Spine MRI and Spine CT Test Request Tip Sheet

Pediatric Imaging Spine MRI and Spine CT MRI is almost always preferred over CT scan; if ordering CT, CLEARLY document why MRI is not appropriate. In cases of back pain without red flags, six weeks of