EMERGENCY RADIOLOGY
References and Abstracts

1: Espinosa JA, Nolan TW. Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. BMJ. 2000 Mar 18;320(7237):737-40.

2: Fleisher G, Ludwig S, McSorley M. Interpretation of pediatric x-ray films by emergency department pediatricians. Ann Emerg Med. 1983 Mar;12(3):153-8.

3: Lufkin KC, Smith SW, Matticks CA, Brunette DD. Radiologists' review of radiographs interpreted confidently by emergency physicians infrequently leads to changes in patient management. Ann Emerg Med. 1998 Feb;31(2):202-7.

4: O'Leary MR, Smith M, Olmsted WW, Curtis DJ. Physician assessments of practice patterns in emergency department radiograph interpretation. Ann Emerg Med. 1988 Oct;17(10):1019-23.

5: Preston CA, Marr JJ 3rd, Amaraneni KK, Suthar BS. Reduction of "callbacks" to the ED due to discrepancies in plain radiograph interpretation. Am J Emerg Med. 1998 Mar;16(2):160-2.

6: Robinson PJ, Wilson D, Coral A, Murphy A, Verow P. Variation between experienced observers in the interpretation of accident and emergency radiographs. Br J Radiol. 1999 Apr;72(856):323-30.

ABSTRACTS

1. Unique Identifier 20185418
Author Espinosa JA; Nolan TW
Institution Department of Emergency Medicine, Overlook Hospital, Atlantic Health System, 99 Beauvoir Avenue, Summit, NJ 07902, USA. jim-010@aol.com.
Title Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study.
Source BMJ 2000 Mar 18;320(7237): p737-40
ISSN 0959-8138
Abstract

OBJECTIVES: To reduce errors made in the interpretation of radiographs in an emergency department.
DESIGN: Longitudinal study. Setting: Hospital emergency department.
INTERVENTIONS: All staff reviewed all clinically significant discrepancies at monthly meetings. A file of clinically significant errors was created; the file was used for teaching. Later a team redesigned the process. A system was developed for interpreting radiographs that would be followed regardless of the day of the week or time of day. All standard radiographs were brought directly to the emergency physician for immediate interpretation. Radiologists reviewed the films within 12 hours as a quality control measure, and if a significant misinterpretation was found patients were asked to return.
MAIN OUTCOME MEASURES: Reduction in number of clinically significant errors (such as missed fractures or foreign bodies) on radiographs read in the emergency department. Data on the error rate for radiologists and the effect of the recall procedure were not available so reliability modelling was used to assess the effect of these on overall safety.
RESULTS: After the initial improvements the rate of false negative errors fell from 3% (95% confidence interval 2.8% to 3.2%) to 1.2% (1.03% to 1.37%). After the processes were redesigned it fell further to 0.3% (0.26% to 0.34%). Reliability modelling showed that the number of potential adverse effects per 1000 cases fell from 19 before the improvements to 3 afterwards and unmitigated adverse effects fell from 2.2/1000 before to 0.16/1000 afterwards, assuming 95% success in calling patients back.
CONCLUSION: Systems of radiograph interpretation that optimise the skills of all clinicians involved and contain reliable processes for mitigating errors can reduce error rates substantially.

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2. Unique Identifier 83150748
Author Fleisher G; Ludwig S; McSorley M
Title Interpretation of pediatric x-ray films by emergency department pediatricians.
Source Ann Emerg Med 1983 Mar;12(3): p153-8
ISSN 0196-0644
Abstract

This study compared the interpretation of pediatric roentgenograms by emergency department pediatricians and radiologists. Data were available from 532 of 600 children who had 564 radiographic studies during a six-week period: 217 examinations of the chest, 200 of the extremities, 74 of the skull, 35 of the abdomen, and 38 of miscellaneous structures. The emergency department pediatricians and the radiologists were in agreement in 91.1% of the cases. Among the 50 of 564 (8.9%) discordant studies, only seven (1.2%) required changes in therapy. The results attest to the accuracy of emergency department pediatricians in interpreting the usual types of films ordered in their department. However, this group specifically erred in the identification of subtle fractures and the detection of abnormalities incidental to the primary purpose for which the film was obtained. Future educational programs should address these areas of deficiency.

3. Unique Identifier 98132766
Author Lufkin KC; Smith SW; Matticks CA; Brunette DD
Institution Emergency Medicine Department, St. Luke's Hospital, Duluth, USA.
Title Radiologists' review of radiographs interpreted confidently by emergency physicians infrequently leads to changes in patient management [see comments] [published erratum appears in Ann Emerg Med 1998 Sep; 32(3 Pt 1):390]
Source Ann Emerg Med 1998 Feb;31(2): p202-7
ISSN 0196-0644
Abstract

STUDY OBJECTIVE: To determine whether radiologists' review of radiographs is unwarranted when emergency physicians are confident in their interpretations.
METHODS: This was a prospective, descriptive study. Treating emergency physicians at a high-volume, urban teaching hospital and a moderate-volume nonteaching hospital indicated their confidence or lack of confidence in their plain-film radiographic study interpretations. All radiographs were then reviewed by radiologists according to the preexisting practice of each hospital. A total of 16,410 emergency department radiographic studies were included, comprising consecutive patients at each hospital. Charts of all discordant readings in the confident group were reviewed and judged clinically significant if treatment was altered. Charges for radiologic review of the confident ED interpretations were calculated.
RESULTS: The ED physicians were confident in 9,599 sets of radiographs out of a total of 16,410 (58%). Discordant interpretation rates for the "confident" and "not confident" groups were 1.2% and 3.1%, respectively (difference, 1.9%; 95% confidence interval [CI] of the difference, 1.44% to 2.36%). Review of the 118 discordant interpretations in the confident group demonstrated that 11 were significant. Few management changes were made as a result of radiologists' review of these radiographs. Total radiology review charges for the confident group were $215,338. Therefore the average radiology charge for each significant discordant interpretation was $19,576.
CONCLUSIONS: Of 9,599 sets of radiographs interpreted confidently by the emergency physicians in this study, there were 11 clinically significant discordant interpretations (0.1%). The standard practice of radiologists' review of all ED radiographs may not be justifiable.

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4. Unique Identifier 89024117
Author O'Leary MR; Smith M; Olmsted WW; Curtis DJ
Institution Department of Emergency Medicine, George Washington University Medical Center, Washington, DC 20037.
Title Physician assessments of practice patterns in emergency department radiograph interpretation.
Source Ann Emerg Med 1988 Oct;17(10): p1019-23
ISSN 0196-0644
Abstract

Emergency and radiology department directors at 517 acute-care US teaching hospitals were sent identical questionnaires surveying practice patterns of ED plain film radiograph interpretation. Fifty-seven percent of ED directors and 51% of radiology department (RD) directors responded. Both groups reported that the most common practice pattern (60%) was alternating responsibility for immediate interpretation between emergency physicians and radiologists during a 168-hour week. Remaining hospitals were nearly equally divided between systems in which radiologists always provided immediate interpretation and those in which the emergency physicians always provided the initial interpretation. In all systems in which emergency physicians provided some immediate radiograph interpretation, radiologists provided subsequent review. Institutions varied as to the level of training of the physician in both the ED and RD who provided immediate radiograph interpretation; at least 30% of the institutions responding were reported to have either emergency physicians or radiologists of resident level providing immediate interpretation at least part of the 24-hour day. Interpretation discrepancy rates between emergency physicians and radiologists were estimated to be 4% to 6%. The large amount of variation among hospitals in ED radiograph interpretation systems suggests that these systems were not designed with quality of care concerns as their primary criterion. As a consequence, objective patient outcome and process measures need to be developed and measured to ensure that a particular internal system for ED radiograph interpretation is providing an acceptably high standard of patient care.

 

5. Unique Identifier 98176872
Author Preston CA; Marr JJ 3rd; Amaraneni KK; Suthar BS
Institution Section of Emergency Medicine, Louisiana State University School of Medicine, New Orleans 70112-2822, USA.
Title Reduction of "callbacks" to the ED due to discrepancies in plain radiograph interpretation.
Source Am J Emerg Med 1998 Mar;16(2): p160-2
ISSN 0735-6757
Abstract

Retrospective and prospective chart review was conducted to study patient callbacks to the emergency department (ED) based on plain radiograph interpretation discrepancies between radiologists and emergency physicians before and after a continuous quality improvement (CQI) intervention. Patients who were called back to the ED because of radiograph interpretation discrepancies were retrospectively studied. These results were reviewed by a CQI team, which recommended greater communication and consultation. A prospective study was then performed. Before quality intervention, 0.7% of the patients were recalled; 0.4% required recall after quality assurance, a reduction of 42.9% (P = .0001). Emergency physicians in this study had a low percentage of patient recall due to discrepancies in radiologic interpretation. CQI further reduced this percentage. The proficiency of emergency physicians interpreting radiographs validates the current practice of emergency physicians rendering treatment based on their interpretations and supports the notion of emergency physicians billing for this service.

6. Unique Identifier 99403738
Author Robinson PJ; Wilson D; Coral A; Murphy A; Verow P
Institution Clinical Radiology Department, St James's University Hospital, Leeds, UK.
Title Variation between experienced observers in the interpretation of accident and emergency radiographs.
Source Br J Radiol 1999 Apr;72(856): p323-30
ISSN 0007-1285
Abstract

Skill mix and role extension initiatives have highlighted the difficulty of establishing quality standards for the accuracy of plain film reporting. An acceptable performance might be one which is indistinguishable from that of a group of experienced consultant radiologists. In order to assess the feasibility of setting such a standard, the variation between experienced observers must first be established. This study examines the variation found between three observers with the three major types of plain film examination. 402 plain film examinations (205 skeletal, 100 chest and 97 abdominal) performed on accident and emergency patients were reported retrospectively and independently by three experienced radiologists. The clinical data supplied on the request cards were available to the readers. Each examination was categorized by each reader as being normal, as showing significant abnormality relevant to the current clinical problem, or as showing insignificant or irrelevant abnormality. Concordance between all three readers was found in 51%, 61% and 74% of abdominal, chest and skeletal radiographs, respectively. Weighted kappa values confirmed that the level of agreement between pairs of observers was higher with skeletal radiographs (kappa w = 0.76-0.77) than with chest (kappa w = 0.63-0.68), or abdominal (kappa w = 0.50-0.78) examinations. However, the frequency of major disagreements (at least one reader reporting "normal" and one reporting "relevant abnormality") was similar for abdominal (11%), chest (12%) and skeletal (10%) radiographs. When the reports were reclassified into only two groups--either significantly abnormal or not--pairs of observers disagreed on 9-10% of skeletal, 11-19% of chest and 8-18% of abdominal cases. The average incidence of errors per observer was estimated to be in the range 3-6%. The magnitude of interobserver variation in plain film reporting is considerable, and must be taken into account when designing assessment techniques and setting quality standards for this activity.

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