National organizations that represent technologists, physicists, and radiologists have created programs to decrease radiation dosages called Image Wisely (adult population) and Image Gently (pediatric population). As much as these programs make perfect sense and reduce exposure to patients, neither program addresses the more pressing radiation dose issue in radiology. Right now, Emergency Departments (EDs) throughout the country have a program that counteracts all of these achievements. I like to call it Image Wildly!
So, what do I mean by that? We, as radiologists, have noticed an epidemic throughout our hospitals. And, no it is not high radiation doses for patients on an exam by exam basis. Instead, we see EDs ordering unnecessary studies indiscriminately. These unwarranted studies significantly increase radiation dose much more steeply than any single exam reduction in radiation dose can achieve. So in today’s rant, I will outline a myriad of factors for the problem. And then, I will identify how we can achieve the goal of reducing radiation dose by decreasing the number of silly studies ordered.
Reasons For Image Wildly
If You Build It, They Will Come
Have you noticed when you either add or replace old imaging equipment with more efficient hardware, the numbers of studies increase accordingly? And, what happened to these patients that didn’t get these studies before the new ED CT scanner arrived? Well, now that the equipment is more readily available to patients, it becomes more convenient for clinicians to order a test instead of waiting to complete an appropriate physical and history to triage patients through the system. But, like many of you, I still believe there is a role for taking a good quality history. It’s the most effective way to reduce exams and also radiation dosage!
Midlevel Providers Automatically Ordering Studies
In some departments, automatic button pushers such as some midlevel providers will sometimes order studies to hasten the final disposition of each patient. The process can become somewhat standardized with any patient labeled with abdominal pain slated for a CT scan. Unfortunately, these formulaic systems do not always work. Not every patient with abdominal pain needs a CT scan. And, the midlevel providers often are just another cog in a wheel run by a larger entity. If only someone would examine the patient well first, the clinician could cancel these unwarranted studies.
CYA (Legal Issues)
Of course, in any discussion of imaging, we need to discuss one of the thousand-pound gorillas, the threat of a lawsuit. Elevated threats of lawsuits lead clinicians to order more studies just to prevent the possibility of “missing” a clinical finding. However, this issue ignores the other complications of imaging- false positives, increased radiation doses, and occasional misdiagnoses. I am a firm believer that the answer often lies in the patient’s history. But, histories are also not perfect. And, how can a clinician transfer the blame from
Quantitative ER Parameters (Time To Disposition)
Often, in a busy ED, it takes less time to order a procedure before a patient needs it rather than to have to order a study when she needs it. And, what is the metric that many Emergency Departments use to measure quality? Well, that would be time to disposition! So, what happens? Patients get additional unneeded studies that rack up increased radiation over time in order to minimize ED time. Statistics like this one emphasize time over quality. And, who suffers? The patient, of course!
How To Solve Image Wildly
Unfortunately, I do not have one straightforward answer to solve every problem that leads up to the Image W
Slowly and deliberately, we need to take a hard look at each of the issues that can cause the problem indiscriminate imaging. Only then, can we significantly reduce radiation dosage of patients and end the problem of Image Wildly!