Does shifting to professional emergency department staffing affect the decision for chest radiography?

doi:10.5847/wjem.j.1920-8642.2021.02.001

Abstract

Abstract:

BACKGROUND: The study aims to determine whether shifting to professional emergency department (ED) teams leads to a higher rate of radiologic workup.

METHODS: We retrospectively analyzed a total of 2,000 patients presenting to the ED of a tertiary teaching hospital in two time periods: group 1 (G1) comprised 1,000 consecutive patients enrolled from December 21, 2012 to January 5, 2013 (all patients were examined by an internal medicine specialist); group 2 (G2) comprised 1,000 consecutive patients enrolled from December 21, 2018 to January 3, 2019 (all patients were examined by an emergency physician).

RESULTS: The chest X-ray (CXR) was performed in 40.6% of all patients. There was no difference in the frequency of CXR (38.9% in G1 vs. 42.3% in G2, P=0.152). More CXRs were performed in G2 patients older than 65 years, in female patients older than 65 years, in patients presenting during the evening and night shifts or off-hours, in patients with a history of malignancy, in patients with gastrointestinal bleeding, and in patients with bradycardia, but fewer in patients presenting with arrhythmia. No difference in the rates of pathological CXR was found (47.3% in G1 vs. 52.2% in G2, P=0.186). Compared with G2, higher sensitivity and specificity were obtained for the binary logistic regression model predicting pathological findings in G1.

CONCLUSIONS: Shifting to professional ED teams does not increase radiologic workup. By implementing deliberate usage of ultrasound, some self-governing procedures, case-oriented investigations, and center-specific recommendations, unnecessary radiologic workup can be avoided. Professional ED teams could lead to a higher standard of emergency care.

Key words: Chest radiography, Emergency department, Emergency physicians, Healthcare organization

Marin Pavlov, Lucija Klobučar, Iva Klobučar, Kristina Žgela, Vesna Degoricija. Does shifting to professional emergency department staffing affect the decision for chest radiography?[J]. World Journal of Emergency Medicine, 2021, 12(2): 87-92.

Figures/Tables 3

Figure 1.

Table 1

Table 2

References 23

1	Totten V, Bellou A . Development of emergency medicine in Europe. Acad Emerg Med. 2013; 20(5):514-21. doi: 10.1111/acem.12126 pmid: 23672367
2	Garcia-Castrillo L, Williams D . Emergency medicine as a specialty in the European context. Emergencias. 2011; 23(6):423-5.
3	Mills AM, Raja AS, Marin JR . Optimizing diagnostic imaging in the emergency department. Acad Emerg Med. 2015; 22(5):625-31. doi: 10.1111/acem.12640 pmid: 25731864
4	Clinton JE, Yaron M, Tsai SH . Chest radiography in the emergency department. Ann Emerg Med. 1986; 15(3):254-6. doi: 10.1016/s0196-0644(86)80558-3 pmid: 3511787
5	Baskerville JR, Herrick J . Head multidetector computed tomography: emergency medicine physicians overestimate the pretest probability and legal risk of significant findings. Am[J] Emerg Med. 2012; 30(2):367-70.
6	Tabas JA, Hsia RY . Invited commentary—Emergency department neuroimaging: are we using our heads?: Comment on “Use of neuroimaging in US emergency departments”. Arch Intern Med. 2011; 171(3):262-4. doi: 10.1001/archinternmed.2010.520 pmid: 21325119
7	Kuhn GJ, Wyer PC, Cordell WH, Rowe BH , Society for Academic Emergency Medicine Evidence-based Medicine Interest Group. A survey to determine the prevalence and characteristics of training in evidence-based medicine in emergency medicine residency programs.[J] Emerg Med. 2005; 28(3):353-9.
8	Kanzaria HK, Hoffman JR, Probst MA, Caloyeras JP, Berry SH, Brook RH . Emergency physician perceptions of medically unnecessary advanced diagnostic imaging. Acad Emerg Med. 2015; 22(4):390-8. doi: 10.1111/acem.12625 pmid: 25807868
9	Hendee WR, Becker GJ, Borgstede JP, Bosma J, Casarella WJ, Erickson BA , et al. Addressing overutilization in medical imaging. Radiology. 2010; 257(1):240-5. doi: 10.1148/radiol.10100063 pmid: 20736333
10	Gardiner FW, Zhai S . Are all after-hours diagnostic imaging appropriate? An Australian emergency department pilot study. Ann Med Surg (Lond). 2016; 12:75-8.
11	Pasha SF, Acosta R, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli R , et al. Routine laboratory testing before endoscopic procedures. Gastrointest Endosc. 2014; 80(1):28-33. doi: 10.1016/j.gie.2014.01.019
12	Archer C, Levy AR, McGregor M. Value of routine preoperative chest X-rays: a meta-analysis.[J] Can D’anesthesie. 1993; 40(11):1022-7.
13	Benacerraf BR, McLoud TC, Rhea JT, Tritschler V, Libby P,. An assessment of the contribution of chest radiography in outpatients with acute chest complaints: a prospective study. Radiology. 1981; 138(2):293-9. doi: 10.1148/radiology.138.2.7455106 pmid: 7455106
14	Stiell IG, Clement CM, Rowe BH, Brison RJ, Wyse DG, Birnie D , et al. Outcomes for emergency department patients with recent-onset atrial fibrillation and flutter treated in Canadian hospitals. Ann Emerg Med. 2017; 69(5):562-71. doi: 10.1016/j.annemergmed.2016.10.013 pmid: 28110987
15	Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury.[J] Trauma. 1999; 47(4):632-7.
16	Shwe S, Witchey L, Lahham S, Kunstadt E, Shniter I, Fox JC . Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center. World[J] Emerg Med. 2020; 11(1):12-7.
17	Rui P, Kang K, Ashman J,. National hospital ambulatory medical care survey: 2016 emergency department summary tables. https://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2016_ed_web_tables.pdf Available at .
18	Katz DA, Williams GC, Brown RL, Aufderheide TP, Bogner M, Rahko PS , et al. Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med. 2005; 46(6):525-33. doi: 10.1016/j.annemergmed.2005.04.016
19	Fatihoglu E, Aydin S, Gokharman FD, Ece B, Kosar PN . X-ray use in chest imaging in emergency department on the basis of cost and effectiveness. Acad Radiol. 2016; 23(10):1239-45. doi: 10.1016/j.acra.2016.05.008 pmid: 27426978
20	Al Zadjali N, Al-Senawi R, Al Reesi A, Al-Zakwani I, Nemeth J, Perry JJ . Predictors of positive chest radiography in non-traumatic chest pain in the emergency department. Oman Med J. 2009; 24(1):22-6. doi: 10.5001/omj.2009.6 pmid: 22303504
21	Hess EP, Perry JJ, Ladouceur P, Wells GA, Stiell IG . Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome. CJEM. 2010; 12(2):128-34. doi: 10.1017/s148180350001215x pmid: 20219160
22	Huang YC, Lin MS, Lin HH . Comparison of emergency physicians and internists regarding core measures of care for admitted emergency department boarders with pneumonia.[J] Acute Med. 2012; 2(2):50-4.
23	Wigton RS, Longenecker JC, Bryan TJ, Parenti C, Flach SD, Tape TG . Variation by specialty in the treatment of urinary tract infection in women.[J] Gen Intern Med. 1999; 14(8):491-4. doi: 10.1046/j.1525-1497.1999.05398.x

Groups	P	OR	95% CI for OR
Groups	P	OR	Lower	Upper
Group 1
Cough	<0.001	32.158	9.330	110.845
Dyspnea	<0.001	20.360	9.242	44.852
Fever	<0.001	10.878	4.253	27.824
GI bleeding	0.010	0.143	0.033	0.624
Chest pain	<0.001	3.776	2.438	5.849
Rales	<0.001	3.128	1.655	5.911
Oedema	0.047	2.166	1.011	4.640
Age	0.001	1.018	1.007	1.029
Group 2
Cough	<0.001	17.498	5.849	52.350
Dyspnea	<0.001	14.862	6.932	31.863
Arrhythmia	0.001	0.107	0.029	0.393
Rales	<0.001	7.107	2.780	18.167
Fever	<0.001	4.861	2.233	10.581
Chest pain	<0.001	4.172	2.727	6.381
GCS	0.003	0.793	0.679	0.925
Age	<0.001	1.020	1.011	1.030

Groups	P	OR	95% CI for OR
Groups	P	OR	Lower	Upper
Group 1
Age	<0.001	1.047	1.027	1.066
Dyspnea	<0.001	4.160	2.057	8.413
Cough	0.021	2.929	1.175	7.303
Rales	<0.001	5.535	2.839	10.792
Workday	0.037	0.526	0.288	0.961
Heart failure	0.045	2.475	1.021	6.000
GCS	<0.001	0.758	0.692	0.830
Group 2
Age	<0.001	1.031	1.018	1.045
Dyspnea	0.001	2.582	1.451	4.594
Cough	0.015	2.522	1.195	5.325
Rales	0.098	1.742	0.903	3.360
Male sex	0.056	0.640	0.405	1.011
Heart failure	0.005	3.031	1.386	6.628
GCS	<0.001	0.853	0.801	0.908

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