Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans
Introduction: A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED. Methods...
| Main Authors: | , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
eScholarship Publishing, University of California
2024-02-01
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| Series: | Western Journal of Emergency Medicine |
| Online Access: | https://escholarship.org/uc/item/19j7199s |
| _version_ | 1827288468722548736 |
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| author | Arjun Dhanik Bryan A. Stenson Robin B. Levenson Peter S. Antkowiak Leon D. Sanchez David T. Chiu |
| author_facet | Arjun Dhanik Bryan A. Stenson Robin B. Levenson Peter S. Antkowiak Leon D. Sanchez David T. Chiu |
| author_sort | Arjun Dhanik |
| collection | DOAJ |
| description | Introduction: A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED. Methods: We performed a retrospective analysis of all CT imaging completed at an urban, tertiary care ED from May 1–July 31, 2021. During that period, 5,685 CTs were performed on 4,344 patients, with a median time from CT order to completion of 108 minutes (Quartile 1 [Q1]: 57 minutes, Quartile 3 [Q3]: 182 minutes, interquartile range [IQR]: 125 minutes). Outliers were defined as studies that took longer than 369 minutes to complete (Q3 + 1.5 × IQR). We systematically reviewed outlier charts to determine factors associated with delay and identified five factors: behaviorally non-compliant or medically unstable patients; intravenous (IV) line issues; contrast allergies; glomerular filtration rate (GFR) concerns; and delays related to imaging protocol (eg, need for IV contrast, request for oral and/or rectal contrast). We calculated confidence intervals (CI) using the modified Wald method. Inter-rater reliability was assessed with a kappa analysis. Results: We identified a total of 182 outliers (4.2% of total patients). Fifteen (8.2%) cases were excluded for CT time-stamp inconsistencies. Of the 167 outliers analyzed, 38 delays (22.8%, 95% confidence interval [CI] 17.0–29.7) were due to behaviorally non-compliant or medically unstable patients; 30 (18.0%, 95% CI 12.8–24.5) were due to IV issues; 24 (14.4%, 95% CI 9.8–20.6) were due to contrast allergies; 21 (12.6%, 95% CI 8.3–18.5) were due to GFR concerns; and 20 (12.0%, 95% CI 7.8–17.9) were related to imaging study protocols. The cause of the delay was unknown in 55 cases (32.9%, 95% CI 26.3–40.4). Conclusion: Our review identified both modifiable and non-modifiable factors associated with significantly delayed CT in the ED. Patient factors such as behavior, allergies, and medical acuity cannot be controlled. However, institutional policies regarding difficult IV access, contrast administration in low GFR settings, and study protocols may be modified, capturing up to 42.6% of outliers. |
| first_indexed | 2024-04-24T11:32:34Z |
| format | Article |
| id | doaj.art-ec0018d1c63549bdb48700937c9a6c91 |
| institution | Directory Open Access Journal |
| issn | 1936-900X 1936-9018 |
| language | English |
| last_indexed | 2024-04-24T11:32:34Z |
| publishDate | 2024-02-01 |
| publisher | eScholarship Publishing, University of California |
| record_format | Article |
| series | Western Journal of Emergency Medicine |
| spelling | doaj.art-ec0018d1c63549bdb48700937c9a6c912024-04-10T08:57:29ZengeScholarship Publishing, University of CaliforniaWestern Journal of Emergency Medicine1936-900X1936-90182024-02-0125222622910.5811/westjem.1783117831Root Cause Analysis of Delayed Emergency Department Computed Tomography ScansArjun Dhanik0Bryan A. Stenson1Robin B. Levenson2Peter S. Antkowiak3Leon D. Sanchez4David T. Chiu5Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MassachusettsBeth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MassachusettsBeth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MassachusettsBeth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MassachusettsHarvard Medical School, Harvard University, Boston, MassachusettsBeth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MassachusettsIntroduction: A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED. Methods: We performed a retrospective analysis of all CT imaging completed at an urban, tertiary care ED from May 1–July 31, 2021. During that period, 5,685 CTs were performed on 4,344 patients, with a median time from CT order to completion of 108 minutes (Quartile 1 [Q1]: 57 minutes, Quartile 3 [Q3]: 182 minutes, interquartile range [IQR]: 125 minutes). Outliers were defined as studies that took longer than 369 minutes to complete (Q3 + 1.5 × IQR). We systematically reviewed outlier charts to determine factors associated with delay and identified five factors: behaviorally non-compliant or medically unstable patients; intravenous (IV) line issues; contrast allergies; glomerular filtration rate (GFR) concerns; and delays related to imaging protocol (eg, need for IV contrast, request for oral and/or rectal contrast). We calculated confidence intervals (CI) using the modified Wald method. Inter-rater reliability was assessed with a kappa analysis. Results: We identified a total of 182 outliers (4.2% of total patients). Fifteen (8.2%) cases were excluded for CT time-stamp inconsistencies. Of the 167 outliers analyzed, 38 delays (22.8%, 95% confidence interval [CI] 17.0–29.7) were due to behaviorally non-compliant or medically unstable patients; 30 (18.0%, 95% CI 12.8–24.5) were due to IV issues; 24 (14.4%, 95% CI 9.8–20.6) were due to contrast allergies; 21 (12.6%, 95% CI 8.3–18.5) were due to GFR concerns; and 20 (12.0%, 95% CI 7.8–17.9) were related to imaging study protocols. The cause of the delay was unknown in 55 cases (32.9%, 95% CI 26.3–40.4). Conclusion: Our review identified both modifiable and non-modifiable factors associated with significantly delayed CT in the ED. Patient factors such as behavior, allergies, and medical acuity cannot be controlled. However, institutional policies regarding difficult IV access, contrast administration in low GFR settings, and study protocols may be modified, capturing up to 42.6% of outliers.https://escholarship.org/uc/item/19j7199s |
| spellingShingle | Arjun Dhanik Bryan A. Stenson Robin B. Levenson Peter S. Antkowiak Leon D. Sanchez David T. Chiu Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans Western Journal of Emergency Medicine |
| title | Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans |
| title_full | Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans |
| title_fullStr | Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans |
| title_full_unstemmed | Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans |
| title_short | Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans |
| title_sort | root cause analysis of delayed emergency department computed tomography scans |
| url | https://escholarship.org/uc/item/19j7199s |
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