Korean Journal of Radiology

The Korean Society of Radiology (대한영상의학회)
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Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study

  • Gil-Sun Hong (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Choong Wook Lee (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Ju Hee Lee (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Bona Kim (Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Jung Bok Lee (Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center)
  • Received : 2022.01.20
  • Accepted : 2022.06.13
  • Published : 2022.09.01
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Abstract

Objective: To investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED). Materials and Methods: This retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate. Results: According to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4-27.5 hours) to 11.6 hours (6.6-21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5-30.1 hours) to 9.6 hours (5.7-19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6-16.5 hours) to 6.7 hours (4.9-11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001). Conclusion: QIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.

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References

  1. Aggarwal G, Peden CJ, Mohammed MA, Pullyblank A, Williams B, Stephens T, et al. Evaluation of the collaborative use of an evidence-based care bundle in emergency laparotomy. JAMA Surg 2019;154:e190145 
  2. Bamber JR, Stephens TJ, Cromwell DA, Duncan E, Martin GP, Quiney NF, et al. Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy. BJS Open 2019;3:802-811 
  3. Peden CJ, Stephens T, Martin G, Kahan BC, Thomson A, Rivett K, et al. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial. Lancet 2019;393:2213-2221 
  4. Jalal S, Ouellette H, Ante Z, Munk P, Khosa F, Nicolaou S. Impact of 24/7/365 attending radiologist coverage on the turnaround time in an emergency and trauma radiology department. Can Assoc Radiol J 2021;72:548-556 
  5. Lamb L, Kashani P, Ryan J, Hebert G, Sheikh A, Thornhill R, et al. Impact of an in-house emergency radiologist on report turnaround time. CJEM 2015;17:21-26 
  6. Mughli RA, Durrant E, Baia Medeiros DT, Shelton D, Robins J, Qamar SR, et al. Overnight attending radiologist coverage decreases imaging-related emergency department recalls by at least 90. Emerg Radiol 2021;28:549-555 
  7. Coleman S, Holalkere NS, O'Malley J, Doherty G, Norbash A, Kadom N. Radiology 24/7 in-house attending coverage: do benefits outweigh cost? Curr Probl Diagn Radiol 2016;45:241-246 
  8. Davis P, Hayden J, Springer J, Bailey J, Molinari M, Johnson P. Prognostic factors for morbidity and mortality in elderly patients undergoing acute gastrointestinal surgery: a systematic review. Can J Surg 2014;57:E44-E52 
  9. Korkut M, Icoz G, Dayangac M, Akgun E, Yeniay L, Erdogan O, et al. Outcome analysis in patients with Fournier's gangrene: report of 45 cases. Dis Colon Rectum 2003;46:649-652 
  10. Loftus TJ, Rosenthal MD, Croft CA, Stephen Smith R, Efron PA, Moore FA, et al. Effect of time to operation on value of care in acute care surgery. World J Surg 2018;42:2356-2363 
  11. McIsaac DI, Abdulla K, Yang H, Sundaresan S, Doering P, Vaswani SG, et al. Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score-matched observational cohort study. CMAJ 2017;189:E905-E912 
  12. Papandria D, Goldstein SD, Rhee D, Salazar JH, Arlikar J, Gorgy A, et al. Risk of perforation increases with delay in recognition and surgery for acute appendicitis. J Surg Res 2013;184:723-729 
  13. Cournane S, Conway R, Creagh D, Byrne DG, Sheehy N, Silke B. Radiology imaging delays as independent predictors of length of hospital stay for emergency medical admissions. Clin Radiol 2016;71:912-918 
  14. Wang DC, Parry CR, Feldman M, Tomlinson G, Sarrazin J, Glanc P. Acute abdomen in the emergency department: is CT a time-limiting factor? AJR Am J Roentgenol 2015;205:1222-1229 
  15. Kluger Y, Ben-Ishay O, Sartelli M, Ansaloni L, Abbas AE, Agresta F, et al. World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS). World J Emerg Surg 2013;8:17 
  16. Koivukangas V, Saarela A, Merilainen S, Wiik H. How well planned urgency class come true in the emergency surgery? Timing of acute care surgery. Scand J Surg 2020;109:85-88 
  17. Pearse RM, Dana EC, Lanigan CJ, Pook JA. Organisational failures in urgent and emergency surgery. A potential perioperative risk factor. Anaesthesia 2001;56:684-689 
  18. Schneider C, Tyler LE, Scull EF, Pryle BJ, Barr H. A case-control study investigating factors of preoperative delay in emergency laparotomy. Int J Surg 2015;22:131-135 
  19. Vogt KN, Allen L, Murphy PB, van Heest R, Saleh F, Widder S, et al. Patterns of complex emergency general surgery in Canada. Can J Surg 2020;63:E435-E441 
  20. Nawijn F, Smeeing DPJ, Houwert RM, Leenen LPH, Hietbrink F. Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 2020;15:4 
  21. Meschino MT, Giles AE, Rice TJ, Saddik M, Doumouras AG, Nenshi R, et al. Operative timing is associated with increased morbidity and mortality in patients undergoing emergency general surgery: a multisite study of emergency general services in a single academic network. Can J Surg 2020;63:E321-E328 
  22. Aiken T, Barrett J, Stahl CC, Schwartz PB, Udani S, Acher AW, et al. Operative delay in adults with appendicitis: time is money. J Surg Res 2020;253:232-237 
  23. Montes FR, Vasquez SM, Camargo-Rojas CM, Rueda MV, Goez-Mogollon L, Alvarado PA, et al. Association between emergency department length of stay and adverse perioperative outcomes in emergency surgery: a cohort study in two Colombian University hospitals. BMC Emerg Med 2019;19:27 
  24. Murphy PB, DeGirolamo K, Van Zyl TJ, Allen L, Haut E, Leeper WR, et al. Impact of the acute care surgery model on disease-and patient-specific outcomes in appendicitis and biliary disease: a meta-analysis. J Am Coll Surg 2017;225:763-777. e13 
  25. Mozer AB, Spaniolas K, Sippey ME, Celio A, Manwaring ML, Kasten KR. Post-operative morbidity, but not mortality, is worsened by operative delay in septic diverticulitis. Int J Colorectal Dis 2017;32:193-199 
  26. Ong M, Guang TY, Yang TK. Impact of surgical delay on outcomes in elderly patients undergoing emergency surgery: a single center experience. World J Gastrointest Surg 2015;7:208-213 
  27. Azuhata T, Kinoshita K, Kawano D, Komatsu T, Sakurai A, Chiba Y, et al. Time from admission to initiation of surgery for source control is a critical determinant of survival in patients with gastrointestinal perforation with associated septic shock. Crit Care 2014;18:R87 
  28. Buck DL, Vester-Andersen M, Moller MH; Danish Clinical Register of Emergency Surgery. Surgical delay is a critical determinant of survival in perforated peptic ulcer. Br J Surg 2013;100:1045-1049 
  29. Ingraham AM, Cohen ME, Bilimoria KY, Ko CY, Hall BL, Russell TR, et al. Effect of delay to operation on outcomes in adults with acute appendicitis. Arch Surg 2010;145:886-892 
  30. Kelz RR, Tran TT, Hosokawa P, Henderson W, Paulson EC, Spitz F, et al. Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. J Am Coll Surg 2009;209:434-445.e2 
  31. Kelz RR, Freeman KM, Hosokawa PW, Asch DA, Spitz FR, Moskowitz M, et al. Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data. Ann Surg 2008;247:544-552 
  32. Sicard N, Tousignant P, Pineault R, Dube S. Non-patient factors related to rates of ruptured appendicitis. Br J Surg 2007;94:214-221 
  33. Pandharipande PV, Alabre CI, Coy DL, Zaheer A, Miller CM, Herring MS, et al. Changes in physician decision making after CT: a prospective multicenter study in primary care settings. Radiology 2016;281:835-846 
  34. Pandharipande PV, Reisner AT, Binder WD, Zaheer A, Gunn ML, Linnau KF, et al. CT in the emergency department: a real-time study of changes in physician decision making. Radiology 2016;278:812-821 
  35. Gergenti L, Olympia RP. Etiology and disposition associated with radiology discrepancies on emergency department patients. Am J Emerg Med 2019;37:2015-2019 
  36. Vaattovaara E, Nikki M, Nevalainen M, Ilmarinen M, Tervonen O. Discrepancies in interpretation of night-time emergency computed tomography scans by radiology residents. Acta Radiol Open 2018;7:2058460118807234 
  37. Weinberg BD, Richter MD, Champine JG, Morriss MC, Browning T. Radiology resident preliminary reporting in an independent call environment: multiyear assessment of volume, timeliness, and accuracy. J Am Coll Radiol 2015;12:95-100 
  38. Smith J, Tan N, Shih W, Mitchell K, Estes M, Dudas R, et al. Availability of a final abdominopelvic CT report before emergency department disposition: risk-adjusted outcomes in patients with abdominal pain. Abdom Radiol (NY) 2021;46:2900-2907