QUALITY MATTERS PAUL NAGY, PHD
Performance Quality Improvement Projects: Suggestions for the Body Imager Serena McClam Liebengood, MD, MHSA, Paul Nagy, PhD Body imaging constitutes a significant portion of diagnostic imaging and incorporates multiple modalities, including CT, MRI, radiography, and ultrasound. The more heavily used modalities in body imaging (ie, CT and MRI) often require specific protocols and techniques to improve diagnostic accuracy for the specified indication. Optimizing the performance of these advanced diagnostic imaging examinations can significantly improve patient safety, quality, workflow efficiency, and patient satisfaction. The scope, frequency, and complexity of body imaging present numerous potential opportunities for performance improvements that may be undertaken. There are several issues to consider when selecting a quality project. Projects chosen should be relevant to your practice, be achievable in your practice setting, produce results that are suited to repeat measurement, and be reasonably expected to bring about quality improvement [1]. On the basis of these principles, we have identified several potential starter quality improvement projects in body imaging.
REDUCTION OF INDETERMINATE CT PULMONARY ANGIOGRAPHY CT pulmonary angiographic (CTPA) imaging is one of the most frequently performed examinations to evaluate for pulmonary embolism. CTPA examinations have been reported to have sensitivity as high as 96% and specificity as high as 100% [2-4]. Treatment decisions
are often made upon the assessment of a technically adequate CTPA examination. However, it is estimated that between 0.5% and 10.8% of examinations are deemed indeterminate (ie, examinations that are deemed insufficient for diagnosis of a pulmonary embolism) [5]. A retrospective study by Jones and Wittram [5] demonstrated an indeterminate rate of 6.6%, with the two main causes identified as motion artifacts and poor contrast enhancement. Other less commonly cited factors included multiple factors, parenchymal disease, and streak and beam hardening artifacts. Indeterminate CTPA examinations may result in delayed or unnecessary preemptive treatment and repeat imaging examinations.
3.
4.
Quality Project n
Project metric: number of indeterminate CTPA examinations/total number of CTPA examinations 1. Prospectively collect acquisition information for every CTPA study performed during a 4-month period. These data should include factors related to the protocol used, contrast route and administration (eg, intravenous gauge, amount, rate of injection), and breathing instructions (if provided). Patient factors such as body habitus (eg, body mass index) might also be collected. 2. Once this information is collected, assess and rate the overall quality of the examination and pulmonary artery opacification. For example, assessment of overall quality might
ª 2015 American College of Radiology 1546-1440/14/$36.00 n http://dx.doi.org/10.1016/j.jacr.2014.10.012
5. 6.
include excellent (ie, optimal examination for pulmonary embolism detection), diagnostic (ie, adequate to render a diagnosis), and nondiagnostic (ie, unable to render definitive diagnosis) examinations. Assess each examination for artifacts (eg, motion, mixing artifact, streak and beam hardening artifacts) and other imaging observations that may limit detection, such as parenchymal disease. Analyze the data. What is the baseline indeterminate CTPA rate? Look for trends. For example, are there particular patient populations that tend to have suboptimal examinations? Are suboptimal examinations associated with a particular scanner or related to injection technique, or do they occur during certain times of the day? What are the main artifacts observed on indeterminate examinations? Design and implement an intervention on the basis of the data analysis. Collect data following intervention implementation. Did the number of indeterminate examinations decrease, and if so, was the decrease clinically significant? Is there a particular subset of the population that did not respond to the intervention? If the intervention was successful, what process modifications are needed to sustain positive change?
REDUCTION OF MRI MOTION ARTIFACTS MRI examinations are subject to motion artifacts due to long acquisition
201
times. Motion has proved to be an extremely common artifact in MRI [6]. Motion can reduce the conspicuity of lesions or yield suboptimal characterizations of lesions. Motion degradation might require repeating sequences or, in some cases, the entire examination. This can adversely affect scanner utilization, efficiency, and cost. Although there are motion correction techniques and software and hardware available, reducing motion from the outset is most advantageous. Motion can be categorized as voluntary or involuntary. Involuntary motion might be related to respiratory motion, cardiac motion, or vascular pulsatility and cannot be prevented. Voluntary motion might be observed in patients who are unable to fully cooperate because of pain or severe illness. It is often observed in patients who experience intense anxiety [7,8]. Although motion is often unintentional, there are many potential opportunities to reduce voluntary motion. For example, one study demonstrated a significant reduction in voluntary patient motion simply by using prescan educational pamphlets [9].
Quality Project n
Project metric: number of motiondegraded MRI examinations/total number of MRI examinations 1. Retrospectively review 75 to 100 abdominal MRI examinations. Record the type of examination and the protocol used. Review and rate the degree of motion present on the examinations and whether the motion artifacts rendered the examinations nondiagnostic or markedly limited. Determine how many sequences were repeated, if applicable. Document if recommendations for repeat imaging were provided. Record the location of the patient when imaged (eg, outpatient, intensive care unit, or floor). If available, document potential communication barriers. 202
2. Analyze the data. Look for trends. Which patient population accounts for the most image-degraded examinations? Which type of examination was most commonly degraded? What percentage of examinations were significantly motion degraded? How many examinations required repeat sequences? Are there potential communication barriers due to language differences? 3. Review and assess relevant MRI protocols, policies, and procedures within the department that might affect patients’ ability to remain still or follow instructions. For example, are claustrophobic patients identified and counseled before scheduling? Are sequences being performed that are of limited value? Are patients adequately educated about the MRI process and provided with instructions? 4. Design and implement an intervention strategy on the basis of the initial data analysis as well as potential weaknesses identified in review of the protocol, policies, and procedures. 5. Collect data after intervention implementation on 75 to 100 cases. Did the percentage of motion-degraded examinations decrease? Did the distribution of mildly, moderately, and severely degraded examinations change?
a reasonable manner. Nonroutine findings should be communicated to the “physician/health care provider or his/ her designee.” An example of nonroutine communication includes findings that require immediate or urgent intervention, such as a pneumothorax and hemoperitoneum. Nonroutine communication also encompasses what institutions would typically categorize as a critical value. An established policy and procedure for communication of critical findings is also mandated by The Joint Commission [11].
Quality Project n
1.
2.
DOCUMENTATION OF NONROUTINE COMMUNICATIONS Often in abdominal imaging, a radiologist identifies critical findings that require communication beyond routine channels established by the health care or imaging facilities. These “nonroutine communications” include communication of findings in emergent or nonroutine clinical situations, as clarified by the ACR Practice Parameter for Communication of Diagnostic Imaging Findings [10]. In these scenarios, radiologists should expedite these findings in
3.
4.
Project metric: number of documented critical values/total number of sampled critical values Over a 1 month period, sample 75 to 100 cases. Review each case for nonroutine findings (the denominator). Assess which cases contain appropriate documentation according to facility requirements. This may include the name of the individual who received information, the date and time, and the information communicated. Calculate the elapsed time between discovery of the nonroutine finding and the communication of the finding. Calculate the documentation rate. How complete are the documented communications for all nonroutine cases sampled? Are there particular staff outliers? Are particular clinical scenarios or patient types less likely to be documented? Did the amount of time between discovery and communication fall within established guidelines? Design and implement intervention on the basis of the information collected. Remeasure the documentation rate.
REFERENCES 1. American Board of Radiology. Maintenance of certification: guidelines for PQI
Journal of the American College of Radiology Volume 12 n Number 2 n February 2015
projects in diagnostic radiology. Available at: http://www.theabr.org/moc-dr-pqiguides. Accessed July 7, 2014. 2. Coche E, Verschuren F, Keyeux A, et al. Diagnosis of acute pulmonary embolism in outpatients: comparison of thin-collimation multi-detector row spiral CT and planar ventilation-perfusion scintigraphy. Radiology 2003;229:757-65. 3. Remy-Jardin M, Remy J, Baghaie F, et al. Clinical value of thin collimation in the diagnostic workup of pulmonary embolism. AJR Am J Roentgenol 2000;175:407-11. 4. Blachere H, Latrabe V, Montaudon M, et al. Pulmonary embolism revealed on helical CT angiography: comparison with ventilation perfusion radionuclide lung
5.
6.
7.
8.
scanning. AJR Am J Roentgenol 2000;174: 1041-7. Jones S, Wittram C. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. Radiology 2005;237:329-37. Stark DD, Bradley WG. Magnetic resonance imaging. 3rd ed. St Louis, Missouri: Mosby; 1999:215-30. Törnqvist E, Månsson A, Larsson E-M, Hallström I. Impact of extended written information on patient anxiety and image motion artifacts during magnetic resonance imaging. Acta Radiol 2006;47:474-80. Dantendorfer K, Amering M, Bankier A, et al. A study of the effects of patient anxiety, perceptions and equipment on motion artifacts
in magnetic resonance imaging. Magn Reson Imaging 1997;15:301-6. 9. Ali SH, Modic ME, Mahmoud SY, Jones SE. Reducing clinical MRI motion degradation using a prescan patient information pamphlet. AJR Am J Roentgenol 2013;200:630-4. 10. American College of Radiology. ACR practice parameter for communication of diagnostic imaging findings. Resolution 11. Available at: http://www.acr.org/w/media/ C5D1443C9EA4424AA12477D1AD1D 927D.pdf. Accessed November 6, 2014. 11. The Joint Commission. Hospital National Patient Safety Goals. Available at: http://www. jointcommission.org/assets/1/6/HAP_NPSG_ Chapter_2014.pdf. Accessed July 4, 2014.
Serena McClam Liebengood MD, MHSA, is from the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland. Paul Nagy, PhD: Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
Journal of the American College of Radiology McClam Liebengood, Nagy n Quality Matters
203
Performance Quality Improvement Projects: Suggestions for the Body Imager Serena McClam Liebengood, MD, MHSA, Paul Nagy, PhD Body imaging constitutes a significant portion of diagnostic imaging and incorporates multiple modalities, including CT, MRI, radiography, and ultrasound. The more heavily used modalities in body imaging (ie, CT and MRI) often require specific protocols and techniques to improve diagnostic accuracy for the specified indication. Optimizing the performance of these advanced diagnostic imaging examinations can significantly improve patient safety, quality, workflow efficiency, and patient satisfaction. The scope, frequency, and complexity of body imaging present numerous potential opportunities for performance improvements that may be undertaken. There are several issues to consider when selecting a quality project. Projects chosen should be relevant to your practice, be achievable in your practice setting, produce results that are suited to repeat measurement, and be reasonably expected to bring about quality improvement [1]. On the basis of these principles, we have identified several potential starter quality improvement projects in body imaging.
REDUCTION OF INDETERMINATE CT PULMONARY ANGIOGRAPHY CT pulmonary angiographic (CTPA) imaging is one of the most frequently performed examinations to evaluate for pulmonary embolism. CTPA examinations have been reported to have sensitivity as high as 96% and specificity as high as 100% [2-4]. Treatment decisions
are often made upon the assessment of a technically adequate CTPA examination. However, it is estimated that between 0.5% and 10.8% of examinations are deemed indeterminate (ie, examinations that are deemed insufficient for diagnosis of a pulmonary embolism) [5]. A retrospective study by Jones and Wittram [5] demonstrated an indeterminate rate of 6.6%, with the two main causes identified as motion artifacts and poor contrast enhancement. Other less commonly cited factors included multiple factors, parenchymal disease, and streak and beam hardening artifacts. Indeterminate CTPA examinations may result in delayed or unnecessary preemptive treatment and repeat imaging examinations.
3.
4.
Quality Project n
Project metric: number of indeterminate CTPA examinations/total number of CTPA examinations 1. Prospectively collect acquisition information for every CTPA study performed during a 4-month period. These data should include factors related to the protocol used, contrast route and administration (eg, intravenous gauge, amount, rate of injection), and breathing instructions (if provided). Patient factors such as body habitus (eg, body mass index) might also be collected. 2. Once this information is collected, assess and rate the overall quality of the examination and pulmonary artery opacification. For example, assessment of overall quality might
ª 2015 American College of Radiology 1546-1440/14/$36.00 n http://dx.doi.org/10.1016/j.jacr.2014.10.012
5. 6.
include excellent (ie, optimal examination for pulmonary embolism detection), diagnostic (ie, adequate to render a diagnosis), and nondiagnostic (ie, unable to render definitive diagnosis) examinations. Assess each examination for artifacts (eg, motion, mixing artifact, streak and beam hardening artifacts) and other imaging observations that may limit detection, such as parenchymal disease. Analyze the data. What is the baseline indeterminate CTPA rate? Look for trends. For example, are there particular patient populations that tend to have suboptimal examinations? Are suboptimal examinations associated with a particular scanner or related to injection technique, or do they occur during certain times of the day? What are the main artifacts observed on indeterminate examinations? Design and implement an intervention on the basis of the data analysis. Collect data following intervention implementation. Did the number of indeterminate examinations decrease, and if so, was the decrease clinically significant? Is there a particular subset of the population that did not respond to the intervention? If the intervention was successful, what process modifications are needed to sustain positive change?
REDUCTION OF MRI MOTION ARTIFACTS MRI examinations are subject to motion artifacts due to long acquisition
201
times. Motion has proved to be an extremely common artifact in MRI [6]. Motion can reduce the conspicuity of lesions or yield suboptimal characterizations of lesions. Motion degradation might require repeating sequences or, in some cases, the entire examination. This can adversely affect scanner utilization, efficiency, and cost. Although there are motion correction techniques and software and hardware available, reducing motion from the outset is most advantageous. Motion can be categorized as voluntary or involuntary. Involuntary motion might be related to respiratory motion, cardiac motion, or vascular pulsatility and cannot be prevented. Voluntary motion might be observed in patients who are unable to fully cooperate because of pain or severe illness. It is often observed in patients who experience intense anxiety [7,8]. Although motion is often unintentional, there are many potential opportunities to reduce voluntary motion. For example, one study demonstrated a significant reduction in voluntary patient motion simply by using prescan educational pamphlets [9].
Quality Project n
Project metric: number of motiondegraded MRI examinations/total number of MRI examinations 1. Retrospectively review 75 to 100 abdominal MRI examinations. Record the type of examination and the protocol used. Review and rate the degree of motion present on the examinations and whether the motion artifacts rendered the examinations nondiagnostic or markedly limited. Determine how many sequences were repeated, if applicable. Document if recommendations for repeat imaging were provided. Record the location of the patient when imaged (eg, outpatient, intensive care unit, or floor). If available, document potential communication barriers. 202
2. Analyze the data. Look for trends. Which patient population accounts for the most image-degraded examinations? Which type of examination was most commonly degraded? What percentage of examinations were significantly motion degraded? How many examinations required repeat sequences? Are there potential communication barriers due to language differences? 3. Review and assess relevant MRI protocols, policies, and procedures within the department that might affect patients’ ability to remain still or follow instructions. For example, are claustrophobic patients identified and counseled before scheduling? Are sequences being performed that are of limited value? Are patients adequately educated about the MRI process and provided with instructions? 4. Design and implement an intervention strategy on the basis of the initial data analysis as well as potential weaknesses identified in review of the protocol, policies, and procedures. 5. Collect data after intervention implementation on 75 to 100 cases. Did the percentage of motion-degraded examinations decrease? Did the distribution of mildly, moderately, and severely degraded examinations change?
a reasonable manner. Nonroutine findings should be communicated to the “physician/health care provider or his/ her designee.” An example of nonroutine communication includes findings that require immediate or urgent intervention, such as a pneumothorax and hemoperitoneum. Nonroutine communication also encompasses what institutions would typically categorize as a critical value. An established policy and procedure for communication of critical findings is also mandated by The Joint Commission [11].
Quality Project n
1.
2.
DOCUMENTATION OF NONROUTINE COMMUNICATIONS Often in abdominal imaging, a radiologist identifies critical findings that require communication beyond routine channels established by the health care or imaging facilities. These “nonroutine communications” include communication of findings in emergent or nonroutine clinical situations, as clarified by the ACR Practice Parameter for Communication of Diagnostic Imaging Findings [10]. In these scenarios, radiologists should expedite these findings in
3.
4.
Project metric: number of documented critical values/total number of sampled critical values Over a 1 month period, sample 75 to 100 cases. Review each case for nonroutine findings (the denominator). Assess which cases contain appropriate documentation according to facility requirements. This may include the name of the individual who received information, the date and time, and the information communicated. Calculate the elapsed time between discovery of the nonroutine finding and the communication of the finding. Calculate the documentation rate. How complete are the documented communications for all nonroutine cases sampled? Are there particular staff outliers? Are particular clinical scenarios or patient types less likely to be documented? Did the amount of time between discovery and communication fall within established guidelines? Design and implement intervention on the basis of the information collected. Remeasure the documentation rate.
REFERENCES 1. American Board of Radiology. Maintenance of certification: guidelines for PQI
Journal of the American College of Radiology Volume 12 n Number 2 n February 2015
projects in diagnostic radiology. Available at: http://www.theabr.org/moc-dr-pqiguides. Accessed July 7, 2014. 2. Coche E, Verschuren F, Keyeux A, et al. Diagnosis of acute pulmonary embolism in outpatients: comparison of thin-collimation multi-detector row spiral CT and planar ventilation-perfusion scintigraphy. Radiology 2003;229:757-65. 3. Remy-Jardin M, Remy J, Baghaie F, et al. Clinical value of thin collimation in the diagnostic workup of pulmonary embolism. AJR Am J Roentgenol 2000;175:407-11. 4. Blachere H, Latrabe V, Montaudon M, et al. Pulmonary embolism revealed on helical CT angiography: comparison with ventilation perfusion radionuclide lung
5.
6.
7.
8.
scanning. AJR Am J Roentgenol 2000;174: 1041-7. Jones S, Wittram C. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. Radiology 2005;237:329-37. Stark DD, Bradley WG. Magnetic resonance imaging. 3rd ed. St Louis, Missouri: Mosby; 1999:215-30. Törnqvist E, Månsson A, Larsson E-M, Hallström I. Impact of extended written information on patient anxiety and image motion artifacts during magnetic resonance imaging. Acta Radiol 2006;47:474-80. Dantendorfer K, Amering M, Bankier A, et al. A study of the effects of patient anxiety, perceptions and equipment on motion artifacts
in magnetic resonance imaging. Magn Reson Imaging 1997;15:301-6. 9. Ali SH, Modic ME, Mahmoud SY, Jones SE. Reducing clinical MRI motion degradation using a prescan patient information pamphlet. AJR Am J Roentgenol 2013;200:630-4. 10. American College of Radiology. ACR practice parameter for communication of diagnostic imaging findings. Resolution 11. Available at: http://www.acr.org/w/media/ C5D1443C9EA4424AA12477D1AD1D 927D.pdf. Accessed November 6, 2014. 11. The Joint Commission. Hospital National Patient Safety Goals. Available at: http://www. jointcommission.org/assets/1/6/HAP_NPSG_ Chapter_2014.pdf. Accessed July 4, 2014.
Serena McClam Liebengood MD, MHSA, is from the Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland. Paul Nagy, PhD: Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
Journal of the American College of Radiology McClam Liebengood, Nagy n Quality Matters
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