Survey of After-Hours Coverage of Emergency Department Imaging Studies by US Academic Radiology Departments Andrew Sellers, MDa,c, Bruce Hillman, MDb, Max Wintermark, MDa
Purpose: The aim of this study was to document how academic radiology departments cover emergency department radiologic services after hours. Methods: Program directors of neuroradiology fellowship programs were invited to participate in a web-based survey addressing how their radiology departments covered after-hours emergency department studies. Results: A total of 67 separate institutional responses were obtained from 96 institutions, for a 70% response rate. Seventy-three percent of programs (49 of 67) reported providing exclusively preliminary interpretations on emergency department reports for some overnight hours. Only 27% of respondents (18 of 67) said that they provided 24-hour real-time staff coverage. Among those who provided aroundthe-clock staff coverage, 72% (13 of 18) did so with dedicated emergency department sections. Only 2 respondents offered 24-hour subspecialty staff coverage. Emergency departments and hospital administrators were noted as the most frequent drivers of these changes. Conclusions: Academic radiology departments vary widely in how they cover after-hours emergency department examinations. A number have recently expanded their hours of coverage under institutional pressures. Key Words: Evening coverage, emergency radiology, academic radiology J Am Coll Radiol 2014;-:---. Copyright © 2014 American College of Radiology
INTRODUCTION
Advances in medical imaging have made radiologic examinations critical in disease diagnosis and patient management. Emergency department patients are no exception. Radiologists have witnessed changes in practice patterns over recent years that include an increased volume of studies ordered from emergency departments as well as increasing requests for advanced imaging studies. With increasing use have come expectations for quicker turnaround times of final reports, as a
Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, Virginia.
b
Department of Radiology, University of Virginia, Charlottesville, Virginia.
c
United States Navy, Bethesda, Maryland.
Corresponding author and reprints: Max Wintermark, MD, UVA Department of Radiology, Neuroradiology Division, Box 800170, Charlottesville, VA 22908; e-mail: [email protected]. A list of the colleagues who filled out the surveys is available in the online version of this article. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Department of the Navy, the US Department of Defense, or the US government. ª 2014 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.11.015
well as pressures for increased coverage by attending radiologists after usual working hours. Despite this trend, few data exist about how departments are covering after-hours emergency department studies. The goal of this study was to assess how academic radiology departments provide services to their institutional emergency departments after hours. METHODS
We conducted a web-based survey of programs listed by the American Society of Neuroradiology as having neuroradiology fellowships. We sent an e-mail to the point of contact listed in the American Society of Neuroradiology fellowship program director listing, which discussed the intent of the project and encouraged participation, with 3 follow-up e-mails for those not responding. A link was provided to the online survey (see Online Appendix), with results imported into Microsoft Excel (Microsoft Corporation, Redmond, Washington) for analysis. Although our department contacts were neuroradiologists, we specifically requested information about the entire department and all imaging studies (not just neuroradiologic and neuroimaging studies). 1
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The questionnaire collected data on the following elements: 1. Composition of staffing in the radiology department 2. Method each department uses to service its emergency department during weekends and weekdays (to include hours covered and the use of residents, fellows, general staff members, subspecialty staff members, dedicated emergency radiology sections, and “nighthawk” services) 3. Incentives associated with after-hours coverage, if any 4. Whether departments have expanded their afterhours coverage in the past 3 years and, if not, whether they are considering expanding their afterhours coverage 5. Forces that led to the expansion of hours, if applicable 6. Metrics used by departments to assess and make decisions regarding emergency department coverage 7. The effect expansion of hours had on key metrics used by the department 8. Negative consequences experienced because of the expansion of hours 9. Number of hospital emergency departments serviced by the department For the purpose of this study, it was necessary to narrowly define the concepts of “staff coverage” so that direct comparison of programs could be made. We were most interested in what hours emergency departments were serviced by a real-time contemporaneous staff attending and whether final interpretations were made by either subspecialty staff members or general staff members. We used the following definitions: Subspecialty coverage. Institutions provide subspecialty coverage for a given time period if the following conditions are met: Subspecialty staff (in house or remote) are reading studies in real time or nearly real time and providing final interpretations only within their subspecialty field. These may be independent interpretations or in combination with oversight of residents and fellows. Staff members must also be immediately available for consultation on difficult cases. Staff coverage. Institutions provide attending staff coverage for a given time period if the following conditions are met: General staff members, emergency department section staff members, or various rotating subspecialist staff members (in house or remote) read studies in real time or nearly real time and provide final interpretations. Preliminary coverage. The department routinely performs preliminary readings for studies, regardless of whether residents, fellows, or staff members provide the service. Teleradiology “nighthawk” services are the most common situation in which staff radiologists provide preliminary interpretations.
Statistics were primarily descriptive. Regressions and correlations (R values) were calculated using the statistical package of Microsoft Excel. RESULTS Response Rate
A total of 100 e-mail invitations were sent to participate in the online survey, of which 96 were to separate institutions. A total of 67 responses were received. Thus, the final institutional response rate was 70% (67 of 96). Of our responding academic programs, 6 were Canadian institutions and 4 were children’s hospitals. Participating institutions are listed in Table 1 as self-described in their responses. Three institutions gave complete survey responses but declined to include their institutions’ names. Surveyed Department Characteristics
The largest program surveyed had 169 attending radiologists, all subspecialties included, while the smallest had 17. The average number of employed radiologists was 53. The program with the most ACGME and nonACGME fellows had 40 and 32, respectively, while the smallest had 1 ACGME fellow and no non-ACGME fellows, with averages of 7.8 and 8.6, respectively (Table 2). Of 58 responses, 65% covered the after-hours imaging studies from the emergency departments of 2 hospitals, 36% 3 hospitals, 22% 4 hospitals, and 15% 5 hospitals. Hours Contemporaneous Staff Final Reads Are Available
The hours and methods of staff coverage varied considerably by institution. Of 67 respondents, 32 (48%) primarily use a form of the traditional call system whereby on-call, on-site residents provide preliminary interpretations, with final interpretations made in the morning hours. Fifteen programs (21%) reported using dedicated emergency department sections to cover some or all after-hours studies. Thirteen programs (19%) use rotating staff schedules to cover some after-hours emergency department studies. However, 11 of these 13 programs still use resident and or fellow preliminary interpretations for coverage of some after-hours periods. The number of departments using out-of-house nighthawk services was 8 (12%), with 7 companies providing preliminary interpretations and 1 providing final interpretations. Weekday Hours of Real-Time Staff Coverage. By far the most common time for subspecialty coverage to end is 5 PM (29 programs [43%]). Forty-two programs (63%) end subspecialty staff coverage by 6 PM. Only 8 programs (12%) provide subspecialty coverage after 10 PM, including 2 programs (3%) that provide 24-hour subspecialty coverage (Table 3). General staff coverage of evening hours is commonly extended beyond subspecialty coverage hours. Only 19
Sellers et al/After-Hours Coverage of ED Imaging 3
Table 1. Institutions that replied to our e-mail survey Allegheny General Hospital Baylor College of Medicine Beth Israel Medical Center and St. Luke’s Roosevelt Hospital Center, New York Boston Children’s Hospital Brigham and Women’s Hospital Children’s Hospital of Pittsburgh Children’s Hospital of Philadelphia Cornell University Detroit Medical Center DHMC-Dartmouth Duke University Emory University Georgetown University Hospital George Washington University Medical Center Georgia Regent University Indiana University School of Medicine Johns Hopkins University Keck Medical Center of University of Southern California London Health Sciences Centre Massachusetts General Hospital Mayo Clinic Rochester McGill University Health Center - Montreal General and Royal Victoria Medical College of Wisconsin Medical University of South Carolina New York-Presbyterian Hospital/Weill Cornell Medical College New York University North Shore LIJ Medical Center Northwestern University Oregon Health & Science University Penn State Hershey Medical Center Phoenix Children’s Hospital Stanford University Temple University The Ohio State University Thomas Jefferson University Hospital UIC - University of Illinois University Hospitals of Cleveland, Case Western Reserve University of Alabama at Birmingham University of Alberta University of Calgary University of California, Davis University of California, Irvine Medical Center (UCIMC) University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Chicago University of Cincinnati Medical Center University of Florida University of Iowa University of Maryland Medical Center University of Michigan University of New Mexico University of North Carolina University of Ottawa, The Ottawa Hospital University of Toronto, University Health Network, Toronto Western Hospital University of Utah University of Virginia Health System University of Washington University of Wisconsin - Madison UTHSC, Houston Vanderbilt University Wake Forest Baptist Medical Center Washington University in St. Louis William Beaumont Hospital Yale University
programs (28%) have no real-time staff coverage after 6 PM. The most common times for evening staff coverage to end are distributed almost evenly between 5 PM (19 programs [28%]) and full 24-hour coverage (18 programs [27%]) (Table 3). Forty-three percent of programs provide general staff final reads after 10 PM, including the 18 programs that provide full 24-hour staff coverage. Weekend Hours of Real-Time Staff Coverage. Fortynine percent of programs (n ¼ 33) have the same level of staff coverage for weekends as weekdays. Ten percent of programs do not have set in-house staff hours on weekends. The staff members at these programs are free to leave after the morning weekend read-outs are complete. However, 5 of the 7 programs had at least one additional read-out during the day and/or evening. The most common system is subspecialty staff coverage until 5 PM (24 programs [39%]). Seventy-two percent of programs end subspecialty coverage by 6 PM. Only 9% of programs provide subspecialty coverage after 10 PM, including the 2 programs (3%) that provide 24-hour subspecialty coverage. On weekends, 27 programs (44%) do not provide any real-time staff coverage after 6 PM. Twenty-four programs (39%) provide staff final reads after 10 PM. No programs provided more real-time staff coverage on weekends than they did on weekdays. Twenty-Four-Hour Staff Coverage. A minority of programs (n ¼ 18 [27%]) are currently providing 24-hour staff coverage. In 13 of these programs (72%), dedicated emergency department sections cover the emergency room studies. One program uses a nighthawk company for around-the-clock final interpretations. One program uses non-ACGME fellows for real-time final interpretations, one program uses a rotating staff call pool, and 2 programs provide 24-hour subspecialty coverage. Of the programs using emergency department sections, 5 of 13 programs commented that they have exclusions for advanced studies and use preliminary resident interpretations for these examinations. “Advanced” radiologic studies were variously defined by each institution. Most commonly, this included CT angiographic and MR angiographic imaging, but some institutions also included body, musculoskeletal, and neurologic MRI studies. Correlation of Number of Staff Members in a Department With Number of Hours Covered
In general, for both weekends and after-hours weekdays, for both general staff coverage and subspecialty coverage, we found a mild correlation between the number of staff members in a department and the number of hours the department staff covered the emergency room in real time. Correlations (R values) for subspecialty after-hours coverage on weekdays and weekends were 0.19 and 0.27, respectively. Correlation for staff after-hours coverage on weekdays and weekends were 0.32 and 0.35, respectively (Figs. 1 and 2).
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Table 2. Type and number of personnel in surveyed departments Personnel Type Average Median Attending neuroradiologists All attending radiologists Non-ACGME fellows ACGME fellows Residents
9 53 9 8 35
Smallest
Largest
4 17 1 1 4
35 169 32 40 71
8 46 6 6 36
Incentives Associated With After-Hours Coverage
Of 67 respondents, 35 (52%) reported that they provide incentives for covering evening or night shifts. Of these, 34 (51%) reported monetary compensation varying from several hundred dollars up to $2,000 for an afterhours shift. Time off is given by 27 programs (40%), but the amount of time varies significantly among institutions. Some institutions give time off the clinical schedule, while others give two-to-one vacation time for additional coverage, with 2 weeks off for every week of nights worked. Some of this variation is explained by the significantly varied hours of coverage expected by different departments, with some staff members covering only a few additional evening hours while others cover complete overnight shifts. Three programs (4%) give both time and monetary incentives, while 1 program lets staff choose between the two. Expansion of After-Hours Coverage
Of 66 respondents, 33 (50%) stated that they have expanded after-hours coverage in the past 3 years. Of the 33 (50%) that have not recently expanded coverage, nearly 50% are considering further expansion of hours. Therefore, 75% of all responding programs have felt or are currently feeling the need to provide more extensive emergency department coverage. When given the opportunity to list all sources spurring coverage change, 81% of those programs that have considered or are considering expansion of after-hours coverage stated that the emergency department itself is a main driver (Tables 4 and 5). Hospital administration
and perceived standard of care are second and third at 51% and 45%, respectively. Only 20% feel that change is or was warranted by performance metrics. Of the 33 departments that have recently expanded after-hours coverage, 28 programs (86%) felt that they were successful resolving the key issue or issues that led to the change, while 5 (15%) felt unsuccessful. In open-text responses, several departments reported improvements in emergency department, hospital administration, and resident and trainee satisfaction as positive effects of the coverage changes. Some responding departments reported decreases in turnaround times and discharge times. DISCUSSION
Our study confirms that there is high variability in the systems used to cover after-hours emergency department imaging studies. Currently, diagnostic radiology residents still provide preliminary interpretations for the majority of nighttime hours at the majority of academic institutions. Seventy-three percent of programs still exclusively provide preliminary interpretations by residents, fellows, and/or nighthawk services for some or all overnight hours. Despite the widespread use of preliminary interpretations, there is significant pressure for academic centers to provide 24-hour staff coverage with final interpretations immediately available to the emergency department clinical staff. These demands are being met by different programs in a multitude of ways, but most commonly by the extension of subspecialty imaging
Table 3. Latest hour contemporaneous staff final reads are available by subspecialists and all staff members Weekend Coverage Weekday Coverage Subspecialty All Staff Subspecialty All Staff No. of % of No. of % of No. of % of No. of % of Hours Programs Programs Programs Programs Programs Programs Programs Programs Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 10 PM 11 PM
4 1 0 2 3 24 8 2 6 2 4 2
6.6 1.6 0 3.3 4.9 39.3 13.1 3.3 9.8 3.3 6.6 3.3
2 1 0 1 2 17 4 2 4 1 3 6
3.3 1.6 0 1.6 3.3 27.9 6.6 3.3 6.6 1.6 4.9 9.8
0 0 0 0 1 29 12 1 9 3 5 4
0 0 0 0 1.5 43.3 17.9 1.5 13.4 4.5 7.5 6.0
0 0 0 0 0 19 1 1 9 3 5 9
0 0 0 0 0 28.4 1.5 1.5 13.4 4.5 7.5 13.4
Sellers et al/After-Hours Coverage of ED Imaging 5 Fig 1. Weekday hours final subspecialty interpretations are available by number of neuroradiologists in the department.
coverage into the early evening hours with additional, primarily general radiology staff coverage for later evening hours. Although overall after-hours staff coverage of the emergency department has been generally increasing, 24-hour real-time staff coverage of the emergency department is still rare at only 27% of all reporting programs. However, this represents a significant increase from 2007, when a similar survey, by Hunter et al [1], found 24-hour general staff coverage at only 10% of surveyed programs. These findings are also consistent with an extension of the recent trend noted in the 2004 and 2012 surveys of chief residents at academic radiology institutions that reported overnight staff coverage at academic hospitals at 7% and 20% of programs, respectively Fig 2. Weekday hours staff final interpretations are available by number of staff radiologists in the department.
[2,3]. An additional important trend is the switch to dedicated emergency department sections, which are now used by 19% of all programs. As noted, 38% of programs (5 of 13) that use 24-hour dedicated emergency radiology sections have exclusions for advanced studies, mostly neuroradiologic studies. This represents a compromise position that provides final interpretations for the bulk of examinations coming through the emergency department. Most of these programs indicated that for advanced studies, the preliminary report is made by a resident and interpreted by a subspecialty staff member the next morning. Some might argue this to be paradoxical, that “advanced studies” are the examinations most likely to be misinterpreted by trainees and that would most benefit
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Table 4. Main drivers reported for the expansion of after-hours coverage (n ¼ 49) Origin % n
Table 5. Reported metrics driving each department’s method of after-hours coverage (n ¼ 44) Metric % n
Emergency department Hospital administration Perceived standard of care Change demanded by the metrics data Other referring clinical services Radiology subspecialists Radiology residents Intensive care unit Finances Emergency radiology division
Turnaround time Time to discharge patients Error rate by residents Sentinel event No specific metric used Specific time of studies
81 51 45 20 10 8 4 2 2 2
40 25 22 10 5 4 2 1 1 1
from staff interpretations. This idea was supported by Ruma et al [4], who demonstrated discrepancy rates between on-call diagnostic radiology residents and subspecialty radiologists to be highest in adult and pediatric neurology MRI studies. Regardless, 24-hour subspecialty coverage remains very rare [1,5] because only very large programs have the resources to offer it. This finding begs the question of whether the general trend of expanding after-hours coverage will continue in the current and projected environment of decreasing reimbursement and remuneration and, if so, what effect this will have on departmental financial health [6]. Generally, the pressure for extended after-hours coverage originates from the emergency department and hospital administration. Eighty-five percent of programs felt that they were successful at resolving the key issue or issues that led to their staffing changes, with resulting effects of improved emergency department and hospital administration satisfaction. One possible bias in our study relates to our decision to contact neuroradiology fellowship program directors rather than department chairs. This decision stemmed from a desire to maximize the survey response rate, as the initial architects of the survey have neuroradiology backgrounds and personal contacts. We reached our goal, with a response rate of 70%, which is higher than the response rates of several prior surveys that have looked at after-hours coverage; the latter varied between 20% and 55% [1,2,7]. However, the survey contacts were specifically asked to give information about their entire departments, not just neuroradiology, and the data presented above reflect coverage of all types of emergency department imaging studies (not just neuroimaging studies).
66 63 21 16 14 11
29 28 9 7 6 5
still exclusively use preliminary interpretations for some overnight hours. There is a general trend toward using dedicated emergency radiology sections, with 72% of programs that provide 24-hour coverage using this method. Subspecialty 24-hour coverage is very rare, at only 3% of programs. Expanding after-hours coverage generally improves the satisfaction levels of emergency department staff members and hospital administrators, but opinions regarding effects on radiology staff members and patient care are mixed and should be studied further. ACKNOWLEDGMENT We wish to thank Suna Sumer for her help in preparing this report. REFERENCES 1. Hunter TB, Taljanovic MS, Krupinski E, Ovitt T, Stubbs AY. Academic radiologists’ on-call and late-evening duties. J Am Coll Radiol 2007;4: 716-9. 2. Peterson CM, Gerstle R, Bhalla S, Menias CO, Jost RG. Results of the 2004 survey of the American Association of Academic Chief Residents in Radiology. Acad Radiol 2005;12:373-8. 3. Sauk S, Jokerst C, Gould J, Evens R. Results of the 2012 survey of the American Association of Academic Chief Residents in Radiology. Acad Radiol 2013;20:320-31. 4. Ruma J, Klein KA, Chong S, Wesolowski J, Kazerooni EA, Ellis JH, et al. Cross-sectional examination interpretation discrepancies between on-call diagnostic radiology residents and subspecialty faculty radiologists: analysis by imaging modality and subspecialty. J Am Coll Radiol 2011;8: 409-14. 5. Branstetter BF IV, Morgan MB, Nesbit CE, et al. Preliminary reports in the emergency department: is a subspecialist radiologist more accurate than a radiology resident? Acad Radiol 2007;14:201-6.
TAKE-HOME POINTS
6. Medverd JR, Muroff LR, Brant-Zawadzki MN, Lexa FJ, Levin DC. ACR white paper: new practice models—hospital employment of radiologists: a report from the ACR Future Trends Committee. J Am Coll Radiol 2012;9:782-7.
Although after-hours staff coverage of the emergency department is generally expanding, 73% of programs
7. Desser TS, Rubin DL, Schraedley-Desmond P. Coverage of emergency after-hours ultrasound cases: survey of practices at U.S. teaching hospitals. Acad Radiol 2006;13:249-53.
Purpose: The aim of this study was to document how academic radiology departments cover emergency department radiologic services after hours. Methods: Program directors of neuroradiology fellowship programs were invited to participate in a web-based survey addressing how their radiology departments covered after-hours emergency department studies. Results: A total of 67 separate institutional responses were obtained from 96 institutions, for a 70% response rate. Seventy-three percent of programs (49 of 67) reported providing exclusively preliminary interpretations on emergency department reports for some overnight hours. Only 27% of respondents (18 of 67) said that they provided 24-hour real-time staff coverage. Among those who provided aroundthe-clock staff coverage, 72% (13 of 18) did so with dedicated emergency department sections. Only 2 respondents offered 24-hour subspecialty staff coverage. Emergency departments and hospital administrators were noted as the most frequent drivers of these changes. Conclusions: Academic radiology departments vary widely in how they cover after-hours emergency department examinations. A number have recently expanded their hours of coverage under institutional pressures. Key Words: Evening coverage, emergency radiology, academic radiology J Am Coll Radiol 2014;-:---. Copyright © 2014 American College of Radiology
INTRODUCTION
Advances in medical imaging have made radiologic examinations critical in disease diagnosis and patient management. Emergency department patients are no exception. Radiologists have witnessed changes in practice patterns over recent years that include an increased volume of studies ordered from emergency departments as well as increasing requests for advanced imaging studies. With increasing use have come expectations for quicker turnaround times of final reports, as a
Department of Radiology, Neuroradiology Division, University of Virginia, Charlottesville, Virginia.
b
Department of Radiology, University of Virginia, Charlottesville, Virginia.
c
United States Navy, Bethesda, Maryland.
Corresponding author and reprints: Max Wintermark, MD, UVA Department of Radiology, Neuroradiology Division, Box 800170, Charlottesville, VA 22908; e-mail: [email protected]. A list of the colleagues who filled out the surveys is available in the online version of this article. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Department of the Navy, the US Department of Defense, or the US government. ª 2014 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.11.015
well as pressures for increased coverage by attending radiologists after usual working hours. Despite this trend, few data exist about how departments are covering after-hours emergency department studies. The goal of this study was to assess how academic radiology departments provide services to their institutional emergency departments after hours. METHODS
We conducted a web-based survey of programs listed by the American Society of Neuroradiology as having neuroradiology fellowships. We sent an e-mail to the point of contact listed in the American Society of Neuroradiology fellowship program director listing, which discussed the intent of the project and encouraged participation, with 3 follow-up e-mails for those not responding. A link was provided to the online survey (see Online Appendix), with results imported into Microsoft Excel (Microsoft Corporation, Redmond, Washington) for analysis. Although our department contacts were neuroradiologists, we specifically requested information about the entire department and all imaging studies (not just neuroradiologic and neuroimaging studies). 1
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The questionnaire collected data on the following elements: 1. Composition of staffing in the radiology department 2. Method each department uses to service its emergency department during weekends and weekdays (to include hours covered and the use of residents, fellows, general staff members, subspecialty staff members, dedicated emergency radiology sections, and “nighthawk” services) 3. Incentives associated with after-hours coverage, if any 4. Whether departments have expanded their afterhours coverage in the past 3 years and, if not, whether they are considering expanding their afterhours coverage 5. Forces that led to the expansion of hours, if applicable 6. Metrics used by departments to assess and make decisions regarding emergency department coverage 7. The effect expansion of hours had on key metrics used by the department 8. Negative consequences experienced because of the expansion of hours 9. Number of hospital emergency departments serviced by the department For the purpose of this study, it was necessary to narrowly define the concepts of “staff coverage” so that direct comparison of programs could be made. We were most interested in what hours emergency departments were serviced by a real-time contemporaneous staff attending and whether final interpretations were made by either subspecialty staff members or general staff members. We used the following definitions: Subspecialty coverage. Institutions provide subspecialty coverage for a given time period if the following conditions are met: Subspecialty staff (in house or remote) are reading studies in real time or nearly real time and providing final interpretations only within their subspecialty field. These may be independent interpretations or in combination with oversight of residents and fellows. Staff members must also be immediately available for consultation on difficult cases. Staff coverage. Institutions provide attending staff coverage for a given time period if the following conditions are met: General staff members, emergency department section staff members, or various rotating subspecialist staff members (in house or remote) read studies in real time or nearly real time and provide final interpretations. Preliminary coverage. The department routinely performs preliminary readings for studies, regardless of whether residents, fellows, or staff members provide the service. Teleradiology “nighthawk” services are the most common situation in which staff radiologists provide preliminary interpretations.
Statistics were primarily descriptive. Regressions and correlations (R values) were calculated using the statistical package of Microsoft Excel. RESULTS Response Rate
A total of 100 e-mail invitations were sent to participate in the online survey, of which 96 were to separate institutions. A total of 67 responses were received. Thus, the final institutional response rate was 70% (67 of 96). Of our responding academic programs, 6 were Canadian institutions and 4 were children’s hospitals. Participating institutions are listed in Table 1 as self-described in their responses. Three institutions gave complete survey responses but declined to include their institutions’ names. Surveyed Department Characteristics
The largest program surveyed had 169 attending radiologists, all subspecialties included, while the smallest had 17. The average number of employed radiologists was 53. The program with the most ACGME and nonACGME fellows had 40 and 32, respectively, while the smallest had 1 ACGME fellow and no non-ACGME fellows, with averages of 7.8 and 8.6, respectively (Table 2). Of 58 responses, 65% covered the after-hours imaging studies from the emergency departments of 2 hospitals, 36% 3 hospitals, 22% 4 hospitals, and 15% 5 hospitals. Hours Contemporaneous Staff Final Reads Are Available
The hours and methods of staff coverage varied considerably by institution. Of 67 respondents, 32 (48%) primarily use a form of the traditional call system whereby on-call, on-site residents provide preliminary interpretations, with final interpretations made in the morning hours. Fifteen programs (21%) reported using dedicated emergency department sections to cover some or all after-hours studies. Thirteen programs (19%) use rotating staff schedules to cover some after-hours emergency department studies. However, 11 of these 13 programs still use resident and or fellow preliminary interpretations for coverage of some after-hours periods. The number of departments using out-of-house nighthawk services was 8 (12%), with 7 companies providing preliminary interpretations and 1 providing final interpretations. Weekday Hours of Real-Time Staff Coverage. By far the most common time for subspecialty coverage to end is 5 PM (29 programs [43%]). Forty-two programs (63%) end subspecialty staff coverage by 6 PM. Only 8 programs (12%) provide subspecialty coverage after 10 PM, including 2 programs (3%) that provide 24-hour subspecialty coverage (Table 3). General staff coverage of evening hours is commonly extended beyond subspecialty coverage hours. Only 19
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Table 1. Institutions that replied to our e-mail survey Allegheny General Hospital Baylor College of Medicine Beth Israel Medical Center and St. Luke’s Roosevelt Hospital Center, New York Boston Children’s Hospital Brigham and Women’s Hospital Children’s Hospital of Pittsburgh Children’s Hospital of Philadelphia Cornell University Detroit Medical Center DHMC-Dartmouth Duke University Emory University Georgetown University Hospital George Washington University Medical Center Georgia Regent University Indiana University School of Medicine Johns Hopkins University Keck Medical Center of University of Southern California London Health Sciences Centre Massachusetts General Hospital Mayo Clinic Rochester McGill University Health Center - Montreal General and Royal Victoria Medical College of Wisconsin Medical University of South Carolina New York-Presbyterian Hospital/Weill Cornell Medical College New York University North Shore LIJ Medical Center Northwestern University Oregon Health & Science University Penn State Hershey Medical Center Phoenix Children’s Hospital Stanford University Temple University The Ohio State University Thomas Jefferson University Hospital UIC - University of Illinois University Hospitals of Cleveland, Case Western Reserve University of Alabama at Birmingham University of Alberta University of Calgary University of California, Davis University of California, Irvine Medical Center (UCIMC) University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Chicago University of Cincinnati Medical Center University of Florida University of Iowa University of Maryland Medical Center University of Michigan University of New Mexico University of North Carolina University of Ottawa, The Ottawa Hospital University of Toronto, University Health Network, Toronto Western Hospital University of Utah University of Virginia Health System University of Washington University of Wisconsin - Madison UTHSC, Houston Vanderbilt University Wake Forest Baptist Medical Center Washington University in St. Louis William Beaumont Hospital Yale University
programs (28%) have no real-time staff coverage after 6 PM. The most common times for evening staff coverage to end are distributed almost evenly between 5 PM (19 programs [28%]) and full 24-hour coverage (18 programs [27%]) (Table 3). Forty-three percent of programs provide general staff final reads after 10 PM, including the 18 programs that provide full 24-hour staff coverage. Weekend Hours of Real-Time Staff Coverage. Fortynine percent of programs (n ¼ 33) have the same level of staff coverage for weekends as weekdays. Ten percent of programs do not have set in-house staff hours on weekends. The staff members at these programs are free to leave after the morning weekend read-outs are complete. However, 5 of the 7 programs had at least one additional read-out during the day and/or evening. The most common system is subspecialty staff coverage until 5 PM (24 programs [39%]). Seventy-two percent of programs end subspecialty coverage by 6 PM. Only 9% of programs provide subspecialty coverage after 10 PM, including the 2 programs (3%) that provide 24-hour subspecialty coverage. On weekends, 27 programs (44%) do not provide any real-time staff coverage after 6 PM. Twenty-four programs (39%) provide staff final reads after 10 PM. No programs provided more real-time staff coverage on weekends than they did on weekdays. Twenty-Four-Hour Staff Coverage. A minority of programs (n ¼ 18 [27%]) are currently providing 24-hour staff coverage. In 13 of these programs (72%), dedicated emergency department sections cover the emergency room studies. One program uses a nighthawk company for around-the-clock final interpretations. One program uses non-ACGME fellows for real-time final interpretations, one program uses a rotating staff call pool, and 2 programs provide 24-hour subspecialty coverage. Of the programs using emergency department sections, 5 of 13 programs commented that they have exclusions for advanced studies and use preliminary resident interpretations for these examinations. “Advanced” radiologic studies were variously defined by each institution. Most commonly, this included CT angiographic and MR angiographic imaging, but some institutions also included body, musculoskeletal, and neurologic MRI studies. Correlation of Number of Staff Members in a Department With Number of Hours Covered
In general, for both weekends and after-hours weekdays, for both general staff coverage and subspecialty coverage, we found a mild correlation between the number of staff members in a department and the number of hours the department staff covered the emergency room in real time. Correlations (R values) for subspecialty after-hours coverage on weekdays and weekends were 0.19 and 0.27, respectively. Correlation for staff after-hours coverage on weekdays and weekends were 0.32 and 0.35, respectively (Figs. 1 and 2).
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Table 2. Type and number of personnel in surveyed departments Personnel Type Average Median Attending neuroradiologists All attending radiologists Non-ACGME fellows ACGME fellows Residents
9 53 9 8 35
Smallest
Largest
4 17 1 1 4
35 169 32 40 71
8 46 6 6 36
Incentives Associated With After-Hours Coverage
Of 67 respondents, 35 (52%) reported that they provide incentives for covering evening or night shifts. Of these, 34 (51%) reported monetary compensation varying from several hundred dollars up to $2,000 for an afterhours shift. Time off is given by 27 programs (40%), but the amount of time varies significantly among institutions. Some institutions give time off the clinical schedule, while others give two-to-one vacation time for additional coverage, with 2 weeks off for every week of nights worked. Some of this variation is explained by the significantly varied hours of coverage expected by different departments, with some staff members covering only a few additional evening hours while others cover complete overnight shifts. Three programs (4%) give both time and monetary incentives, while 1 program lets staff choose between the two. Expansion of After-Hours Coverage
Of 66 respondents, 33 (50%) stated that they have expanded after-hours coverage in the past 3 years. Of the 33 (50%) that have not recently expanded coverage, nearly 50% are considering further expansion of hours. Therefore, 75% of all responding programs have felt or are currently feeling the need to provide more extensive emergency department coverage. When given the opportunity to list all sources spurring coverage change, 81% of those programs that have considered or are considering expansion of after-hours coverage stated that the emergency department itself is a main driver (Tables 4 and 5). Hospital administration
and perceived standard of care are second and third at 51% and 45%, respectively. Only 20% feel that change is or was warranted by performance metrics. Of the 33 departments that have recently expanded after-hours coverage, 28 programs (86%) felt that they were successful resolving the key issue or issues that led to the change, while 5 (15%) felt unsuccessful. In open-text responses, several departments reported improvements in emergency department, hospital administration, and resident and trainee satisfaction as positive effects of the coverage changes. Some responding departments reported decreases in turnaround times and discharge times. DISCUSSION
Our study confirms that there is high variability in the systems used to cover after-hours emergency department imaging studies. Currently, diagnostic radiology residents still provide preliminary interpretations for the majority of nighttime hours at the majority of academic institutions. Seventy-three percent of programs still exclusively provide preliminary interpretations by residents, fellows, and/or nighthawk services for some or all overnight hours. Despite the widespread use of preliminary interpretations, there is significant pressure for academic centers to provide 24-hour staff coverage with final interpretations immediately available to the emergency department clinical staff. These demands are being met by different programs in a multitude of ways, but most commonly by the extension of subspecialty imaging
Table 3. Latest hour contemporaneous staff final reads are available by subspecialists and all staff members Weekend Coverage Weekday Coverage Subspecialty All Staff Subspecialty All Staff No. of % of No. of % of No. of % of No. of % of Hours Programs Programs Programs Programs Programs Programs Programs Programs Noon 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 10 PM 11 PM
4 1 0 2 3 24 8 2 6 2 4 2
6.6 1.6 0 3.3 4.9 39.3 13.1 3.3 9.8 3.3 6.6 3.3
2 1 0 1 2 17 4 2 4 1 3 6
3.3 1.6 0 1.6 3.3 27.9 6.6 3.3 6.6 1.6 4.9 9.8
0 0 0 0 1 29 12 1 9 3 5 4
0 0 0 0 1.5 43.3 17.9 1.5 13.4 4.5 7.5 6.0
0 0 0 0 0 19 1 1 9 3 5 9
0 0 0 0 0 28.4 1.5 1.5 13.4 4.5 7.5 13.4
Sellers et al/After-Hours Coverage of ED Imaging 5 Fig 1. Weekday hours final subspecialty interpretations are available by number of neuroradiologists in the department.
coverage into the early evening hours with additional, primarily general radiology staff coverage for later evening hours. Although overall after-hours staff coverage of the emergency department has been generally increasing, 24-hour real-time staff coverage of the emergency department is still rare at only 27% of all reporting programs. However, this represents a significant increase from 2007, when a similar survey, by Hunter et al [1], found 24-hour general staff coverage at only 10% of surveyed programs. These findings are also consistent with an extension of the recent trend noted in the 2004 and 2012 surveys of chief residents at academic radiology institutions that reported overnight staff coverage at academic hospitals at 7% and 20% of programs, respectively Fig 2. Weekday hours staff final interpretations are available by number of staff radiologists in the department.
[2,3]. An additional important trend is the switch to dedicated emergency department sections, which are now used by 19% of all programs. As noted, 38% of programs (5 of 13) that use 24-hour dedicated emergency radiology sections have exclusions for advanced studies, mostly neuroradiologic studies. This represents a compromise position that provides final interpretations for the bulk of examinations coming through the emergency department. Most of these programs indicated that for advanced studies, the preliminary report is made by a resident and interpreted by a subspecialty staff member the next morning. Some might argue this to be paradoxical, that “advanced studies” are the examinations most likely to be misinterpreted by trainees and that would most benefit
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Table 4. Main drivers reported for the expansion of after-hours coverage (n ¼ 49) Origin % n
Table 5. Reported metrics driving each department’s method of after-hours coverage (n ¼ 44) Metric % n
Emergency department Hospital administration Perceived standard of care Change demanded by the metrics data Other referring clinical services Radiology subspecialists Radiology residents Intensive care unit Finances Emergency radiology division
Turnaround time Time to discharge patients Error rate by residents Sentinel event No specific metric used Specific time of studies
81 51 45 20 10 8 4 2 2 2
40 25 22 10 5 4 2 1 1 1
from staff interpretations. This idea was supported by Ruma et al [4], who demonstrated discrepancy rates between on-call diagnostic radiology residents and subspecialty radiologists to be highest in adult and pediatric neurology MRI studies. Regardless, 24-hour subspecialty coverage remains very rare [1,5] because only very large programs have the resources to offer it. This finding begs the question of whether the general trend of expanding after-hours coverage will continue in the current and projected environment of decreasing reimbursement and remuneration and, if so, what effect this will have on departmental financial health [6]. Generally, the pressure for extended after-hours coverage originates from the emergency department and hospital administration. Eighty-five percent of programs felt that they were successful at resolving the key issue or issues that led to their staffing changes, with resulting effects of improved emergency department and hospital administration satisfaction. One possible bias in our study relates to our decision to contact neuroradiology fellowship program directors rather than department chairs. This decision stemmed from a desire to maximize the survey response rate, as the initial architects of the survey have neuroradiology backgrounds and personal contacts. We reached our goal, with a response rate of 70%, which is higher than the response rates of several prior surveys that have looked at after-hours coverage; the latter varied between 20% and 55% [1,2,7]. However, the survey contacts were specifically asked to give information about their entire departments, not just neuroradiology, and the data presented above reflect coverage of all types of emergency department imaging studies (not just neuroimaging studies).
66 63 21 16 14 11
29 28 9 7 6 5
still exclusively use preliminary interpretations for some overnight hours. There is a general trend toward using dedicated emergency radiology sections, with 72% of programs that provide 24-hour coverage using this method. Subspecialty 24-hour coverage is very rare, at only 3% of programs. Expanding after-hours coverage generally improves the satisfaction levels of emergency department staff members and hospital administrators, but opinions regarding effects on radiology staff members and patient care are mixed and should be studied further. ACKNOWLEDGMENT We wish to thank Suna Sumer for her help in preparing this report. REFERENCES 1. Hunter TB, Taljanovic MS, Krupinski E, Ovitt T, Stubbs AY. Academic radiologists’ on-call and late-evening duties. J Am Coll Radiol 2007;4: 716-9. 2. Peterson CM, Gerstle R, Bhalla S, Menias CO, Jost RG. Results of the 2004 survey of the American Association of Academic Chief Residents in Radiology. Acad Radiol 2005;12:373-8. 3. Sauk S, Jokerst C, Gould J, Evens R. Results of the 2012 survey of the American Association of Academic Chief Residents in Radiology. Acad Radiol 2013;20:320-31. 4. Ruma J, Klein KA, Chong S, Wesolowski J, Kazerooni EA, Ellis JH, et al. Cross-sectional examination interpretation discrepancies between on-call diagnostic radiology residents and subspecialty faculty radiologists: analysis by imaging modality and subspecialty. J Am Coll Radiol 2011;8: 409-14. 5. Branstetter BF IV, Morgan MB, Nesbit CE, et al. Preliminary reports in the emergency department: is a subspecialist radiologist more accurate than a radiology resident? Acad Radiol 2007;14:201-6.
TAKE-HOME POINTS
6. Medverd JR, Muroff LR, Brant-Zawadzki MN, Lexa FJ, Levin DC. ACR white paper: new practice models—hospital employment of radiologists: a report from the ACR Future Trends Committee. J Am Coll Radiol 2012;9:782-7.
Although after-hours staff coverage of the emergency department is generally expanding, 73% of programs
7. Desser TS, Rubin DL, Schraedley-Desmond P. Coverage of emergency after-hours ultrasound cases: survey of practices at U.S. teaching hospitals. Acad Radiol 2006;13:249-53.
