- Email: [email protected]
A pilot study on radiologists’ compliance with ACR Appropriateness Criteria® for management of urinary tract obstruction
S144
’
Tuesday
Scientific Session
JVIR
femoral access. Interventional radiologists should consider the benefits of radial access to both patients and staff when appropriate.
Hopkins Hospital, Baltimore, MD; 2Johns Hopkins Hospital, Baltimore, MD; 3Johns Hopkins University School of Medicine, Baltimore, MD.
Reference
Purpose: The Interventional Radiology Center team performs up to 700 invasive procedures every month. Due to various inefficiencies and system limitations, procedure room downtime between patient cases averages 65 hours per week. Subsequently, the department experiences delayed case starts, reduced capacity, delayed inpatient discharge, patient and staff dissatisfaction, and significant financial cost. The purpose of this project is to achieve a 15% short term and 50% long term reduction in room downtime. Additional areas of focus include patient delays, patient volumes, staff satisfaction, and financial cost. Materials: A multidisciplinary team utilized Lean Sigma methodology for this quality improvement project. A patient tracker system was used to capture downtime minutes between cases. A web-based form was used to capture the reason for each episode of downtime. A computer application was developed to measure patient procedure delay minutes. A bundled set of interventions targeted transport, room turnover, scheduling, pre-procedure care coordination, prep area processes, and anesthesia management. Results: Mean room downtime was reduced by 15%, from 13.6 hours to 11.4 hours per day (po0.05). There was a corresponding 12% increase in IRC patient volumes. Surveyed staff strongly agreed that the piloted interventions improved room turnover and patient flow (Likert scale 4.7/5). Improved room utilization rates resulted in a revenue opportunity of $2,600 per day. Patient start-time delays were not improved. 22% of patients were delayed greater than 60 minutes and 23% were delayed 30-60 minutes. Conclusions: Interventions resulted in significant improvement in room downtime, opportunity cost, and staff satisfaction. However, patient procedure start-time delays, inpatient length of stay, and patient satisfaction with their experience remain problems for future investigation.
1. Lange HW, von Boetticher H. Randomized comparison of operator radiation exposure during coronary angiography and intervention by radial or femoral approach. Catheter Cardiovasc Interv 2006; 67:12–16.
3:09 PM
Abstract No. 317
Discrete data field templates results in high compliance of data entry R. Shah1, L. Hofmann2; 1Stanford University, Stanford, CA; 2Stanford University Medical Center, Palo Alto, CA.
TUESDAY: Scientific Sessions
’
Purpose: To evaluate the compliance of complete data entry using discrete data field templates (DDFT) to generate interventional radiology structured procedure reports. Materials: DDFTs were created and implemented in PowerScribe 360 (Nuance Communications) for complex procedures at a single tertiary care center in March 2015, and replaced the narrative free-text generated procedural reports. Reports were divided into modules containing discrete variables. Chemoembolization reports were electronically pulled from the electronic medical record (EMR) and the data from reports between March 2015 and August 2015 were parsed using a custom developed Java-based program and stored in a relational database linked to all data from the EMR. The data from modules that did not undergo any significant evolutionary alteration during the implementation period was evaluated to determine the compliance of data entry by residents, fellows, and attendings performing dictations. Results: 184 chemoembolization reports were parsed during the implementation period. The following modules within the DDFT chemoembolization reports were evaluated: technical details, access artery, catheterized artery, and chemoembolized artery. Within these modules, 55 discrete data elements were present with collection of 18,466 data points. The compliance of data entry were as follows: technical details containing 19 data elements with a compliance rate of 95% (95% CI 94.2%95.7%), access artery containing 14 data elements with a compliance rate of 99% (95% CI 98.6%-99.4%), catheterized artery containing 10 data elements with a compliance rate of 94% (95% CI 93.5%-94.5%), chemoembolized artery containing 12 data elements with a compliance rate of 95.5% (95% CI 94.7%-96.1%). Conclusions: Use of DDFT for complex procedure reports results in a high compliance of data entry. Data structuring methodologies should be considered for procedure reports to control data input for research and quality assurance, and should be considered for creation of local and national registries.
3:18 PM
Abstract No. 318
IR patient throughput: applying lean sigma methodology to reduce procedure room downtime A. Owens1, D. Abdollahian1, J. Dinicola2, S. Denker2, W. Parduba2, M. Dawson1, L. Winner3, K. Hong2; 1Johns
3:27 PM
Abstract No. 319
A pilot study on radiologists’ compliance with ACR Appropriateness Criteria® for management of urinary tract obstruction H. YU1, K. Patel2, M. Harvill3, J. Critchfield4, S. Danier5, R. Kakos3; 1DETROIT MEDICAL CENTER, Novi, MI; 2 Wayne State University, Detroit, MI; 3Harper University Hospital, Detroit, MI; 4Troy, MI; 5Grosse Pointe Shores, MI. Purpose: ACR Appropriateness Criteria provides evidencebased guideline for approaching urinary tract obstruction (UTO), indicating that percutaneous nephrostomy (PCN) and retrograde ureteral stenting are successful techniques to decompress UTO. An appropriate radiologist’s recommendation will provide patient with treatment choices and decrease the hospitalization and costs. The purpose of this study was to analyze the radiologists’ recommendation on managing UTO and their compliance with ACR Appropriateness Criteria. Materials: The radiology reports of all patients undergoing PCN in 2013 and 2014 at a metropolitan medical center were retrospectively reviewed. Diagnostic imaging reports performed
JVIR
’
Scientific Session
Tuesday
30 days before the first PCN were analyzed in terms of findings and recommendation (including percutaneous, endourologic, and open surgical procedures). The identified etiologies were categorized and subcategorized. Comparisons of recommendation rate among categories were performed using chi-square (po0.05 statistically significant). Results: 260 cases of unilateral UTO undergoing at least one attempt of PCN had diagnostic imaging prior to the procedure. 9 cases (3.46%) were recommended for operation in radiologists’ report, including 1 case of unknown etiology and 8 cases of neoplasm (3 advanced cervical cancer/uterine mass, 2 prostate cancer, 2 advanced colon cancer, and 1 retroperitoneal mass). In contrast, 251 cases (96.54%) had no recommendation on the management in which the neoplasm was the most common etiology and 2). There is relatively high recommendation rate in neoplasm group, although there is no significant difference in recommendation rate among all categories (p¼0.56). Similarly, there is no significant difference in the recommendation rate among the subcategories of neoplasms (p¼0.06). This comparison implies a low recommendation rate that is not associated with any etiology. The higher incidence of malignant UTO does not make radiologists be more aware of the necessity of decompressing urinary tract. Conclusions: Only a small proportion (3.46%) of UTO was appropriately recommended for operation, indicating low compliance with ACR Appropriateness Criteria in light of managing UTO. References
3:36 PM
S145
Materials: This retrospective study reviewed the radiological and biochemical success rate of cannulating both adrenal veins and its correlation with computed tomography (CT) and histology where available from 2008 to 2015. Results: In total 47 AVS were performed, out of which 17 were using the old protocol (pre-2012) and 30 using the new protocol (post-2012). Using pre-2012 protocol, the biochemical success rate of the left and the right adrenal vein cannulation were 64.7% and 29.0% respectively. This significantly improved to 93.3% (Po0.02) (left) and 76.7% (Po0.01) (right), respectively, when new interventional radiology as well as biochemical strategies including cosyntropin stimulation were used (post-2012). There was no relationship between the failure of cannulation of the right adrenal vein and presence of adrenal adenoma. There was significant concurrence between the CT and AVS result (po0.001). Conclusions: Our experience shows that by optimising the AVS protocol within the interventional department as well as using cosyntropin stimulation significantly improves the AVS technical success rate. References 1. Catena C, Colussi G, Di Fabio A et al. Mineralocorticoid antagonists treatment versus surgery in primary aldosteronism. Horm Metab Res 2010; 42: 440–445. 2. Funder JW, Carey RM, Fardella C, et al, Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2008; 93:3266–3281. 3. Davidson JK, Morley P, Hurley GD, Holford NG. Adrenal venography and ultrasound in the investigation of the adrenal gland: an analysis of 58 cases. Br J Radiol 1975; 48:435–450. 4. Blondin D, Quack I, Haase M, Ku¨cu¨kko¨ylu¨ S, Willenberg HS. Indication and technical aspects of adrenal blood sampling. Rofo 2015; 187(1):19–28.
3:45 PM
Abstract No. 321
Labeling interventional radiology drains to prevent medical errors and improve patient care D. Dasilva1, A. Sparks2, A. Kim1, G. Lynskey3, J. Spies1, T. Chang4, D. Buckley5, T. Caridi1; 1Georgetown University Medical Center, Washington, DC; 2Edmond, OK; 3Georgetown University Medical Center, Arlington, VA; 4Georgetown University Medical Center, Potomac, MD; 5Georgetown University Medical Center, Gaithersburg, MD.
Abstract No. 320
Improving the radiological and biochemical success in adrenal venous sampling M. Husainy1, C. Fang2, A. Nicolescu2, D. Lewis2, R. Vincent2, P. Kane2; 1King’s College Hospital NHS Trust, London, United Kingdom; 2King’s College Hospital NHS Trust, London, London. Purpose: Adrenal venous sampling (AVS) is the gold standard for lateralising aldosterone-production in proven primary aldosteronism. The right adrenal venous cannulation is technically challenging and in spite of obvious radiological successful cannulation, the samples may not be biochemically suitable to achieve any clinically significant information. Following a change to our AVS protocol, (both radiological and biochemical) in 2012 we assessed its impact on the success rate of the procedure.
Purpose: To evaluate the perception of errors in charting and patient care related to drains placed in IR and the need for an IR drain labeling system. Materials: Nurses (n¼55) and house staff (n¼51) of our single institution were anonymously surveyed on the accuracy of medical charting and subsequent errors in patient care regarding drains placed by IR. An initiative was then undertaken to label all drains placed in IR at the time of the procedure. Tyvek material was selected for its strength and chemical/liquid resistance. Repeat surveys of 51 nurses and 41 house staff were performed at 1 year post initiation of the drain labeling system. Based on the analysis of these results, adjustments were made in the drain labeling technique. Results: When surveyed to assess if IR drains were usually/ always labeled, 20% of nurses and 20% of house staff initially agreed. Surveys also found that 80% of nurses and 53% of
TUESDAY: Scientific Sessions
1. ACR Appropriateness CriteriaAˆ- Radiologic Management of Urinary Tract Obstruction. Am Coll Radiol 2013. 2. Ng CK, Yip SKH, Sim LSJ, Tan BH, Wong MYC, Tan BS, Htoo A. Outcome of Percutaneous Nephrostomy for the Management of Pyonephrosis. Asian J Surg 2002; 25(3):215–219. 3. Ramsey S, Robertson A, Ablett MJ, Meddings RN, Hollins GW, Little B. Evidence-Based Drainage of Infected Hydronephrosis Secondary to Ureteric Calculi. J Endourol 2010; 24(2):185–189. 4. Sommer CM, Huber J, Radeleff BA, Hosch W, Stampfl U, Loenard BM, Hallscheidt P, Haferkamp A, Kauczor HU, Richter GM: Combined CT- and fluoroscopy-guided nephrostomy in patients with non-obstructive uropathy due to urine leaks in cases of failed ultrasound-guided procedures. Eur J Radiol 2011; 80(3):686–691. 5. Farrell TA, Hicks ME: A Review of Radiologically Guided Percutaneous Nephrostomies in 303 Patients. J Vasc Interv Radiol 1997; 8(5):769–774.
’
’
Tuesday
Scientific Session
JVIR
femoral access. Interventional radiologists should consider the benefits of radial access to both patients and staff when appropriate.
Hopkins Hospital, Baltimore, MD; 2Johns Hopkins Hospital, Baltimore, MD; 3Johns Hopkins University School of Medicine, Baltimore, MD.
Reference
Purpose: The Interventional Radiology Center team performs up to 700 invasive procedures every month. Due to various inefficiencies and system limitations, procedure room downtime between patient cases averages 65 hours per week. Subsequently, the department experiences delayed case starts, reduced capacity, delayed inpatient discharge, patient and staff dissatisfaction, and significant financial cost. The purpose of this project is to achieve a 15% short term and 50% long term reduction in room downtime. Additional areas of focus include patient delays, patient volumes, staff satisfaction, and financial cost. Materials: A multidisciplinary team utilized Lean Sigma methodology for this quality improvement project. A patient tracker system was used to capture downtime minutes between cases. A web-based form was used to capture the reason for each episode of downtime. A computer application was developed to measure patient procedure delay minutes. A bundled set of interventions targeted transport, room turnover, scheduling, pre-procedure care coordination, prep area processes, and anesthesia management. Results: Mean room downtime was reduced by 15%, from 13.6 hours to 11.4 hours per day (po0.05). There was a corresponding 12% increase in IRC patient volumes. Surveyed staff strongly agreed that the piloted interventions improved room turnover and patient flow (Likert scale 4.7/5). Improved room utilization rates resulted in a revenue opportunity of $2,600 per day. Patient start-time delays were not improved. 22% of patients were delayed greater than 60 minutes and 23% were delayed 30-60 minutes. Conclusions: Interventions resulted in significant improvement in room downtime, opportunity cost, and staff satisfaction. However, patient procedure start-time delays, inpatient length of stay, and patient satisfaction with their experience remain problems for future investigation.
1. Lange HW, von Boetticher H. Randomized comparison of operator radiation exposure during coronary angiography and intervention by radial or femoral approach. Catheter Cardiovasc Interv 2006; 67:12–16.
3:09 PM
Abstract No. 317
Discrete data field templates results in high compliance of data entry R. Shah1, L. Hofmann2; 1Stanford University, Stanford, CA; 2Stanford University Medical Center, Palo Alto, CA.
TUESDAY: Scientific Sessions
’
Purpose: To evaluate the compliance of complete data entry using discrete data field templates (DDFT) to generate interventional radiology structured procedure reports. Materials: DDFTs were created and implemented in PowerScribe 360 (Nuance Communications) for complex procedures at a single tertiary care center in March 2015, and replaced the narrative free-text generated procedural reports. Reports were divided into modules containing discrete variables. Chemoembolization reports were electronically pulled from the electronic medical record (EMR) and the data from reports between March 2015 and August 2015 were parsed using a custom developed Java-based program and stored in a relational database linked to all data from the EMR. The data from modules that did not undergo any significant evolutionary alteration during the implementation period was evaluated to determine the compliance of data entry by residents, fellows, and attendings performing dictations. Results: 184 chemoembolization reports were parsed during the implementation period. The following modules within the DDFT chemoembolization reports were evaluated: technical details, access artery, catheterized artery, and chemoembolized artery. Within these modules, 55 discrete data elements were present with collection of 18,466 data points. The compliance of data entry were as follows: technical details containing 19 data elements with a compliance rate of 95% (95% CI 94.2%95.7%), access artery containing 14 data elements with a compliance rate of 99% (95% CI 98.6%-99.4%), catheterized artery containing 10 data elements with a compliance rate of 94% (95% CI 93.5%-94.5%), chemoembolized artery containing 12 data elements with a compliance rate of 95.5% (95% CI 94.7%-96.1%). Conclusions: Use of DDFT for complex procedure reports results in a high compliance of data entry. Data structuring methodologies should be considered for procedure reports to control data input for research and quality assurance, and should be considered for creation of local and national registries.
3:18 PM
Abstract No. 318
IR patient throughput: applying lean sigma methodology to reduce procedure room downtime A. Owens1, D. Abdollahian1, J. Dinicola2, S. Denker2, W. Parduba2, M. Dawson1, L. Winner3, K. Hong2; 1Johns
3:27 PM
Abstract No. 319
A pilot study on radiologists’ compliance with ACR Appropriateness Criteria® for management of urinary tract obstruction H. YU1, K. Patel2, M. Harvill3, J. Critchfield4, S. Danier5, R. Kakos3; 1DETROIT MEDICAL CENTER, Novi, MI; 2 Wayne State University, Detroit, MI; 3Harper University Hospital, Detroit, MI; 4Troy, MI; 5Grosse Pointe Shores, MI. Purpose: ACR Appropriateness Criteria provides evidencebased guideline for approaching urinary tract obstruction (UTO), indicating that percutaneous nephrostomy (PCN) and retrograde ureteral stenting are successful techniques to decompress UTO. An appropriate radiologist’s recommendation will provide patient with treatment choices and decrease the hospitalization and costs. The purpose of this study was to analyze the radiologists’ recommendation on managing UTO and their compliance with ACR Appropriateness Criteria. Materials: The radiology reports of all patients undergoing PCN in 2013 and 2014 at a metropolitan medical center were retrospectively reviewed. Diagnostic imaging reports performed
JVIR
’
Scientific Session
Tuesday
30 days before the first PCN were analyzed in terms of findings and recommendation (including percutaneous, endourologic, and open surgical procedures). The identified etiologies were categorized and subcategorized. Comparisons of recommendation rate among categories were performed using chi-square (po0.05 statistically significant). Results: 260 cases of unilateral UTO undergoing at least one attempt of PCN had diagnostic imaging prior to the procedure. 9 cases (3.46%) were recommended for operation in radiologists’ report, including 1 case of unknown etiology and 8 cases of neoplasm (3 advanced cervical cancer/uterine mass, 2 prostate cancer, 2 advanced colon cancer, and 1 retroperitoneal mass). In contrast, 251 cases (96.54%) had no recommendation on the management in which the neoplasm was the most common etiology and 2). There is relatively high recommendation rate in neoplasm group, although there is no significant difference in recommendation rate among all categories (p¼0.56). Similarly, there is no significant difference in the recommendation rate among the subcategories of neoplasms (p¼0.06). This comparison implies a low recommendation rate that is not associated with any etiology. The higher incidence of malignant UTO does not make radiologists be more aware of the necessity of decompressing urinary tract. Conclusions: Only a small proportion (3.46%) of UTO was appropriately recommended for operation, indicating low compliance with ACR Appropriateness Criteria in light of managing UTO. References
3:36 PM
S145
Materials: This retrospective study reviewed the radiological and biochemical success rate of cannulating both adrenal veins and its correlation with computed tomography (CT) and histology where available from 2008 to 2015. Results: In total 47 AVS were performed, out of which 17 were using the old protocol (pre-2012) and 30 using the new protocol (post-2012). Using pre-2012 protocol, the biochemical success rate of the left and the right adrenal vein cannulation were 64.7% and 29.0% respectively. This significantly improved to 93.3% (Po0.02) (left) and 76.7% (Po0.01) (right), respectively, when new interventional radiology as well as biochemical strategies including cosyntropin stimulation were used (post-2012). There was no relationship between the failure of cannulation of the right adrenal vein and presence of adrenal adenoma. There was significant concurrence between the CT and AVS result (po0.001). Conclusions: Our experience shows that by optimising the AVS protocol within the interventional department as well as using cosyntropin stimulation significantly improves the AVS technical success rate. References 1. Catena C, Colussi G, Di Fabio A et al. Mineralocorticoid antagonists treatment versus surgery in primary aldosteronism. Horm Metab Res 2010; 42: 440–445. 2. Funder JW, Carey RM, Fardella C, et al, Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2008; 93:3266–3281. 3. Davidson JK, Morley P, Hurley GD, Holford NG. Adrenal venography and ultrasound in the investigation of the adrenal gland: an analysis of 58 cases. Br J Radiol 1975; 48:435–450. 4. Blondin D, Quack I, Haase M, Ku¨cu¨kko¨ylu¨ S, Willenberg HS. Indication and technical aspects of adrenal blood sampling. Rofo 2015; 187(1):19–28.
3:45 PM
Abstract No. 321
Labeling interventional radiology drains to prevent medical errors and improve patient care D. Dasilva1, A. Sparks2, A. Kim1, G. Lynskey3, J. Spies1, T. Chang4, D. Buckley5, T. Caridi1; 1Georgetown University Medical Center, Washington, DC; 2Edmond, OK; 3Georgetown University Medical Center, Arlington, VA; 4Georgetown University Medical Center, Potomac, MD; 5Georgetown University Medical Center, Gaithersburg, MD.
Abstract No. 320
Improving the radiological and biochemical success in adrenal venous sampling M. Husainy1, C. Fang2, A. Nicolescu2, D. Lewis2, R. Vincent2, P. Kane2; 1King’s College Hospital NHS Trust, London, United Kingdom; 2King’s College Hospital NHS Trust, London, London. Purpose: Adrenal venous sampling (AVS) is the gold standard for lateralising aldosterone-production in proven primary aldosteronism. The right adrenal venous cannulation is technically challenging and in spite of obvious radiological successful cannulation, the samples may not be biochemically suitable to achieve any clinically significant information. Following a change to our AVS protocol, (both radiological and biochemical) in 2012 we assessed its impact on the success rate of the procedure.
Purpose: To evaluate the perception of errors in charting and patient care related to drains placed in IR and the need for an IR drain labeling system. Materials: Nurses (n¼55) and house staff (n¼51) of our single institution were anonymously surveyed on the accuracy of medical charting and subsequent errors in patient care regarding drains placed by IR. An initiative was then undertaken to label all drains placed in IR at the time of the procedure. Tyvek material was selected for its strength and chemical/liquid resistance. Repeat surveys of 51 nurses and 41 house staff were performed at 1 year post initiation of the drain labeling system. Based on the analysis of these results, adjustments were made in the drain labeling technique. Results: When surveyed to assess if IR drains were usually/ always labeled, 20% of nurses and 20% of house staff initially agreed. Surveys also found that 80% of nurses and 53% of
TUESDAY: Scientific Sessions
1. ACR Appropriateness CriteriaAˆ- Radiologic Management of Urinary Tract Obstruction. Am Coll Radiol 2013. 2. Ng CK, Yip SKH, Sim LSJ, Tan BH, Wong MYC, Tan BS, Htoo A. Outcome of Percutaneous Nephrostomy for the Management of Pyonephrosis. Asian J Surg 2002; 25(3):215–219. 3. Ramsey S, Robertson A, Ablett MJ, Meddings RN, Hollins GW, Little B. Evidence-Based Drainage of Infected Hydronephrosis Secondary to Ureteric Calculi. J Endourol 2010; 24(2):185–189. 4. Sommer CM, Huber J, Radeleff BA, Hosch W, Stampfl U, Loenard BM, Hallscheidt P, Haferkamp A, Kauczor HU, Richter GM: Combined CT- and fluoroscopy-guided nephrostomy in patients with non-obstructive uropathy due to urine leaks in cases of failed ultrasound-guided procedures. Eur J Radiol 2011; 80(3):686–691. 5. Farrell TA, Hicks ME: A Review of Radiologically Guided Percutaneous Nephrostomies in 303 Patients. J Vasc Interv Radiol 1997; 8(5):769–774.
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