Requiring referring physicians to view a warning about radiation dose before ordering exams helped reduce the use of portable radiography studies at a New York City hospital, according to a study presented this week at the American College of Radiology annual meeting (ACR 2016) in Washington, DC.
Researchers from Richmond University Medical Center in Staten Island saw the use of elective portable radiographs drop 16% after they inserted the radiation dose warning into the hospital's electronic medical record (EMR) software. Physicians who wanted to order a portable radiography exam had to check a box before the order would be processed, according to Dr. Daniel Fung, a radiology resident at the facility who is lead author on the study, with co-authors including Dr. Michael Meshreki and Dr. Jonathan Appel.
Unhappy technologists
Radiology staff at Richmond University Medical Center had long been dissatisfied with the number of portable radiographs that were being performed at the facility. For starters, the image quality from portable x-ray machines just doesn't compare to what's available with radiography units operated in the radiology department.
Dr. Daniel Fung from Richmond University Medical Center.In addition, the hospital's radiologic technologists were often discouraged when they had to travel to other departments to perform portable x-ray exams on a patient, only to see that very same patient in the radiology department later for a CT or MRI exam -- a dead giveaway that the patients were ambulatory enough to have come to the department for their x-ray as well.
"We asked the technologists what annoyed them the most, and that was doing portables on patients they knew were ambulatory," Fung told AuntMinnie.com.
So, Fung and colleagues decided to perform a quality improvement project with the goal of reducing unnecessary portable exams. They brainstormed about the issues that might have the most impact in getting referring physicians to reconsider orders for portable studies, and settled on radiation dose as the most compelling.
Fung wrote a disclaimer that hospital IT staff incorporated into the EMR software. The disclaimer contained a short note about radiation dose, describing how images acquired with portable radiography units usually delivered a higher radiation dose than x-ray systems in the radiology department. Referring physicians had to check off a box acknowledging the warning before they could proceed with the order.
The text of the disclaimer is as follows:
Disclaimer: To ensure the highest image quality and reduce scatter radiation to the public, the department of radiology recommends, when clinically feasible for the patient, to perform dedicated radiographic studies within the department.
Question: Please specify why the exam cannot be performed in the department:
Fung noted that the disclaimer doesn't prevent clinicians from ordering portable exams; it simply alerts them to the radiation issue. Indeed, many of the referring resident physicians he spoke with during the study period told him they weren't aware of the difference in radiation exposure between portable and in-department exams.
The researchers then decided to assess the effect of the disclaimer on orders for portable radiographs. They compared radiograph orders for two time periods, before and after the warning was added, and analyzed whether a reduction occurred.
The control period ran from January to May 2015, during which time 19,119 total radiographs were performed. Of these, 8,892 were portables; however, the researchers excluded orders they considered to be mandatory, leaving 5,510 elective radiographs.
During the intervention period from June to October 2015, when the disclaimer was in effect, the institution performed a total of 19,708 radiographs, of which 4,796 were elective portable studies. This constituted a decline of 4.7 percentage points, or 16.1%, for elective portable studies as a proportion of overall exams.
| Effect of patient safety disclaimer on elective portable radiographs | |||
| Before use of disclaimer | After use of disclaimer | Relative % change | |
| Total No. of inpatient radiographs | 19,119 | 19,708 | 3.1% |
| No. of elective portable radiographs | 5,510 | 4,796 | -13% |
| Elective portables as percent of overall inpatient radiographs | 29.3% | 24.6% | -16% |
Fung said the researchers were satisfied with the magnitude of the decline in portable exams, and the disclaimer remains in use. He expects that its impact may decline as clinicians get used to seeing it -- especially as the more senior residents know it's not mandatory -- but he plans to perform a training session when the new crop of interns arrives in July.
"We are going to keep using it going forward, until someone complains that it's annoying," Fung said.
