Reducing Interruptions in the Reading Room: Standardized CT/MRI Contrast Orders
This article was originally published in the Journal of the American College of Radiology - Volume 12, Issue 9, Pages 1196-1199, November 2015
by Elizabeth M. Hecht, MD, John Simmons, BSRT, MBA, CRA, Martin R. Prince, MD, PhD
Article has an altmetric score of 2
DOI: http://dx.doi.org/10.1016/j.jacr.2015.03.033 |
One major source of interruptions in workflow that we identified in our academic practice was phone calls to the radiology reading room from technologists and nursing staff members requesting written prescription orders for oral and intravenous contrast and prescription of protocols to be entered into our computerized protocoling system. Technologists would routinely call for protocols and nurses would call for contrast media, with potentially a minimum of two phone calls per patient examination. Although prescribing imaging protocols and contrast orders are essential tasks for quality patient care, this pattern of workflow in our department was problematic, inevitability leading to delays and interruptions of patient care at multiple levels. For patients, wait times were potentially prolonged because orders were not in place in advance of patients’ arrival to the department. For technologists and nurses, the time spent trying to contact physicians negatively affected throughput and could potentially lead to errors due to interruptions in their workflow. For radiologists, interruptions in the reading room lead to prolonged turnaround times, foreshortened consultations with referring clinicians and readout sessions with trainees and potential errors in image interpretation or reports.
Error rates in interpretations rendered by radiologists range from 0.8% to 4.4% and are potentially increased as a result of interruptions [1, 2]. A recent prospective study demonstrated that radiologists spend only 36.4% of their time on image interpretation and 43.8% on noninterpretive tasks . The average number of interactions radiologists experienced resulted in only 5 to 10 min of uninterrupted work per hour. Another study found an increase in the average number of phone calls in the hour leading up to the generation of a discrepant preliminary report, with a 12% increased likelihood of a radiology resident error (P = .017) . Therefore, to reduce reading room interruptions in our practice, we established standardized protocols that included standard contrast orders based on a given protocol. The implementation and outcome of this intervention were assessed.
How We Proceeded
This quality improvement project was performed at Columbia University Medical Center and New York-Presbyterian Hospital from 2011 to 2014. The effort was carried out primarily through the work of radiology representatives on the institution’s Radiology Subcommittee of the Formulary and Therapeutics Committee. The approach to this problem was biphasic.
First, the effort focused on updating the two-campus radiology contrast media policies to comply with current ACR guidelines  and establish an algorithmic approach for nurses and technologists to screen patients undergoing contrast studies. This would clarify when consultation from a radiologist was warranted.
Second, a new policy was created and approved by the medical boards to permit the use of standardized order sets for patients on the basis of the radiologic procedure ordered. Simultaneously, the development of standardized contrast order sets for all CT and MRI protocols at each campus was required. The effort was not intended to limit radiologists in terms of choice of contrast media or dose, as individual patients and clinical situations may require alternative contrast media and doses. The policy allowed radiologists or radiologists in training to substitute any standard contrast order with a US Food and Drug Administration–approved contrast agent on the hospital formulary as long as a signed order accompanied that deviation from the standardized protocol. All oral and intravenous contrast would continue to require medical record documentation, but this was created automatically when a standardized protocol was selected for the patient in our computerized protocoling system. Once the new standardized protocol and contrast-ordering system was implemented, monitoring of quality and compliance would be performed by the Department of Radiology and periodically reviewed by the Subcommittee on Radiology of the Formulary and Therapeutics Committee.
After these policy changes were approved and before implementation of the new policies, teaching in-service sessions were required for radiology department nursing and technology staff members and for radiologists and radiologists in training. Contact information was updated for the reading rooms and radiologists and posted online. The online protocoling system was updated to list the new naming convention of the standard protocols and the contrast type and dose designated for each protocol, in compliance with the new policy. This online protocoling system was also used for the documentation of contrast administration for outpatients. For inpatients, the inpatient electronic medical charting system was used. A radiologist for each division was assigned on a rotating basis to be the point person for protocols and was responsible for protocoling cases up to a week in advance, as well as any add-on case and protocol- or contrast media–related questions.
An online, voluntary, and anonymous survey (SurveyMonkey; https://www.surveymonkey.com) was provided to all radiologists and nursing and technology staff members before and three and six months after the implementation of the new policies and procedures. This survey assessed the number of phone calls and in-person interruptions and time spent per day for protocols or contrast orders, the nature of the most common work interruptions, and the impact of the standardized contrast orders on the daily routine at three and six months after the introduction of the new policy and procedures regarding standardize contrast orders (Tables 1 and 2).
Response to radiologist survey at baseline and 3 and 6 months after the implementation of standardized order policy and procedures
|Survey Question||Answer||Before Standardized Orders (n = 57)||3 Months After (n = 22)||6 Months After (n = 22)||Percentage Change Over 6 Months|
|Number of phone calls to reading room/day for contrast orders and protocols||≥6–10||39/57 (68%)||4/21∗(19%)||7/22 (32%)||−36%|
|Number of in-person visits to the reading room/day to find radiologist for contrast orders and protocols||≥3–5||46/56∗ (82%)||1/19∗(5%)||1/22 (4%)||−78%|
|Number of repeated (>1) phone calls/day or visits for the same request||≥3–5||3/56∗ (7%)||0/20∗(0%)||0/22 (0%)||−7%|
|Minutes/day spent on phone or in person regarding contrast orders/protocols||≥21||34/56∗ (61%)||3/22 (14%)||5/22 (23%)||−38%|
|Minutes/day spent trying to contact referrers for patient data to protocol an imaging examination||≥21||27/57 (47%)||6/22 (27%)||5/22 (23%)||−4.2%|
|Minutes/day spent in consultation with referrers regarding image interpretation/reporting results||≥21||38/58 (65%)||11/22 (50%)||8/22 (36%)||−29%|
∗Number who responded to this question was less than total number who responded to the survey.
Response to technologist and nursing survey at baseline and 3 and 6 months after the implementation of standardized order policy and procedures
|Survey Question||Answer||Before Standardized Orders (n = 49)||3 Months After (n = 10)||6 Months After (n = 24)||Percentage Change Over 6 Months|
|Number of phone calls to reading room/day for contrast orders and protocols||≥6–10||23/49 (47%)||2/10 (20%)||7/24 (29%)||−18%|
|Number of in-person visits to the reading room/day to find radiologist for contrast orders and protocols||≥3–5||14/49 (29%)||0/10 (0%)||2/24 (8%)||−21%|
|Number of repeated (>1) phone calls/day for the same request||≥3–5||19/49 (39%)||1/10 (10%)||3/24 (13%)||−26%|
|Number of times/day you could not find a radiologist and had to call multiple people, a supervisor, or manager to assist for contrast orders and protocols||≥3–5||14/48∗ (29%)||1/10 (10%)||0/24 (12%)||−17%|
|Minutes/day spent trying to contact a physician for contrast orders and protocols||≥21||17/48∗ (35%)||1/10 (20%)||2/24 (21%)||−15%|
*Number who responded to this question was less than total number who responded to the survey.
Major challenges included (1) achieving radiologist consensus on protocols and contrast media type and (2) educating staff members about the updated contrast media–related policies and guidelines, as many myths and misconceptions regarding contrast media had accumulated over time. The ACR guidelines were a helpful resource of evidence-based data to support the new policies and protocols. These policies were aimed to educate staff members on contrast media in addition to creating an algorithmic approach to screening of patients with specific guidelines on when to contact radiologists for consultation. The two major campuses, Columbia University Medical Center and Weill Cornell Medical Center, each established their own contrast order data sets and naming conventions of imaging protocols on the basis of institutional convention.
Radiologists and Radiologists in Training
There were 57 responses to the initial preintervention assessment survey, 22 to the three-month survey, and 22 to the six-month survey (Table 1). Six months after the implementation of standardized orders, 2 of 21 radiologists (10%) perceived no change in the number of daily interruptions to nursing and technologist workflow, 4 (19%) perceived a mild decrease in the number of interruptions, and 15 (71%) perceived a marked decrease in the number of interruptions. The most common reasons for interruptions according to the radiologists at six months after the standardization of contrast orders were phone calls from technologists and nurses regarding protocols and contrast orders (9 of 21 [43%]) and from clinicians asking for consultations (12 of 21 [57%]).
Nurses and Technologists
Survey responses from nurses and technologists included 49 to the preintervention assessment survey, 10 at three months after implementation, and 24 at six months after implementation (Table 2). Six months after the implementation of standardized orders, 8 of 24 technologists and nurses (33%) perceived no change in the number of daily interruptions to nursing and technologist workflow, 6 (25%) reported a mild decrease in the number of interruptions, and 9 (38%) reported a marked decrease in interruptions.
The most common reasons for having trouble finding a radiologist for contrast orders or protocols before standardized orders were “I call the reading room but no one answers” (30 of 48 [79%]), “I can’t easily access contact numbers for radiologist or reading room” (22 of 48 [46%]), “radiologist passes the buck and multiple calls are needed” (13 of 48 [27%]) (only 48 of 49 responded to this question). Six months after the intervention was implemented, common responses were as follows: “I call the reading room but no one answers” (12 of 19 [63%]), “radiologist passes the buck and multiple calls are needed” (6 of 19 [32%]), and “I can’t easily access contact numbers for radiologist or reading room” (1 of 19 [5%]) (only 19 of 24 responded to this question).
Interruptions in the reading room are a major source of inefficiency and potentially lead to interpretive errors. These data from two tertiary care medical centers demonstrate that standardization of protocols and contrast media dose and type leads to fewer interruptions. Furthermore, technologists and nurses reported fewer interruptions in their workflow related to contacting radiologists for protocol and contrast media order clarifications. Interruptions for image quality or interpretive issues still occur and will continue to be addressed in future work. The ongoing sources of interruption include the need to log into at least three different computer programs to review patients’ clinical and laboratory data and to prescribe protocol and contrast media for inpatients and outpatients. If a blood test is needed for renal function or additional medications such as antiperistaltic agents for bowel imaging, written orders are still required. These are periodically faxed to the reading room for signing and faxed back to limit disruption.
Having better integration of the electronic medical record and decision-making support software would likely improve workflow, but that would require an institutional administrative and financial support effort outside the Department of Radiology. Our institution is purchasing software that will automatically alert clinicians to urgent results to assist radiologists in communicating critical results in a timing fashion. On the basis of our survey, there are persistent perceived communications barriers among radiologists, technologists, and nurses. Technologists and nurses have difficulty contacting radiologists in a timely fashion with questions regarding contrast and protocols, particularly during midday conference hours, despite access to radiologists’ cell phones, increasing the number of landlines in the reading rooms, and assigning a radiologist on a rotating basis to serve as the protocol point person. We will be investigating whether a radiology reading room assistant would further facilitate communication among radiologists and referring clinicians, nurses, and technologists and further minimize interruptions to workflow.
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