CTs per 1000 ED pts

[EMEDPA]

So we have been on epic for a few years now and able to access some interesting stats. Our dept chair just posted (unblinded) CTs/1000 pts for all PA, NP, and MD/DO providers in the dept as well as avg acuity by provider.

I was interested to see my avg acuity is higher than most others(all but 2 of around 20) and my CT utilization is the lowest in the dept...by a lot....what does that mean?

avg for the group was around 160 CTs/1000 pts

the highest utilizer was a new grad np at 260/1000

my # was 45/1000. the next closest provider was at 100/1000.

Am I not ordering enough or are all my colleagues CT crazy? ingrown toenail? CT!

very strange.

anyone else follow this stat and what do your personal and dept #s look like?

[WeBuyAndSellJunk]

I would be curious to see alternative imaging utilization. I feel like there are people who use CT for everything and there are people who are comfortable trying other imaging methods first. I suspect it would also depend on your inpatient/surgery services. Some people want imaging for things that other teams will just admit or take to surgery directly. It is really interesting though and speaks volumes to some need for appropriate imaging utilization. 

[EMEDPA]

we generally don't call our surgeons or hospitalists until the workup is done, so they don't really play much into diagnostic imaging trends.

I probably do more u/s studies than many of my colleagues, so that is probably part of it. I know I do waaaaaaaay fewer MRis than my colleagues. I probably order maybe 5/year if I really think someone has an epidural abscess or cauda equina syndrome. never for extremity stuff like knees, etc That should be an outpt workup.

I work with 1 guy who MRIs everybody. back pain with sciatica x 30 min after minor mva? MRI!...not me....

[WeBuyAndSellJunk]

The real question is whether the dept chair is happy with your utilization or wants that sweet $$$ from extra orders :) Of course, that all may be just going to the hospital or rads group if you are contracted in. 

[sk732]

I work with a doc that I nick named Capt CAT Scan, since they've literally got half the population of my area glowing in the dark - I'd say maybe half of these were actually indicated.  They're a zebra hunter - always looking for something that isn't there, either literally or statistically.  I swear they use the ER as their own little internal medicine lab...and that shows in how long it takes them to assess and manage even a cold.

 

The last MRI I ordered was about a year ago  - person presented to the ER with classic MS symptoms...I don't usually order them in the ER, except for cauda or epidural abscess, though this dude had been sick for a year or so - the neurologist I consulted LP'd him right after the scan.

 

Thing with MRI's I've found over the years is that people think of them as status symbols for some retarded ​ mentally challenged reason I've yet to understand.  I've had a couple - but one was an MRA after putting up with 6 months of  a? labral tear to my hip (don't recommend it if you can avoid it)  and the other was because I was being worked up as a liver segment donor.

 

SK

[Boatswain2PA]

I try not to scan young people. 

 

Old people?  Gimme a reason.

One CT may (actually) cost $250.  

 

One missed CT may cost $11.3 million.  https://madmimi.com/p/ab1fd9?fe=1&pact=23339-139014736-9685000803-a6c8173bf13bd15739694eda3be2f203b132e199

 

That's 45,200 CTs.

 

I may over CT people (again, not kids), but when someone gets around to changing the Med Mal laws then I'll start using better statistical analysis on when to do CT.

 

Also...it's good to be in the middle.

[sk732]

I remember us talking aobut that CT...I ultrasound kids a lot for appendicitis and kidney stuff, even though we have the lowest radiation scanner in the province where I work (even better than the one at the Children's Hospital).  If a kid needs a scan, I let a pediatrician order it.

 

SK

[LT_Oneal_PAC]

[TheGunsnMoses]

Still waiting for the read on that sock from radiology...

[tunafish]

So we have been on epic for a few years now and able to access some interesting stats. Our dept chair just posted (unblinded) CTs/1000 pts for all PA, NP, and MD/DO providers in the dept as well as avg acuity by provider.

I was interested to see my avg acuity is higher than most others(all but 2 of around 20) and my CT utilization is the lowest in the dept...by a lot....what does that mean?

avg for the group was around 160 CTs/1000 pts

the highest utilizer was a new grad np at 260/1000

my # was 45/1000. the next closest provider was at 100/1000.

Am I not ordering enough or are all my colleagues CT crazy? ingrown toenail? CT!

very strange.

anyone else follow this stat and what do your personal and dept #s look like?

 

I had 4 cases of terminal cancer in different parts of the gut discovered by CT in the last 6 months. Guy with lower GI bleed and pencil stools - 5 docs were poking in his belly for a year with their fingers - maybe colitis, maybe hemorrhoids etc etc. R/O spine fractures - you do films for the neck and miss a hairline Fx and that lawyer would chew your ass that you should have gotten CT. This is just a tool, just like US, Xray or your stethoscope. You can get KUB for bowel obstruction, but you will not know the transition point and it is much harder to track dynamics if you want to treat conservatively. What's wrong with CT. Radiation? There is no evidence it does anything (just read the article looking for evidence base for ALARA) Cost? Well, in my humble opinion salami slicing diabetic foot for 2 years and 20 surgeries that always end up BKA is much more waste let alone waste on bombing Iraq and Syria. 

[EKPA]

During my recent EM rotation, I saw a 45 year old guy with hx DM, 10 days s/p MVC who was well initially but developed dizziness x 3 days. A car backed up into his parked car while he sat. He denied head trauma,  LOC + no focal neuro findings. I presented to my preceptor and said I don't feel this warrants a CT and I got chewed out a little for my choice of diagnostics (lack of). Still don't get it. CT was negative. 

[ventana]

This is one of my push button items

 

What ever happened to hands on assessement? Not saying ordering a CT covers you, but it seemingly is what some providers due when "I just don't know"

 

One of my last main side ER shifts - a guy came in with Abd pain, seemed real, didn't give much for Hx - review of EMR shows 30+ ABD/Pelvis CT's in the prior 10 years for same complaints.... Back into room I go explaining that he has has 30 CT's already, and ask if this is the prior s/s he always gets - yup they are. Talk to him for about 10 min about risks of CT (he says no one ever told him this before). He decides on no CT (I think cause he was not getting any narc's out of me an that was stated to him).

 

Point is - I could have ordered a CT - and it honestly would have been faster and easier - probably would have saved close to 20 min on this one patient - and dispo would have been much easier..... but I choose the hard path because it is the right path...... and saved a CT. As the ER's have become more focused on "though put" and volume I think this is one of the things you get from it.

 

I love it when a Doc says I was looking for. 'Zebra X" and everyone shakes their heads in agreement, but when I (a PA) says I am looking for Zebra X they all try to correct me and say "thats a zebra".

Oh well I am no longer doing ER stuff (partly due to this)

[sk732]

Still waiting for the read on that sock from radiology...

 

It'll read "Clinical correlation still required"...

 

So it is only probably a sock.

 

In my case, I'd still be waiting on getting the person into the scanner...

 

SK

[Boatswain2PA]

This is one of my push button items

 

What ever happened to hands on assessement? Not saying ordering a CT covers you, but it seemingly is what some providers due when "I just don't know"

 

One of my last main side ER shifts - a guy came in with Abd pain, seemed real, didn't give much for Hx - review of EMR shows 30+ ABD/Pelvis CT's in the prior 10 years for same complaints.... Back into room I go explaining that he has has 30 CT's already, and ask if this is the prior s/s he always gets - yup they are. Talk to him for about 10 min about risks of CT (he says no one ever told him this before). He decides on no CT (I think cause he was not getting any narc's out of me an that was stated to him).

 

Point is - I could have ordered a CT - and it honestly would have been faster and easier - probably would have saved close to 20 min on this one patient - and dispo would have been much easier..... but I choose the hard path because it is the right path...... and saved a CT. As the ER's have become more focused on "though put" and volume I think this is one of the things you get from it.

 

I love it when a Doc says I was looking for. 'Zebra X" and everyone shakes their heads in agreement, but when I (a PA) says I am looking for Zebra X they all try to correct me and say "thats a zebra".

Oh well I am no longer doing ER stuff (partly due to this)

 

There are LOTS of studies that show that many of those clinical tests, named after docs who practiced before CT scanners, have terrible sensitivity/specificity.  

 

My job in the ED isn't to be specific.  My job in the ED is to be SENSITIVE....to catch EVERYTHING, including some bycatch (stuff ya didn't want to catch).

 

This means I admit almost all chest pains.  This means I CT almost all old people with belly pain.  This means I image everything that hurts after trauma.  

 

Ventana - The functional belly pain with hx of 30 scans in past 2 years is a different beast.  If their pain is EXACTLY the same as it's been all 40 times they have been to the ED, then I won't CT them.  But, if they say something's "different"...okay, one more it is.

 

E- imagine you miss a AAA and are sued.  You being the lowest CT utilizer will likely be used against you.  Being in the middle of the school of fish does offer protection against the sharks. 

 

 

[GetMeOuttaThisMess]

It'll read "Clinical correlation still required"...

 

So it is only probably a sock.

 

In my case, I'd still be waiting on getting the person into the scanner...

 

SK

You forgot to mention the second part of the read, "rescan in six months to confirm no change in baseline finding".

[GetMeOuttaThisMess]

During my recent EM rotation, I saw a 45 year old guy with hx DM, 10 days s/p MVC who was well initially but developed dizziness x 3 days. A car backed up into his parked car while he sat. He denied head trauma, LOC + no focal neuro findings. I presented to my preceptor and said I don't feel this warrants a CT and I got chewed out a little for my choice of diagnostics (lack of). Still don't get it. CT was negative.

Should've done a cerebral arteriogram to r/o vertebral artery dissection due to dizziness and mechanism of injury. In all seriousness I DO auscultate these folks for bruits just to be able to say that I did. Had an ED pt. a couple of decades ago that the director DID pick one up on (not my pt.). You would've thought we had a peacock in the department from all the strutting.

[sk732]

CT'd a 17 yo today...unfortunately because his CXR had "LYMPHOMA" written all over it.

 

SK

[EKPA]

My job in the ED is to be SENSITIVE....to catch EVERYTHING, including some bycatch (stuff ya didn't want to catch).

Excellent point...

 

 

[Guest ERCat]

I probably order more scans than my colleagues do, especially when it comes to any neurological symptoms.

 

90 percent of my head CTs come back totally negative which makes me thinks I over order them. I've ordered thousands of head and c-spine scans on old people who hit their head and they're usually negative!

 

But it's often the patients I least expect would have anything wrong with them that have positive findings. Like a kid who was boxing and had a headache with no other symptoms including vision changes or vomiting. I got the scan which showed a subdural bleed. My attending physician interrupted my history when I was telling her about the patient and said "I hope you didn't order a scan on this young kid" and I felt so great when I told her what I had NOT missed. And what SHE would have missed.

 

I do feel a lot of imaging is ordered to cover my ass. But at the same time, I think all of my imaging is justified because in the emergency department we are here to rule out the bad crap. As long as I have some clinical justification for ordering a scan I try not to worry about it.

 

And yeah, old people get scanned like mad and that doesn't bother me. Young adults? I use a lot of restraint and try to avoid. Kids? I can count the number of scans I have ordered on kids and when I did, I'm usually glad I did because I caugh something.

[Boatswain2PA]

I probably order more scans than my colleagues do, especially when it comes to any neurological symptoms.

 

90 percent of my head CTs come back totally negative which makes me thinks I over order them. I've ordered thousands of head and c-spine scans on old people who hit their head and they're usually negative!

 

But it's often the patients I least expect would have anything wrong with them that have positive findings. Like a kid who was boxing and had a headache with no other symptoms including vision changes or vomiting. I got the scan which showed a subdural bleed. My attending physician interrupted my history when I was telling her about the patient and said "I hope you didn't order a scan on this young kid" and I felt so great when I told her what I had NOT missed. And what SHE would have missed.

 

I do feel a lot of imaging is ordered to cover my ass. But at the same time, I think all of my imaging is justified because in the emergency department we are here to rule out the bad crap. As long as I have some clinical justification for ordering a scan I try not to worry about it.

 

And yeah, old people get scanned like mad and that doesn't bother me. Young adults? I use a lot of restraint and try to avoid. Kids? I can count the number of scans I have ordered on kids and when I did, I'm usually glad I did because I caugh something.

Or the LOL 2 weeks ago came in from NH with decreased LOC.  CT head negative, mild dehydration, rehydration & sent back to NH.  Next day she's totally unresponsive and febrile, CT of sinuses from PCM caught a big interparenchymal bleed.

 

Agree with the differences of scanning young vs old.  Young people = I gotta have a reason TO scan ya.  Old people = I gotta prove I DON'T have to scan ya.