The value of official reinterpretation of trauma computed tomography scans from referring hospitals

doi:10.1016/j.jpedsurg.2015.08.006

Journal of Pediatric Surgery

Volume 51, Issue 3, March 2016, Pages 486-489

https://doi.org/10.1016/j.jpedsurg.2015.08.006 Get rights and content

Abstract

Introduction

Historically, computed tomography (CT) scans of injured children obtained at referring emergency departments were not reinterpreted by trauma center radiologists at our institution, creating a dilemma for trauma physicians: rescan, use the outside interpretation, or interpret scans themselves. In 2010, our radiologists began reinterpreting all referring hospital trauma CT scans; this study examines the effect of that change.

Methods

Transferred patients who had undergone an abdomen/pelvis CT (CTAP) scan between December 2010 and December 2012 were identified in our trauma registry. Pediatric radiologist reinterpretations were compared to referring hospital radiologist reports.

Results

We identified 168 patients transferred to our institution with a CTAP. Seventy patients were excluded owing to lack of: complete study, referring hospital interpretation, or reinterpretation. Of the remaining 98 cases, 12 new injuries were identified: 3 splenic and 3 liver injuries, 1 adrenal hematoma, 2 pelvic fractures, 1 spinal fracture, 1 duodenal hematoma and 1 jejunal perforation. Three patients had solid organ injuries upgraded (grade II to III liver laceration; 2 renal lacerations with active extravasation initially missed), and 4 patients downgraded to no injury.

Conclusion

Reinterpretation of referring hospital CT scans by pediatric radiologists is beneficial to appropriate management of pediatric trauma patients with concern for blunt abdominal trauma.

Section snippets

Methods

This study was performed at a level I pediatric trauma center that accepts transfers from hospitals throughout the 6 New England states. In 2010, our institution instituted a policy of official pediatric radiological reinterpretation of trauma CT scans performed at referring institutions prior to transfer. After obtaining institutional review board approval, we reviewed our hospital's trauma registry to identify trauma patients 21 years of age or younger admitted between December 2010 and

Results

We identified 168 patients transferred to our institution with a CTAP performed prior to transfer. Sixty-eight patients were excluded because there was no CT interpretation sent from the referring institution (61) or there was no documented interpretation by our pediatric radiologists (7). An additional 2 patients were excluded because the full pelvis was not included in the imaging; this resulted in a study population of 98 patients. The average age was 11.7 years, with a range from 1 to 17

Discussion

Official reinterpretation of outside hospital CT images by pediatric trauma center radiologists is a helpful component of the complete evaluation of a pediatric trauma patient referred from another hospital. Reinterpretation is important owing to the frequency with which scans arrive without accompanying interpretation (36% of patients in this series). Without reinterpretation, the trauma providers would be required to base important care decisions on their own interpretation of the images,

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Cited by (13)

Transfer Patient Imaging: Assessment of the Impact of Discrepancies Identified by Emergency Radiologists
2022, Journal of the American College of Radiology
Citation Excerpt :
Numerous studies have been done examining discrepancy rates, typically between residents and attending radiologists [9,10] but also between general and subspecialist radiologists [11] and between radiologists and other specialists [12]. However, few studies have compared community and referral center radiologists [13-18]. Involvement of medical specialties outside of radiology has been shown to substantially influence the assessment of report concordance [19].
Advanced imaging examinations of emergently transferred patients (ETPs) are overread to various degrees by receiving institutions. The practical clinical impact of these second opinions has not been studied in the past. The purpose of this study is to determine if emergency radiology overreads change emergency medicine decision making on ETPs in the emergency department (ED).
All CT and MRI examinations on patients transferred to a level I trauma center during calendar year 2018 were routinely overread by emergency radiologists and discrepancies with the outside report electronically flagged. All discrepant reports compared with the outside interpretations were reviewed by one of four emergency medicine physicians. Comparing the original and final reports, reviewers identified changes in patient management that could be attributed to the additional information contained in the final report. Changes in patient care were categorized as affecting ED management, disposition, follow-up, or consulting services.
Over a 12-month period, 5,834 patients were accepted in transfer. Among 5,631 CT or MRI examinations with outside reports available, 669 examinations (12%) had at least one discrepancy in the corresponding outside report. In 219 examinations (33%), ED management was changed by discrepancies noted on the final report; patient disposition was affected in 84 (13%), outpatient follow-up in 54 (8%), and selection of consulting services in 411 (61%), and ED stay was extended in 544 (81%). Discrepant findings affected decision making in 613 of 669 of examinations (92%).
Emergency radiology overreading of transferred patients’ advanced imaging examinations provided actionable additional information to emergency medicine physicians in the care of 613 of 669 (92%) examinations with discrepant findings. This added value is worth the effort to design workflows to routinely overread CT and MRI examinations of ETPs.
Rates and clinical impact of discordant X-ray and CT imaging in transfers to a pediatric emergency department
2021, American Journal of Emergency Medicine
Citation Excerpt :
A recent adult ED study of trauma center reinterpretations of diagnostic imaging performed at community EDs identified “management-changing interpretive changes affecting 16% of transferred patients” who underwent CT at an outside facility [14]. A single center study from the pediatric surgery literature has supported reinterpretation of referral hospital CT abdomen in cases of blunt abdominal trauma, citing 12 additional injuries detected from 98 patient encounters [15]. Surprisingly, there was only one missed case of non-accidental trauma in our study.
Children are often transferred to a Pediatric Emergency Department (PED) for definitive care after completion of diagnostic imaging. There is a paucity of data on the concordance rates of interpretation of imaging studies between referral and PED. Our objective is to describe the rates and clinical impact of discordant interpretation of X-rays and CT in children transferred to a PED.
This was a retrospective cohort study of patients over a 12-month period from 12/1/2017–11/30/2018 with X-ray (XR) and CT performed prior to transfer to our PED. We compared referral radiology interpretations to those of pediatric radiologists to determine concordance. Encounters with discordant imaging interpretations were further evaluated for clinical impact (none, minor or major) based on need for additional laboratory workup, consultation, and changes in management and disposition.
We analyzed 899 patient encounters. There were high rates of concordance in both XR and CT interpretation (668/743; 89.9%, 95% CI 0.87–0.91 and 205/235; 87.2%, 95% CI 0.82–0.91, respectively). XR discordance resulted in minor clinical impact in 34 patients (45%, 95% CI 0.35–0.57) and a major clinical impact in 28 patients (37%, 95% CI 0.27–0.49). CT discordance resulted in minor clinical impact in 10 patients (33%, 95% CI 0.19–0.51) of patients and major clinical impact in 15 patients (50%, 95% CI 0.33–0.67). The most common discordances with major clinical impact were related to pneumonia on XR chest and appendicitis or inflammatory bowel disease on CT abdomen.
In patients transferred to the PED, concordance of XR and CT interpretations was high. A majority of discordant interpretations led to clinical impact meaningful to the patient and emergency medicine (EM) physician. Referring EM physicians might consider the benefit of pediatric radiology consultation upon transfer, especially for imaging diagnoses related to pneumonia, appendicitis, or inflammatory bowel disease.
Second-Opinion Reads in Interstitial Lung Disease Imaging: Added Value of Subspecialty Interpretation
2020, Journal of the American College of Radiology
Citation Excerpt :
At another institution, an analysis of secondary interpretations for 409 musculoskeletal examinations submitted to a multidisciplinary orthopedic oncology conference revealed a discrepancy rate of 22.2%, resulting in differences in management [3]. Reinterpretation of nononcologic imaging, such as pediatric trauma imaging, by subspecialists shows similar clinically relevant discrepancies, including the detection of new injuries in 12% of 98 cases, upgraded injuries in 3% of cases, and downgraded (no injury) in 4%[4]. In practices not aligned with academic centers, subspecialty training in thoracic radiology and expertise in interpretation of interstitial lung disease (ILD) are uncommon.
The purpose of this study was to determine how often a second-opinion interpretation of interstitial lung disease (ILD) by an academic cardiothoracic radiologist is discordant with the initial interpretation by a nonacademic radiologists and how often the clinical diagnosis determined by multidisciplinary consensus agrees with the initial and second-opinion interpretations.
This retrospective study included 364 consecutive second-opinion CT examination reports of imaging from nonacademic radiology practices from July 2014 to May 2016. The second-opinion interpretations, provided by seven fellowship-trained cardiothoracic radiologists, were compared with the initial interpretations and the clinical diagnoses determined by multidisciplinary consensus.
Two hundred ninety-six consecutive reports met the inclusion criteria, and two hundred had findings of ILD. The initial interpretations lacked specific diagnoses in 41% of reports, but the second-opinion reports lacked specific diagnoses in only 7%. When a diagnosis was provided, the second-opinion diagnosis disagreed with the initial interpretation in 25% of cases. The clinical-consensus diagnosis was concordant with that of the academic radiologists 85% of the time but concordant with the initial interpretation only 44% of the time. The academic radiologists’ diagnostic sensitivity was higher than that of the initial radiologists for the four most common diagnoses: usual interstitial pneumonitis (0.91 versus 0.4), sarcoidosis (0.94 versus 0.60), hypersensitivity pneumonitis (0.79 versus 0.17), and nonspecific interstitial pneumonitis (0.72 versus 0.14).
Academic cardiothoracic radiologists were more likely to provide specific diagnoses for ILD, and these diagnoses were more likely to be concordant with the multidisciplinary consensus.
Discrepancy Rates and Clinical Impact of Imaging Secondary Interpretations: A Systematic Review and Meta-Analysis
2018, Journal of the American College of Radiology
Citation Excerpt :
Among the 48 articles reviewed at the full-text level, an additional 19 were excluded. This process provided a final sample of 29 included studies for the meta-analysis, including one conference proceeding [7-35]. Table 2 summarizes the included studies.
To conduct a meta-analysis of studies investigating discrepancy rates and clinical impact of imaging secondary interpretations and to identify factors influencing these rates.
EMBASE and PubMed databases were searched for original research investigations reporting discrepancy rates for secondary interpretations performed by radiologists for imaging examinations initially interpreted at other institutions. Two reviewers extracted study information and assessed study quality. Meta-analysis was performed.
Twenty-nine studies representing a total of 12,676 imaging secondary interpretations met inclusion criteria; 19 of these studies provided data specifically for oncologic imaging examinations. Primary risks of bias included availability of initial interpretations, other clinical information, and reference standard before the secondary interpretation. The overall discrepancy rate of secondary interpretations compared with primary interpretations was 32.2%, including a 20.4% discrepancy rate for major findings. Secondary interpretations were management changing in 18.6% of cases. Among discrepant interpretations with an available reference standard, the secondary interpretation accuracy rate was 90.5%. The overall discrepancy rates by examination types were 28.3% for CT, 31.2% for MRI, 32.7% for oncologic imaging, 43.8% for body imaging, 39.9% for breast imaging, 34.0% for musculoskeletal imaging, 23.8% for neuroradiologic imaging, 35.5% for pediatric imaging, and 19.7% for trauma imaging.
Most widely studied in the context of oncology, imaging secondary interpretations commonly result in discrepant interpretations that are management changing and more accurate than initial interpretations. Policymakers should consider these findings as they consider the value of, and payment for, secondary imaging interpretations.
Ensuring Appropriateness of Pediatric Second Opinion Consultations
2020, Current Problems in Diagnostic Radiology
We sought to evaluate discrepancy rates between outside interpretations, radiology trainee preliminary reports, and subspecialist attending final interpretations for pediatric second opinion consultations on plain film and computed tomography imaging and to evaluate the impact of a process improvement for second opinion consultations.
Of a total of 572 requests for second opinion consultations during 1-year preintervention period, we utilized RADPEER to score concurrence of 158 requests which occurred overnight and included outside radiologist interpretations and resident preliminary reports. In consultation with clinician committees, we developed new guidelines for requesting second opinion consultations. We evaluated the impact on the number of consultations for the 1-year period following implementation of this process improvement.
There was concurrence between the outside interpretation and pediatric subspecialist second opinion in 146 of 158 cases (92%). There was concurrence between the radiology resident and pediatric subspecialist second opinion in 145 of 158 cases (92%). During the 1-year period following our process improvement implementation, the total number of second opinion consultations decreased to 185 (from 572, a decrease of 68%) and the number of overnight requests for resident preliminary reports decreased to 11 (from 158, a decrease of 93%).
There was a high degree of concurrence between interpretations provided by outside radiologists, overnight radiology residents, and attending pediatric radiologists at our institution. Analyzing institutional-specific discrepancy rates is a valuable first step in partnering with clinicians to develop appropriate guidelines for second opinion consultations.
Curbside consults: Practices, pitfalls and legal issues
2019, Clinical Imaging
Citation Excerpt :
Some facilities provide true informal “wet reads” to answer specific targeted clinician questions, others as a form of participation at tumor boards, while a minority re-interpret studies de novo and enter a report into the medical record, often for a fee. Clearly, there is value for the treating clinician to be able to consult his radiology colleague, and studies have suggested that there may be significant clinical value in obtaining a reinterpretation, with as much as a 12–28% discrepancy rate between first and second interpretations [5,6]. This survey showed that the clear majority of radiologists are at least somewhat concerned by liability risks of curbside consults, and that the concern appears to be well grounded.
“Curbside consults” are informal opinions provided by one physician to another. In radiology, it often refers to opinions rendered on imaging performed at outside facilities and has evolved from being a targeted response to a discrete clinical question to a complete over-read in recent years. Given that the consults are usually sought for patients with complex conditions, the potential for error increases with informal reads, often due to the time constraint and lack of adequate information. Misinterpretations and inaccurate documentation by the referring clinician are also more likely. This study assesses the policies and views on curbside consults at academic centers in the United States.
An online survey (via SurveyMonkey.com) was circulated to the 319 active radiologist members of the Association of Program Directors. There were 80 responses, representing a 25% response rate.
While most facilities provided second reads (92%), only a few (23%) provided written reports and read the case entirely. The majority (77%) tailored their read to answer specific clinical questions. Approximately two-thirds did not require the outside radiologist's report to be available before their interpretation. Seventy-nine percent were at least mildly concerned about liability. Up to 45% billed for the study; 39% were not aware of the billing practice.
Curbside consults are widely provided at U.S. academic institutions with only a minority documenting their opinions. The majority are concerned about the legal implications and this paper puts forth recommendations to minimize the potential for errors in patient care and decrease liability.

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^☆: Presented in part at the 15th Annual John M. Templeton Jr. Pediatric Trauma Symposium, Pittsburgh, PA.

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Original ArticleThe value of official reinterpretation of trauma computed tomography scans from referring hospitals☆

Abstract

Introduction

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Ann Emerg Med

J Pediatr Surg

J Pediatr Surg

Inefficiencies in a rural trauma system: the burden of repeat imaging in interfacility transfers

J Trauma

Original Article
The value of official reinterpretation of trauma computed tomography scans from referring hospitals☆