Transcript PE Exam Analysis Breakdown - College Of Imaging Administrators

A Physician’s Perspective
Lisa A. Laurent, MD
Advanced Radiology Consultants
Park Ridge, Illinois
Fellow Institute of Medicine of Chicago
Medical Director Body CT
Medical Director Ultrasound
Advocate Lutheran General Hospital
Park Ridge, Illinois
Unless otherwise indicated, all trademarks are owned by MEDRAD, INC. or licensed for its use.
Current Situation
• Advocate Lutheran General Hospital
– 638 bed hospital
– 5 CT suites
– 22 technologists (all registry certified)
• Upgraded 16 GE slice to 64-slice GE Discovery™
CT750 HD
• Commenced implementation of Adaptive Statistical
Iterative Reconstruction (ASIR)
• Located in busy Level I ED trauma center
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Implementation Issues
• Creation of contrast protocols for the new scanner with
ASIR technology
– How do you create protocols as you change radiation dose?
– How do you increase image quality?
– What are tools to ensure continuous improvement?
• Partners in development
– Contrast company
– OEM scanner
– Injector company
• Identified PE studies as a potential challenge
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CT Pulmonary Angiography (PA)
Challenges
• Gold standard for diagnosis of pulmonary embolism
• High percentage of sub-optimal diagnostic studies
– University of Pittsburgh Medical Center
– University of Albany
– Kelly AM, Patel S, Kazerooni EA. CT pulmonary
angiography for accurate pulmonary embolism in
ICU patients clinical experience (abstr.) Radiology.
2002; 225(p):385
27%*
30%†
24%
• Sub-optimal studies have been shown to result in additional*
– Imaging studies
– Medical therapy
– Hospital admission
*A Clinical Evaluation of an Automated Software Program (CardiacFlow) for Patient Specific Contrast Injection During Chest CTA to Exclude Pulmonary Embolism. Christopher R Deible MD,
PHD1, Jacob Alexander MD1, Iclal Ocak MD1, Maryam Ghadimi Mahani MD1, John Kalafut BS, MS2,Janet RN, MSN1, Karen M Pealer BA,CCRC1, Michael P. Federle MD1, Joan M Lacomis
MD1. Society of Thoracic Radiology 2008. E Durick MD1, Carl R Fuhrman MD1, Darlene Frasher University of Pittsburgh Medical Center.
†Patient Outcomes and Resource Utilization for Emergency Department Patients with Suspected Pulmonary Embolism and Initial Chest Computed Tomography Angiography Studies Deemed
Suboptimal for Interpretation; Annals of Emergency Medicine; VOLUME 54 NUMBER SEPTEMBER 2009; Weinstein J, Burton J, Katz B/Albany Medical Center, Albany, NY
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P3T® PA Clinical Trial*
• “Higher percentage of exams
ranked as diagnostic without
limitation…”
• “Better contrast enhancement of
pulmonary arteries…”
• Note: at a slightly higher contrast
dose than standard scan
protocol at 80 mL
*A Clinical Evaluation of an Automated Software Program (CardiacFlow) for Patient Specific Contrast Injection During Chest CTA to Exclude Pulmonary Embolism. Christopher R Deible MD,
PHD1, Jacob Alexander MD1, Iclal Ocak MD1, Maryam Ghadimi Mahani MD1, John Kalafut BS, MS2,Janet RN, MSN1, Karen M Pealer BA,CCRC1, Michael P. Federle MD1, Joan M Lacomis
MD1. Society of Thoracic Radiology 2008. E Durick MD1, Carl R Fuhrman MD1, Darlene Frasher University of Pittsburgh Medical Center.
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P3T® PA Results: Pulmonary CTA
Qualitative Assessment of CTs Obtained With P3T® vs Standard Protocol*
(Lacomis, Deible, Federle)
University of Pittsburgh
Presented at Society Thoracic
Radiology 2008, Submitted to AJR in
2010
• 60 patient (prospective and
randomized design) study,
ED patients suspected of PE
• 64-slice VCT (GEHC)
• Omnipaque 350 mg/ml
• August 2006 to March 2007
*Used by permission.
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Advocate Lutheran General
Hospital Experience
Implementation Plan
• Invest in Certegra™ software package from MEDRAD
–
–
–
–
P3T® PA – weight-based dosing software for PA
Connect.PACS™ Application
Manage.Report™ Application
Significant training plan
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P3T® Software
P3T® calculates the appropriate dose for each
patient by computing custom injection protocols,
enabling personalized care and patient care
while maintaining efficient workflow
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P3T® Software
P3T® calculates custom injection protocols as well as
scan timing for each patient using 4 primary
components
• Patient and procedure data gathered by health care
personnel
• P3T® algorithm for protocol generation
• DualFlow technology (the simultaneous injection of
contrast and saline)
• Use of a transit or timing bolus
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PE Exam Challenge and Process
• The challenge: to perform diagnostic quality PE exams in
a consistent fashion for all patient body habitus types,
regardless of age and clinical presentation
• The process: to implement P3T® Software
– Retrospectively reviewed all adult PE studies performed since
May 1, 2011
– Used software tracking processes
– Determined best practices for coaching technologists, educating
radiologists, and developing a team approach to create total
departmental engagement
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How Is This Analysis Made Possible?
• Data
– Accurate
– Accessible
– Automated
• Connect.PACS™ Application
– Point-of-care decision
– Provides a way to retrospectively analyze data
– Real-world proof as opposed to assumption
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Using the Data to Drive Results
Easily able to identify reasons behind PE limitations
• Technologist adoption
• Flow-rate—limiting issues
• Contrast efficiency
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Using the Data to Drive Results
Building a Team
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Protocol Adherence: First 6 Weeks
100%
90%
80%
70%
Other
60%
PE
50%
Abd
40%
P3T
30%
20%
10%
0%
May 4th
May 11th
May 18th
May 25th
June 2nd
June 9th
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Protocol Adherence: Last 6 Weeks
100%
90%
80%
70%
Other
60%
PE
50%
Abd
P3T
40%
30%
20%
10%
0%
Sept 10th
Sept 17th
Sept 24th
Oct 1st
Oct 8th
Oct 15th
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PE Exam Analysis Breakdown
• 199 PE exams completed (May 1, 2011, through
July 31, 2011)
• 23 exams deemed nondiagnostic (11.6%)
– 14 of these exams, the technologist did not use P3T® (7.0%)
– 9 nondiagnostic exams used P3T® (4.5%)
• 3 caused by motion artifact
• 1 caused by the use of Isovue® 300 vs Isovue 370
• 5 caused by flow-rate-limiting issues due to catheter restrictions
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CT Chest Pulmonary Embolism
Suboptimal Analysis
199 Total Studies
May 1st – July 31st
110 with P3T
55%
89 without P3T
45%
9 Sub-Optimal
8%
14 Sub-Optimal
16%
23 Total Suboptimal
Studies
PE Exam Analysis Breakdown
• 219 exams reviewed (August 1, 2011 through
October 19, 2011)
• 17 exams deemed suboptimal (7.8%)
– All exams used P3T® software
• Cross referenced Certegra™ data vs RIS
• Data-mining capabilities identified that 8 of the 17 exams were
performed during a certain time of the day
• Facilitated focused education and coaching to improve results
in the future
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PE Exam Analysis Breakdown
• ALGH results and progress since May 1st Certegra™ implementation
Non-diagnostic/Suboptimal PE Exams
35%
30%
25%
20%
15%
10%
5%
0%
Kelly AM et al
UPMC
Albany
ALGH
May 1st to
Jul 31st
ALGH
Aug 1st to
Oct 19th
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Snapshot of Data
Study Description
Brand
Concentration
Lot
Loaded
(mL)
Delivered
(mL)
2:54
CT CHEST PULM
EMBOLISM
Isovue
370
--
96.51
95.43
Female
1:24
CT CHEST PULM
EMBOLISM
Isovue
370
--
92.5
73.61
Male
21:00
CT CHEST PULM
EMBOLISM
Isovue
370
--
96.51
95.44
Female
11:12
CT CHEST PULM
EMBOLISM
Isovue
370
--
74.45
49.59
Female
5:00
CT CHEST PULM
EMBOLISM
Isovue
370
--
100.61
73.35
Female
0:33
CT CHEST PULM
EMBOLISM
Isovue
370
--
92.54
91.68
Female
11:53
CT CHEST PULM
EMBOLISM
Isovue
370
--
74.55
73.14
Female
18:14
CT CHEST PULM
EMBOLISM
Isovue
370
--
96.59
95.24
Female
1:12
CT CHEST PULM
EMBOLISM
Isovue
370
--
120.78
119.45
Male
17:04
CT CHEST PULM
EMBOLISM
Isovue
--
--
92.54
90.78
Female
23:34
CT CHEST PULM
EMBOLISM
Isovue
370
--
68.55
67.15
Gender
Study Time
Female
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ACR Guidelines for Communication of
Diagnostic Findings
Procedures and materials
• The report should include a description of the studies
and/or procedures performed and any contrast media
and/or radio-pharmaceuticals (including specific
administered activities, concentration, volume, and route
of administration when applicable), medications,
catheters, or devices used, if not recorded elsewhere.
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Documentation Gaps
• Analysis of Documentation Accuracy
– RIS (Manual Capture)
– PACS (Manual Capture)
– Injector (Automated)
• Methodology
– Pulled 102 accounts and reviewed documentation across 3
different documentation techniques
Examples
Study Date Study Description
A Loaded (ml) A Delivered (ml) RIS Volume RIS Volume Variance PACS Volume PACS Variance
Saline in PACS
8/14/2011 11:04 CT CHEST PULM EMBOLISM
71.49
70.14
200
129.86
51
19.14
Study Date Study Description
A Loaded (ml) A Delivered (ml) RIS Volume RIS Volume Variance PACS Volume PACS Variance
Saline in PACS
8/28/2011 0:05 CT CHEST, ABDOMEN AND
150.55
149.75
97
52.75
97
52.75
Results of Documentation
• Deviation from Actual Injection Record
RIS Differential
Greater than 5 mls
Greater than 10 mls
Greater than 20 mls
75%
61%
35%
PACS Differential
22%
14%
7%
Other Observations on Manual Data
• No Saline Delivery Information Captured
• No Flow Rate Information Captured
• Protocol Information Not Captured
Vision – Offer Closed Loop Contrast Dose
Management
Contrast
history
Hospital
Ref
Physician
HL/7
Radiology
HL/7
ISI
Protocol
Management
HIS/EMR
PHR
CT scanner
DICOM
Stellant
RIS
-Pharmacy
-Billing
DICOM
Certegra
Speech
Recognition
Reporting
PACS
MEDRAD Confidential, Internal Use Only
Modality
Utilization
and Analytics
Appendix
Flow Rates and Pressures
Pressure Related to Contrast Flow Rates with 22 g Catheters for CT Exams
300
A Peak Pressure (psi)
250
PSI
200
150
100
50
0
1.06
1.31
1.37
1.57
1.66
1.69
1.79
1.8
1.9
1.9
1.91
1.97
2.23
2.33
2.42
2.62
2.85
Flow rates with Isovue® 300 concentration (mL/s)
Isovue® is a registered trademark of Bracco Diagnostics Inc. MEDRAD, INC. has no relationship with Bracco
and none should be implied.
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Flow Rates and Pressures
Pressure Related to Contrast Flow Rates with 20 g Catheters for CT Exams
300
A Peak Pressure (psi)
250
PSI
200
150
100
50
0
4.76
4.76
4.77
4.77
4.78
4.79
4.8
4.95
4.97
5.24
5.26
5.26
5.3
5.37
5.41
Flow rates with Isovue® 370 concentration (mL/s)
Isovue® is a registered trademark of Bracco Diagnostics Inc. MEDRAD, INC. has no relationship with Bracco
and none should be implied.
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Using the Data to Drive Results
Contrast Efficiency
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Contrast Efficiency
For the past 219 PE exams:
ALGH averaged 79.3 mL of contrast
Compared to 100 to 125 mL of contrast
without P3T® software
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Contrast Waste Per Month
2000
1800
1600
Contrast mL
1400
1200
1000
800
600
400
200
0
May
June
July
August
2011
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Conclusions
• Delivering contrast has become more challenging with the
faster scanners
• CT suites need more tools to customize the dose per
patient and manage results
• Using P3T® PA for PE exams, ALGH improved diagnostic
outcomes while lowering contrast volumes
• Connect.PACS™ tools allowed for accurate quality
analysis of PE exams and established action plans for
further improvement
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THANK YOU
Questions?
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