Healthcare Consulting Services
Healthcare Consulting Services with a Focus on Patient Safety Solutions and Quality Improvement Across the Health Care Continuum. Your Patient Safety Resource Solution.
January 17, 2017
Pediatric MRI Safety
In our January 2017 What's New in the Patient Safety World column “Still Too Many CT Scans for Pediatric Appendicitis” we cited a recent presentation at the 2016 RSNA meeting that showed the use of MRI scanning in pediatric patients has been increasing in the emergency department at a major New York City hospital (Hulkower 2016). We suspect that is a trend we’d see at many hospitals across the country. The reasons for more MRI scans are mostly due to the increased availability of MRI, the campaigns to reduce the use of ionizing radiation, particularly in children, such as the Imaging Gently® campaign, and the fact that some diagnoses are more readily found on MRI than on CT scan. In the Hulkower study the increase in MRI was primarily driven by neurological imaging and there was a corresponding decrease in the use of CT scanning.
Along with that trend we’d be concerned we may see more patient safety issues arising. We’ve actually done numerous columns on patient safety related to MRI scanning (see the full list at the end of today’s column) and pediatric patients have special concerns that render them more vulnerable to safety incidents during MRI.
In our February 19, 2008 Patient Safety Tip of the Week “MRI Safety” we noted that not even a month after the first published paper on projectile cylinder accidents in MRI units (Chaljub 2001) there was a fatality related to an MR-related projectile accident. A 6 y.o. boy developed respiratory distress while undergoing an MRI. There was a problem with the oxygen source in the MRI suite. Both MR technologists briefly left the MR suite to try to resolve the issue but in the interim a nurse responding to anesthesiologist’s calls for help found an oxygen cylinder in the control room and brought it into the MR room. Unfortunately, it was steel cylinder and the MR pulled the cylinder free, thrusting it into the bore of the MR machine and causing a fatal head injury to the boy. Root cause analysis of the latter event by Tobias Gilk and Robert Latino (Gilk 2011, video ) showed the typical cascade of events and errors that collectively led to the unfortunate outcome. Many of the same conditions and events occurred in the cases assembled by Chaljub et al. had reported on 5 projectile cylinder accidents at 2 academic medical centers. Cases involved ferromagnetic cylinders of oxygen or nitrous oxide inadvertently being introduced into the MR rooms and turned into projectiles by the magnetic forces of the MR machine, resulting in patient injury or damage to the MR unit or both. They also sent out questionnaires to multiple academic MR units and found slightly more than 50% of those who responded had experienced similar projectile incidents. Objects involved included vacuum cleaners, mop buckets, tools boxes, ventilators, defibrillators, wheelchairs, IV poles, etc. Failure to adhere to MR safety policies and human error were cited as the most common reasons for the accidents.
Another recent presentation at the 2016 RSNA meeting showed that the prevalence of safety reports in MRI performed in children is increased relative to previously published data on adults (Jaimes Cobos 2016). They found the rate of such reports was 0.53%, compared to a 0.35% rate of incident reporting for adults at the same hospital (Mansouri 2016). Jaimes Cobos and colleagues found that younger children had higher rates of safety reports: newborns (1.1%), infants (1.1%), and young children (0.9%). Those rates were significantly higher than those in older children. The odds ratio of younger children (<6 yrs) having a safety report relative to older children (>6yr) was 2.2. As in adults, the rates were highest for inpatients, followed by ER patients, then outpatients. The majority of events caused no harm or only minor harm. There were no deaths and only 3% of the incidents reported involved major harm. Children below the age of 6 years, inpatients, and use of sedation or general anesthesia were all factors associated with higher safety report rates. The most common causes of safety reports were service coordination and adverse drug reactions. You’ll recall from our numerous columns on patient safety in the radiology suite (full list below) that the majority of patient safety issues seen in the radiology suite have little to do with the imaging study or radiology itself. Rather it is the confluence of vulnerable patients being temporarily in an environment where communication and coordination issues can be problematic.
In our Patient Safety Tips of the Week for March 17, 2009 “More on MRI Safety” and October 25, 2011 “Renewed Focus on MRI Safety” we discussed some of the care coordination issues that arise for any patient undergoing MRI. We discussed the American Society of Anesthesiologists Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging, which has now been updated in 2015 (ASA 2015). It states that the anesthesiologist needs to develop a plan for implementing anesthesia care before each individual case. Such a plan should be done in collaboration with other personnel who will be involved in the care of the patient, including the MRI technician, radiologist, radiology nurse, other clinical personnel accompanying the patient and even the facility biomedical engineer. In addition to the anesthetic plan, preparation includes a plan for optimal positioning of equipment and personnel in the MRI suite during the procedure. We refer you to that guideline for details. The anesthesiologist should also prepare a plan for rapidly summoning additional personnel in the event of an emergency.
We suggested a few additions to this otherwise excellent ASA practice advisory. First is the importance of determining up front whether the MRI is truly indicated, whether the potential benefits of performing the MRI outweigh the potential risks, and whether alternative safer imaging modalities might suffice. In many of the incidents we’ve seen occurring in ICU patients transported to the MRI suite or radiology suite, we’ve been surprised at how often the scan being done was really of marginal value.
Second is the need for a huddle/timeout before the procedure is performed. We should approach doing MRI on these critically ill patients in the same manner in which we approach patients going to the OR. A “huddle” or whatever else you’d like to call a pre-procedure briefing is very important in such cases. Not only do you need to know you have all the equipment needed, but you also need to know everyone’s role and have contingency plans for emergencies. This is where you ensure all parties know what to do if there is a fire or if there is a cardiopulmonary arrest or a “quench”. You discuss what location you will need to move the patient to in such events. You discuss the availability and location of equipment and medications you may need. You discuss the line of sight required and where the monitoring equipment will be deployed. You may need to discuss also how you will communicate (with both staff and patient) given the high noise levels associated with MRI scanning. You should probably even discuss the potential impact of the lighting levels in the various zones (and fact that you may not be able to wear your ferromagnetic glasses in Zones III and IV).
Third, really related to the above, is use of a checklist. To remember all the needs for the procedure (which vary be individual patient) and the contingencies you have to plan for is really too much to expect for any individual or group of individuals. That’s where the simple checklist comes in: it helps you to remember details you might otherwise overlook.
Fourth, you need to practice. We wonder how many MRI facilities, particularly hospital-based ones, actually simulate an emergency during MRI scanning.
Use of sedation is probably the most serious issue in pediatric MRI safety. Our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation” discussed the recently updated American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” (Coté 2016). We refer you to our prior column and the updated guideline itself for all the details needed in performing safe sedation in pediatric patients for any procedure. But the guideline has an excellent section on sedation in the MRI suite, which is a very restricted environment and has needs for special equipment and monitoring techniques as we have discussed in our numerous columns on patient safety issues in the radiology and MRI suites. It notes that MRI-compatible pulse oximeters and capnographs capable of continuous function during scanning should be used in any sedated or restrained pediatric patient. Appropriate precautions must be taken to avoid thermal injuries. For example, the practitioner is cautioned to avoid coiling of all wires (oximeter, ECG) and to place the oximeter probe as far from the magnetic coil as possible to diminish the possibility of injury. It notes that ECG monitoring during MRI has been associated with thermal injury and that special MRI-compatible ECG pads are essential to allow safe monitoring. If sedation is achieved by using an infusion pump, then either an MRI-compatible pump is required or the pump must be situated outside of the room with long infusion tubing so as to maintain infusion accuracy. All equipment must be MRI compatible, including items such as laryngoscope blades and handles, oxygen tanks, and any ancillary equipment. In addition, all individuals, including parents, must be screened for ferromagnetic materials, phones, pagers, pens, credit cards, watches, surgical implants, pacemakers, etc, before entry into the MRI suite.
In our August 2010 What's New in the Patient Safety World column “Sedation Costs for Pediatric MRI” we discussed a study (Vanderby 2010) that addressed the financial impact of sedation for MRI scanning in pediatrics. They analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario. They found that the average time spent in the MRI suite was 2 hours and 21 minutes for children scanned awake, 3 hours 38 minutes for those sedated, and 4 hours 7 minutes for those anesthetized. Corresponding average costs (in Canadian dollars) were $54.68, $177.27, and $522.73 respectively. The Toronto group used their analysis to significantly redesign workflow and scheduling. This article has a good discussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization. To their recommendations we would again add that strong consideration needs to be given to the appropriateness of the MRI scan, in light of the patient safety and cost issues involved.
Note that the Hulkower study noted above (Hulkower 2016) also had some workflow implications. They found the highest pediatric MRI volume was during the evening and early nighttime hours with peak volume occurring during the 10 PM hour when 8.2% of MRI exams were performed. That suggested the need for deployment of additional resources at certain times and need for availability of radiologists, particularly those with expertise in neurological MRI, to read the MRI scans.
We discussed another issue primarily related to pediatric patients in our August 2012 What's New in the Patient Safety World column “Newest MRI Hazard: Ingested Magnets”: harm due to MRI in patients who have ingested magnets. Small children frequently ingest non-food items and may not be able to verbally tell you they did so. A cited paper (Bailey 2012) described a case of a 5 y.o. boy who had ingested magnets and had an MRI that led to bowel perforation. The authors reviewed the literature and came up with a recommended tool to screen for magnets before MRI is performed. The authors note that most cases of ingested magnets occur in young children and most often boys and are often, in fact typically, not witnessed. Most are passed in the stool without incident and less than 10% require intervention (only 1% requiring surgery). However, swallowing multiple magnets may be more troublesome since the magnets adhere to each other, increasing the likelihood they might obstruct the bowel. In their index case, the authors note the patient actually presented to an ED with complaints of neck pain. Initial workup focused on the cervical spine and included a normal CT scan of the neck and normal lumbar puncture. A decision to do an MRI of the brain and cervical spine was then done under moderate sedation and was also negative. The following day his neck pain was better but he now had severe abdominal pain and would not eat. Abdominal X-rays showed air in the peritoneal cavity and 11 small round metallic objects in the left upper quadrant. At surgery, four full-thickness small intestinal perforations were found and 11 small spherical magnets were removed from the peritoneal cavity. The magnets were most likely from a magnetic game the child had been playing near. He had an uneventful recovery.
The hospital changed their MRI screening protocol. While they still do a written and verbal questionnaire of the children and parents for presence of metallic objects, they now also have all children change into a hospital gown and undergo screening using a hand-held ferromagnetic detection scanner.
An FDA safety warning just released (FDA 2017a) about MRI and implantable infusion pumps could apply to children as well as adults. FDA has received reports, including some with serious patient harm or death, of problems with such pumps following MRI. They have noted issues such as medication dosing inaccuracies (e.g., over-infusion or under-infusion, unintended bolus) and other mechanical problems with the pump (e.g., motor stall, pump not restarting after an MRI exam). FDA recommends that the “implant card” (which is usually issued at the time of pump implantation) for the specific implantable infusion pump accompany the patient to the MRI site so that the MRI technologist and team can identify the specific pump model to locate the specific MRI safety information for that pump. It even recommends patients consider obtaining a medical alert bracelet or necklace to notify medical professionals that they have an implantable pump. Even when the specified conditions of MR Conditional use have been followed, the implantable pump may need to be checked and/or reprogrammed by the healthcare team responsible for the pump. And don’t forget that only implantable infusion pumps labeled as “MR Conditional” may be safely scanned, and only under the specific conditions of safe use. A companion document (FDA 2017b) provides recommendations for patients, MRI technologists, radiologists, healthcare professionals who implant and those who manage the infusion pumps, and those who prescribe/order MRI exams.
Lastly, a coalition of societies and organizations dealing with MRI has proposed a delineation of responsibilities for the management of MRI facilities (Calamante 2016). Though it does not specifically note issues related to pediatric patients, this document does a nice job of identifying the roles of various people in ensuring overall safety in an organization’s MRI activities and the types of safety activities that should be undertaken.
You’ll also find many valuable tips on MRI safety for both children and adults in our previous columns listed below.
Some of our prior columns on patient safety issues related to MRI:
Some of our prior columns on patient safety issues in the radiology suite:
Hulkower M, Taragin B, Davoudzadeh R, et al. Pediatric MRI in the Emergency Department Over Five Years: An Analysis of Usage and Trends. Program SSQ17-06. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
Imaging Gently® Campaign
Chaljub G, Kramer LA, Johnson RF, Johnson RF, Singh H, Crow WN. Projectile Cylinder Accidents Resulting from the Presence of Ferromagnetic Nitrous Oxide or Oxygen Tanks in the MR Suite. Am. J. Roentgenol 2001; 177: 27-30
Gilk T, Latino RJ. MRI Safety 10 Years Later. What can we learn from the accident that killed Michael Colombini? Patient Safety and Quality Healthcare 2011; online first Nov-Dec 2011
Latino RJ, Gilk T. Healthcare RCA - Michael Colombini MRI. Root Cause Analysis Movie: Colombini MRI Case: - 10 Years Later. Reliability Center, Inc. 2011
Jaimes Cobos C, Murcia D, Miguel K, et al. Identification of Quality Improvement Areas in Pediatric MRI from Analysis of Patient Safety Reports. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
Mansouri M, Aran S, Harvey HB, et al. Rates of safety incident reporting in MRI in a large academic medical center. Journal of Magnetic Resonance Imaging 2016. 43(4): 998-1007
ASA (American Society of Anesthesiologists). Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging: An Updated Report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. Anesthesiology 2015; 122(3): 495-520
Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138(1): e2016121
Vanderby SA, Babyn PS, Carter MW, et al. Effect of Anesthesia and Sedation on Pediatric MR Imaging Patient Flow. Radiology 2010; 256(1): 229-237
Bailey JR, Eisner EA, Edmonds EW. Unwitnessed magnet ingestion in a 5 year-old boy leading to bowel perforation after magnetic resonance imaging: case report of a rare but potentially detrimental complication. Patient Safety in Surgery 2012; 6: 16 (19 July 2012)
FDA (US Food & Drug Administration). Implantable Infusion Pumps in the Magnetic Resonance (MR) Environment: FDA Safety Communication - Important Safety Precautions. FDA 2017; January 11, 2017
FDA (US Food & Drug Administration). Safety Concerns with Implantable Infusion Pumps in the Magnetic Resonance (MR) Environment: FDA Safety Communication. FDA 2017; January 11, 2017
Calamante F, Ittermann B, Kanal E, The Inter-Society Working Group on MR Safety and Norris D. Recommended responsibilities for management of MR safety. JMRI 2016; Early View 3 Jun 2016
Print “Pediatric MRI Safety”
To get "Patient Safety Tip of the Week " emailed to you, click here and enter "subscribe" in the subject field.
If you don't see the search term you expected to see here, its probably because that tip already went to our Tip of the Week Archive. We do a new tip every week. Click here to search the entire site or you can Go to Tip of the Week Archive a patient safety resource solution loaded with tips, tools, and techniques you can use in your patient safety and quality improvement initiatives. Or it may have moved to our What's New Archive.
Click here to see the consulting services and patient safety solutions that we provide.
Click on the "Contact Us" button at the left to send us your comments on our "What's New in the Patient Safety World" columns.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
Thank goodness The Joint Commission listens. In our May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?” we decried The Joint Commission’s proposed rescinding of its ban on texted orders.
The Joint Commission had announced its intent to rescind the ban on texting orders in April 2016 (TJC 2016a, TJC 2016b). But shortly thereafter TJC put a temporary hold on that rescinding, therein keeping the ban on texting orders while it gathered more input and information (TJC 2016c).
In our May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?” we identified the following areas of concern regarding texted orders:
See that previous column for details on each of those concerns.
Now The Joint Commission, in conjunction with CMS (Centers for Medicare & Medicaid Services), has clarified position on texting orders, reaffirming that sending orders via a secure text messaging is not permitted at this time (TJC 2016d). It highlighted several factors influencing its decision. For example, compared to verbal orders which allow for a real-time two-way discussion that allows for clarification of orders, texted orders would not allow such synchronous real-time discussion. And it would likely add to the burden on nurses (in our May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?” we noted that nurses would have additional burdens due to more telephone tag and to physicians taking the shortcut and avoiding having to input orders via CPOE). It also noted that clinical decision support tools would not be directly available to the ordering physician and that nurses entering the orders would need to track down the ordering physician if clinical decision support messages popped up when they were inputting orders. TJC reaffirms that CPOE is the preferred method for order entry.
The Joint Commission, in its clarification, recognizes that “CPOE is increasingly available through secure, encrypted applications for smartphones and tablets, which will make following this recommendation less burdensome.” It then notes that when access to CPOE is not directly available verbal orders would be an acceptable alternative, keeping in mind that verbal orders must meet all Joint Commission requirements for verbal orders. We also encourage you to look back at the recommendations in our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders”. Keep in mind that some of the security issues (pro and con) related to texting apply even more so to verbal orders. In particular, you should have a mechanism in place to ensure the identity of the person phoning in a verbal order. You’d be surprised how often staff at hospitals tell us they identify the caller “because we know his/her voice”.
It’s been reported that vendors and patient advocates have criticized this continuation of the ban following new Joint Commission and CMS clarification of secure texting rules (Sutner 2016). It’s pretty clear why vendors of secure texting applications would oppose continuation of the ban. But we don’t understand how patient advocates would oppose keeping in place something that can prevent significant patient safety risks.
We remain staunch advocates for use of advanced technology to improve healthcare. Secure text messaging has numerous ways to improve communication in healthcare and we advocate its use (for example, it can be extremely useful in helping to prevent alarm fatigue). But texting orders should not be allowed. We commend the Joint Commission’s decision to keep the ban on texting orders in place.
TJC (The Joint Commission). Orders – Texting. What is The Joint Commission's position on texting orders? The Joint Commission 2016
TJC (The Joint Commission). Update: Texting Orders. Joint Commission Perspectives 2016; 36(5): 15
TJC (The Joint Commission). Joint Commission Online. June 8, 2016
TJC (The Joint Commission). Clarification: Use of Secure Text Messaging for Patient Care Orders Is Not Acceptable. Joint Commission Perspectives 2016;
36(12): 9 December 2016
Sutner S. Joint Commission bans CPOE secure texting for physicians. Vendors and patient advocates criticize computerized physician order entry ban following new Joint Commission and CMS clarification of secure texting rules. SearchHealthIT 2016; December 28, 2016
In our September 2016 What's New in the Patient Safety World column “Too Much of a Good Thing” we noted some studies that suggested that some quality of care measures and even mortality might be lower at hospitals having high ICU utilization rates.
In that column we noted that the Society for Critical Care Medicine has just updated its guidelines for admission to and discharge from critical care units (Nates 2016). The guidelines also have recommendations for prioritization and triage of potential ICU patients based upon factors such as severity of illness, functional impairment, comorbidities, prognosis for recovery and quality of life, patient preferences with regard to life-sustaining treatment, etc. Chronological age should not be a primary determinant in the elderly. One important recommendation under discharge guidelines is to avoid “after hours” discharge (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” regarding huddles with bed coordinators to avoid such after hours transfers from the ICU). The guidelines also discuss potential sites to which discharge from the ICU can occur, including general wards, step down units, post-acute care facilities, etc. They also discuss use of outreach programs to supplement ICU care, such as rapid response teams and ICU consult teams on wards.
Using those SCCM guidelines, Chang and colleagues (Chang 2016) retrospectively analyzed a year’s worth of ICU admissions at Harbor-UCLA Medical Center to determine appropriateness for ICU use. The levels were priority1 (critically ill and needing intensive treatment and monitoring that cannot be provided outside an ICU), priority 2 (not critically ill, but requiring close monitoring or potential immediate intervention), priority 3 (critically ill but with reduced likelihood of recovery because of underlying diseases or severity of acute illness), and priority 4 (not appropriate for ICU, similar outcomes can be achieved in non-ICU settings), and a fifth priority category they added for patients awaiting transfer out of the ICU.
Not surprisingly, only 46.9% were determined to be priority 1 so just over 50% were deemed to potentially have received adequate care in non-ICU settings. And 65% of total ICU bed days were “allocated to care that was considered discretionary monitoring (priority 2), low likelihood of benefit despite critical illness (priority 3), or manageable in non-ICU settings (priority 4 or 5).”
Of the priority 3 patients (those critically ill but having an underlying disease that led to a limited likelihood of recovery), 26% had advance malignant neoplasms and 27% had advanced dementia.
We’re not surprised by the findings. For years we (medical director and director of nursing) would periodically do “ICU Bed Rounds” where we similarly assessed appropriateness for ICU level care, albeit with criteria that were less well-established than those in the SCCM guidelines. We also routinely found that about half the patients could be receiving care in alternative sites.
We recognized several factors that contributed to putting patients in an ICU who could have received adequate care elsewhere. Sometimes it was pressure from families to “do everything possible”. Other times it was pressure from housestaff to move “sicker” patients to a different service. Occasionally, it was unavailability of “downstream” beds. But there were other less obvious factors. Most prominent was the disconnect between a physician’s concern that a patient needs a higher level of nursing care when what the patient needed primarily was monitoring. For example, patients who were stable but had conditions that could conceivably have fatal outcomes were often put in the ICU for monitoring even though they actually needed very little nursing intervention (roughly equivalent to priority 2 in the SCCM guidelines). Second, Roemer’s Law (if you have beds someone will fill them) applies. While Roemer’s Law was intended to apply to a region’s supply of hospital beds, the same concept applies to ICU beds within a hospital. A third, and usually unmentionable, factor has to do with reimbursement. While hospital reimbursement may or may not be impacted by the level of care utilized by patients, there may be physician reimbursement issues (for daily care and for procedures) that serve as barriers to moving patients to other levels of care. You’d be surprised how ICU utilization can be reduced if your intensivists are paid in a manner that removes such financial incentives “to do more”. As long as hospitals are on a DRG (or other fixed payment) methodology and physicians on a fee-for-service methodology you will always have conflicts of interest that impact both total hospital utilization and ICU utilization.
Chang and colleagues also point out that there are other important factors, such as the level of availability of monitoring and care in the non-ICU areas. You’ll recall that we have even recommended ICU care for some high-risk patients (such as a patient with sleep apnea receiving opioids) if continuous physiological monitoring and capnography are not available on a med-surg floor or step-down unit.
Our previous column concluded that hospitals need to take a close look at their ICU utilization. We still see hospitals that lack formal criteria for ICU admission and discharge or have them but don’t adhere to them. Yes, ICU’s provide patients with levels of nursing care and monitoring that should be advantageous but they also expose patients to a variety of potential hazards (nosocomial infections, invasive procedures, etc.). And provision of services that don’t result in better patient outcomes may be detrimental to the fiscal health of the hospital.
Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines. A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med 2016; 44(8): 1553-1602
Chang DW, Dacosta D, Shapiro MF. Priority Levels in Medical Intensive Care at an Academic Public Hospital. JAMA Intern Med 2016; Published online December 27, 2016
It’s been a while since we last discussed efforts to reduce patient exposure to ionizing radiation. We’ve previously discussed the Imaging Gently® and Imaging Wisely® campaigns, which are attempts to reduce the inappropriate use of imaging with ionizing radiation when safer alternatives are available (see our multiple columns on radiation safety and the Imaging Gently® and Imaging Wisely® campaigns listed below).
One particular area in which efforts have been focused is minimizing use of CT scanning for pediatric appendicitis, instead using modalities that avoid ionizing radiation like ultrasound or, to a lesser degree, MRI.
A retrospective study looked at imaging performed in children prior to appendectomy for acute appendicitis at a metropolitan hospital system that had one children’s hospital and eight non-children’s hospitals (Anderson 2016). They found that children's hospital patients had fewer computed tomography scans (23% vs 70%) and more ultrasonography (75% vs 20%). At non–children's hospitals, older age (age >10) and higher patient weight (>45 kg) predicted computed tomography use. Another recent retrospective study compared imaging for suspected pediatric appendicitis between definitive care hospitals and the hospitals referring to those centers (Glass 2016). About a third of patients had an attempt at imaging before transfer to the definitive care hospitals. The overall odds of an initial attempt at ultrasound prior to CT was 11.1 times greater and the odds of receiving any ultrasound was 6.25-times greater at definitive care hospitals compared to referral hospitals. A 2015 study of over 2500 Washington State appendectomy patients 18 years old and under (Kotagal 2015) found that 52.7% had a CT scan as their first imaging study. Evaluation at a non-children’s hospital was associated with higher odds of CT use (OR 7.9). Similar to the Anderson study, children age >10 and obesity were associated with higher rates of CT scanning.
Russell and colleagues developed a clinical practice guideline that focused on examination, early surgeon involvement, and utilization of ultrasound as the initial imaging modality for evaluation of abdominal pain concerning for appendicitis in a children’s hospital emergency department (Russell 2013). After implementation of that guideline for evaluation of abdominal pain concerning for appendicitis they saw a 41% decrease in CT use for patients undergoing appendectomy without an increase in the negative appendectomy rate or missed appendicitis. Even more striking, in the subset of patients undergoing appendectomy without imaging from an outside hospital, CT scan utilization decreased from 82% to 20%, a 76% reduction.
Ultrasound is the modality used most often as an alternative to CT scanning for suspected appendicitis. What about MRI scanning? A 2015 study found that MRI had excellent diagnostic accuracy and was associated with good outcomes in cases of suspected appendicitis (Kulaylat 2015). Those findings, in conjunction with avoiding ionizing radiation, led to the authors’ suggestion that MRI may supplant the role of CT scans in pediatric appendicitis imaging. We don’t have any statistics on how often MRI scanning is being used for pediatric appendicitis. However, a recent presentation at the 2016 RSNA meeting showed that use of overall MRI scanning in pediatric patients has been increasing at a major New York City hospital (Hulkower 2016). In a discussion of that presentation (Forrest 2016) it was noted that the rates for “trunk” exams were steady until the final year of the study (2015) “when there was an uptick, likely due to an emphasis on performing more MRIs than CTs for appendicitis workups”. We don’t have a position on the role of MRI in suspected pediatric appendicitis. We expect, however, to be doing another column in the future on issues of safety in pediatric patients undergoing MRI.
There likely are multiple factors, aside from lack of awareness, contributing to the continued performance of CT scans for suspected pediatric appendicitis that seems prevalent in non-children’s hospitals. One is that the early surgical consultation, as emphasized in the Russell study, may not be readily available in the non-children’s hospitals (since such patients are often transferred to children’s hospitals if they need surgery). Another and perhaps more likely factor is that it’s often easier to find a CT technician than a pediatric ultrasound technician at non-children’s hospitals.
Bottom line: there continue to be too many CT scans for suspected appendicitis in children seen at non-children’s hospitals. This makes for an opportunity to do community-wide collaboratives that identify and track the rates of such CT use at all area hospitals, look for root causes, and perhaps set up programs where pediatric surgeons would be available via telemedicine for early evaluation of such patients and discussion as to whether imaging without ionizing radiation is possible or whether the patient should be transferred to the children’s hospital for such studies.
Some of our previous columns on the issue of radiation risk:
Anderson KT, Putnam LR, Caldwell KM, et al. Imaging gently? Higher rates of computed tomography imaging for pediatric appendicitis in non–children's hospitals
Presented at the 11th Annual Academic Surgical Congress in Jacksonville, FL, February 2–4, 2016. Surgery 2016; Articles in Press December 2, 2016
Glass CC, Saito JM, Sidhwa F, et al, Diagnostic imaging practices for children with suspected appendicitis evaluated at definitive care hospitals and their associated referral centers. J Pediatr Surg 2016; 51: 912-916
Kotagal M, Richards MK, Flum DR, et al. Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis. J Pediatr Surg 2015; 50: 642-646
Russell WS, Schuh AM, Hill JG, et al, Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care 2013; 29: 568-573
Kulaylat AN, Moore MM, Engbrecht BW, et al. An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis. J Pediatr Surg 2015; 50: 1359-1363
Hulkower M, Taragin B, Davoudzadeh R, et al. Pediatric MRI in the Emergency Department Over Five Years: An Analysis of Usage and Trends. Program SSQ17-06. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
as discussed in:
Forrest W. Why are pediatric MRI scans on the rise in the ED? AuntMinnie.com 2016; December 27, 2016
Studies have generally shown that higher nurse:patient ratios are associated with better quality of care and lower mortality rates. But the number of nurses is not the only important factor. Nursing skill mix is another consideration.
A recent study from European hospitals participating in the RN4CAST Consortium looked at the relationship between hospital nursing skill mix and quality of care, mortality, and patient ratings (Aiken 2016). They found that every 10-point increase in the percentage of professional nurses among all nursing personnel was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80<OR<0.93), after adjusting for patient and hospital factors. Each 10 percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death.
In a commentary (Needleman 2016) on the Aiken study, Needleman notes that previous studies from Canada and the US have also shown lower nursing skill mix to be associated with higher rates of adverse events and longer lengths of stay. Needleman in a previous study (Needleman 2006) had shown that greater use of RNs in preference to LPNs appears to reduce in-hospital patient deaths and pay for itself.
These studies, of course, fly in the face of recent trends to replace RN’s with less skilled levels of nursing care in attempt to reduce hospital costs. Such reductions in higher level nursing staff may paradoxically (because of increased adverse events and longer lengths of stay) increase hospital costs.
A 2015 review of the literature on nursing case mix (Jacob 2015) found that economic savings from substituting registered nurses with other health professionals may be offset by increased patient length of stay in hospital and increased patient mortality.
Some studies have suggested that differences in the importance of skill mix may differ between medical and surgical admissions. Li and colleagues, using data on both nursing staffing and nurse skill mix at the unit, rather than hospital, level (Li 2011) found that for medical admissions, a business case could be made for improving nurse staffing by increasing the proportion of RN hours while holding total nursing hours unchanged.
Ironically, almost the same day that the Aiken study was published a news article was published on the development of a nurse robot through collaboration between Duke’s School of Engineering and School of Nursing (Bridges 2016). But don’t worry- it’s not intended to replace nurses! Rather it is being developed to assist nurses and other healthcare workers in certain environments. The example given in the article is assisting in the care of an Ebola patient.
We’d like to add one other consideration. In our multiple columns on the “weekend” or “after hours” effect we’ve pointed out the numerous non-nursing tasks that nurses end up doing. The roles of clerical staff, housekeeping staff, transport staff, etc. are not accounted for in the nursing skill mix formulas in studies done to date. We think that in addition to maintaining good nurse:patient ratios and high levels of nursing skill mix you need to ensure that nurses have time to attend to clinical tasks and not be burdened by non-clinical tasks.
Aiken LH, Sloane D, Griffiths P, et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care
BMJ Qual Saf 2016; Published Online First 15 November 2016
Needleman J. Nursing skill mix and patient outcomes (Editorial). BMJ Qual Saf 2016; December 30, 2016
Needleman J, Buerhaus PI, Stewart M, et al. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood) 2006; 25: 204-211
Jacob ER, McKenna L, D'Amore A. The changing skill mix in nursing: considerations for and against different levels of nurse. J Nurs Manag 2015; 23: 421-426
Li Y-F, Wong ES, Sales AE, et al. Nurse staffing and patient care costs in acute inpatient nursing units. Med Care 2011; 49: 708-715
Bridges V. Duke officials test, refine robot-nurse. The News & Observer (North Carolina) 2016; November 16, 2016
Go to the "Whats New Archive"
To get "What's New in the Patient Safety World"emailed to you,click here and enter "subscribe" in the subject field.
To get "What's New in the Patient Safety World"emailed to you,click here and enter "subscribe" in the subject field.