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Just as interruptions and distractions can be problematic for any clinician, they can also impact radiologists (see our Patient Safety Tip of the Week for July 1, 2014 Interruptions and Radiologists and our What's New in the Patient Safety World columns for November 2014 More Radiologist Interruptions and May 2018 Cost of Interrupting a Radiologist). If a radiologist gets interrupted while interpreting an imaging study, he/she may forget a point they were intending to make in a report. Or they may have to go back to square one and begin review of the imaging study as a brand new one. If interrupted while dictating a report, they may have to go back to the beginning to be sure they have included all the necessary information.
Unfortunately, radiology rounds have largely become a thing of the past. In the old days our team of attendings, residents and students would finish rounding on patients and then head down to the radiology suite. There we would meet with a radiologist and review the images of our patients that were all hanging on the radiology boards?. So, it was a time the radiologist set aside from interpreting images and dictating reports. Today, with images on PACS systems, clinicians are likely to view images on their patients remotely. When they have questions, they contact the radiologist by phone (or other method). This results in the radiologist having more frequent interruptions and incursions on their workflow.
In our July 1, 2014 Patient Safety Tip of the Week Interruptions and Radiologists we took a look at the impact of interruptions and distractions on the workflow of radiologists. A study (Yu 2014) found that during a typical 8PM to 8AM overnight shift there was an average of 72 telephone calls, with a median call duration 57 seconds, and the average time spent on the phone was 108 minutes. The median interval from the start of one telephone call to the start of the next ranged from 3 to 10 minutes, depending on the time of day. There was also a correlation between volume of phone calls and the volume of CT scans being done (volume of other imaging studies was not measured as part of this study). That study did not include any measure of image interpretation accuracy or disparities between interpretations by the on-call radiologist and any subsequent interpretations.
In our What's New in the Patient Safety World column for November 2014 More Radiologist Interruptions we noted another study found a relationship between telephone calls to radiology residents on-call and discrepancies on reports (Balint 2014). There was a statistically significant increase in the average number of phone calls in the 1 hour preceding the generation of a discrepant preliminary report. The authors suggest that one additional phone call during the hour preceding the generation of a discrepant preliminary report resulted in a 12% increased likelihood of a resident error.
Recently, Shah and colleagues (Shah 2022) studied the workflow and impact of interruptions on pediatric radiologists at a large academic free-standing pediatric tertiary care facility with level 1 trauma. They found that total interruption time nearly equaled the total time interpreting studies for radiologists!
A business process improvement team was consulted to observe the activity of academic pediatric radiologists in the general, neuroradiology, and body reading rooms during daytime, evening, weekday, and weekend shifts. Activities were broken down into interpretation time (time spent reviewing and dictating studies), active interruptions (disruptions in interpretation initiated by the radiologist), and passive interruptions (disruptions in reading studies not initiated by the radiologist).
Three reading rooms were studied. The main reading room was responsible for interpreting the bulk of the radiographs and all inpatient ultrasound exams. It is situated close to the emergency department and is considered the central hub of the department. The neuroradiology reading room was responsible for all head, neck, and spine cross sectional imaging including CT and MRI scans. The body reading room was responsible for all cross-sectional non-neuro exams including musculoskeletal, cardiac, abdomen, and pelvic exams. Each reading area typically has 2 radiologists and up to 3 trainees, which may include medical students, residents, and fellows. Each reading area has its own workflow and resources. The main reading room had a dedicated reading room assistant who answers and triages incoming phone calls before notifying the radiologist.
Overall, radiologists spent 53% of their time interpreting studies, 18% on passive interruptions, and 29% on active interruptions, though the numbers varied by reading room type. Interruptions also varied by time of day with peaks during mid-morning and midafternoon times, corresponding with increased hospital-wide consultation of radiology. A majority of the interruptions were related to patient care.
Approximately 50% of non-interpretive time involved in-person conversations or consults (51% with colleagues, 17% with trainees, 16% with clinicians, and 14% with technologists). Other examples of non-interpretive activities included: calling a clinician, talking to a technologist, teaching a trainee, speaking with a colleague, signing paper orders, protocoling studies, responding to emails, administrative work, and technology issues. Phone calls represented 16% of non-interpretive time, of which 67% were incoming calls. Administrative work, including e-mail, comprised 13% of all non-interpretive time.
The longest time period recorded without an interruption was 20 minutes. Perhaps most importantly, 85% of the time an interruption came within 3 minutes of beginning an interpretation. 90% of interruptions lasted less than 3 minutes or less and 70% lasted 1 minute or less.
Interruptions clearly decreased efficiency and increased report interpretation times for all modalities studied. Interruptions not only cost the radiologist whatever time it took to address the interruption, but also cost additional total time to finalize the report dictation. Duplication of work occurred, as radiologists often needed to start again from the beginning when interpreting imaging studies.
There, of course, are bad interruptions and good interruptions. An interruption during which a radiologist conveys important information to a clinician is a good interruption. But, are there better ways to convey that information without interrupting the workflow of the radiologist? Shah and colleagues have some useful recommendations. They redesigned the central radiology reading room, combining the neuroradiology and body radiology reading rooms with sound barriers and strategic placement of a reading room assistant at the entrance to triage phone calls and direct visitors to the appropriate location. The reading room assistant hours were expanded to 24/7 and training was improved to assure consistency. Standardized phone call intake forms helped radiologists filter out non-urgent requests that could wait until an interpretative task was completed.
Asynchronous communication can help reduce radiologist interruptions and improve their workflow. Rather than having to respond to every individual phone call, some questions may be posed by text message or email and the corresponding responses made in between times when the radiologist is interpreting an imaging study or dictating a report. Fewer interruptions also mean the radiology reports can be posted on the PACS system or in the electronic medical record more promptly, further reducing the need for some interruptions. (Keep in mind the dangers of texting noted in our several columns listed below. However, most of those cautions apply to the issue of texting orders.)
Shah and colleagues implemented text-based communication through the EMR and phone-based application for more efficient communication with other departments and clinicians. A new PACS with worklist orchestrator and department-wide text-based communication is planned for the future.
They also addressed interruptions from radiology technologists. Imaging protocols were improved and standardized to minimize phone calls from technologists while assuring high quality image acquisition. Technologist training was also increased to allow for more independence and fewer instances of interrupting the radiologist.
And they modified trainee rotation schedules to assure that no more than one trainee would be with a radiologist at a time.
We suspect that an audit of interruptions for radiologists in most hospitals would reveal similar findings. The study by Shah and colleagues should give you some ideas to jump start a program of minimizing those interruptions and improving workflow and productivity of your radiologists.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
· January 28, 2020 Dang Those Cell Phones!
· September 2020 AORN on Distractions and Interruptions
· February 23, 2021 Cellphones and the OR
· November 2021 New Risk Factor for Patient Safety Events: Motor Vehicle Accidents
· January 11, 2022 Documenting Distractions in the OR
See our other Patient Safety Tip of the Week columns dealing with texting:
· January 28, 2020 Dang Those Cell Phones!
· February 23, 2021 Cellphones and the OR
Some of our prior columns on patient safety issues in the radiology suite:
· October 2020 New Warnings on Implants and MRI
· January 2021 New MRI Risk: Face Masks
· May 25, 2021 Yes, Radiologists Have Handoffs, Too
Yu J-P, Kansagra AP, Morgan J. The Radiologist's Workflow Environment: Evaluation of Disruptors and Potential Implications. JACR 2014; published online April 26, 2014
Balint BJ, Steenburg SD, Lin H, et al. Do Telephone Call Interruptions Have an Impact on Radiology Resident Diagnostic Accuracy? Academic Radiology 2014; published online September 30, 2014
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