Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study

Abstract

Objective: To investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED).

Materials and methods: This retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate.

Results: According to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4-27.5 hours) to 11.6 hours (6.6-21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5-30.1 hours) to 9.6 hours (5.7-19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6-16.5 hours) to 6.7 hours (4.9-11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001).

Conclusion: QIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.

Keywords: Dedicated emergency radiology; Emergency department length of stay; Intensive care unit admission rate; Quality improvement program; Timing of emergency surgery.

Fig. 1. Schematic time interval of the preoperative ED workflow.

The primary time intervals were designated as follows: 1) ED arrival to CT order, 2) CT order to CT completion, 3) CT completion to written radiology reporting (radiology TAT), and 4) radiology reporting to emergency surgical intervention (wait time for emergency surgery). The TES was defined as the interval from ED arrival to emergency surgical intervention (operating room entry). The ED LOS was defined as the interval from ED arrival to ED departure. ED = emergency department, LOS = length of stay, TAT = turnaround time, TES = timing of emergency surgery

Fig. 2. Proportion of patients whose written radiology reports were available before surgery in surgical emergency cases.

The curve shows the number of patients who underwent ES over time. Note that the rate of available written radiology reports is well maintained after implementing the quality improvement program including dedicated emergency radiology personnel despite an increase in the number of ES. ES = emergency surgery

Fig. 3. Flowchart of study patients.

ES = emergency surgery, QIP-DERP = quality improvement program including dedicated emergency radiology personnel

Fig. 4. Proportion of emergency surgery cases according to surgical timing before and after implementing the QIP-DERP.

A-D. Parts (A) to (D) represents a descending priority of surgical urgency. QIP-DERP = quality improvement program including dedicated emergency radiology personnel