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Computed Tomography Risk Disclosure in the Emergency Department: A Survey of Pediatric Emergency Medicine Fellowship Program Leaders.

ABSTRACT: Given the potential malignancy risks associated with computed tomography (CT), some physicians are increasingly advocating for risk disclosure to patients/families. Our goal was to evaluate the practices and attitudes of pediatric emergency medicine (PEM) fellowship program leaders' regarding CT radiation-risk disclosure.We conducted a cross-sectional survey study of the United States and Canadian PEM fellowship directors and associate/assistant directors. We developed a web-based survey using a modified Dillman technique. Primary outcome was the proportion who "almost always" or "most of the time" discussed potential malignancy risks from CT prior to ordering this test.Of 128 physicians who received the survey, 108 (86%) responded. Of those respondents, 73%, 95% confidence interval (CI) [64-81] reported "almost always" or "most of the time" discussing potential malignancy risks when ordering a CT for infants; proportions for toddlers, school-age children, and teenagers were 72% (95% CI [63-80]), 66% (95% CI [56-75]), and 58% (95% CI [48-67]), respectively (test for trend, p=0.008). Eighty percent reported being "extremely" or "very" comfortable discussing radiation risks. Factors of "high" or "very high" importance in disclosing risks included parent request for a CT not deemed clinically indicated for 94% of respondents, and parent-initiated queries about radiation risks for 79%. If risk disclosure became mandatory, 82% favored verbal discussion over written informed consent.PEM fellowship program leaders report frequently disclosing potential malignancy risks from CT, with the frequency varying inversely with patient age. Motivating factors for discussions included parental request for a CT deemed clinically unnecessary and parental inquiry about risks.

SUBMITTER: Marin JR

PROVIDER: S-EPMC6040898 | biostudies-other | 2018 Jul

REPOSITORIES: biostudies-other

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Computed Tomography Risk Disclosure in the Emergency Department: A Survey of Pediatric Emergency Medicine Fellowship Program Leaders.

Marin Jennifer R JR Thomas Karen E KE Mills Angela M AM Boutis Kathy K

The western journal of emergency medicine 20180604 4

<h4>Introduction</h4>Given the potential malignancy risks associated with computed tomography (CT), some physicians are increasingly advocating for risk disclosure to patients/families. Our goal was to evaluate the practices and attitudes of pediatric emergency medicine (PEM) fellowship program leaders' regarding CT radiation-risk disclosure.<h4>Methods</h4>We conducted a cross-sectional survey study of the United States and Canadian PEM fellowship directors and associate/assistant directors. We ...[more]

PMID: 30013709

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Project description:BACKGROUND:Reliably abstracting outcomes from free-text electronic health records remains a challenge. While automated classification of free text has been a popular medical informatics topic, performance validation using real-world clinical data has been limited. The two main approaches are linguistic (natural language processing [NLP]) and statistical (machine learning). The authors have developed a hybrid system for abstracting computed tomography (CT) reports for specified outcomes. OBJECTIVES:The objective was to measure performance of a hybrid NLP and machine learning system for automated outcome classification of emergency department (ED) CT imaging reports. The hypothesis was that such a system is comparable to medical personnel doing the data abstraction. METHODS:A secondary analysis was performed on a prior diagnostic imaging study on 3,710 blunt facial trauma victims. Staff radiologists dictated CT reports as free text, which were then deidentified. A trained data abstractor manually coded the reference standard outcome of acute orbital fracture, with a random subset double-coded for reliability. The data set was randomly split evenly into training and testing sets. Training patient reports were used as input to the Medical Language Extraction and Encoding (MedLEE) NLP tool to create structured output containing standardized medical terms and modifiers for certainty and temporal status. Findings were filtered for low certainty and past/future modifiers and then combined with the manual reference standard to generate decision tree classifiers using data mining tools Waikato Environment for Knowledge Analysis (WEKA) 3.7.5 and Salford Predictive Miner 6.6. Performance of decision tree classifiers was evaluated on the testing set with or without NLP processing. RESULTS:The performance of machine learning alone was comparable to prior NLP studies (sensitivity = 0.92, specificity = 0.93, precision = 0.95, recall = 0.93, f-score = 0.94), and the combined use of NLP and machine learning showed further improvement (sensitivity = 0.93, specificity = 0.97, precision = 0.97, recall = 0.96, f-score = 0.97). This performance is similar to, or better than, that of medical personnel in previous studies. CONCLUSIONS:A hybrid NLP and machine learning automated classification system shows promise in coding free-text electronic clinical data.

Project description:BackgroundPediatric emergency physicians complete either a pediatric or emergency residency before fellowship training. Fewer emergency graduates are pursuing a pediatric emergency fellowship during the past decade, and the reasons for this decrease are unclear.ObjectivesThe purpose of this study was to explore emergency residents' incentives and barriers to pursuing a fellowship in pediatric emergency medicine (PEM).MethodsThis was a cross-sectional survey-based study. In 2016, we emailed the study survey to all Emergency Medicine Residents' Association (EMRA) members. Survey questions included respondents' interest in a PEM fellowship and perceived incentives and barriers to PEM.ResultsOf 6620 EMRA members in 2016, 322 (5.0%) responded to the survey. Respondents were 59.6% male, with a mean age of 30.6 years. A total of 105 respondents (32.6%) were in their first year of emergency medicine residency, 92 (28.6%) were in their second year, 77 (23.9%) were in their third year, and 48 (14.9%) were in their fourth or fifth year. A total of 102 (31.8%) respondents planned to pursue fellowship training, whereas 120 (37.4%) were undecided. A total of 140 (43.8%) respondents reported considering a PEM fellowship at some point. Among these respondents, the most common incentives for PEM fellowship were (1) a desire to improve pediatric care in community emergency departments (86, 26.7%), (2) to develop an academic focus (54, 16.8%), and (3) because a mentor encouraged a PEM fellowship (40, 12.4%). A perceived lack of financial benefit (142, 44.1%) and length of PEM fellowship training (89, 27.6%) were the most commonly reported barriers.ConclusionIn a cross-sectional survey of EMRA members, almost half of the respondents considered a PEM fellowship. PEM leaders who want to promote emergency medicine to pediatric emergency residents will need to leverage the incentives and mitigate the perceived barriers to a PEM fellowship to increase the number of emergency residency applicants.

Project description:ObjectivesMost children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine.MethodsRetrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition.ResultsTwenty-five EM residents evaluated 17,642 patients (median = 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median = 22) medical resuscitations and 483 (median = 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses.ConclusionsEmergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.

Project description:BackgroundRapid magnetic resonance imaging (MRI) protocols may be effective in the emergency department (ED) to evaluate nontraumatic neurologic complaints. We evaluate neuroimaging (rapid MRI [rMRI]), head computerized tomography [HCT], and full MRI) use following widespread implementation of rMRI protocols in a pediatric emergency department (ED).MethodsWe conducted a retrospective study in a tertiary care pediatric ED of encounters with neuroimaging during two 9-month periods: one prior to (control period) and one after generalized availability of 4 rMRI protocols (rMRI period). The primary outcome was differences in neuroimaging rates between the two periods. Secondary outcomes included ED process measures, unsuccessful imaging, and undetected pathology, with full MRI within 14?days as the reference standard.ResultsThere were 1052 encounters with neuroimaging during the control and 1308 during the rMRI periods. Differences in neuroimaging between periods were 27.7% for rMRI (95% CI, 24.4, 31.0), -?21.5% for HCT (95% CI, -?25.5, -?17.5), and?-?6.2% for full MRI (95% CI, -?9.3, -?3.1%.) Time to imaging (182 [IQR 138-255] versus 86 [IQR 52-137] minutes) as well as ED length of stay (396 [IQR 304-484] versus 257 [IQR 196-334] minutes) was longer for rMRI versus HCT (p?<?0.01). Between the control and rMRI periods, there were differences in types of neuroimaging performed for patients with altered mental status, headache, seizure, shunt dysfunction, stroke, syncope, trauma, vomiting, infection, and other neurologic complaints (p?<?0.05). rMRI studies were unsuccessful in 3.6% of studies versus 0.0% of HCTs (p?<?0.01). The 22 unsuccessful rMRI studies were unsuccessful due to artifacts from dental hardware (n?=?2) and patient motion (n?=?20). None of the rMRI studies with full MRI follow-up imaging had undetected pathology; the false negative rate for the HCT exams was as high as 25%.ConclusionsAfter routine ED use of 4 rMRI protocols, there was a more than 20% decrease in HCT use without missed diagnoses. Time to neuroimaging and length of stay were longer for rMRI than HCT, with higher rates of unsuccessful imaging. Despite these limitations, rMRI may be an alternative to HCT for nontraumatic complaints in the ED.

Dataset Information

Computed Tomography Risk Disclosure in the Emergency Department: A Survey of Pediatric Emergency Medicine Fellowship Program Leaders.

Publications

Computed Tomography Risk Disclosure in the Emergency Department: A Survey of Pediatric Emergency Medicine Fellowship Program Leaders.

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