Donna Magid, MD, M.Ed
One does not ‘order’ an exam, one requests a consultation from a Radiologist. The actual process of inputting a request, either on-line through Physician Order Entry (POE), Epic, or via the fax forms on the floor, is subject to constant change; therefore showing you the actual mechanics will be left up to the individual floors and services. In the same vein, many studies—especially after 5 PM or on weekends—must be approved in direct discussion with the relevant Radiologist. Again, the array of timetables and phone numbers—where to call until 5 PM, where to call nights and weekends, which subspecialty service, who is on call—is confusing and in constant flux.
The simplest access to phone numbers and information 24/7 is 3rads.jhmi.edu. It has all the contact #'s for the different departments during different times of the day. After hours call 3 RADS; the complexity of subspecialty Imaging and call is daunting. During business hours, one generally calls the imaging location itself—i.e. Tower Fluoroscopy (GI studies) 5-2818, Body CT 5-5050, Cardio Vascular Diagnostic Lab On-Call (443-28)7-CVDL; NeuroRadiology 5-7350, 5-7440, 7-6297 (Reader); US 5-7488 or 5-5811; MRI Body 5-4147. The Central Radiology front desk, 5-6501 (8:30-5, M-F), also can help steer traffic through the maze with an astonishing wealth of knowledge and numbers. HOWEVER the sprawl of each modality across multiple buildings—Body CT for example, in Zayed is divided into Emergency Dept (G) , Adult In-Patient (4th), Pediatric In-Patient, Weinberg 2, and JHOC 3—and the shift changes (some at 4PM, some at 5PM, some at 8:30PM, some at 11 PM) make it beyond confusing. When in doubt, ask the house officer/physician who has asked you to help schedule a study how to proceed; then if still unsure, call the Emergency Radiology Resident on beeper 3-RADS.
Whether scheduling a non-emergent, emergent, in-, or out-patient, for same day or for several days hence, there are certain basic immutable constants which must be observed, no matter how and when a study is requested. Absence or inaccuracy in any of these will lead to study cancellation, delay, and/or enormous safety issues:
- Patient ID: Name, Medical Record (MR) number, date of birth (DOB), location
- Requesting Physician ID and Contact Info
- Clinical Information: Question to be answered and supporting/background Information and history
- Potential Pregnancy Status
- Relevant Information Not Yet on EPR (Outside studies, labs, history, findings)
PATIENT ID: Full name, correctly spelled; there are an astonishingly large number of patients with nearly-identical or identical names even when the name is uncommon (nor is it rare for these family members to be hospitalized or assessed at the same time— e.g. infection, car accident or other group trauma, food poisoning, genetic work-up, shared traits, live far from hospital). Medical record also number non-negotiable. DOB helps confirm we have the correct Sylvester SpongeBob on the table, esp. when there are Jrs, Srs, and III in the family. We will not move forward with any patient or any procedure until there is redundant ID confirmation. Wristband must match requisition must match chart.
REQUESTING PHYSICIAN ID/CONTACT: There are often unexpected urgent or emergent findings (pneumothorax, dissecting aneurysm, pneumoperitoneum, newly-discovered suspicious lung nodule, subdural hematoma…) or unusual reactions (arrest, allergy, angina, syncope, seizure…) requiring immediate clinical response or communication. We cannot find you (nor will you receive the final report) if we do not have your full name, phone and/or beeper number, and Hopkins ID code (letter plus 4 numbers). If you are the student, the floor/service will tell you whose to use—ask!
CLINICAL INFORMATION: Why is this study indicated? What question are you hoping to have answered? What information do you wish to obtain? What are the relevant rule-outs? It is not uncommon for clinicians to request the wrong study; we cannot help target your requests without clinical information. The patient’s history is also relevant—HIV or Hep C status, drug-resistant infections, cardiac or respiratory compromise, transplants, medications, allergies, surgical history, patient ability to cooperate/communicate/comprehend (if patient cannot follow instructions, or cannot give informed consent, we cannot image them), and other factors, all help custom-tailor the study, insure patient and medical worker safety, and maximize the cost/benefit ratio in the patient’s favor. It is not only unhelpful and potentially dangerous just to say “Routine”, “Admission”, “Pre-op”, “AM ICU”, “Foot”, “Pain”, but also a medical-legal/insurance issue. Such ‘indications’ cannot be accepted and may delay your patients’ studies. 3rd party payers will be delighted to disallow any study where the history is inadequate or incorrect (as each of these histories is), or contraindicated (recent studies show the ‘routine AM ICU” chest film is neither warranted not clinically productive and leads to undue dose and cost.). Be more specific: “Admission, chest pain”; “Admission, ankle fracture”, “Pre-op cholecystectomy”,”Pre-op patella fracture”, “20 pack-yr smoker”, “Line placement”, “F/U known RUL pneumonia”, would all be accepted as indications for a chest study.
POTENTIAL PREGNANCY STATUS must be mentioned for any female of potential child-bearing age, which currently appears to be between ages 8 and 88. Ie: specify that ‘patient denies possibility of pregnancy” (being incarcerated, under 11, or in a nursing home do NOT preclude sexual activity; 'trust no one believe no one!'), “Pt blood test neg for pregnancy”, “Pt had hysterectomy 30 years ago”, “Pt claims birth control”, or other relevant info. Be careful how you phrase it (hence the “Pt states…pt. claims…pt. denies…”instead of “Pt. not pregnant”) since several times a year we unwittingly discover a pregnancy on an adolescent’s ‘back pain’ work-up or a ‘no chance of pregnancy’ patient’s abdominal radiograph or CT for abdominal pain.
OUTSIDE INFORMATION NOT IN E.P.R.: If the patient arrived with outside imaging (hard copy or CD) we can get it entered into the Hopkins computers (call RADIOLOGY CUSTOMER SERVICE (443 28)7-7378, conventional hours). Eventually clinicians tend to incorporate or document outside medical history into current notes, but until then let us know what you know about (alleged) outside imaging, medications, procedures, or history. A blank requisition or ‘Routine’ or ‘Admission’ are not only medically-legally inadequate, but will lead to a less targeted, less problem-centric report than if we are informed that the patient has known HIV and dropping CD4 count, large thigh sarcoma biopsied elsewhere, or altered mental status. Clinical input also allows us to comment if we believe other imaging or other views would help better address your posed clinical question.
CHECK THE FINAL REPORT! It is unwise, and illegal, to request any sort of consultation or test or procedure if its outcome will not be reviewed in a timely manner to support clinical care decisions. Especially as duty hours mandate earlier and earlier departures post-call, it gets easier to overlook the final report on a study. There are several obvious ways to err in failing to confirm the final, official reading:
- You (or you and the service) looked at the images on the floor and reached your own conclusions. How many of the team are Board-certified radiologists? And have you ever compared the image quality of the floor monitors to the Radiology Department’s reading monitors? The resolution, detail, and ability to manipulate the image cannot be compared. And while many clinicians become quite astute at interpreting the studies relative to their field, it is the unexpected finding—the pleural-based rib metastasis on the Orthopaedist’s shoulder study, the unpredicted solitary pulmonary nodule on the Ophthalmologist’s pre-op chest request, the adrenal tumor on the biliary patient’s CT, the myeloma or compression fracture on the abdominal radiograph ordered for RLQ pain—which may be easily overlooked by the non-radiologist yet have lethal consequences for the patient.
- We already notified you in person of a Critical Finding. Even so, the final report may have more details or other, less urgent but very important findings impacting the big picture.
- You already checked with the Radiology Resident. Our residents are stupendous and enormous resources, especially after-hours, but like all residents are supervised by faculty who will approve the final report. While we will convey significant changes to the service, be compulsive—check the final report.
CRITICAL FINDINGS in imaging refer to the discovery of an unexpected, urgent, life-threatening, inexplicable and/or unstable finding which we believe is not known to the patient’s physicians. A list of the most common Critical Findings is below although we will call any time we believe it is warranted, whether or not specified on this list. If your patient has a large pneumothorax, misplaced catheter, or neoplasm (for example) and it is clear from previous imaging reports, information on the current requisition, and/or clinical notes in the computer that this is known, routine reporting will ensue. If we have reason to believe this is unknown or underappreciated, we are obliged to pursue the clinicians and communicate these urgencies—and then document to whom and when we communicated. GIVE ADEQUATE and ACCURATE physician contact information! Weekly, if not daily, a significant number of our patients turn out to have dramatic and possibly totally unexpected findings on their studies: our seemingly-healthy little old lady getting a pre-op chest before elective cataract surgery has a previously-unknown nasty-looking lung neoplasm or TB…that not-too-sick 23 year old coming in with a cough may have a huge pneumothorax or septic emboli…the vague abdominal pain on an out-patient’s elective CT or US is actually a newly-diagnosed metastasis, or infection, or ectopic pregnancy… the patient who slipped on the floor and is protesting they are fine may have a very subtle proximal femur (‘hip’) or cervical spine fracture, or a subdural hematoma.
The following is from Radiology and reflects official policy:
"Communication of Critical Findings: Critical findings on any imaging exam should be communicated immediately to the referring physician or house officer by the radiologist. A critical finding is generally defined as:
- Any condition which, in the judgment of the radiologist, requires immediate intervention or a change in care
- A clinically significant revised interpretation
For more information, refer to the JHH Policy on Critical Radiologic Results Reporting [PDF]. To communicate critical findings on psychiatric patients, use the list [PDF] provided by the psychiatry department.
Examples of critical general radiologic findings:
- New pneumothorax, no chest tube in place
- New pneumoperitoneum, no surgical or dialysis history, no gastrostomy tube visible
- Device in unusual position/misplaced central access device
- Unexplained foreign body
- Dramatic change in existing pneumonia
- New pneumonia
- New pulmonary edema
- New pleural effusion
- New or previously undocumented fracture
- New lesion with enough suspicion for malignancy so that a further evaluation is recommended: CT, MR, or other special study exams
- New intra-cranial bleeding
- New cerebral edema
- Positive exam for pulmonary embolism
- Mal-positioned ET tube
- New, previously undocumented, or expanding abscess
- Evidence for bowel or solid organ ischemia/infarction
- Acute appendicitis
- Significant free intra-abdominal/pelvic fluid
- Findings suggestive of child abuse
- Ectopic pregnancy
- Testicular torsion
- Evidence of airway compromise
Examples of critical neuroradiologic findings:
- New hemorrhage (epidural, subdural, intraparenchymal, subarachnoid, intraventricular, intramedullary)
- New stroke
- New mass, markedly enlarging mass
- New herniation
- Increased intracranial pressure, brain edema
- New or worsening hydrocephalus
- Misplaced surgical drainage catheters
- Misplaced surgical hardware
- Findings suggestive of meningitis or abscess
- Incompletely clipped aneurysm
- Clipped normal vessel
- Findings suggestive of child abuse
- New or enlarging aneurysm or AVM
- Spinal cord compression
- New or enlarging spinal cord mass
- Suspected spinal cord infarction
- Spinal ligamentous injury in a trauma patient
- Findings of spinal instability in a trauma patient
- Congenital variations that may alter a surgical approach
- New aneurysm, AVM, or vascular malformation
WHO GETS ADMISSION CHEST RADIOGRAPHS? The ACR AC (American College of Radiology Appropriateness Criteria, www.acr.org) currently support chest radiography at admission for the patient with acute cardiopulmonary symptoms (hx or physical) or chronic cardiopulmonary disease in the elderly (>70), pointing out that there is very little supporting data for routine chest radiographs in admissions for other non-cardiopulmonary issues. Evidence-based medicine is evolving better criteria for when imaging ICU or in- patients may be warranted. However, remember that our particular patient population is atypical; patients have far more complex or unusual medical histories, far more risk factors, far less historical accuracy, and far less medical compliance than the typical community patient elsewhere; meaning we tend to get more studies than average.
WHO GETS AN AP PORTABLE ON THE FLOOR vs PA/LAT DOWNSTAIRS? The PA chest (posterior-anterior, with x-ray beam entering patient from behind and image cassette against patient’s anterior chest wall) can only be obtained in a patient able to comply and get out of bed. Ditto the lateral chest. The image quality tends to be far better than that of a portable exam, which should only be obtained if the patient is physically unable to leave the floor. DO NOT order a portable just because the patient complains about how long it took last time, or that they missed their favorite TV show, or that their coffee got cold— listen to the patient, try to placate them or work around these complaints, but do not compromise their care. Explain how much better the downstairs PA is, and offer to reheat their coffee, put a sign on the patient’s room door advising visitors they will be back, or offer an extra blanket if they founf the waiting room downstairs too cool.
The AP chest (x-ray tube at the foot of the bed enters anterior, strikes cassette placed posterior to patient) can be obtained in bed or in the ICU but will be a less precise image for several reasons. The positioning and exposure are nearly always suboptimal, due to patient inability to comply and inability to take/hold deep breath. Many patients can only be raised partially upright, changing the appearance and distribution of air and fluids as well as dimensionally distorting anatomy. The reversal from PA to AP introduces significant magnification of the heart and mediastinum (see Kiddy Physics). The tendancy to be underexposed accentuates lung markings, creating spurious ‘pulmonary vascular prominence’, and limits detail base of lungs, posterior to the heart, and under the hemidiaphragms, often obscuring the observation of line placement or other important information. Portable studies cannot include a lateral, and ‘One view is NO view” therefore becomes an issue.
Speaking of the lateral chest—it remains controversial (ie not clearly documented) when it is necessary and when it does not definitely contribute. Certainly in terms of confirming presence or position of findings on a frontal, it remains the quickest, cheapest, and most cost/dose effective source of additional information. In the younger pre-operative patients (especially for non-cardiopulmonary procedures) it is likely unnecessary. It has been suggested that it may not be necessary in patients being screened for positive TB skin tests (Chest 2003; 124(5):1824-1827), but that may also depend on whether CT is to follow. Another study suggested it could be eliminated in many emergency medicine department assessments since the PA alone appeared to have high efficacy in triaging patients between ‘worry’ and ‘don’t worry’ initial categorization (Emerg Rad 1997; 4(1):26-29). The definitive cost-effective, dose-effective documentation is still in progress and under assessment both nationally and world-wide.
AP in the ICU: Again, check the ACR AC. There is no such thing as a ‘routine daily chest’ in the ICU; there is NO evidence to support either the cost or dose in a stable or non-cardiopulmonary patient, nor will such studies be reimbursed. Patients who are worsening or in some way changing/deteriorating, patients with respiratory failure or compromised respiratory function, patients on mechanical ventilators, or patients with line/catheter manipulations or adjustments, *do* mandate chest radiography. Remember even the mandated or indicated study will NOT be reimbursed or approved unless appropriate history is provided. Ask the team what the indications are—especially if house officers are using the history ‘Routine AM ICU Chest” or “Routine Chest” (both verboten)—but be tactful.
For (hopefully) obvious reasons, many studies are simply not available to a patient unable to leave the floor: many types of radiographs (plain films) are suboptimal or impossible on the immobile supine patient; nor can we perform bedside CT, MR, GI contrast studies such as upper or lower GIs, arthrograms, etc. US equipment, on the other hand, *is* portable and can be done bedside.
Donna Magid M.D., M.Ed.