1. A collaborative tale of
Quality AND Quantity:
Enabling Emergency Physicians
to order CT scans without prior
consultation with Medical
Imaging did not increase CT
utilization
D MacKinnon1, 2 M McGowan1 DM King3 T Dowdell3, 4 G Bandiera1, 5
Emergency Medicine, St. Michael’s Hospital
Department of Family and Community Medicine, University of Toronto
3
Medical Imaging, St. Michael’s Hospital
4
Department of Medical Imaging, University of Toronto
5
Department of Medicine, University of Toronto
1
2

2. Enabling EPs to order CTs without prior consultation with MI
Context
• CT is a diagnostic tool ordered at the discretion of the Emergency Physician (EP) to aid in
the diagnosis, treatment and disposition of patients; however, there is growing concern
about the increasing patient radiation exposure with its more frequent use
• Perceptions exist that CT requests by EPs should be “approved” in advance by Medical
Imaging (MI) to manage utilization, organize workflow and monitor radiation exposure to
patients
St. Michael’s Hospital, Toronto, ON
• Urban, academic, inner city, level-1 trauma centre (ED volume 72,000 in 2012)
Problem and Issue
• Mandating discussion between the EP and MI prior to “approving” contrast CT orders
involved challenges in contacting the appropriate person in MI, leading to delays in timeto-imaging, time-to-diagnosis and increasing patients’ ED length of stay
• Collaboratively, the ED and MI made multiple attempts to overcome these
communication and workflow challenges
• MI voiced concern if a process similar to the non-contrast CT (no consultation needed)
was implemented the impact on utilization and workflow would need to be closely
monitored

3. Enabling EPs to order CTs without prior consultation with MI
Measurement
• A collaborative change in practice to streamline the process of ordering CT scans M-F
8-5 enabled EPs to order contrast CTs without prior consultation with MI M-F (nonholidays) starting October 25, 2010
• Bi-directional communication was available and encouraged for EP consultation with MI
AND MI consultation with EP to discuss CT requests if considered necessary
• A retrospective review of PACS for contrast CTs ordered by EPs and patient volumes
was conducted pre- and post- implementation of change of practice
• The change on absolute number and rate of CT ordering by the EPs 1-year pre- and
post- process change was measured
Figure 1. Absolute Number CTs by Emergency Physicians
Table 1. Rate of CTs ordered by Emergency Physicians
Metric
By Year
Pre-
Post-
Overall Change
62,881
67,282
6.9%
Total CTs by EPs
6815
6618
-2.9%
CTs ordered per Pt
0.11
0.10
-1.0%
Total Pt Visits

4. Enabling EPs to order CTs without prior consultation with MI
Contribution to Patient Safety & Quality Improvement
• Enabling Emergency Physicians to order contrast CT without prior discussion with
Medical Imaging did not increase CT utilization and thus did not increase patient radiation
exposure
Collaborative Emergency-Medical Imaging
• Ongoing monitoring of absolute number and rate of CT ordering by EPs is an important
quality metric
Innovative Patient Flow Initiative
• This process change may be considered by other Emergency Departments to address
patient flow and length of stay metrics and targets
Lessons Learned
• Collaborative efforts between hospital departments, such as this, can lead to positive
changes in patient care and flow processes at minimal to no cost