Timing and diplomacy are keys to CT scans in the emergency department

Avoid using contrast in many cases to save time, some experts advise

Your ED is overflowing with patients, the wait time is heading toward double-digit hours, and you’re short-staffed again. So when you walk by an exam room and see a patient sitting there sipping contrast fluid — the same contrast he was drinking an hour ago — your blood pressure goes through the roof.

Isn’t there a better solution than having patients clog up your ED while they wait for abdominal computed tomography (CT) scans? After all, fast flow through is just a dream when patients sit in your exam rooms for hours because they need a contrast study.

There are ways to reduce the effects of CT studies in your ED, but the experts say it may take a change in the way you think about these exams, along with a good dose of diplomacy when working with the radiology department.

Timing your work is a big part of the solution, suggests Conrad D. Brown, PhD, director of the ED at the Oklahoma University (OU) Medical Center in Oklahoma City. At his hospital, the radiology department agreed to expedite CT scans for the ED in an effort to improve flow through.

The ED department worked out an agreement with radiology so scans could be performed within about an hour, rather than waiting a more typical two hours.

"We give the oral contrast in the ED and call ahead to the CT scan to schedule it," he says. "They usually get the patient in about an hour later, and that is a huge improvement over waiting twice as long. And we also worked out the way in which we’ll call each other to say when radiology is ready for the patient, instead of us calling radiology over and over again to see if they’re ready."

After the CT scan, when the patient is waiting for the results and a decision on whether to go to surgery or elsewhere, the OU Medical Center avoids putting patients back into the main ED system. Instead, they are held in the observation unit or its fast-track area, which usually has more space available.

That arrangement minimizes the effect of CT scans in the ED, but it requires a substantial dose of diplomacy with the radiology department, Brown notes.

"We had to go talk to them and help them understand why this was so important to us," he says. "We sat down with them and presented the facts about our volume and how much these patients can cause a delay, and we showed them how much this can factor into whether we have to go on diversion."

Brown addressed the CT problem about a year ago as part of an overall effort to improve patient flow through. Time studies revealed that patients waiting for CT scans or results were a significant factor in hampering patient flow through, he says.

Brown cautions that such studies are necessary before you launch a campaign to address delays caused by CT scans. Otherwise, it is easy for other department managers to dismiss your complaints and say ED managers tend to blame all ED delays on other departments.

"It’s also in how you say it," he says. "It helps a lot when they can see that you’re looking at the whole process and looking for solutions, rather than just pointing fingers."

Work with radiology

Brown also advises ED managers to consider factors such as whether the radiology department has a CT tech on duty at all hours or needs to call one when a scan is needed after hours. Also, does the tech have to cover more than just your ED?

Are there two EDs on your campus that the tech must cover simultaneously? Brown supported the OU radiology department’s efforts to hire another CT tech.

"Look at those issues from the radiology perspective, and see what improvements are possible," he says. "You might find opportunities to support radiology’s efforts for better staffing, which is part of working collaboratively to solve this problem."

Better CT procedures, along with other improvements in the ED, helped the OU ED reduce its door-to-disposition time from an average of three hours a year ago to fewer than two hours now, Brown says.

Establish protocols for scans

CT scan times also can be reduced by agreeing up front with radiology about what patients require a scan and which ones require contrast, says Jonathan Siff, MD, MBA, FACEP, assistant director of medical operations with the department of emergency medicine at MetroHealth Medical Center and assistant professor of emergency medicine at Case Western University, both in Cleveland.

"That way, you’re not arguing with a tech at 2 in the morning about whether your patient needs a scan," he says. "Come to an understanding ahead of time about the protocols. Every minute you spend fighting about appropriateness for a patient is another minute they spend in your ED."

Use of contrast, for instance, is an issue where clinicians can disagree about necessity. Using oral contrast can be a huge problem for abdominal CT scans in the ED because it takes so long for some patients to ingest it and then they must wait for it to move to the intestines, Siff adds. That’s why his ED tries to avoid using contrast unless it is absolutely necessary.

"We try to identify those patients whose primary concern is a renal stone, for instance, where contrast is an excellent modality, but you don’t really need it. In some cases, it may even get in the way of a good diagnosis," he notes.

"We also look for patients in which the emergency is so pressing that the risk/benefit of waiting for the contrast isn’t justified. For our trauma patients, we have said that contrast is not going to be used for the initial study," Siff points out.

Ingesting oral solution can be slow

Eliminating the contrast studies, even in just a subset of ED patients getting CT scans, can go a long way toward solving the problem of flow through, Siff explains.

With most patients, such as those with suspected renal stones, a contrast study still is an option if the initial scan is unclear, he notes. But that second, lengthier scan is likely to take place outside the ED.

Patients who really do need contrast studies can create many bottlenecks in the ED, Siff says. Getting patients to drink an oral contrast solution can be a major challenge, especially if they already are feeling nauseated, he adds.

"It can take forever. They’ll sit there and sip and sip, and they’re still only halfway done," Siff says. "And if they throw up, you have to start all over again."

Use antiemetic, nasogastric tube

Siff tries to speed the process by starting the patient on an oral contrast solution as soon as he suspects an abdominal CT scan will be needed.

Many physicians wait until all the blood tests are back, but Siff says he gets a head start whenever possible. "The other thing I do is, if there is any question at all that they can tolerate the contrast, I go ahead and premedicate with antinausea medication," he says.

"Earlier in my career, I would ask the patient if he could drink this stuff, and he’d say he’d do his best to get it all down," Siff adds. "Twenty minutes later, the nurse would come in and say he threw it all up. Now I don’t even bother asking and just give the antiemetic instead."

He also suggests another strategy: For patients who really are not well, Siff cuts to the chase by using a nasogastric tube to provide the oral contrast. He still uses an antiemetic as well.

"Some people will say that is brutal and barbaric, but it helps with patient flow, and the truth of the matter is some patients prefer that to trying to force down something they don’t feel up to drinking," he concludes. "Some have had it administered that way before, and they ask for that again instead of trying to drink it."

Sources

For more information on abdominal scans in the ED, contact:

  • Conrad D. Brown, PhD, Director of the ED, Oklahoma University Medical Center, 1200 Everett Drive, Oklahoma City, OK 73104. Phone: (405) 271-4700.
  • Jon Siff, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109-1998. Phone: (216) 778-7800.