Random ER Metrics Thread

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thegenius

thegenius

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(This can be a random ER metric thread.)

We got notice recently from admin that we "order too many MRIs". LOL. I have no clue if we order too many. I did see from our internal metric database website that on average 1.2% of all patients who show up to the ED get an MRI ordered by an ER MD.

How does that compare to your ED?
 
You more than 1.5%? I know it may not be a great comparison. We too are a stroke center but we only see about 50,000 pts/year
 
Dude, that sounds crazy high.

I've ordered one this calendar year, and even that was questionably indicated. You guys are ordering an MRI on one out of every 84 patients...that's like one every 4 shifts.
 
I do wonder if they are counting the MRIs I order out of convenience for the inpatient team. Like a stroke come to ED, I admit, and I put in the MR Brain w/o contrast. I bet it probably does.

I don't know what's high. I mean conceptually there are very few indications for emergency MRIs I am aware of that. I diagnosed transverse myelitis the other day (cool exam...) but patient has had symptoms for over a month and I could have just admitted her. Might be our culture here as well because we get a lot of push back from the hospitalist.

There are also cases where there is low prob of stroke and all they really need is an MRI, and if negative they can go home. Doesn't make sense to admit them and take up a bed for 12-24 hours to get an MRI when then they are discharged.
 
We do strike so I often order it on stroke patients after neuro says they want it. Bet that counts vs the ED doc in your scenario.
 
They're definitely counting any MRIs that you order to facilitate the inpatient w/u. How would they be able to differentiate? LPT-- if you have cerner you can change the 'ordering physician' by right-clicking on the order and enter it under the admitting doc or neuro if they're requesting it.

If you're able to get reasonable turn-around on patients that would otherwise be admitted for cva w/u, then I think it's reasonable. Although, I could see this leading to 'indication-creep' where anyone w/ some tingles gets an MRI when they'd otherwise be discharged. Most places I've worked at, we've had to admit these patients. I'm struggling to think of a *true* indication for emergent MRI other than acute spinal pathology. I guess belly pain in preggos or peds, if institutional policy favors it.
 
Sounds reasonable depending on who’s putting in orders for MRIs for stroke alerts.

My number is probably around 5% but with the huge caveat that I currently only work shifts in our critical care zone and normally have at least 1 stroke alert a shift.
 
A few of our stroke neurologists drive me insane. They want an MRI before they admit the patient with questionable findings. If MRI shows stroke, they want to admit. If MRI doesn't show a stroke, they want the hospitalist to admit. It just makes it hard to sell to the hospitalist when the patient is having symptoms and the MRI is negative. If I truly think it's psych, I'll boot them out. I would rather just admit to the hospitalist before the MRI and let them manage it.
 
Back of the napkin guestimate is that I probably order one mri for every 2000 patients I see on average. At most. If you don't work at a tertiary care center, that number sounds insanely high. Even if you do, it still sounds high.
 
southerndoc said:
A few of our stroke neurologists drive me insane. They want an MRI before they admit the patient with questionable findings. If MRI shows stroke, they want to admit. If MRI doesn't show a stroke, they want the hospitalist to admit. It just makes it hard to sell to the hospitalist when the patient is having symptoms and the MRI is negative. If I truly think it's psych, I'll boot them out. I would rather just admit to the hospitalist before the MRI and let them manage it.
Click to expand...

Yea it goes to show the low utility of even doing a neuro exam when a neurologist wants confirmation with an MRI.

I really almost never order an MRI because I’m trying to help the patient. Sounds terrible, doesn’t it. I order it because I call a specialist and they want it, or just order it because I’ve asked the question 20 times in the past and they always answer the same way: get an MRI.

I’m on the low end but it’s non-zero. It’s like 0.8% of 900 pts this past quarter. The avg in our group what I quoted above.

The other reason it’s hard is we are 80-85% Medicaid pts and they can never get this stuff done as an outpatient, for whatever reason. And Medicaid patients tend to have more weird paresthesias than insured patients.
 
Do any of you get radiation phobic patients who insist on MRI instead of CT? I’ve seen quite a few, mostly among the overly concerned and middle aged country club crowd.
 
thegenius said:
I do wonder if they are counting the MRIs I order out of convenience for the inpatient team. Like a stroke come to ED, I admit, and I put in the MR Brain w/o contrast. I bet it probably does.

I don't know what's high. I mean conceptually there are very few indications for emergency MRIs I am aware of that. I diagnosed transverse myelitis the other day (cool exam...) but patient has had symptoms for over a month and I could have just admitted her. Might be our culture here as well because we get a lot of push back from the hospitalist.

There are also cases where there is low prob of stroke and all they really need is an MRI, and if negative they can go home. Doesn't make sense to admit them and take up a bed for 12-24 hours to get an MRI when then they are discharged.
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EctopicFetus said:
We do strike so I often order it on stroke patients after neuro says they want it. Bet that counts vs the ED doc in your scenario.
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100%
Unless you've specifically instructed admin to exclude you as the ordering physician in these cases, they're going in your numerator.
 
thegenius said:
Yea it goes to show the low utility of even doing a neuro exam when a neurologist wants confirmation with an MRI.
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I feel like over the course of my career I've seen tPA indication creep bring Neurologists into the ED and this has led to MRI overuse (because Neurologists get auto-consulted on stroke alerts and inevitably recommend an MRI), and this has actually led to a degradation of both EM & Neurology resident training. We used to have to make actual decisions. Now we punt to Rads. I recently had a patient with FOUR stroke alerts in the last couple years with multiple admissions and negative workups (including EEG) come in with unilateral weakness that I could spot as functional from the door. I showed the Neurology resident all the positive "turkey tests". Their recommendation - CT head, CTA/CT Perfusion. If negative, get an MRI.

For about 3 years I griped that 95% of the MRIs we ordered were non-emergent, and nobody cared. Now I just make sure to teach the residents "if you order an MRI for this, and then sign it out, in the community - your partners will hate you" then I order the MRI that the "expert" has recommended in the medical record.
 
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benem said:
Do any of you get radiation phobic patients who insist on MRI instead of CT? I’ve seen quite a few, mostly among the overly concerned and middle aged country club crowd.
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Not often, but yeah. I don't offer it. CT or documented refusal of CT unless there's a legit reason for MR over CT. I thankfully work in a place where my chief does a spectacular job of filtering out BS complaints, so unless I actually screw up medically, I don't really care if they complain.
 
I’ll order MRIs if clinically indicated even if it doesn’t directly change ED management (ie, spinal cord injuries, c-spine fractures, MS/optic neuritis). I’ll never order it for strokes though as that is clearly non-emergent and will never change management (exception: MRA in someone that has contrast anaphylaxis and is otherwise a good thrombectomy candidate). My note and order entry reflect that results should be relayed to the inpatient team. I don’t see why it’s a big deal as it gives a lay up for the inpatient team and expedites care. This is probably institution-dependent though.
 
benem said:
Do any of you get radiation phobic patients who insist on MRI instead of CT? I’ve seen quite a few, mostly among the overly concerned and middle aged country club crowd.
Click to expand...
Seems like a good indication that they don't need any emergent imaging
WilcoWorld said:
For about 3 years I griped that 95% of the MRIs we ordered were non-emergent, and nobody cared. Now I just make sure to teach the residents "if you order an MRI for this, and then sign it out, in the community - your partners will hate you" then I order the MRI that the "expert" has recommended in the medical record.
Click to expand...
This is such a key learning point. Also key is learning when a certain study or consult or treatment is actually required vs just done for patient or consultant convenience, b/c your future practice might not always have certain capabilities, and it might mean a 2 hr transfer for the patient.
Jabbed said:
I’ll order MRIs if clinically indicated even if it doesn’t directly change ED management (ie, spinal cord injuries, c-spine fractures, MS/optic neuritis). I’ll never order it for strokes though as that is clearly non-emergent and will never change management (exception: MRA in someone that has contrast anaphylaxis and is otherwise a good thrombectomy candidate). My note and order entry reflect that results should be relayed to the inpatient team. I don’t see why it’s a big deal as it gives a lay up for the inpatient team and expedites care. This is probably institution-dependent though.
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Can someone get a thrombectomy or IA TPA w/o iodinated contrast? Honestly asking.
 
We’re a 80K?+ academic ED and I rarely order MRIs on anything other than the occasional rule out EDA. Every blue moon I might do an MRI Brain for those unconvincing TIA/CVA type patients that have atypical features if I anticipate being able to discharge them myself and I have time to complete the MRI during my shift.

Luckily, I don't have to do bridging/admit orders for any of my hospitalists at our academic location but at the community site, I may need to put in an a.m. MRI Brain for the stroke/tia patients.

About once a year I may have a pregger pt that I do an MRI A/P to rule out appy.
 
WilcoWorld said:
100%
Unless you've specifically instructed admin to exclude you as the ordering physician in these cases, they're going in your numerator.
Click to expand...
Because our radiologist get butt hurt about reading stat ER MRIs and report offending docs, I do not do these “help a buddy out” MRI orders. I simply tell them they should order it themself or I tell the hospitalist to order it. I do not order MRIs that I do not need for my own disposition or intervention.
 
RoyBasch said:
Because our radiologist get butt hurt about reading stat ER MRIs and report offending docs, I do not do these “help a buddy out” MRI orders. I simply tell them they should order it themself or I tell the hospitalist to order it. I do not order MRIs that I do not need for my own disposition or intervention.
Click to expand...

This.
If our rads weren't so pissypants about it, I would order the MRI for the inpatient team.
 
The reason rads is so concerned about ED MRIs is because they're billed as STAT MRIs. The vast majority of insurance companies do not pay for half the MRIs we order as STAT in the ER (especially those with herniated discs -- insurance doesn't care if they're high risk for cauda equina or cord impingement). Also, most places don't have 24/7 MRI techs. A lot of techs have to be called in for studies at night/weekends.
 
RustedFox said:
This.
If our rads weren't so pissypants about it, I would order the MRI for the inpatient team.
Click to expand...
The other reason some people get up in arms about it are for TATs. Often private practice contracts have the expected average TAT directly in the contract. If you are ordering a study that can somehow be not marked as STAT that would help the metrics substantially and decrease the crankiness. You guys have door to doc times and LOS metrics, we have Stroke CT TAT, Stroke CTA HN TAT, and generic STAT exam metrics.

I've long gotten over complaining about what you guys order as non-indicated. Whatever. Send it. I'll love you more if you order CAP with contrast as I can read those faster.
 
maxxor said:
The other reason some people get up in arms about it are for TATs. Often private practice contracts have the expected average TAT directly in the contract. If you are ordering a study that can somehow be not marked as STAT that would help the metrics substantially and decrease the crankiness. You guys have door to doc times and LOS metrics, we have Stroke CT TAT, Stroke CTA HN TAT, and generic STAT exam metrics.

I've long gotten over complaining about what you guys order as non-indicated. Whatever. Send it. I'll love you more if you order CAP with contrast as I can read those faster.
Click to expand...

Help a vulpine brother out: "CAP with contrast"?
 
maxxor said:
Chest abdomen pelvis
Click to expand...
I’m genuinely curious, I would think that although contrast increases the diagnostic yield, it would take more time to read as there is more information to process. Apparently this is not so?
 
RoyBasch said:
I’m genuinely curious, I would think that although contrast increases the diagnostic yield, it would take more time to read as there is more information to process. Apparently this is not so?
Click to expand...

We are still responsible for the findings on the CT CAP with or without contrast. You can actually see a lot of the stuff on a noncontrast exam (liver lesions, renal lesions, etc) but it requires more careful scrutiny of the images, sometimes going through multiple window settings (I use brain window in the abdomen a lot now during this whole contrast shortage). It takes me longer to go through and tease out what is going on than if I have contrast where I can more quickly identify what's going on in the first pass. I still want to a do a good job for the patients and to help you guys out, but fact is, it just takes me longer to fully interpret a noncon, ER setting exam with limited followup, possibly no priors.

We don't get to drop the radiology standard of detection just because it's "not acute".
 
door to speculum time is a metric we have been tracking for a few months. We are down from 80 mins to 43 mins and admin wants our goal around 30 or so.
 

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thegenius said:
(This can be a random ER metric thread.)

We got notice recently from admin that we "order too many MRIs". LOL. I have no clue if we order too many. I did see from our internal metric database website that on average 1.2% of all patients who show up to the ED get an MRI ordered by an ER MD.

How does that compare to your ED?
Click to expand...
1.2% seems super high. I would guess in 15 yrs x 20 pt/shift x 15 shifts/mo x 12 months = 54K pts. I believe I have done 2 MRIs of joints and 2 MRIs of back pain (b/c pt begged me and was in lots of pain).

Prob 10 MRI brain b/c Neuro asked.

I worked in a receiving hospital so had all modalities present 24hr/dy.

So I am at 0.01%.

1.2% seems standards of deviation high to me. That would come out to about 1 MRI a week
 
So what do you guys do with terrible back pain? Just admit them if you can't control it? Don't your hospitalists say "get an MRI?" that's what our say.
Or these questionable strokes / TIA's that you know can go home, but maybe have a pre-test prob of 2-5% of having a TIA/Stroke? hard to send that home without confirmation.
 
'Terrible back pain' that I'm sure is musculoskeletal (with no red flags) I'll just admit (this is very rare) if I'm convinced they can't handle ADLs at home. This is almost always someone who weighs > 300-400 lbs. whom (1) live alone and/or (2) family can't/won't help. I will have at least gotten a CT lumbar and some labs to convine myself there's likely no major badness. I'll pitch it to the hospitalist as 'yeah, they probably need placement, and PT/OT eval.' This has happened maybe ~10 times in a 25+ year career.
Obviously if they have red flags, I want an MRI. I have never ordered a brain MRI for the neurologists, but we have an extremely active Stroke Team in my city. They will actually come in (I think ~13 hospitals) and see the patient if needed. (in person, Vizio etc. ) I don't send TIAs home uness they've already had the workup sometime, and that hasn't been a problem.

BTW, I love the 'Door to Speculum' metric. That's just awesome......😉
 
thegenius said:
So what do you guys do with terrible back pain? Just admit them if you can't control it? Don't your hospitalists say "get an MRI?" that's what our say.
Or these questionable strokes / TIA's that you know can go home, but maybe have a pre-test prob of 2-5% of having a TIA/Stroke? hard to send that home without confirmation.
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Terrible back pain gets discharged to pain clinic or gets ed obs for PT/CM eval and likely dispo to rehab. Rehab can order an outpatient MRI as they see fit.

The TIA patient gets admitted and gets an MRI as an inpatient. I order maybe 1 brain MRI every 18 months to avoid admitting the patient and this is only when I'm working daytime hours, have MRI available, and there are no inpatient beds and the pt will be boarding in the ED for over 20 hrs. Otherwise, it can wait till they go up.
 
thegenius said:
So what do you guys do with terrible back pain? Just admit them if you can't control it? Don't your hospitalists say "get an MRI?" that's what our say.
Or these questionable strokes / TIA's that you know can go home, but maybe have a pre-test prob of 2-5% of having a TIA/Stroke? hard to send that home without confirmation.
Click to expand...
If it's admission for pain or inability to perform ADLs 2/2 pain, then I just admit. If my spidey sense tingles, or they have r/f's for SEA, then I get inflammatory markers and if elevated order an MRI. If they have neuro deficits worrisome for myelopathy or CES, then that's a different story. Herniated discs and spinal stenosis just aren't an emergency, sorry. Even NBA players don't get same day MRIs for back pain.

Neuro presentations typically just get admitted for w/u. My old shop had a TIA clinic w/ good next day followup, so we'd send them home and they'd get an expedited outpt workup. However, my current shop and most places I've been, haven't had good neuro (or any for that matter) followup, so they get brought in. I don't admit paresthesias or non-anatomic subjective neuro syndromes though.
 
3rdJob said:
'Terrible back pain' that I'm sure is musculoskeletal (with no red flags) I'll just admit (this is very rare) if I'm convinced they can't handle ADLs at home. This is almost always someone who weighs > 300-400 lbs. whom (1) live alone and/or (2) family can't/won't help. I will have at least gotten a CT lumbar and some labs to convine myself there's likely no major badness. I'll pitch it to the hospitalist as 'yeah, they probably need placement, and PT/OT eval.' This has happened maybe ~10 times in a 25+ year career.
Obviously if they have red flags, I want an MRI. I have never ordered a brain MRI for the neurologists, but we have an extremely active Stroke Team in my city. They will actually come in (I think ~13 hospitals) and see the patient if needed. (in person, Vizio etc. ) I don't send TIAs home uness they've already had the workup sometime, and that hasn't been a problem.

BTW, I love the 'Door to Speculum' metric. That's just awesome......😉
Click to expand...
I see that you work in a functional system - good on ya 😊
 
BoardingDoc said:
Terrible back pain gets discharged to pain clinic or gets ed obs for PT/CM eval and likely dispo to rehab. Rehab can order an outpatient MRI as they see fit.

The TIA patient gets admitted and gets an MRI as an inpatient. I order maybe 1 brain MRI every 18 months to avoid admitting the patient and this is only when I'm working daytime hours, have MRI available, and there are no inpatient beds and the pt will be boarding in the ED for over 20 hrs. Otherwise, it can wait till they go up.
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So your inpatient beds are at a lower premium than are your MRI spots, makes sense to admit for MRI in that case.

For those that don't even have beds to admit septic DKA patients to, these neuro cases can wait in the ED for the bed...or for the MRI.
 
southerndoc said:
The reason rads is so concerned about ED MRIs is because they're billed as STAT MRIs. The vast majority of insurance companies do not pay for half the MRIs we order as STAT in the ER (especially those with herniated discs -- insurance doesn't care if they're high risk for cauda equina or cord impingement). Also, most places don't have 24/7 MRI techs. A lot of techs have to be called in for studies at night/weekends.
Click to expand...
Actually curious about this. Who is actually paying for the clearly non-indicated ED MRI? Do patients actually have to pay for the MRIs? I would really love to tell my patients who are requesting bull**** MRIs will not be covered, and coming in to the ED instead of their 6 week PT is not buying them a free MRI.
 
pkwraith said:
Actually curious about this. Who is actually paying for the clearly non-indicated ED MRI? Do patients actually have to pay for the MRIs? I would really love to tell my patients who are requesting bull**** MRIs will not be covered, and coming in to the ED instead of their 6 week PT is not buying them a free MRI.
Click to expand...

Plus, insurance should be responsible for the imaging if there truly are risk factors for emergent pathology. I mean, come ON.
 
pkwraith said:
Actually curious about this. Who is actually paying for the clearly non-indicated ED MRI? Do patients actually have to pay for the MRIs? I would really love to tell my patients who are requesting bull**** MRIs will not be covered, and coming in to the ED instead of their 6 week PT is not buying them a free MRI.
Click to expand...
Some health systems sue patients, file liens, etc. You'd be surprised at how far some health systems will go to get paid. Three-lettered health systems come to mind.
 
pkwraith said:
Actually curious about this. Who is actually paying for the clearly non-indicated ED MRI? Do patients actually have to pay for the MRIs? I would really love to tell my patients who are requesting bull**** MRIs will not be covered, and coming in to the ED instead of their 6 week PT is not buying them a free MRI.
Click to expand...
Depends on the situation, but yeah we bill somebody (insurance first then patient gets it). Sometimes they get sent to collections. Once it goes to collections the actual amount retrieved is basically zero though. It’s funny, our billing company had like three tiers for “aggressiveness” when we signed up. I think we picked tier 2. Tier 1 is never send to collections. I don’t remember what Tier 3 was. Maybe they break your legs.
 
2brads said:
Depends on the situation, but yeah we bill somebody (insurance first then patient gets it). Sometimes they get sent to collections. Once it goes to collections the actual amount retrieved is basically zero though. It’s funny, our billing company had like three tiers for “aggressiveness” when we signed up. I think we picked tier 2. Tier 1 is never send to collections. I don’t remember what Tier 3 was. Maybe they break your legs.
Click to expand...
That’s really interesting .. I work for a big cmg so I have no idea .. do they get a % of collections or a flat rate? Do they take a lower percentage if you let them go more aggressive? It never occurred to me they did anything besides whatever is allowed by law.
 
I find this thread fascinating...especially about MRI utilization. And mgmt of LBP. I wished I worked in a system where I never ordered an MRI for just about anything.
I was just looking at the board at our place now...and there is a guy who is admitted who has an MRI ordered of the C/T/L spine by the ED. Now the patient is admitted, but yes I think this counts against us.
 
I know for regular billing it’s a flat rate. I don’t know exactly how the billing works once it goes to collection, but I think still a flat rate.

Also, I wish our EM docs were as judicious as you guys. We are a small hospital and read bogus ER MRI's all the time. Stuff like "Leans to the right, used to lean to the left", "Pt reports history of brain aneursym, wants MRI". And more recently, it's "Pan scan the entire neuraxis because neurology wants it".
 
2brads said:
"Pan scan the entire neuraxis because neurology wants it"
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Well, this is typical of small hospitals in the middle of nowhere when the specialists wants to do the least amount of work especially when it is off hours. I guess if I were a neurologist, I would want a pan scan so I can sleep til the am to see the pt.
 
emergentmd said:
Well, this is typical of small hospitals in the middle of nowhere when the specialists wants to do the least amount of work especially when it is off hours. I guess if I were a neurologist, I would want a pan scan so I can sleep til the am to see the pt.
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This is teleneurology.
 
2brads said:
This is teleneurology.
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That makes even more sense. I really never understood how a neurologist could do telemedicine when they can not examine the pt. You can get away with alot from other specialists, but how do you do that as a neurolgist?

If I were a Tele ER doc (dream job) and someone came in with abdominal pain, I would likely CT everyone b/c how can I trust the exam?
 
emergentmd said:
That makes even more sense. I really never understood how a neurologist could do telemedicine when they can not examine the pt. You can get away with alot from other specialists, but how do you do that as a neurolgist?

If I were a Tele ER doc (dream job) and someone came in with abdominal pain, I would likely CT everyone b/c how can I trust the exam?
Click to expand...
Yeah, I don’t get it either. Liability seems like a nightmare.
 
emergentmd said:
That makes even more sense. I really never understood how a neurologist could do telemedicine when they can not examine the pt. You can get away with alot from other specialists, but how do you do that as a neurolgist?

If I were a Tele ER doc (dream job) and someone came in with abdominal pain, I would likely CT everyone b/c how can I trust the exam?
Click to expand...
Right? Tele neuro is a joke. My old shop had that, one of them (my favorite) would call after his "assessment" and say something along the lines of 'obviously a video exam is not that useful, I'll put in my note recommendations for w/e you want'.
2brads said:
Yeah, I don’t get it either. Liability seems like a nightmare.
Click to expand...
It's what you get from a specialty that recommends tpa for stroke mimics.
 
So you guys don't ever get ophtho sending in patients to get a "stat" MRI? (There is one on our board right now.) I see this about 1-2x/month.
 
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