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  • Imaging use rises in emergency department

    Posted by sharonoladeji02_713 on August 7, 2023 at 8:43 am

    I worked in a level one trauma center. A cause for increased volume rarely mentioned is that the ED physicians could not make outpatient referrals to specialists unless the imaging and lab work ups were done. They otherwise had no place to refer patients for follow up after discharge. Otherwise in many  cases imaging could be done later as an outpatient. 

    buckeyeguy replied 1 year, 2 months ago 22 Members · 49 Replies
  • 49 Replies
  • ebshanon

    Member
    August 7, 2023 at 10:22 am

    I never heard that reason before. Volume at my workplace is driven by clueless midlevels and ER docs that just want to churn people people out as quickly as possible.  

    • smfst7_929

      Member
      August 8, 2023 at 3:34 am

      Title of this thread reads like water is wet or the sun sets in the west.

      Increased ED imaging volume is a given. One of the few things you can count on in life. Like death and taxes.

    • tdetlie_105

      Member
      August 8, 2023 at 3:50 pm

      Quote from Gotham

      I never heard that reason before. Volume at my workplace is driven by clueless midlevels and ER docs that just want to churn people people out as quickly as possible.  

       
      Ditto…I actually don’t fully understand it.  Trauma 1 is typically blatantly positive or negative.  
       
      With this said I myself am getting burnt out from working at a trauma/stroke center…Past week we had a slew of helmet-less bike riders with depressed skull fx’s followed by multiple craniotomies etc.  These pt’s then end up becoming complex long-term in-pts with scans that can be extremely tedious/energy consuming to get through.  I miss my days working at a small semi-rural community Hospital.  

      • sehyj1

        Member
        August 9, 2023 at 5:56 am

        Our ED has slowly progressed to getting CT head and C-spine for altered mental status. If those are negative, then they get a CTA head and neck. If that’s negative, they get a CT pulmonary arteries with CT abd/pelvis.
         
        I read 80 CTs from the ED on Saturday

        • elikot

          Member
          August 9, 2023 at 6:00 am

          Well at least there is an (illogical) progression. Our ED just orders those all at once. and they usually throw in the MRI brain w/wo- why wait to see what the CT shows? Savings comes in not having the transport the patient twice.

          • lisbef3_453

            Member
            August 9, 2023 at 6:29 am

            This will continue to accelerate for as long as they are paid for it.
            Options, all or in combination:
            Scale back ED technical reimbursement to IDTC levels.
            DRG type payments in ED for all treatment even if not admitted.
            Big copays to piss off insured patients.
            Compliance penalties for ordering CT in triage.
            Penalties to referring docs using ED to circumvent preauth for imaging.

            • buckeyeguy

              Member
              August 9, 2023 at 3:29 pm

              The boomers and older are going to get a rude awakening within only 3 years. 1 trillion a year now in just interest payments. Bye bye America
               
              But first, bye bye to other countries with high debt to gdp ratios and high USD denominated debt, that is true as well.

        • reza800p_368

          Member
          August 9, 2023 at 4:33 pm

          Quote from api7342

          Our ED has slowly progressed to getting CT head and C-spine for altered mental status. If those are negative, then they get a CTA head and neck. If that’s negative, they get a CT pulmonary arteries with CT abd/pelvis.

          I read 80 CTs from the ED on Saturday

          Same here. 

          Our ED orders everything without contrast except for vascular studies. 

          • daberechimoses59_164

            Member
            August 9, 2023 at 4:44 pm

            If I didnt know them personally , I would think the humans that staff the er are the most obtuse on the planet. The massive waste that goes on in these departments almost defies belief

            • sumeerkumar.t

              Member
              August 13, 2023 at 7:09 am

              Same ludicrous ER imaging experience here, including some ER physicians ALWAYS ordering CTA chest for PE with CT A and P with contrast simultaneously , because if they order one or the other and it is negative, they wouldn’t be able to order the other in the ED because the IV contrast from the first CTwouldnt have cleared. As a neuroradiologist, the most frustrating thing has been the increased unindicated CTA head and neck for clearly non-stroke  presentations like altered mental status, syncope, generalized weakness etc.

              • ruszja

                Member
                August 13, 2023 at 7:21 am

                Talked to an older ER doc (meaning mid 40s, they burn out quickly) the other day and asked him whether we used to miss all these grievous injuries 10 years ago when someone who ‘fell out’ at church got a head CT and a recommendation to drink more fluids ? We didn’t.

              • ruszja

                Member
                August 13, 2023 at 7:33 am

                Quote from Nabdul

                Same ludicrous ER imaging experience here, including some ER physicians ALWAYS ordering CTA chest for PE with CT A and P with contrast simultaneously , because if they order one or the other and it is negative, they wouldn’t be able to order the other in the ED because the IV contrast from the first CTwouldnt have cleared. As a neuroradiologist, the most frustrating thing has been the increased unindicated CTA head and neck for clearly non-stroke  presentations like altered mental status, syncope, generalized weakness etc.

                Oh, I get the calls from the CT techs once in a while on how to get all the studies ordered at the same time using the allowable contrast. ‘NP X’ will order not only that combo of CTPA and AP with, no she also wants a dry head and a CTA head and neck. Because you know, ‘cough, nausea, fever headache’ could be caused by a brain bleed, an aneurysm, a PE and a intraabdominal abscess.

                • farzadahmadimedrn710_43

                  Member
                  August 13, 2023 at 10:25 am

                  I don’t understand why any radiologist in private practice where the group eats what they kill whines about having to read a bunch of high RVU exams. 
                   
                  Suck it up buttercup, this is why you make more than the hospitalist or the ER doctor.
                   
                  If the ER was wanting stat fluoros on all these cases I’d be sympathetic. Burning through CTA head/necks with low positive rate is ez money.

                  • ahmetkarabulut_383

                    Member
                    August 13, 2023 at 11:42 am

                    Our reimbursement for ED imaging is low something less than 35%. We are working for free. 

                    • farzadahmadimedrn710_43

                      Member
                      August 14, 2023 at 12:33 am

                      Quote from radsDOIR

                      Our reimbursement for ED imaging is low something less than 35%. We are working for free. 

                      That sounds like an opportunity to get the hospital to increase their subsidy to cover the lack of reimbursement for 65% of your cases. Are you running a business or a charity?

                  • ruszja

                    Member
                    August 13, 2023 at 12:06 pm

                    Quote from bluedeep

                    I don’t understand why any radiologist in private practice where the group eats what they kill whines about having to read a bunch of high RVU exams. 

                     
                    It’s  not ‘eat what you kill’.
                     
                    It’s ‘eat what you can put in the cooler’.

                    • Unknown Member

                      Deleted User
                      August 13, 2023 at 3:22 pm

                      The frustration with isnt reading the exams, its the forced participation in second and third rate medicine that is frustrating.

                    • buckeyeguy

                      Member
                      August 13, 2023 at 5:08 pm

                      Quote from uncleduke

                      The frustration with isnt reading the exams, its the forced participation in second and third rate medicine that is frustrating.

                       
                      yup, and something’s gotta give

                  • reza800p_368

                    Member
                    August 13, 2023 at 6:09 pm

                    Quote from bluedeep

                    I don’t understand why any radiologist in private practice where the group eats what they kill whines about having to read a bunch of high RVU exams. 

                    Suck it up buttercup, this is why you make more than the hospitalist or the ER doctor.

                    If the ER was wanting stat fluoros on all these cases I’d be sympathetic. Burning through CTA head/necks with low positive rate is ez money.

                     
                    Some of us care about quality of patient care in addition to money. 

                    We are all get paid well even if we only read indicated exams.  The extra 50K versus providing a higher quality of care. It’s your choice. 

                    • radiologistkahraman_799

                      Member
                      August 13, 2023 at 6:16 pm

                      Question, do ER docs get paid more/bill more based on the “complexity”/volume of studies they order?  

                    • ruszja

                      Member
                      August 15, 2023 at 10:54 am

                      Quote from TurboEcho

                      Question, do ER docs get paid more/bill more based on the “complexity”/volume of studies they order?  

                      Yes. The complexity of the case as evidenced by the need to order advanced imaging whose ‘tracings and images you personally interpreted’.

                    • farzadahmadimedrn710_43

                      Member
                      August 14, 2023 at 12:42 am

                      Quote from OnsiteRad

                      Quote from bluedeep

                      I don’t understand why any radiologist in private practice where the group eats what they kill whines about having to read a bunch of high RVU exams. 

                      Suck it up buttercup, this is why you make more than the hospitalist or the ER doctor.

                      If the ER was wanting stat fluoros on all these cases I’d be sympathetic. Burning through CTA head/necks with low positive rate is ez money.

                      Some of us care about quality of patient care in addition to money. 

                      We are all get paid well even if we only read indicated exams.  The extra 50K versus providing a higher quality of care. It’s your choice. 

                       
                      Did you examine the patient? How do you know the study isn’t indicated or not considered quality care?

                    • sehyj1

                      Member
                      August 14, 2023 at 6:55 am

                      That’s a good question for the NPs

                    • lisa.kipp_631

                      Member
                      August 14, 2023 at 7:32 am

                      CTA bilateral lower extremities for a 27 y/o patient whos feet her after standing for 12 hours at work.

                    • reza800p_368

                      Member
                      August 14, 2023 at 9:13 am

                      @bluedeep

                      For a specific case, it is hard to say and you are right.
                      But in general, there is no doubt that ED does a good number of unidicated studies.

                      Yesterday, I was reading a CT and pelvis without contrast on a 36 year old witch was diagnosed with IBS many years ago. She had a total 16 CT s in the last 2 yearss all of them negative in addition to 9 ultrasounds and multiple KUBs.

                    • ipadfawazipad_778

                      Member
                      August 14, 2023 at 1:26 pm

                      Local ER group was recently bought out by a mega national group and encouraged to order more imaging verbally. Wish I could get proof in writing. Whistleblower for fraud and kickbacks is probably better than my 401k for retirement. Not all orders are innocent and clueless.

                    • afazio.uk_887

                      Member
                      August 14, 2023 at 1:36 pm

                       
                      CT is a very good test.  Who would really trust a Noctor physical exam over a CT and official Rad report?  
                       
                      Demand is high because the product is so good.  

                    • lisbef3_453

                      Member
                      August 15, 2023 at 9:25 am

                      Spikes like this make big cuts like the DRA more likely.

                    • Unknown Member

                      Deleted User
                      August 15, 2023 at 10:24 am

                      1. Its comforting to know this is a ubiquitous trend.
                      2. Unfortunately, it is a fait accompli for most of us.
                      3. Unless aiming for a system wide medical directorship etc, as a radiologist are stuck loading the truck, not driving it. No one cares what we think. The appropriateness criteria are a joke.
                      4. Best to adapt, and staff up. Ow, you will burn out your rads.
                      5. The animal that does not adapt; dies.

                    • buckeyeguy

                      Member
                      August 19, 2023 at 7:42 pm

                      Quote from Waduh Dong

                       
                      CT is a very good test.  Who would really trust a Noctor physical exam over a CT and official Rad report?  

                      Demand is high because the product is so good.  

                       
                      Haha, loving these posts. On fire.
                       
                      fw with a solid one too (wink wink)

                    • Unknown Member

                      Deleted User
                      August 21, 2023 at 4:46 am

                      CTA head and neck are the worst. They are time consuming and sometimes a significant vascular finding is subtle.

                    • sehyj1

                      Member
                      August 21, 2023 at 5:35 am

                      Quote from vonbraun

                      CTA head and neck are the worst. They are time consuming and sometimes a significant vascular finding is subtle.

                      It’s usually a 95 year old patient with “altered mental status” who already had a negative CT head and C spine. If the CTA is negative, they just move on to CAP/pulm arteries

                    • ebshanon

                      Member
                      August 21, 2023 at 7:38 am

                      Yeah its pretty absurd how CTA head/neck is overly abused ordered by people with little education or training.
                       
                      I dont see this trend abating or getting better.  ER is even more dominated by PE scum bags and their whole incentive structure is to staff the the place with cheap undertrained labor or turnover pts as quickly as possible with questionable billing tactics.  There is just upside and no downside to these people ordering as many imaging studies as possible assuming the imaging TAT is not going to kill their TAT.   
                       
                       
                       
                       

                    • farzadahmadimedrn710_43

                      Member
                      August 21, 2023 at 12:52 pm

                      The RVUs for CTA head and neck are good. Keep them coming. Especially when most are negative or minor stenosis.

                    • reza800p_368

                      Member
                      August 21, 2023 at 1:08 pm

                      Let them do their part and you do your part.

                    • Unknown Member

                      Deleted User
                      August 22, 2023 at 8:15 am

                      They. Are. Not. Doing. Their. Part.

                      Not by any rational medical standard.

                    • reza800p_368

                      Member
                      August 22, 2023 at 9:48 am

                      I hear you. I have talked about it in another thread. It is a losing battle. Believe me. You will be eventually accused of “Obstructing or delaying care”.
                      Don’t confront the system. Just dance with it.  

                    • Unknown Member

                      Deleted User
                      August 22, 2023 at 7:48 pm

                      Noctors kind of do the History.
                       
                      Radiology is the Physical Exam.

                    • ruszja

                      Member
                      August 22, 2023 at 8:16 pm

                      Ok. I’ll never complain again. Found a nondisplaced fractured rib on a pan-scan for a GLF today. It’s clearly necessary to do those.

                    • 6541165

                      Member
                      August 22, 2023 at 8:32 pm

                      My uncle is an old school ED doc (30+ years) and he gets in trouble for not ordering enough tests. He prefers to use his brain. 
                       
                      I mostly feel bad for EM. Seems like such a garbage speciality these days. Occasionally you get to stabilize a crashing patient (must be super fun and rewarding) but otherwise it is dealing with frequent fliers, following algorithms and order sets, getting yelled at by consults, “supervising” the midlevels who are hollowing out the profession, etc.
                       

                    • ruszja

                      Member
                      August 22, 2023 at 9:07 pm

                      Quote from chilldude22

                      I mostly feel bad for EM. Seems like such a garbage speciality these days. Occasionally you get to stabilize a crashing patient (must be super fun and rewarding) but otherwise it is dealing with frequent fliers, following algorithms and order sets, getting yelled at by consults, “supervising” the midlevels who are hollowing out the profession, etc.

                       
                      Funny. There was a point it was pretty competitive and the specialty those who wanted excitement went into. Not sure how much of that was driven by its depiction in TV shows of the day rather than the reality of ER practice.

                    • consuldreugenio

                      Member
                      August 23, 2023 at 4:27 am

                      I knew ER was a mess the first few hours I didnt the rotation as a med studies. There were med students chasing a thrill so to speak. I didnt see many high stress situations. It was my more rare compared to the nonspecific pains and pain med seekers.

                      Or they saw perks of shift work. I believe some jobs are 15 days/month for 1 FTE. However, ED docs do random overnight and 2nd shifts as part of it. The standard only 8-5 jobs are harder to get.

                      The specifically has gone down the drain a bit.

                    • ruszja

                      Member
                      August 23, 2023 at 12:13 pm

                      Read a negative sinus CT and a negative head for ‘sinusitis’. Tech calls me back, ER now wants a sinus CT with contrast ‘to see it better’.

                      And I think we should revert to ‘ER’ instead of ‘EM’. It’s truly a room and it contains no brain matter.

                    • afazio.uk_887

                      Member
                      August 23, 2023 at 12:38 pm

                       
                      It’s weird – I also dislike ER over ordering exams… but honestly I really love Radiology.   Perhaps it is because I don’t overwork on purpose, but I do love the field and reading studies.  It is just extremely interesting stuff.  
                       
                      Like anything, too much of it turns it into a horrible experience. 
                       

                       
                       

                    • buckeyeguy

                      Member
                      August 23, 2023 at 7:58 pm

                      Do you think they have intermittent meetings with admins? Do they make them watch videos like clockwork orange that imbue ordering more studies? There was a study the other day where a patient found down (not young) was dropped off at the ER and there were like 10 studies ordered, most of which were CTs. You’re telling me you can’t order like 2 or 3? And once the non con CT brain is “No acute” you can’t call most of the others off? A lot of these people are already seem like they are half dead. That doesn’t mean they shouldn’t get some care, but why are we maxxing out all possible studies, lol, as they say, “good for business” – sorta

                    • 6541165

                      Member
                      August 23, 2023 at 8:03 pm

                      Quote from Dream Run

                      A lot of these people are already seem like they are half dead. That doesn’t mean they shouldn’t get some care, but why are we maxxing out all possible studies, lol

                       
                      Similar but different — reminds me of my favorite, code strokes for inpatient elderly in the middle of the night.
                       
                      Me: “What are the symptoms?”
                      Neuro: “Confused, mildly aphasic, slow to respond.”
                      Me: “You realize it’s 3am and they are 85 years old, right?”
                       

                    • [email protected]

                      Member
                      August 24, 2023 at 9:32 am

                      Quote from OnsiteRad

                      Don’t confront the system. Just dance with it.  

                      Although I agree with the seeming futility of going against the grain, I think we all need to realize this exact mentality and/or it’s good for our pockets is what’s landed us where we are.

                      We are now the dumping ground of ‘providers’ (how I loathe that word but it is so fitting) who practice bad medicine by indiscriminate and inappropriate use of imaging.

                      Patients are being exposed to ionizing radiation, iodinated contrast, and gadolinium much more often than indicated. Draining their hard-earned savings. Driving increased healthcare costs. We are complicit in this.

                      Looking forward, does anyone here want to run faster on the treadmill year after year for less money? Budget neutrality translates into year-over-year decreased reimbursement per study due to increased imaging utilization.

                      I think we need to unionize. Yes, unions have their issues. But recently nurses, United and American airline pilots, UPS drivers – all have flexed their muscle and improved their compensation, recognition, and value. Unionized we’d have a better chance at increasing reimbursement and creating negative feedback loops for inappropriate imaging, offering escape from forced participation in bad medicine.

                    • buckeyeguy

                      Member
                      August 24, 2023 at 10:53 am

                      Quote from vadoc

                      Quote from OnsiteRad

                      Don’t confront the system. Just dance with it.  

                      Although I agree with the seeming futility of going against the grain, I think we all need to realize this exact mentality and/or it’s good for our pockets is what’s landed us where we are.

                      We are now the dumping ground of ‘providers’ (how I loathe that word but it is so fitting) who practice bad medicine by indiscriminate and inappropriate use of imaging.

                      Patients are being exposed to ionizing radiation, iodinated contrast, and gadolinium much more often than indicated. Draining their hard-earned savings. Driving increased healthcare costs. We are complicit in this.

                      Looking forward, does anyone here want to run faster on the treadmill year after year for less money? Budget neutrality translates into year-over-year decreased reimbursement per study due to increased imaging utilization.

                      I think we need to unionize. Yes, unions have their issues. But recently nurses, United and American airline pilots, UPS drivers – all have flexed their muscle and improved their compensation, recognition, and value. Unionized we’d have a better chance at increasing reimbursement and creating negative feedback loops for inappropriate imaging, offering escape from forced participation in bad medicine.

                       
                      I’ve generally agreed with this sentiment but there are far too many roadblocks. If you are a vadoc in fact, you already figured this out and went to essentially that kind of system. The larger US healthcare system, just like the monetary system, has to collapse first to see any change – and that can offer both brutal, dystopian, or ‘struggles leading to proper rebuilding’ outcomes. We will see within the next few years, unlike the main sentiment on this board, it’s going to happen.

  • kiqbns_134

    Member
    August 8, 2023 at 8:30 am

    I second that there is some extra imaging happening because ortho wont see unless there is an MRI etc. We dont have enough PCPs in my rural area to do the right thing so well cave here and there and do the non emergent MR etc. Most of the volume increase is because of mid levels and having to rule out a PE on any and everyone. Also pan scanning ground level falls in basically asymptomatic patients because we can.