June 1, 2021
Appropriate Advanced Imaging in the Emergency Department
Focus: In order to expedite appropriate patient care, minimize patient/provider conflicts, improve patient satisfaction, meet patient expectations and to minimize waste in both cost and imaging in the emergency department with respect to advanced imaging requests from the primary care and consulting base.
Basis: It is a common occurrence for outpatient providers to refer patients to the emergency department to secure advanced imaging in order to avoid perceived long delays in securing desired testing, to avoid potential insurance obstacles and/or patient dissatisfaction with not knowing the exact diagnosis. In the emergency department patient’s may present with a statement “my PCP wanted me to come to the ED and get my MRI” or some variation. Our goal today is to discuss some of the myths and strategies around appropriate use of these tests and alternatives to support the patient’s care plan and support best practice in patient satisfaction.
MRI:
- MRI from the ED is limited to time sensitive neurological conditions.
- Typical wait from MRI order to completion is 6-10 hours.
- Hospital MRI units are usually booked with inpatient/outpatient scheduled tests and ED requests mean “bumping” a scheduled patient.
- Patients are often referred to the ED for an MRI when it is not appropriate, i.e. low back pain of 1-2 weeks duration.
Recommendation: MRI is best reserved for the outpatient setting unless a true life or limb threatening issue has arisen. Dedicated discussion with patients and families to manage their expectations about the need for the testing, what we hope to find with that testing, and the options for further diagnostic services and treatment.
Ultrasound:
- Different emergency departments have different hours of availability. Become familiar with what the capabilities and limitations are at your local hospital.
- Should be used for emergent clinical conditions such as testicular torsion, suspected ectopic pregnancy.
- Venous doppler for suspected DVT can be arranged as an outpatient and the patient can be anticoagulated with a novel oral anticoagulant until the test can be obtained.
- Gall bladder ultrasounds should also be arranged on an outpatient basis.
Recommendation: If safe to do so order your US as an outpatient for routine issues. If there is clinical indication that the patient would need a DVT study and you do not have the resources to initiate anticoagulation, send the patient to the ED with a plan in mind for continuation of treatment. If you call ahead and communicate the plan, we can assist in streamlining the care when your patient arrives.
Nuclear Medicine:
- Obtaining nuclear medicine studies such as HIDA scans, nuclear stress tests, V/Q scans, bone scans through the ED is not appropriate. Most of these are lengthy studies and require an admission or observation stay.
Recommendation: Please schedule your nuclear medicine studies as a routine outpatient.
Summary: As emergency physicians we understand and sympathize with the frustrations that a primary care physician can experience when trying to obtain an advanced imaging study for their patient. Hopefully this communication will help all understand the limitations that emergency departments have in providing these studies. We enjoy when our primary care and specialty providers participate in the care of the ED patient, a well-placed phone call to the ED physician can really enhance the patient experience in the ED and assist in supporting our patient experience initiatives and goals. With proper choices and communication between our two teams, we can avoid unnecessary patient frustration, manage everyone’s expectations, and provide high value coordinated care to the patients we serve.
Special thanks to Dr. Brad Blaker- McLaren Bay ER, and Dr. James Larkin- McLaren Macomb ER and the MPP ED PAC (Physician Advisory Council) for the content of this clinical corner.
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