Hippocratic Medicine No. 2: Between a Rock and a Hard Place

Clinical Scenario:
You are working in the emergency department on a typical busy day. There are fifteen boarding patients waiting for their bed upstairs, another thirty-plus in the waiting room.  You walk into a room to assess a 75 yo female with confusion. Family says that she has been confused: forgetting to put on one shoe, unable to finish her crossword puzzles, and no longer able to bowl without throwing a gutter ball. Amazingly, the urinalysis is negative. Concerned that she may have had a subacute stroke, you order a head CT without contrast which shows “a large amount of vasogenic edema concerning for neoplasm.” The radiologist recommends a follow up MRI for further evaluation. The consulting neurologist instead asks for a Head CT (HCT) with contrast, reasoning they would not be the admitting service if the patient is found to have a mass. Neurosurgery recommends an MRI to evaluate for a suspected mass, and you learn that it will be 8 hours before the patient can go to MRI. With the pressure of the waiting room, the full rooms, and the boarding patients in the ED, you reluctantly order the HCT with contrast, which shows a right parietal neoplasm. Having rarely, if ever, ordered HCT with contrast, you ask- What are the indications for HCT with contrast in a patient with subacute onset of focal neurological deficits?

Literature Review:
The American College of Radiology (ACR) publishes evidence-based guidelines to help direct the efficacious use of radiologic studies. Their 2012 Appropriateness Criteria for Focal Neurologic deficits discusses the use of HCT vs. MRI. HCT without contrast is recommended for initial evaluation in this case. While contrast can provide additional information, “some pathology is difficult to visualize with CT under any circumstances,” and “MRI is more sensitive than CT for detecting primary and secondary brain lesions and for defining extent of disease.” Additionally, MRI spares the patient exposure to ionizing radiation and “provides information that…approaches the accuracy of a neuropathologic diagnosis” [1].  Specifically, for our patient with subacute onset of neurological deficits, the ACR recommends a HCT without contrast for acute screening. The highest rated imaging for further evaluation is an MRI head with and without contrast, rated an 8/9 for “usually appropriate.” A HCT with contrast was rated a 4/9, for “may be appropriate,” with the typical indication being inability to get an MRI. This patient had no contraindications to MRI and should not have had the contrasted HCT. Eight hours later she had a MRI to more appropriately plan her operative course. 

The Lancet covered the Pitfalls in the Diagnosis of Brain tumors, and lists several elements that indicate a non-neoplastic diagnosis: young adults, recent travel, sexual risk behavior, IV drug addiction, TB, immunosuppression [2]. Some non-neoplastic tumor lesions are abscesses, vascular lesions, or infectious which can be better evaluated with HCT with contrast. Our patient had none of these risk factors.

Reflecting on these guidelines and indications for imaging, the head CT with contrast should not have been ordered for this patient before the MRI. While the non-contrast HCT identified a neoplasm, more definitive testing in the form on an MRI was still required. The HCT with contrast only expedited the patient’s disposition from the ED, yet it added minimally to her care and increased her risk for contrast-induced nephropathy and exposed her to risk of allergic reaction.

So why did the HCT with contrast get ordered? The junior consulting neurologist, the ED attending, radiology and the ED resident (myself) all knew it was an inappropriate next test. For the neurologists, they saw potential harm in an additional handoff of the patient to yet another team (in this case, neurosurgery).  Neurology’s concern was not wrong. Medical error because of a poor handoff is the third most common reason for adverse events leading to patient harm in hospitals [3]. From my perspective as the ED resident, there were multiple perceived harms. For my patient, I saw potential harm for her in staying in the emergency department. She would remain on a gurney, in a curtain-partitioned room, where the next gunshot victim or cardiac arrest would be resuscitated next to her. She would not rest, her home medications were likely to be lost in the shuffle, and the bathroom was further away increasing the risk of falls. She would be at increased risk for delirium. As Aminzadeh found in the study, "Older Adults in the Emergency Department" [4], the longer ED stay the greater number of diagnostic tests performed creating higher risk for adverse outcomes. Most EDs do not have an environment that follows new geriatric ED guidelines [5].  Stuck between ordering a likely unnecessary test with potential for harm and exposing the patient to a prolonged ED stay and patient hand off with their associated risks, we chose by physician gestalt the lesser of two evils.

But in truth, there was more to it than just the calculated risks and benefits for my patient alone.  The prolonged ED stay for my patient also conferred potential harms for the patients  still waiting to be seen in our overcrowded waiting room.  According to the Institute of Medicine report, "On Hospital-Based Emergency Care: At the Breaking Point", 70% of urban emergency departments go on diversion at some time during the year. In 2003, ambulances were diverted 501,000 times, almost once a minute [6].  Our hospital, Barnes-Jewish, operates at 100% capacity more than half the time.  ED overcrowding was found to contribute to 31% of sentinel events. 29 of 55 sentinel events were due to delays in care occurred in emergency department [7].  ED overcrowding is attributed to boarding patients, where “output”- transferring patients to their inpatient bed- is held up. My patient had become an “output” problem: she had an inpatient ready bed but no team willing to take her for 8 hours until an MRI was complete. My fix for this output issue was the unnecessary, potentially harmful HCT with contrast to get her upstairs 6 hours sooner. Length of boarding time has been associated with higher mortality- 2.5% mortality for boarding time < 2hours, and 4.5% for boarding time >12 hours(8). While I recognized the potential harm to my patient, I ordered the test thinking of other harms to my patient and patients I had not yet seen. How do we know which is greater?  The harm of an unnecessary head CT with contrast in one patient or the harm in delaying care for others?  While the squables of establishing an admitting team may be specific to academic centers, the issues of advocating for inpatient admission, transferring to higher level of care, or managing ED throughput are not.  All along the way to doing the right thing, EM physicians can get caught between a rock and a hard place.

What are the solutions to this problem? Moskop, et al. proposed a number of "throughput solutions" to this problem, including disposition lounges and bed management planning teams [7].   Some of these are already used in our system.  We could adopt an “admission pending unit” where admitted patients await testing when the inpatient unit is full [9]. Utilizing a “full-capacity protocol”- moving boarding patients to inpatient hallways throughout the hospital- can ease the burden on the ED and distribute patients to all care areas. Our hospital could also adopt a practice of “smoothing”, which uses data about predictable weekly demands for admissions from the ED (ie Monday afternoon), to spread elective surgeries to other days of the week [9].

Clinical Take home: 

In emergency medicine, we are often stuck between a rock and a hard place when we are just trying to do the right thing by our patients.  When faced with these challenges, we can continue to be patient advocates by:
       - Referring to the American College of Radiology Appropriateness Criteria when considering patient imaging. A great evidence based resource for all radiology studies. http://www.acr.org/Quality-Safety/Appropriateness-Criteria
     - Respecting our elders! Consider the needs of your geriatric patient in the ED    

     - Remembering that boarding times, limitations, and diversion lead to increased mortality
     - Working with our specialists to facility inpatient admission
     - Promoting Full Capacity protocols, and Smoothing which can alleviate the burden of ED     overcrowding and likely save lives.

Submitted by Alicia Oberle, PGY-3
Edited by Maia Dorsett (@maiadorsett), PGY-3
Faculty Reviewed by Douglas Char, Ryan Schneider, and Rob Poirier

The WUSM Do No Harm Project is supported by a grant provided by The Foundation for Barnes Jewish Hospital

1. Wippold FJ, Cornelius RS, Aiken AH, et al. Expert Panel on Neurologic Imaging: Focal Neurological Deficit. American College of Radiology Appropriateness Criteria. 2012.
2. Omuro AM, Leite CC, Mokhtari K, Delattre JY. Pitfalls in the diagonosis of brain tumors. The Lancet. Neurology. 2006 Nov; 5(11):937-48.
3. Jagsi R, Kitch CT, Weinstein EG, et al. Residents report on adverse events and their causes. Archives of Internal Medicine. 2005 Dec 12-26; 165(22): 2607-13.
4. Aminzadeh F, Dalziel WB. Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions.
5. Carpenter CR, Bromley M, Caterino JM, et al. Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Academic Emergency Medicine. 2014 July; 21(7): 806-809.
6. Institute of Medicine " Front Matter ." Hospital-Based Emergency Care: At the Breaking Point . Washington, DC: The National Academies Press, 2007 .
7. Moskop JC, Sklar DP, Geiderman JM, et al. Emergency Department Crowding, Part 1- Concept, Causes, and Moral Consequences. Annals of Emergency Medicine. 53(5).
8. Singer AJ, Thode HC, Viccellio P, Pines JM. The Association Between Length of Emergency Department Boarding and Mortality. Academic Emergency Medicine. 2011; 18: 1324-1329.
9. Moskop JC, Sklar DP, Geiderman JM, et al. Emergency Department Crowding, Part 2- Barries to Reform and Strategies to Overcome Them. . Annals of Emergency Medicine. 53(5) 612-617.