My motivation for this article came while I was on a recent call shift. I was opening up a chest radiograph on the PACS workstation when I saw the clinical history field (filled in by the clinician) which read “chest.” That was it. Just “chest.” Not even “pain,” or “chest pain.” Nope, just “chest.” As if I needed to know that I was looking at a patient’s chest x-ray as opposed to their foot x-ray. Thus, the impetus to give three brief tips on how to order a radiology test.
1. Order the right test – this is detailed at length in the American College of Radiology Appropriateness Criteria (see above photo). To avoid going into too much detail here, these criteria have been established after much hard work by mutlidisciplinary groups of physicians and professionals in order to “assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. Employing these guidelines helps providers enhance quality of care and contribute to the most efficacious use of radiology.” You can also use the ACRselect clinical decision support tool, which essentially is the appropriateness criteria put into an easy to use application.
2. Give the right history – this cannot be overstated. Our sensitivity and specificity in radiology are directly affected by the given clinical history. If you told me the patient had pain on a hand x-ray order that would be much less helpful than if you told me the patient had tenderness to palpation with swelling at the 5th metacarpalphalangeal joint, typical in a patient with a Boxer fracture. The same goes for the chest x-ray I referenced above. This patient had a left lateral 6th rib fracture. I would be much better at finding the fracture if the clinician told me the patient had left lateral chest pain, or even just “left chest pain.” Most clinicians will say “pain.” Its somewhat rare for them to give the laterality, although just giving the laterality will increase accuracy immensely.
3. Send the patient at the right time – the radiology department is probably one of the last places that you as a clinician should want your patient to be in when he or she has a cardiac arrest. Please don’t send unstable patients for a CT scan, or any radiology test for that matter. If there is any concern that your patient is likely going to need cardiopulmonary resuscitation, the best place for them to be is in the emergency department or intensive care unit. Aside from unstable patients, there are other inappropriate times to obtain a radiology test, such as obtaining a CT angiogram of the head outside the window of time to treat an ischemic stroke with tissue plasminogen activator (tPA). Many more inappropriate times to obtain a study exist.
Have any more tips? Please feel free to add them in the comments below!
J. L. Koning, MD
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