Emergency departments have appropriately developed a role as the diagnostic and treatment center of excellence (and availability) in the health system. Diagnostic testing has changed over the years but still consists mostly of obtaining and analyzing blood, urine, and other body fluids; obtaining tracings of electrical activity in the body; and obtaining images of the body using a broad range of modalities (ionizing radiation, magnetic resonance, positron emissions, and ultrasound). These sophisticated tools provide unprecedented evaluation of patients presenting with a wide array of illness and injury.
Explore This IssueACEP Now: Vol 36 – No 05 – May 2017
There is significant interest in the use of diagnostic testing, particularly imaging, in the emergency department. Quality measures are being developed that compare the use of diagnostic procedures among different emergency departments and among individual practitioners. It is necessary to have historical comparatives and trend data on the use of diagnostics to prepare for the use of new metrics as quality indicators. It is also necessary to understand the difference in utilization among emergency departments that serve different patient populations.
The Emergency Department Benchmarking Alliance (EDBA) uses a voluntary data submission process for a large number of emergency departments and has collected and reported on data through the year 2016. Definitions for the various performance measures are uniform.1 The EDBA measures ED utilization of diagnostic testing in the number of procedures performed per 100 patients seen. The latest survey is compiling data from approximately 1,400 emergency departments that saw 55 million patients in 2016 and reports in cohorts based on type and volume of patients seen in the emergency department (see Table 1). The data would be considered “macro data” in measuring the performance of the entire large set of emergency departments and not for individual emergency physician performance.
Table 1 shows differences in utilization of diagnostic testing based on volume served and patient population that is predominantly served in the emergency department. There are very significant increases in use of diagnostic testing in adult-serving emergency departments when compared to those serving pediatric populations. Pediatric emergency departments only use CT imaging about four times per 100 patients seen. Plain diagnostic X-rays show little difference in utilization based on volume. Volume over 40,000 patients per year also results in more frequent use of testing, including 12-lead ECGs.
Table 2 displays the trend data for 11 years of comparison. There is a trend to increasing utilization of ECGs, ultrasound, and MRI imaging. MRI utilization across all emergency departments has now reached about 1.6 procedures per 100 patients seen, but this increases to 2.0 in trauma centers. The reporting of MRIs has only occurred over the last five years, and the reporting of ultrasound has only occurred over the last four years, with each showing expanding use. The 11-year trend shows a decrease in the use of simple X-rays and a slight reduction in the use of CT imaging.
To further characterize performance, hospitals have been sorted based on trauma center designation (see Table 3). The four cohorts are adult-serving Level I and II trauma centers, all Level I and II trauma centers, Level III and IV trauma centers, and all other emergency departments. A comparison of these cohorts finds that designation of the hospital as a Level I or II trauma center is associated with a significant increase in the utilization of diagnostic imaging. In the subset of trauma centers serving a population that is almost exclusively adults, there is a further increase in the use of imaging.
The management of trauma volumes is associated with an overall increase in the acuity of patients as measured by the percentage of patients who are reported as CPT code 99284, 99285, or 99291 (high acuity). Trauma designation also results in higher arrival rates by EMS, higher admission rates, and longer median lengths of stay for all patients served in the emergency department. There is about a 30 percent difference in CT utilization based on higher-level trauma center status and a doubling of the use of MRI procedures.
The emergency department has a critical and growing role as the diagnostic center for the medical community. This role is particularly important for patients who are being evaluated for potential admission to the hospital related to an acute episode of injury or illness. Because about 66 percent of inpatients are processed through the emergency department, physicians are responsible for a disproportionate share of diagnostic testing and the patient-flow issues related to it. Emergency physicians must understand the data on diagnostic testing in their department and have comparison data available. This will allow for better decision making by all parties involved in utilization management and the rate of use of diagnostic imaging as a marker of quality.
- Wiler JL, Welch S, Pines J, et al. Emergency department performance measures update: proceedings of the 2014 Emergency Department Benchmarking Alliance Consensus Summit. Acad Emerg Med. 2015;22(5):542-553.