MSS003: IMPACT OF IMAGING MODALITY ON LENGTH OF STAY IN RIGHT UPPER QUADRANT PAIN: A PROCESS IMPROVEMENT INITIATIVE AT A TERTIARY CARE MILITARY TREATMENT FACILITY
Danielle Isaacson, BS1; Sophia McKenzie, BS1; Vera Funk, MD2; Mason Remondelli, MD2; Megan Breckheimer, MD2; Matthew Bradley, MD2; 1Uniformed Services University of the Health Sciences; 2Walter Reed National Military Medical Center
Objectives: A cornerstone of favorable treatment outcomes for patients with right upper quadrant pain is the timeliness of initial diagnostic imaging. Several societies, including The American College of Radiology, the World Society of Emergency Surgery, and the Infectious Diseases Society of America (IDSA) recommend ultrasound as the first-line imaging for suspected acute cholecystitis or cholangitis, with the addition of CT if uncertainty remains. However, studies have shown poor adherence to these guidelines, which may lead to delayed timing to surgery and increased hospital lengths of stay. The purpose of this study is to evaluate the right upper quadrant imaging practices at our military treatment facility. From this study, we hope to guide process improvement and decrease time to surgery, optimize resource utilization, and improve patient outcomes.
Methods: We conducted a retrospective analysis of the WRNMMC Emergency General Surgery Registry (EGS) from 2017 to 2021. Non-pregnant adults presenting with RUQ pain were included. Patient demographics, laboratory and imaging workup, antibiotics, length of stay (LOS), and hospital course details were reviewed. Based on societal guideline recommendations, an appropriate workup is defined as either a right upper quadrant ultrasound (RUQUS) alone or a RUQUS followed by an abdominal CT. Imaging modalities were compared with average hospital LOS using ANOVA and pairwise tests.
Results: A total of 221 patients were included in our study. 61% of the patients were female (135 female, 86 male) with the average age of 54±18years. Of these patients, 52% (n=116) were evaluated with only a RUQUS and 9% (n =19) with only a CT scan. 31% of patients were evaluated with both a RUQUS and a CT, and of these patients, 18% received a CT scan before the RUQUS (n=39), and 14% received a RUQUS before the CT scan (n=30). In total, 66% of patients (n=146) adhered to recommended diagnostic imaging guidelines. Hospital LOS was significantly longer in patients who received a CT before RUQUS compared to RUQUS alone (mean difference 1.5 days, SD 0.58; p<0.009).
Conclusion: Our institution had poor adherence to recommended societal guidelines for initial imaging modalities for patients with RUQ pain, with 18% of patients receiving an additional CT prior to diagnostic RUQUS. Unnecessary imaging prolonged LOS by 1.5 days, underscoring the need for better adherence to RUQ imaging protocols to ensure accurate and timely diagnosis, reduce complications, and improve patient outcomes.