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Patient Imaging Quality and Safety Laboratory (PIQS Lab)

Principal Investigator: Leora Horwitz, M.D., New York University (NYU), New York, NY
AHRQ Grant No.: HS24376
Project Period: 09/30/15-06/30/20
Description: The goal of the PIQS Lab was to be a dynamic learning environment focused on improving safety and outcomes for patients. The multidisciplinary PIQS Lab connected experienced clinicians in the NYU departments of Radiology, Emergency Medicine, Medicine, Surgery, and Urology with operations, human factors, and management experts at NYU Langone Medical Center, the NYU Wagner School of Public Policy, and the NYU Stern School of Business and with design experts at the design firm IDEO.

The project aims were to:

  • Redesign the radiology ordering process in the outpatient setting to minimize inappropriate or unnecessary radiology tests.
  • Redesign the inpatient consultation process to improve patient safety.
  • Enhance the followup of radiology test results to improve patient outcomes.

After conducting problem analysis, the PIQS Lab identified numerous process failures and opportunities for improvement in its three focus areas, such as (1) lack of routine calculation of risk for pulmonary emboli (PE) before ordering CT pulmonary angiography (CTPA) in the emergency department (ED); (2) lack of standard policies and procedures for pre- and post-vascular interventional radiology (VIR) care; and (3) inconsistent reporting of incidental findings of incidental pulmonary nodules.

The PIQs Lab conducted a number of interventions, including auto calculation of risk scores, audit and feedback reports, peer comparison dashboards, institution of new work procedures, standardization of policies, training sessions on optimal pain and sedation management, creation of new templated notes in the electronic health record, and macros for radiology reports. A few of the lab's many achievements are outlined below:

  • The PIQs Lab assessed 212 consecutive ED encounters with CTPA ordered and found that the frequency of guideline-discordant studies ranged from 53 (25%) to 79 (37%), depending on the scoring system used; a total of 46 (22%) were guideline discordant under all three scoring systems. Of these, 18 (39%) had at least one patient-specific factor associated with increased risk for PE but not included in the risk stratification scores (e.g., travel, thrombophilia). These findings were reported in the Journal of the American College of Radiology.[1]
  • The PIQs Lab developed and implemented a clinical decision support (CDS) intervention to promote guideline-concordant CTPA ordering. The tool combines risk stratification and lab results to generate a recommendation to providers if, and only if, they are attempting to order a guideline-discordant exam. The results of the development and validation of this auto-calculated version of the revised Geneva score were published in Academic Emergency Medicine.[2] However, following complete evaluation of the CDS intervention, the PIQs Lab found that while the intervention improved the main outcome of guideline adherence from 67 percent to 78 percent, it did not sufficiently improve other outcomes (i.e., CTPA yield or CTPA rate/1,000), and was therefore not adopted.
  • The PIQs Lab assessed adverse event reports related to VIR over a 6-year period, finding that 45 percent of reports involved harm to patients. The most commonly reported adverse events were procedural complications (109; 29.1%), many of which had implications for postprocedure care. Results of this study are under review.
  • The PIQS Lab developed and implemented standardized documentation and communication between VIR and the referring specialties. Incoming phone calls to VIR decreased from 19,625 in the 6 months preintervention to 9,370 in the 6 months postintervention (p<0.001). This work was presented at the Society of General Internal Medicine annual meeting and the American Medical Informatics Association meeting.
  • The PIQS Lab developed a natural language processing tool to identify incidental pulmonary nodules from unstructured radiology reports. The sensitivity and specificity of the algorithm were 96 percent and 86 percent, respectively. This algorithm was published in the Journal of the American College of Radiology.[3]

This PSLL's work has resulted in at least 11 peer-reviewed journal publications, with 22 citations in other publications.

Publications

2021

  • Gyftopoulos S, et al. Efficacy of a multi-modal intervention on CT pulmonary angiography ordering behavior in the emergency department, under review.
  • Horwitz LI, et al. Adverse events associated with peri-procedural handoffs, under review.

2020

2019

2018

2016

References

  1. Gyftopoulos S, et al. Qualitative study to understand ordering of CT angiography to diagnose pulmonary embolism in the emergency room setting. J Am Coll Radiol. 2018;15(9):1276-84.
  2. Koziatek CA, et al. Automated pulmonary embolism risk classification and guideline adherence for computed tomography pulmonary angiography ordering. Acad Emerg Med. 2018;25(9):1053-61.
  3. Simon E, et al. An evaluation of guideline-discordant ordering behavior for CT pulmonary angiography in the emergency department. J Am Coll Radiol. 2019;16(8):1064-72.
Page last reviewed April 2021
Page originally created April 2021

Internet Citation: Patient Imaging Quality and Safety Laboratory (PIQS Lab). Content last reviewed April 2021. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/resources/learning-lab/imaging-quality-long-desc.html

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