Trends in Lumbar Puncture Over 2 Decades: A Dramatic Shift to Radiology

Kroll, Hannes; Duszak, Richard; Nsiah, Eugene; Hughes, Danny R.; Sumer, Suna; Wintermark, Max

doi:10.2214/ajr.14.12622

Cited by 55 publications

(64 citation statements)

References 17 publications

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“…Although the number of definite indications for LP has decreased with the introduction of streamlined neuroimaging procedures, LP is commonly performed in EDs in adult subjects with some combination of fever, altered mental status, headache, or meningeal signs to confirm diagnosis of ABM, and CSF sample analysis is usually performed in accordance with urgent procedures, including cell counts, biochemistry, and microbiological evaluation (7,10,11). Our clinical microbiology laboratory was used to perform CSF Gram stain and bacterial culture (and also RT-PCR in selected cases) as urgent exams, on a 24-hours-a-day, 7-days-a-week schedule, on all CSF specimens collected in the ED from cases of suspected ABM.…”

Section: Discussionmentioning

confidence: 99%

Proposal for a New Score-Based Approach To Improve Efficiency of Diagnostic Laboratory Workflow for Acute Bacterial Meningitis in Adults

Lagi

Bartalesi

Pecile³

et al. 2016

J Clin Microbiol

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Microbiological tests on cerebrospinal fluid (CSF) utilize a common urgent-care procedure that does not take into account the chemical and cytological characteristics of the CSF, resulting sometimes in an unnecessary use of human and diagnostic resources. The aim of this study was to retrospectively validate a simple scoring system (bacterial meningitis-Careggi score [BM-CASCO]) based on blood and CSF sample chemical/cytological parameters for evaluating the probability of acute bacterial meningitis (ABM) in adults. BM-CASCO (range, 0 to 6) was defined by the following parameters: CSF cell count, CSF protein levels, CSF lactate levels, CSF glucose-to-serum glucose ratio, and peripheral neutrophil count. BM-CASCO was retrospectively calculated for 784 cases of suspected ABM in adult subjects observed during a four-and-a-halfyear-period (2010 to 2014) at the emergency department (ED) of a large tertiary-care teaching hospital in Italy. Among the 28 confirmed ABM cases (3.5%), Streptococcus pneumoniae was the most frequent cause (16 cases). All ABM cases showed a BM-CASCO value of >3. Most negative cases (591/756) exhibited a BM-CASCO value of <1, which was adopted in our laboratory as a cutoff to not proceed with urgent microbiological analysis of CSF in cases of suspected ABM in adults. During a subsequent 1-year follow-up, the introduction of the BM-CASCO in the diagnostic workflow of ABM in adults resulted in a significant decrease in unnecessary microbiological analysis, with no false negatives. In conclusion, BM-CASCO appears to be an accurate and simple scoring system for optimization of the microbiological diagnostic workflow of ABM in adults. C ases of acute bacterial meningitis (ABM) require prompt diagnosis and treatment due to significant mortality rates (1, 2). A delay in starting appropriate therapy may worsen the prognosis (1). Recently, the epidemiology of ABM has shifted to older age groups due to the increasing child vaccination rates against the most common meningeal pathogens (3, 4). Streptococcus pneumoniae is currently the leading cause of ABM in adults and is associated with a 17 to 30% mortality rate (2-4).Diagnosis of ABM at the time of clinical presentation is often difficult and requires laboratory investigation of cerebrospinal fluid (CSF) specimens. A Gram stain of the CSF sediment is a widely used test for the rapid detection of bacteria but may suffer from low sensitivity (5). When evaluated on adult subjects not previously treated with antibiotics, the CSF Gram stain has been reported to have a sensitivity between 60% and 92% (6). Sensitivity can be increased by molecular tests, such as real-time PCR (RT-PCR), but these tests are still not widespread due to their high cost and the need for expensive equipment and experienced laboratory personnel. Bacterial culture remains the gold standard for microbiological diagnosis of ABM, but it requires longer times and suffers from reduced sensitivity in cases involving previous antimicrobial chemotherapy (6). In addition, biochemical and cyto...

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Section: Discussionmentioning

confidence: 99%

Proposal for a New Score-Based Approach To Improve Efficiency of Diagnostic Laboratory Workflow for Acute Bacterial Meningitis in Adults

Lagi

Bartalesi

Pecile³

et al. 2016

J Clin Microbiol

View full text Add to dashboard Cite

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“…The number of procedures general internists perform has decreased substantially over the last 30 years, [1][2][3] and the American Board of Internal Medicine (ABIM) no longer requires procedural competency for internal medicine (IM) residency graduates. 4 Resident opportunities to perform procedures have diminished, as a number of procedures formerly performed by internists are now being performed by interventional radiologists.…”

Section: Introductionmentioning

confidence: 99%

The Procedure Coordinator: A Resident-Driven Initiative to Increase Opportunity for Inpatient Procedures

Gorgone

McNichols

Lang

et al. 2018

Journal of Graduate Medical Education

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Background Training residents to become competent in common bedside procedures can be challenging. Some hospitals have attending physician-led procedure teams with oversight of all procedures to improve procedural training, but these teams require significant resources to establish and maintain. Objective We sought to improve resident procedural training by implementing a resident-run procedure team without routine attending involvement. Methods We created the role of a resident procedure coordinator (RPC). Interested residents on less time-intensive rotations voluntarily served as RPC. Medical providers in the hospital contacted the RPC through a designated pager when a bedside procedure was needed. A structured credentialing process, using direct observation and a procedure-specific checklist, was developed to determine residents' competence for completing procedures independently. Checklists were developed by the residency program and approved by institutional subspecialists. The service was implemented in June 2016 at an 850-bed academic medical center with 70 internal medicine and 32 medicine-pediatrics residents. The procedure service functioned without routine attending involvement. The impact was evaluated through resident procedure logs and surveys of residents and attending physicians. Results Compared with preimplementation procedure logs, there were substantial increases postimplementation in residentperformed procedures and the number of residents credentialed in paracenteses, thoracenteses, and lumbar punctures. Fifty-nine of 102 (58%) residents responded to the survey, with 42 (71%) reporting the initiative increased their ability to obtain procedural experience. Thirty-one of 36 (86%) attending respondents reported preferentially using the service. Conclusions The RPC model increased resident procedural training opportunities using a structured sign-off process and an operationalized service.

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“…12 Although a large body of literature exists comparing the market share of interpretation by radiologists versus nonradiologists for a variety of diagnostic and interventional radiology services, little work, to date, has focused on how those specialty differences vary by time and location. [13][14][15][16] Recent work suggests that emerging pay-for-performance models could unintentionally compromise patient access, particularly in areas where different specialty groups render similar services. 17 Further investigation into potential specialist variation-and the drivers thereof-could potentially help inform policy initiatives to ensure consistent and equitable access of all patients to high-quality services, regardless of time, date, geography, or patient complexity.…”

mentioning

confidence: 99%

Characteristics of MR Neuroimaging Services Billed by Radiologists versus Nonradiologists

Sharp

Lall

Hughes

et al. 2018

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Although most neuroimaging examinations are interpreted by radiologists, many nonradiologists provide interpretation services. We studied day of the week, site of service, and patient complexity differences for common Medicare MR neuroimaging examinations interpreted by radiologists versus nonradiologists. MATERIALS AND METHODS: Using carrier claims files for a 5% sample of Medicare beneficiaries from 2012 to 2014, we identified all claims for brain and lumbar spine MR imaging examinations. Services were categorized by physician specialty, day of the week, and the site of service. Patient complexity was calculated using Charlson Comorbidity Indices. The 2 was performed to test statistical significance. RESULTS: A provider specialty could be identified for 568,423 brain and lumbar spine MR imaging examinations. Of weekday examinations, radiologists interpreted 475,288 (92.3%), and nonradiologists, 39,510 (7.7%). Of weekend examinations, radiologists interpreted 52,028 (97.0%) and nonradiologists 1597 (3.0%). Radiologists interpreted 145,904 (98.7%) examinations in the inpatient hospital and emergency department settings versus 1882 (1.3%) by nonradiologists. Of all examinations, 44,547 of those interpreted by radiologists (8.4%) were on the most clinically complex patients versus 2139 (5.2%) for nonradiologists. All interspecialty differences for day of the week, the site of service, and patient complexity were statistically significant (P Ͻ .001). CONCLUSIONS: Although radiologists interpret most common MR neuroimaging examinations for Medicare beneficiaries, in contrast to nonradiologists, they disproportionately render those services on weekends, in higher acuity sites, and on more complex patients. To optimize access and minimize disparities in necessary neuroimaging, quality metrics should consider such service characteristics.

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Trends in Lumbar Puncture Over 2 Decades: A Dramatic Shift to Radiology

Cited by 55 publications

References 17 publications

Proposal for a New Score-Based Approach To Improve Efficiency of Diagnostic Laboratory Workflow for Acute Bacterial Meningitis in Adults

Proposal for a New Score-Based Approach To Improve Efficiency of Diagnostic Laboratory Workflow for Acute Bacterial Meningitis in Adults

The Procedure Coordinator: A Resident-Driven Initiative to Increase Opportunity for Inpatient Procedures

Characteristics of MR Neuroimaging Services Billed by Radiologists versus Nonradiologists

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