Scientific Papers

Factors contributing to uncertainty in paediatric abdominal ultrasound reports in the paediatric emergency department | BMC Emergency Medicine

In this study, the factors contributing to uncertainty in abdominal US reports in children visiting the PED were US examinations by a radiology resident, body habitus, and age. In addition, uncertain radiological reports significantly increased the rate of children undergoing additional CT scans.

The most important factor leading to uncertain radiologic reports was US examinations by a radiology resident. Previous studies have shown discrepancies between radiology residents’ preliminary radiology reports and faculty members’ formal reports [15]. Body habitus was also an important factor because the rate of uncertain reports increased in obese group. Obesity or a high BMI is a well-known factor that reduces the diagnostic ability of abdominal US in both adults and children [16, 17]. There are previous studies that reports decreased sensitivity of ultrasound diagnosing appendicitis in obese/overweight children [18,19,20], and Sulowski et al. [21] emphasized the significance of reexamination and reimaging in cases of obese children suspected of having appendicitis and undergoing screening abdominal ultrasound.

A higher number of additional CT scans were performed in cases with uncertain radiological reports, whereas a higher rate of children underwent urgent intervention if they had certain reports. Among the 210 patients with uncertain reports, 65 (31.0%) underwent CT due to uncertain radiologic reports. Only 18 of the 65 children needed urgent intervention within 24 h, suggesting that a large number of children received unnecessary radiation exposure due to uncertain radiologic reports. In contrast, among the 796 children who had certain radiological reports, only 20 (2.5%) underwent an additional CT scan due to medical necessity (such as evaluation for metastasis of a newly diagnosed malignancy). Therefore, although 13 of the 20 children did not require urgent intervention, it cannot be assumed that radiation exposure was unnecessary. In this study, additional CT scans due to uncertain radiological reports resulted in a median additional effective radiation dose of 1.73 mSv per child. Larger radiation doses and a younger age at exposure increase the lifetime risk of cancer [22,23,24]. The effective radiation dose of 1.73 mSv is less than the annual exposure to background radiation (approximately 3.0 mSv) [25] but up to 500 times higher than that of simple chest x-rays [26].

In a previous study, 74% of children with suspected appendicitis who underwent abdominal US had non-definitive conclusions, 60% had disclaimers, and 25% of those patients underwent a subsequent CT scan. Among the non-definitive conclusions, when the CT scan was performed because of the disclaimer, positive appendicitis was observed in 29% of cases [6]. In this study, the proportion of uncertain reports was smaller (20.87%) than that in a previous study, whereas 31.0% of patients had additional CT scans, which is similar to that of the previous study.

In our study, the most common reason for uncertainty in radiologic reports was ‘abundant bowel gas’ (33.81%), followed by ‘not confident’ (28.57%) and ‘irritable child’ (22.38%). While it is plausible that our hospital’s practice of not adhering to fasting times before conducting ultrasounds may play a role in generating uncertain radiologic reports due to bowel gas, it’s important to note that gas-generated reverberation artefacts are a well-known cause of US artifacts [27, 28], and adequate training for techniques, such as graded compression, can help improve study quality [28, 29]. Nevertheless, the exact prevalence of these artifacts remains poorly documented. Additionally, hydrosonography can be considered for specific indications [30].

Radiological reports are the most important means of communication between radiologists and clinicians. However, radiologists with less experience than specialists may have limitations when performing and reading abdominal US images. This may explain why many patients did not receive a confident examination by a radiology resident. Residents may be unable to find the target organ as well as the specialist, and even if they do find the target organ, they may report uncertainty with the intention of protecting themselves from medicolegal problems due to a lack of confidence in their interpretation. Furthermore, radiology reports can be interpreted differently by different treating physicians [7, 8]. Phrases like ‘probably’ and ‘unlikely’, which are commonly used in radiology reports, do not represent exact probabilities and may confuse physicians.

However, it is important for children to receive consistent, quality care, regardless of day or night. It would be ideal to have certified paediatric radiologists working 24 h a day; unfortunately, not every hospital has a full-time, certified paediatric radiologist, and in many institutions, radiology residents interpret radiologic studies after working hours. Several methods can be considered to reduce uncertain radiological reports and improve the quality of care during PED off-hours.

Encouraging education and proper training of paediatric radiologists are important for improving the quality of US imaging performed by radiology residents. Previous studies have shown that hospitals with more paediatric patients or a paediatric-focused ED had significantly lower CT scan rates for abdominal pain [31, 32] due to better accessibility and more experience, emphasizing the importance of proper training. In addition, standardization of radiology reporting, such as a structured report template, can be considered [33, 34] for better communication between radiologists and treating physicians. Furthermore, it is important that physicians provide radiologists with accurate clinical information. Adopting a low-dose CT protocol can also help prevent excessive radiation exposure [35].

Our study had some limitations. First, because this study was a retrospective study conducted in a single hospital, we could not follow up with individual children. If a child was discharged from the PED and never returned, we could not determine whether the child had a true surgical diagnosis that required intervention without a repeat visit to our hospital. Given that a substantial number of children in our study population were discharged, we recommend that future research consider a prospective approach, possibly involving outpatient clinic follow-ups or phone-call monitoring, to address this limitation. Additionally, potential bias from the treating PED physicians or caregivers was not considered. In our hospital, although emergency medicine residents and paediatric emergency medicine specialists work in pairs and are responsible for making important decisions, the decision to order an additional CT scan might have been affected by the previous experience or personal preference of each specialist, or even the patient density of the PED at the time. In addition, if caregivers were especially anxious or if it was difficult for the patient to visit the hospital several times, they might have wanted to obtain a definitive result from a single visit. These problems were difficult to overcome owing to the retrospective design of this study, and further research into these factors is needed in the future. Additionally, we did not include children with a history of previous abdominal surgery or those with chronic intra-abdominal pathology, despite this potentially representing a significant portion of the pediatric patients seen in the PED. However, detailed demographic information and the reasons for uncertain conclusions regarding these excluded children can be found in Supplementary Tables 2 and 3.

US examination by a radiology resident was the most important factor contributing to uncertainty in abdominal US reports in the paediatric population. Uncertain radiological reports increase the likelihood of additional CT scans. Measures to improve the clarity of radiological reports must be considered to improve the quality of care for children visiting the PED.

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