RSNA 2017: Overuse of STAT designation slows MRI workflow, causes confusion

The term “STAT” implies urgency: act immediately.

But when clinicians overuse that designation, it becomes more difficult and time-consuming to distinguish true emergencies from cases that can wait, said Anna Trofimova, MD, PhD, a diagnostic radiology resident at Emory University School of Medicine in Atlanta. It can also lead to surprising consequences, according to research Trofimova presented Nov. 29 at RSNA 2017 in Chicago.

Trofimova and colleagues found radiologists and technologists were so flooded with STAT brain MRIs at their medical center that the mean turnaround time for those imaging studies was roughly 50 percent longer than routine brain MRIs (23.43 hours versus 15.46 hours).

“The number of the STAT brain MRI has increased so significantly that eventually we ended up having a situation where we had 60 percent of all MRI orders ordered as STAT, meaning that we just cannot complete all of them in a timely manner,” said Trofimova, who studied the MRI order prioritization at Grady Memorial Hospital in Atlanta from 2012 to 2015.

Total brain MRIs increased over the study period, but STAT MRIs grew by 82 percent while routine MRIs increased by a modest 2 percent.

Trofimova attributed this growth in STAT orders to a pass-down culture within the medical practice. Senior residents would tell their junior colleagues to order STAT if they wanted diagnostic imaging to be completely quickly, to a point where many providers used the STAT designation as a default.

Even more puzzling is that few clinicians seemed to be aware of the hospital’s policy for STAT MRIs. In an online survey of 97 providers (36 percent faculty; 64 percent trainees), only 4 percent correctly stated a STAT imaging study should be initiated within 30 minutes of the order. Many had the expectation a STAT MRI would be completed within the same day for inpatients and within two to three days for outpatients. Notably, outpatient STAT MRI orders also rose substantially during the study period.

“The ordering providers were just using this STAT MRI category as an instrument to have your study get done in an expedited manner,” Trofimova said. “Obviously, in very many cases we demonstrated it was used to expedite patient discharge or to … have it done faster for some other reasons. There are not that many true indications for a STAT MRI study.”

Even though Trofimova attributed the increasing proportion of STAT MRI orders to a culture within Grady Memorial Hospital, one of her co-researchers, Amanda S. Corey, MD, pointed out this is a widespread problem.

“It’s the whole McDonald’s mentality,” Corey said. “You want your fries right now. … Healthcare has become a fast-food restaurant.”

To expedite workflow and eliminate unwarranted urgency, Corey, Trofimova and colleagues have proposed adding order prioritization criteria to their electronic health record (EHR). This would include clinical examples and definitions to help clinicians determine which category to use for an MRI order. It would also contain definitions for each of those categories, as well as an expectation for when imaging would be completed.

The same surveyed population who showed a poor knowledge of the hospital’s definition of STAT seemed receptive to the idea. More than 70 percent said they would find clinical examples or a detailed order prioritization scheme useful, and only 16 percent said they would still order STAT MRIs if assured a routine MRI would be completed within 24 hours.

The researchers are waiting for the hospital’s IT department to integrate the proposed features into the EHR. They realize that is a major step, but provider buy-in is also key.

The changes will only work if everyone focuses on cleaning up inappropriate order classification.

“In the end, you want to make sure clinicians get to the point where they understand it’s really going to help them care for their patients better,” Corey said.