339EMF Identifying Barriers to MRI and Ultrasound Use in the Emergency Department

Emergency department (ED) visits frequently involve use of medical imaging. While CT is more commonly used than ultrasound or MRI, it exposes patients to ionizing radiation, a known carcinogen. The purpose of this study was to conduct focus group discussions with key stakeholders (emergency physicians and radiologists, hospital administrators, and imaging technologists) at hospitals across Wisconsin to discuss barriers and facilitators to using radiation-free imaging tests in the ED. Using a commercially available database through the Wisconsin Hospital Association, we randomly selected 7 hospitals where we held a series of semi-structured focus group discussions from 2016-2018. We first screened for hospitals that had access to MRI, ultrasound, and CT technology, as documented in the hospital association database. Next, we categorized these hospitals by size (small, medium, or large) per definitions used by the hospital association. We then subdivided each category by the type of community they served (rural, suburban, or urban) according to thresholds used in US Census reports. The resulting matrix had 9 cells, 2 of which had no hospitals (medium-rural and large-rural). We then generated a random list for each of the cells, providing an order to which hospitals would be approached first for study participation. Hospital administration was first contacted to obtain permission for study involvement. They also provided contact information for possible participants in each of the stakeholder groups. We obtained informed consent before each of the hour-long focus group discussions, which were recorded and professionally transcribed. In each discussion, the moderator followed a preset question guide and queried discussants on their perspectives and experiences with radiation-free imaging in the ED. The investigators then conducted independent, inductive thematic coding of the transcripts to identify themes. Inter-coder discrepancies were resolved through consensus discussion. We conducted discussions with each stakeholder group at 7 hospitals throughout the state, except for 1 stakeholder group that refused to participate after the study had begun at their site (physicians at the small-rural site). Despite the diversity in size of participating hospitals (bed size: 25-393) and community they served (population: 882-598,672), notable overlap existed within the discussions. Limited staffing for imaging technologies (ie, call in after hours), difficulty in scheduling ED cases within a full outpatient schedule, and physician practice inertia (ie, ordering what they usually order) were all identified as dominant barriers. Despite our initial conceptions, imaging test cost was not mentioned as a barrier to ordering MRI. Facilitators to using MRI and ultrasound in the ED included having a radiologist available for imaging selection consultation, concern over radiation exposure with CT, and the ability to do bedside ultrasound. Use of imaging guidelines was not a facilitator since almost none of the stakeholders knew of their existence. Despite the variety of practice settings, the barriers and facilitators to the use of MRI and ultrasound in the ED were quite common. Barriers focused on resource availability, largely scheduling and technologist staffing, while facilitators mostly reflected knowledge considerations like expert consultation and concerns of radiation exposure.