A digital audit of emergency upper gastrointestinal fluoroscopy workflow in children with bilious vomiting

SA Journal of Radiology ISSN: (Online) 2078-6778, (Print) 1027-202X Page 1 of 6 Original Research A digital audit of emergency upper gastrointestinal fluoroscopy workflow in children with bilious vomiting Authors: Bradley C. Messiahs1 Richard D. Pitcher1 Affiliations: 1 Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Corresponding author: Bradley Messiahs, Dates: Received: 18 Sept. 2021 Accepted: 05 Dec. 2021 Published: 30 Mar. 2022 How to cite this article: Messiahs BC, Pitcher RD. A digital audit of emergency upper gastrointestinal fluoroscopy workflow in children with bilious vomiting S Afr J Rad. 2022;26(1), a2300. https://doi. org/10.4102/sajr.v26i1.2300 Copyright: © 2022. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License Background: Bilious vomiting in children requires an urgent evaluation with upper gastrointestinal (UGI) fluoroscopy as it may herald life-threatening midgut malrotation with volvulus (MMWV). There are no published data available on the duration of time-critical UGI workflow steps. Objectives: A digital audit of workflow in emergency UGI contrast studies performed on children with bile-stained vomiting at a large South African teaching hospital. Method: A retrospective study was conducted from 01 May 2012 – 31 May 2019. A customised search of the institutional radiology information system (RIS) defined all children with bilious vomiting who underwent emergency UGI fluoroscopy. Extracted RIS timestamps were used to calculate the median duration of the ‘approval’, ‘waiting’, ‘study’ and ‘reporting’ times. Oneway analysis of variance and Chi-squared tests assessed the association between key parameters and the duration of workflow steps, with 5% significance (p < 0.05). Results: Thirty-seven patients (n = 37) with median age 0.8 months were included, of whom 20 (54%) had an abnormal C-loop. The median ‘total time’ from physician request to report distribution was 107 min (interquartile range [IQR]: 67−173). The median ‘approval’ (6 min; IQR: 1–15) and ‘reporting’ (38 min; IQR: 17–91) times were the shortest and longest workflow steps, respectively. Abnormal C-loops (p = 0.04) and consultant referrals (p = 0.03) were associated with shorter ‘approval’ times. The neonatal ‘waiting’ time was significantly longer than that for older patients (p = 0.02). Conclusion: The modern RIS is an excellent tool for time-critical workflow analyses, which can inform interventions for improved service delivery. Keywords: bilious; vomiting; malrotation; midgut volvulus; upper gastrointestinal series; paediatric. Introduction Vomiting in childhood should be categorised clinically as either bile-stained (bilious) or non-bilestained (non-bilious). The differentiation may be challenging, but is crucial. Non-bilious vomiting is commonly innocuous and occurs as a result of gastro-esophageal reflux while bile-stained vomiting is typically caused by partial or complete bowel obstruction distal to the ampulla of Vater.1 Bilious vomiting in the paediatric age-group requires urgent evaluation. It may herald lifethreatening midgut malrotation with volvulus (MMWV) of the intestine about the superior mesenteric artery (SMA) and associated bowel ischaemia or necrosis. Intestinal malrotation is present in approximately one in 500 live births.2 Normal intestinal rotation occurs in the 10th week of gestation as the bowel migrates back into the abdominal cavity following a brief period at the base of the umbilical cord. As the intestine returns to the abdominal cavity, it makes two rotations and becomes fixed into its normal position, with the colon draped lateral and superior to the centrally located small intestine.3 Read online: Scan this QR code with your smart phone or mobile device to read online. Malrotation results from incomplete intestinal rotation, and failure of fixation. As a result, the large intestine lies on the left side of the abdominal cavity and the small intestine on the right. The caecum and appendix, normally fixed posteriorly in the right lower abdomen, are free and located centrally in the mid-upper abdomen. The duodenum, normally attached dorsally across the midline in the upper abdomen, is also not fixed and typically lies in the right upper quadrant of the abdomen. The root of the small bowel mesentery is thus narrow, and prone to twist http://www.sajr.org.za Open Access Page 2 of 6 Original Research and time-critical. It should be performed as the first investigation and as soon as possible, since delayed diagnosis can be life-threatening, while early diagnosis has an excellent prognosis.14 A water soluble, low osmolality contrast medium is preferred.17,18 Despite the urgency of UGI contrast studies in this clinical setting, to the best of our knowledge, there are no published data on the duration of workflow steps. The modern digital radiology department, with an integrated picture-archiving and communication system/radiology information system (PACS/RIS) provides the ideal platform for conducting such audits. The integrative functions of the modern PACS/RIS include the capacity to provide timestamps for each step in the digital imaging workflow.19 Additionally, there has been no detailed description of the fluoroscopic findings in children with bilious vomiting in our setting. FIGURE 1: Normal upper gastrointestinal series in an infant with vomiting. Fluoroscopic frontal view shows the duodenojejunal junction (arrow) to the left of a vertebral body pedicle and at the level of the duodenal bulb. around the SMA and superior mesenteric vein (SMV).4 This twisting or ‘volvulus’ of small bowel on its own blood supply may result in ischaemia and ultimately necrosis. Seventy-five per cent of symptomatic cases of malrotation occur in neonates, and up to 90% of such cases occur within the 1st year of life.2,5,6 Whilst MMWV most commonly presents in the neonatal period, it can present at any time during childhood, although the frequency decreases with increasing age.7 The classical clinical manifestation of malrotation with volvulus is bilious vomiting.5,8,9 Among children with bile-stained vomiting in the first 72 h of life, approximately one-fifth required surgical intervention.7 Mortality in neonates with MMWV was as high as 30% as recently as the 1960s10,11 but has subsequently decreased to approximately 3% − 5%.9,12,13 Because of the life-threatening potential of MMWV, this must be excluded as a matter of urgency in any child presenting with bile-stained vomiting. Upper gastrointestinal (UGI) fluoroscopy is the examination of choice. It is performed to assess the position of the duodeno-jejunal (DJ) flexure.14 On the frontal projection, the normal DJ flexure lies lateral to the left pedicle of the vertebral body adjacent to the duodenal bulb (Figure 1).15 The demonstration of (...truncated)