Background

Communication and human errors are common sources of unfavourable clinical outcomes and management in emergency cases [1–6]. Acute arterial bleeding is associated with high mortality but can be treated effectively by interventional radiology utilizing embolization techniques [7].

Intra-clinical communication has been found to be key of successful for a long time [8]. Yet, publications about practical activation algorithms and suggestions about their implementation are rare. Is has been published that steamlining activation processes of interventional therapy is beneficial for the patients outcome [9]. Still communication structures in that publication rely on in clinic calls and parallel structures. Recent study about calling the interventional radiologist for emergency cases highlight the importance of early contact but also point out inefficient communication structures promoting even more pre-emptive calls [6]. Until August 2020, the in-house standard of IR (Interventional Radiology) activation in acute bleeding cases differed between working hours and night shifts. Outside of regular working hours, the diagnostic radiologist on call reviewed the CT scan, screened for possible treatment indications, and determined the responsible IR and the assisting personnel using a printed-out roster before calling each team member via their private mobile phone numbers. Additional phone calls between IR and the referring physician were frequently necessary to re-evaluate the treatment indication or to collect additional patient information. This concept was prone to ineffective communication because of its structure. Time delays occurred, for instance, when other emergencies occupied the attention of the diagnostic radiologist, but also whenever other involved physicians wanted to discuss the case at hand, as multiple individual phone numbers resulted in a laborious and time-consuming communication chain. During regular working hours, the reporting radiologist usually called the more generally known IR department numbers. As an outlined responsible IR was non-existent, activation of the treatment was uncoordinated, and calls could be addressed to the wrong contact persons resulting in several phone calls, thereby potentially hindering activation of the IR treatment. These activation methods are prone to causing treatment delay and misinformation. The initial activation pathway is shown in Fig 1.

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Fig 1. Illustrates the activation pathway of interventional radiology (IR) without an emergency phone in and outside regular working hours.

This is an example of activation via the diagnostic radiologist. Other clinical partners would have to contact the diagnostic radiologist first outside the normal working hours to determine the IR on call.

https://doi.org/10.1371/journal.pone.0313008.g001

Therefore, an emergency phone was established with an easy-to-remember four-number combination. This number and its purpose were distributed throughout the clinic and it is still part of every IR report. The phone itself is routed to the mobile phone of the responsible physician on call. Consequently, calls to this number can be answered directly 24 hours per day, seven days a week, and 365 days per year by an experienced IR.

This step led to a substantial increase in contact between referring and IR physicians.

Hereafter we investigate the effect of an improved activation algorithm for acute arterial bleedings treated by interventional radiology. We hypothesize that simplified structures allow for shorter intervals between diagnosis and treatment. The improved algorithm is shown in Fig 2.

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Fig 2. Illustrates the activation pathway of interventional radiology (IR) after implementing an emergency phone in and outside regular working hours.

This is an example of activation via the diagnostic radiologist. Other clinical partners can contact the IR directly during and outside regular working hours.

https://doi.org/10.1371/journal.pone.0313008.g002

Methods

Results

Study population

During the study period, 1322 registered calls led to 625 emergency procedures, of which 120 bleeding interventions met the abovementioned requirements. In the study population, 44 patients (37%) were treated via the conventional activation pathway as opposed to 76 patients (63%), where contact was established using the emergency phone. In 49 cases (41%), treatment was performed during regular working hours compared with 71 cases (59%) outside regular working hours. Further details of the study population are provided in Table 1 and Fig 3.

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Fig 3. Illustrates the selection process for the study population.

https://doi.org/10.1371/journal.pone.0313008.g003

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Table 1. Patient characteristics and procedural data.

https://doi.org/10.1371/journal.pone.0313008.t001

Interventions

The treatment strategies, including the specification of bleeding vessels, are provided in Table 1. The technical success rate was 87%. In cases that were not considered technically successful, no bleeding was detectable at the time of intervention. No detectable bleeding remained untreated or insufficiently embolized. The activation algorithm utilizing the emergency phone led to a slight decrease in radiation doses and the fluoroscopy times by trend, as provided in Table 2.

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Table 2. Comparison of interventional parameters: Use of emergency phone vs. non-use.

https://doi.org/10.1371/journal.pone.0313008.t002

Discussion

Interventional radiology often is confronted with acute and life-threatening conditions requiring immediate treatment. Besides the logistical challenges to the interventionalist and the patient, as well as other supporting specialties such as technicians and anaesthesiologists, effective communication structures are crucial [4, 6, 9, 11]. Nevertheless, publications about effective and standardized communication structures for activation algorithms in interventional radiology are unavailable. Even recent papers highlighting the importance of effective and quick communications underlines the need for more simplified structures [6, 9, 11, 12]. Although, the crucial role of phone call chains have been identified by several medical disciplines, data about the implementation of direct call routing has not been published yet [13]. In this study, we present the results after implementing a standardized activation pathway via an emergency phone that is constantly routed to a corresponding interventional radiologist and compare activation times before and after taking this measure.

The main findings of this study are i) the standardized activation pathway leads to shorter activation times allowing for faster treatment of patients after diagnosis of bleeding in CT. ii) implementation of the emergency phone leads to improved intervention quality. iii) improved communication structures for activation algorithms might lead to lower radiation exposure and procedure times.

On call physicians for after-hours compared to in-house physicians do not necessary delay treatment while the on-call concept is cost-efficient [14]. Activation of the interventional team often happens unstructured [6, 9]. That leads to inefficient communication pathways with parallel structures that may result in prolonged intervals before patients get lifesaving treatment with the inherent risk of additional information loss [1–3, 15]. The results of this study show a faster time to treatment and a lower standard deviation when activation was done via the emergency phone. This is an indicator of increased process quality. The activation via one IR emergency phone has several further advantages. First, clinical partners just need to remember one number. A simple number with repeated digits is advisable. Second, the simplified activation pathways facilitate information flow. Even when several specialties are responsible for the same patient, implementing the emergency phone makes the IR on-call the only recipient for all requests and requirements, omitting parallel communication. Thirdly, the emergency phone allows close contact between all participants and the department of interventional radiology. We experienced an increase in calls after the implementation of the phone and a slight amount of abuse. In some cases referring physicians call the emergency number so schedule urgent but elective interventions. Also when the regular line is occupied the emergency line is dialled for organisational purposes. However, the abuse is tolerable regarding the benefits of the improved activation algorithm. Fourthly, the emergency phone allows for more direct communication between the participants; the clinical partners can call the IR when they have patients with a clinical issue and discuss further steps. Then, in the following, the diagnostic radiologist can directly contact the IR when detecting the clinical cause or when unsure about the relevance of a finding. However, these aspects were outside the scope of the study.

In this study, we observed a highly significant increase in technical success rate after implementing the emergency phone. As stated under the result section, in all cases that lack technical success, no bleeding was detectable in the angio suite anymore. Considering that the emergency phone leads to faster reaction times of the IR with shorter intervals from diagnosis to treatment, the main reason for the higher success rate is probably the bleeding rates still being above the detection limit of digital subtraction angiography [16]. This is of note because non-detectable bleedings in the angio might still be hemodynamically relevant and even can increase bleeding rates again [16]. Although the procedure times after activation with the emergency phone were lower, the effect of a better-informed interventional radiologist because of improved communication structures is probably neglectable. Since introduction of the improved algorithm yearly phone contacts have multiplied; this probably partially linked to a more prominent appearance of IR in our clinic through the easy accessibility. The positive effects of the implementation of the new pathway were noticeable from the beginning which is why the improved activation algorithm is still in use.

Supporting information

Acknowledgments

We are indebted to the medical and technical staff members of our interventional laboratories for their invaluable contribution. We especially thank Stephan Forster, Melanie Fritz, Christoph Knappe, Melessa Mayr, Neriban Ramadani, Adriana Torre and Katharina Scherer for their effort, patience, and constant support.