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Imaging Decisions Vary On Shift – Are We Feeling More Confident, Fatiguing, or Somewhere In Between?

September 22, 2022

Written by Megan Hilbert

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Emergency physicians have dynamic changes to their work-ups (particularly in the selection of imaging) related to how busy, not how long a shift is.

Why does this matter?
Over-imaging results in higher healthcare costs, more radiation exposure, and longer ED length of stay.  Are differences in ordering of images over the course of a shift a result of decision fatigue or are we gaining confidence as the shift goes on and “tuning up”?

I’m tuning up my medical decision making
This was a retrospective study reviewing nearly 850,000 ED visits in a healthcare system in Canada. Outcomes included whether diagnostic imaging was ordered and adverse events (defined as 7 day re-presentation to the ED or admission). They found that relative to the first 15 minutes, patients seen in the 180th minute of a shift were more likely to have imaging ordered. Relative to the first patient however, the 15th patient was less likely to receive imaging. The authors posit that this rapid increase with subsequent plateau is due to a “tuning up” – a building of confident momentum as it were. They found this to be a function of number of patients evaluated, not how much time had elapsed. The authors don’t suggest that decision fatigue has gone away, they simply suggest that tuning up may occur to an even greater degree. More imaging did not lead to fewer 7-day bouncebacks.

A major confounder to consider – physicians may inherently lean toward patients that require less diagnostic work-up (and therefore less imaging) as they approach quitting time. Is this because they are honing their skills or because they hope to maintain some semblance of work-life balance? I’ll leave you to decide.

How are Patient Order and Shift Timing Associated With Imaging Choices in the Emergency Department? Evidence From Niagara Health Administrative Data. Ann Emerg Med. 2022 Aug 8;S0196-0644(22)00412-7. doi: 10.1016/j.annemergmed.2022.06.002. Online ahead of print.

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