Boston Marathon Bombing ED Imaging Brings Improvement

The sudden and high number of imaging tests required after the Boston Marathon bombing stressed the emergency system, but analysis of the procedures allowed for improvements in ongoing emergency operations planning, according to an article published in the journal Radiology.

Researchers from Brigham and Women’s Hospital (BWH) in Boston, Mass., analyzed emergency department (ED) image utilization and turnaround times immediately following the April 15, 2013 bombing. Their goal was to identify opportunities for improvement in the hospital’s emergency operations plan.

"It's important to analyze our response to events like the Boston Marathon bombing to identify opportunities for improvement in our institutional emergency operations plan," senior author Aaron Sodickson, MD, PhD, said in a release. Sodickson is the emergency radiology director at BWH.

Emergency radiology staffing at the facility includes an attending physician (24 hours/day, seven days/week), a second attending physician on site from 6 pm to 3 am, and two fellow and two resident shifts that vary throughout 24-hour cycles. Additional staff was mobilized for the emergency. The usual emergency radiology imaging equipment (two portable X-ray machines and two fixed digital X-ray units, an ultrasound machine and a CT scanner) were supplemented with additional imaging machines from elsewhere in the hospital, including two additional CT scanners and additional portable X-ray units.

A total of 40 patients presented at the BWH emergency department after the bombing. The first patient arrived 19 minutes following the first explosion; median time to arrival was 97 minutes. Sixteen patients were admitted to the hospital, 10 of whom needed emergent surgery. Median time from arrival to radiography was 18 minutes and to CT was 55 minutes.

"Imaging is one of the best ways to decide who needs attention most quickly," lead researcher John Brunner, MD, said in the release. "The use of shrapnel-laden explosive devices resulted in extensive shrapnel injuries that required evaluation with X-ray and computed tomography, or CT."

A total of 149 imaging orders were placed for 31 patients (78 percent):

• 57 radiographic examinations were performed on 30 patients

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• 16 CT examinations were performed on seven patients

• There were no orders for MRIs or ultrasounds

• 62 radiographic and 14 CT orders were cancelled

The hospital's system for naming unidentified patients contributed to a large number of duplicate imaging orders. This process has since been replaced with a system of combining a unique color, gender and numeral, (eg, Crimson Male 12345). This should reduce confusion when there is an influx of multiple patients, the researchers said.

A bottleneck that caused delays in obtaining X-rays was likely created by the use of conventional radiography portable X-ray machines relying on a single X-ray plate readout device, the researchers noted. This was corrected by replacing the portable units by digital radiography equipment with wireless image transfer.

"Hospitals need to have emergency operations plans in place, and emergency radiology is a crucial component of that preparedness," Sodickson said. "When an event occurs, it is important to direct a critical eye to the plan's operation in order to refine it for the future."