Attrition in emergency department point-of-care ultrasound workflow adherence for the evaluation of cutaneous abscesses

Background: Many emergency departments (ED) have implemented software solutions for ordering, documenting, and interpreting point-of-care ultrasound (POCUS) scans before healthcare bill generation. However, there are human and design barriers that prevent workflow completion. We sought to evaluate attrition in adherence to this step-wise workflow for evaluating cutaneous abscesses in a large urban ED, while quantifying missed potential revenue. Methods: Patient charts in 2017 with discharge diagnoses containing “abscess”, “boil”, or “cyst” were retrospectively extracted. Exclusion criteria included: POCUS not reasonably performed, abscess already draining, advanced imaging ordered, or consultant involvement. Each workflow step was assessed for completion. Revenue estimation was performed by multiplying number of scans by the appropriate relative value unit and medicare conversion factor. Results: Of 2,240 total charts, 710 abscesses (31.7%) met inclusion. Of those, 283 (39.8%) POCUS were performed, of which 213 (30.0%) were ordered, 198 (27.8%) interpreted, and 180 (25.3%) had images saved. Professional fees were billed for 120 POCUS examinations (16.9%). There were 66 payments collected (9.3%), amounting to $1,400.69 revenue. Estimated billing for the 120 POCUS was $2,546.71. If proper workflow had been implemented for all 283 POCUS performed, estimated revenue would have been $6,006.00. If POCUS had been performed with proper workflow for all 710 abscesses, estimated revenue would have been $15,068.05. Conclusions: POCUS workflow was interrupted at several points and completed sub-optimally. This attrition directly affected optimal patient care, documentation, and departmental revenue. Since cutaneous abscesses represent one of many ED POCUS applications, the extrapolated missed potential revenue would be much greater overall.