Breast Ultrasound in the Emergency Department

While breast ultrasound is most often thought of as supplemental screening for mammography, it is also used in other settings to screen patients and diagnose potential problems. Frequently, it’s used in the emergency department for women who present with a variety of unsettling breast symptoms.

But, with few trained breast imagers working in emergency departments, there’s a question of how effectively this modality can be applied. According to a new study published in Emergency Radiology, breast ultrasound used in this setting can identify abscesses, cancer, and mastitis, but there’s still room for improvement.

Based off of 581 breast ultrasounds conducted on 498 women in the emergency department, researchers determined providers identified abnormalities in 308 ultrasounds that prompted specific recommendations. But, they only identified abscesses in 26% of studies and failed to diagnose six out of 29 (21%) cancers. Overall, when the studies were forwarded on to radiology, the interpreting radiologist deemed 40% exams as incomplete.

According to researchers, study results could be suboptimal because few emergency departments maintain a breast-certified technologist on staff, and the level of ultrasound training and experience can vary widely by institution, especially during nights and weekends. In fact, a 2018 Diagnostics study supports the need for having a radiologist or technologist highly-experienced in breast imaging on call during off-peak hours as an effective way to identify which women need immediate intervention.

Despite these misses, however, breast ultrasound is still a valuable tool, investigators said, and the study results highlight several avenues for potential improvement in how the modality is utilized in the emergency department.

First, they said, the findings suggest that women who present with breast pain as their only complaint-and no other symptoms-could be best served by scheduling an exam in a dedicated breast imaging center that can provide a more comprehensive examination.

Second, to make breast ultrasound imaging as effective as possible in the emergency department, researchers recommended designing a clinical care pathway that can be used to categorize patients with breast complaints by risk stratification. Using clinical factors, such as smoking history, diabetes, drainage, redness, fluctuance, and soft tissue hardening, could inform the decision about whether providers should perform an emergent breast ultrasound or refer a woman at low risk for an abscess for outpatient breast imaging.

Not only would this type of risk stratification help patients receive the service they need, but it could also reduce the utilization of radiology department resources. Having a more targeted approach to identifying which patients actually need breast ultrasound in the emergency department could also reduce waiting times for those patients with more critical problems.

Using risk stratification can also prevent the possibility that a woman who receives a false negative result in the emergency department setting will forego follow-up imaging in a more appropriate clinical environment, researchers said. Of the women imaged in the emergency department, however, only 63% went on to receive follow-up imaging in an outpatient clinic. That follow-up rate points to the need for greater clinician-guided patient education, according to the findings of a 2016 Emergency Radiology study.

Regardless of the result, researchers said, they recommend emergency department radiologists include the need for follow-up in their reports, noting any supplemental imaging should be conducted within 2-to-4 weeks of any emergency department imaging. Doing so could reduce the likelihood that many malignancies would go unidentified.