What The Heck Is It?
This patient presented to an ED after work complaining of mild shortness of breath.
Answer and more images on Monday.
Source: Personal archive photo. Patient not treated at Regions Hospital.
What The Heck Is It?
This patient presented to an ED after work complaining of mild shortness of breath.
Answer and more images on Monday.
Source: Personal archive photo. Patient not treated at Regions Hospital.
In my previous post (click here to view) I discussed an imaging protocol that we developed and implemented last year. Today, I’ll detail what it has accomplished in our patients.
We looked at 229 patients who had their imaging performed according to the new protocol during a 3 month period and compared them to 215 patients who were imaged the previous year. Each scan administered to each body area (head, chest, abdomen/pelvis, c-spine, t-spine, l-spine, face, neck angio) were tabulated separately.
We found that the overall number of scans performed decreased significantly. We looked at our data and generated numbers per 100 patients. During the control period, we did 298 CT scans per 100 patients. This decreased to 271 during the study period. The number of head scans remained the same (82 per 100 patients during control, 85 per 100 during the study), as did the cervical spine scans (84 vs 86).
The biggest declines were seen in chest CT (53 per 100 control vs 33 per 100 study) and abdominal CT (57 vs 43).
We did see an increase in conventional xrays of the thoracic and lumbar spines to offset the absence of reformatted spine images that would have been generated from the chest and abdominal CT scans. We also noted small increases in CT of the head, cervical spine, and neck angio. This was likely due to better adherence to specific guidelines.
Bottom line: we believe that our work shows that careful adoption of well thought out guidelines can make a difference in practice and significantly decreases radiation exposure in our blunt trauma patients.
To read the post on this protocol, or to download it, click here.
Click here to download the Blunt Trauma Radiographic Imaging Protocol Worksheet
Last year, we developed an evidence-based protocol for deciding what radiographic images to order in our blunt trauma patients. For some body regions, there is fairly good literature available for guidance (i.e. Canadian head and cervical spine rules). For other areas, there is not nearly as much.
We convened a small group of people, including trauma surgeons, emergency physicians, radiologists and a radiation physicist to combine the information into a practical tool.
You can view or download the worksheet we use by clicking the link at the bottom of this post. The protocol has been in use for about 9 months, and has significantly decreased the use of higher radiation dose imaging (CT). As a result, there has been a small increase in the use of lower dose conventional imaging (plain spine studies), but no missed injuries.
Tomorrow, I’ll write about the specifics of how this protocol has changed our ordering habits. Click here to view it.
Click here to download the Blunt Trauma Radiographic Imaging Protocol Worksheet
Click here to download a bibliography of the literature used to develop the protocol
Typical order: “chest CT with and without contrast”
A review of Medicare claims from 2008 showed that 5.4% of patients received double CT scans of the chest. Although the median was about 2% across 3,094 hospitals, 618 hospitals performed double scans on more than 10% of their patients. And 94 did it on more that half! One of the outliers was a small hospital in Michigan that double scanned 89% of Medicare patients! As expected, there was wide variation from hospital to hospital, and from region to region around the US.
Time for some editorial comment.
This practice is very outdated and shows a lack of understanding of the information provided by CT. Furthermore, it demonstrates a lack of concern for radiation exposure by both the ordering physician and the radiologist, who should know better.
Some officials at hospitals that had high scan rates related that radiologists ordered or okayed the extra scan because they believed that “more information was better.” There are two problems with this thinking.
The solution is to do only what is clinically necessary and safe. The tests ordered should be based on the best evidence available, which demands familiarity with current literature.
In trauma, there are a few instances where repeat scanning of an area is required. Examples include solid organ lesions which may represent an injury or a hemangioma, and CT cystogram to exclude bladder trauma. In both cases, only a selected area needs to be re-scanned, not the entire torso.
Bottom line: Physicians and hospitals need to take the lead and rapidly adopt or develop guidelines which are literature-based. State or national benchmarking is essential so that we do not continue to jeopardize our patient’s safety and drive up health care costs.
Tomorrow I’ll share the blunt trauma imaging protocol we use which has decreased trauma CT use significantly at Regions Hospital.
Related posts:
Trauma professionals worry about radiation exposure in our patients. A lot. There are a growing number of papers dealing with this topic in the journals every month. The risk of dying from cancer due to CT scanning is negligible compared to the risk from acute injuries in severely injured patients. However, it gets a bit fuzzier when you are looking at risk vs benefit in patients with less severe injuries. Is it possible to quantify this risk to help guide our use of CT scanning in trauma?
A nice paper from the Mayo clinic looked at their scan practices in 642 adult patients (age > 14) over a one year period. They developed dose estimates using a detailed algorithm, and combined them with data from the Biological Effects of Ionizing Radiation VII data. The risk level for injury was estimated using their trauma team activation criteria. High risk patients met their highest level activation criteria, and intermediate risk patients met their intermediate level activation criteria.
Key points in this article were:
Bottom line: Appropriate CT scan use in trauma evaluation is challenging. It’s use is widespread, and although it changes management it has not decreased trauma mortality. This paper shows that the risk of death from trauma in the elderly outweighs the risk of death from CT scan radiation. However, this gap narrows in younger patients with less serious injuries because of their very low mortality rates. Therefore, we need to focus our efforts to reduce radiation exposure on our young patients with minor injuries.
Related posts:
References: