Computed Tomography In Emergency Department Research Articles

Incidence of Traumatic Brain Injury in a Longitudinal Cohort of Older Adults

Traumatic brain injury (TBI) occurs at the highest rate in older adulthood and increases risk for cognitive impairment and dementia. To update existing TBI surveillance data to capture nonhospital settings and to explore how social determinants of health (SDOH) are associated with TBI incidence among older adults. This nationally representative longitudinal cohort study assessed participants for 18 years, from August 2000 through December 2018, using data from the Health and Retirement Study (HRS) and linked Medicare claims dates. Analyses were completed August 9 through December 12, 2022. Participants were 65 years of age or older in the HRS with survey data linked to Medicare without a TBI prior to HRS enrollment. They were community dwelling at enrollment but were retained in HRS if they were later institutionalized. Baseline demographic, cognitive, medical, and SDOH information from HRS. Incident TBI was defined using inpatient and outpatient International Classification of Diseases, Ninth or Tenth Revision, diagnosis codes received the same day or within 1 day as the emergency department (ED) visit code and the computed tomography (CT) or magnetic resonance imaging (MRI) code, after baseline HRS interview. A cohort with TBI codes but no ED visit or CT or MRI scan was derived to capture diagnoses in nonhospital settings. Descriptive statistics and bivariate associations of TBI with demographic and SDOH characteristics used sample weights. Fine-Gray regression models estimated associations between covariates and TBI, with death as a competing risk. Imputation considering outcome and complex survey design was performed by race and ethnicity, sex, education level, and Area Deprivation Index percentiles 1, 50, and 100. Other exposure variables were fixed at their weighted means. Among 9239 eligible respondents, 5258 (57.7%) were female and 1210 (9.1%) were Black, 574 (4.7%) were Hispanic, and 7297 (84.4%) were White. Mean (SD) baseline age was 75.2 (8.0) years. During follow-up (18 years), 797 (8.9%) of respondents received an incident TBI diagnosis with an ED visit and a CT code within 1 day, 964 (10.2%) received an incident TBI diagnosis and an ED code, and 1148 (12.9%) received a TBI code with or without an ED visit and CT scan code. Compared with respondents without incident TBI, respondents with TBI were more likely to be female (absolute difference, 7.0 [95% CI, 3.3-10.8]; P < .001) and White (absolute difference, 5.1 [95% CI, 2.8-7.4]; P < .001), have normal cognition (vs cognitive impairment or dementia; absolute difference, 6.1 [95% CI, 2.8-9.3]; P = .001), higher education (absolute difference, 3.8 [95% CI, 0.9-6.7]; P < .001), and wealth (absolute difference, 6.5 [95% CI, 2.3-10.7]; P = .01), and be without baseline lung disease (absolute difference, 5.1 [95% CI, 3.0-7.2]; P < .001) or functional impairment (absolute difference, 3.3 [95% CI, 0.4-6.1]; P = .03). In adjusted multivariate models, lower education (subdistribution hazard ratio [SHR], 0.73 [95% CI, 0.57-0.94]; P = .01), Black race (SHR, 0.61 [95% CI, 0.46-0.80]; P < .001), area deprivation index national rank (SHR 1.00 [95% CI 0.99-1.00]; P = .009), and male sex (SHR, 0.73 [95% CI, 0.56-0.94]; P = .02) were associated with membership in the group without TBI. Sensitivity analyses using a broader definition of TBI yielded similar results. In this longitudinal cohort study of older adults, almost 13% experienced incident TBI during the 18-year study period. For older adults who seek care for TBI, race and ethnicity, sex, and SDOH factors may be associated with incidence of TBI, seeking medical attention for TBI in older adulthood, or both.

Factors Associated with Overutilization of Computed Tomography of the Cervical Spine.

Introduction: Despite the wide availability of clinical decision rules for imaging of the cervical spine after a traumatic injury (eg, NEXUS C-spine rule and Canadian C-spine rule), there is significant overutilization of computed tomography (CT) imaging in patients who are deemed to be at low risk for a clinically significant cervical spine injury by these clinical decision rules. The purpose of this study was to identify the major factors associated with the overuse of CT cervical spine imaging using a logistic regression model. Methods: This was a retrospective review of all adult patients who underwent CT cervical spine imaging for evaluation of a traumatic injury at a tertiary academic emergency department (ED) and three affiliate community EDs in January and February 2019. We performed multivariable logistic regression to identify factors associated with obtaining CT cervical spine imaging despite low-risk classification by the NEXUS C-spine Rule. Results: A total of 1,051 patients underwent CT cervical spine imaging for traumatic indications during the study period, and 889 patients were included in the analysis. Of these patients, 376 (42.3%) were negative by the NEXUS C-spine rule. Variables that were associated with increased likelihood of unnecessary imaging included age over 65, Emergency Severity Index (ESI) score 2 and 3, arrival as a walk-in, and anticoagulation status. Patients who presented to the tertiary academic ED had a significantly lower likelihood of unnecessary imaging. Twenty-one patients (2.4%) were found to have cervical spine fractures on imaging, two of whom were negative by the NEXUS C-spine rule, but neither had a clinically significant fracture. Conclusion: Cervical spine imaging is vastly overused in patients presenting to the ED with traumatic injuries, as adjudicated using the NEXUS C-spine rule as a reference standard. Older age, ESI level, arrival as a walk-in, and taking anticoagulation drugs were associated with overutilization of CT imaging. Conversely, presenting to the tertiary academic ED was associated with a lower likelihood of undergoing unnecessary imaging. This model can guide future interventions to optimize ED CT utilization and minimize unnecessary testing.

Examining racial and ethnic disparities in adult emergency department patient visits for concussion in the United States.

BackgroundRacial and ethnic differences in emergency department (ED) visits have been reported among adolescent patients but are unsubstantiated among adults. Therefore, our purpose in this study was to examine the relationship between race/ethnicity and adult ED visits for concussions, their injury mechanisms, and computed tomography (CT) scan use among a nationally representative sample.MethodsWe used the National Hospital Ambulatory Medical Care Survey database from 2010–2015 to examine 63,725 adult (20–45 years old) patient visits, representing an estimated 310.6 million visits presented to EDs. Of these visits, 884 (4.5 million national estimate) were diagnosed with a concussion. Visit records detailed patient information (age, sex, race/ethnicity, geographic region, primary payment type), ED visit diagnoses, injury mechanism (sport, motor vehicle, fall, struck by or against, “other”), and head CT scan use. The primary independent variable was race/ethnicity (non-Hispanic Asian, non-Hispanic Black or African American, Hispanic/Latinx, non-Hispanic multiracial or another, and non-Hispanic White). We used multivariable logistic and multinomial regression models with complex survey sampling design weighting to examine the relationship between concussion ED visits, injury mechanisms, and CT scan use separately by race/ethnicity while accounting for covariates.ResultsThere were no associations between race/ethnicity and concussion diagnosis among adult ED visits after accounting for covariates. Relative to sports-related injuries, non-Hispanic Black or African American patient visits were associated with a motor vehicle (OR = 2.69, 95% CI: 1.06–6.86) and “other” injury mechanism (OR = 4.58, 95% CI: 1.34–15.69) compared to non-Hispanic White patients. Relative to sports-related injuries, non-Hispanic Asian, multiracial, or patients of another race had decreased odds of falls (OR = 0.20, 95% CI: 0.04–0.91) and “other” injuries (OR = 0.09, 95% CI: 0.01–0.55) compared to non-Hispanic White patients. The odds of a CT scan being performed were significantly lower among Hispanic/Latinx patient visits relative to non-Hispanic White patients (OR = 0.52, 95% CI: 0.30–0.91), while no other race/ethnicity comparisons differed.ConclusionOur findings indicate that the overarching concussion ED visit likelihood may not differ by race/ethnicity in adults, but the underlying mechanism causing the concussion and receiving a CT scan demonstrates considerable differences. Prospective future research is warranted to comprehensively understand and intervene in the complex, multi-level race/ethnicity relationships related to concussion health care to ensure equitable patient treatment.

Impact of a Faster Computed Tomography Scanner on Sedation for Pediatric Head Computed Tomography Scans in 2 Large Emergency Departments-A Retrospective Study.

Children in the emergency department (ED) often require sedation for head computed tomography (CT) to ensure adequate image quality. Image acquisition time for a head CT using a conventional single-source CT scanner is approximately 12 seconds; however, after installation in November 2017 of 2 new dual-source dual-energy CT scanners, that time decreased to 1 to 3 seconds. We hypothesized that fewer patients would require sedation using the faster CT scanners. We conducted a retrospective chart review of patients aged 0 to 18 years undergoing head CT at 2 pediatric EDs within 1 hospital system, 2 years before and 2 years after installation of the faster CT scanner. Patients undergoing multiple CTs or other procedures were excluded. Demographic information, diagnosis, disposition, sedatives (chloral hydrate, dexmedetomidine, etomidate, fentanyl, ketamine, midazolam, methohexital, pentobarbital, and propofol) administered before imaging, and ED length of stay were analyzed. A total of 15,175 patient encounters met inclusion criteria, 7412 before and 7763 after installation of the new CT. The median age was 7 years and 44% were female. Before the new CT scanner was installed 8% required sedation, compared with 7% after (effect size, 0.0341). Midazolam was the most commonly administered sedative. Fewer patients required deep sedation using the faster CT scanner. After installation of a dual-source dual-energy CT scanner, fewer patients required sedation to complete head CT in the pediatric ED. Faster image acquisition time decreased the need for deep sedation.

Impact of the COVID pandemic on emergency department CT utilization: where do we go from here?

PurposeTo analyze the impact of the coronavirus disease (COVID) pandemic on emergency department (ED) computed tomography (CT) utilization.MethodsA retrospective observational study was conducted assessing seven hospitals’ ED imaging volumes between Jan. 6, 2019, and Feb. 27, 2021. Weekly CT utilization is reported as CTs ordered per 100 ED visits. Utilization was ascertained in aggregate and by body area. Interrupted time series analysis was performed to assess significance of utilization change. Prespecified sensitivity analysis was performed for influenza-like or COVID-like illness (ILI/CLI).ResultsWeekly ED CT utilization increased from 35.9 CTs per 100 visits (95% confidence interval [95% CI] 35.8–36.1) to 41.8 per 100 visits (95% CI 41.7–42.0) in pre- and post-pandemic periods. Weekly ED CT chest utilization increased immediately following the pandemic declaration (+ 0.52 chest CTs per 100 ED visits, 95% CI 0.01–1.03, p < 0.05) and compared to pre-pandemic period (+ 0.02 per 100 ED visits, 95% CI 0.02–0.05, p < 0.02). For both CT abdomen/pelvis and CT head, there was neither an immediate effect (+ 0.34 CT-AP per 100 ED visits, 95% CI − 0.74 to 1.44, p = 0.89; − 0.42 CT-H per 100 ED visits, 95% CI − 1.53 to 0.70, p = 0.46) nor a change in weekly CT utilization (+ 0.03 CT-AP per 100 ED visits, 95% CI − 0.01 to 0.05, p = 0.09; + 0.03 CT-H per 100 ED visits, 95% CI − 0.01 to 0.06, p = 0.10). ConclusionThese data may help formulate future strategies for resource utilization and imaging operations as we envision a future with COVID and other federal mandates affecting imaging utilization and appropriateness.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10140-022-02071-z.

The appendicitis algorithm five years later: Variability remains

Cost-effective care and minimizing computed tomography (CT) in children remain ideal. Our appendicitis work-up guideline decreased CT use when instituted in 2010. We reviewed 2015–2017 utilization to assess the need for modifications or education. A retrospective review identified all emergency department (ED) patients (0–18 years) evaluated for abdominal pain from 2015 to 2017. Associations with ED return, CT use, and guideline adherence were examined using multivariable logistic regressions. We obtained detailed cost of all services during the ED encounter; standardized cost was calculated in 2018 dollars. 1,678 individuals were evaluated for abdominal pain; 43 underwent appendectomy. The guideline was applied to 8% all patients. For those undergoing appendectomy, there was no difference in guideline utilization rates between EM-trained and Pediatric EM-trained physicians (77.3% vs 81.0%). Guideline utilization was not associated with reduced CT use, with no difference by training (28.8% vs 36.4%). Ultrasound use, Pediatric Surgery consultation, antibiotics use, and ED time did not vary with guideline use or EM physician training type. Guideline adherence was associated with a lower likelihood of ED return (2 vs 4 patients, p = 0.015, OR = 0.004, 95% CI: 0.001 – 0.137). There was no difference in ED return by training (2/22 vs 4/21 patients). The mean total ED encounter cost difference by training was $158 ( p = 0.101) Abdominal pain evaluation in pediatric patients remains variable. ED return for abdominal pain, potentially a proxy for diagnostic uncertainty, may be reduced with guideline adherence. Periodic education may improve compliance.

EP.FRI.376 Early Routine CT Scans for All Surgical Admissions for Abdominal Pain May Improve Patient Outcomes

Abstract Aim Acute abdominal pain remains a diagnostic challenge in the Emergency Department (ED) as pathologies can involve various surgical craft groups. Computed tomography (CT) enables accurate diagnosis of abdominal pathologies. However, with pressures on ED such as the “4 hour rule” established by the Australian NSW Health Emergency Performance Plan, there may be resistance or omission of early CT in ED. We hypothesise that early, routine CT in adult patients presenting with acute abdominal pain requiring hospital admission improves patient outcomes by increasing diagnostic and referral accuracy. This study compares the proportion of correct ED diagnosis of abdominal pain presentations with and without formal imaging reports. Methods Data from 118 patients presenting with abdominal pain are collected prospectively in a regional hospital and analysed. Patient demographics, imaging results, initial ED diagnosis and final discharge diagnosis are further examined. Results Out of the 118 patients who had abdominal pain, 32 patients obtained complete imaging with a radiology report whilst 86 patients either did not have any imaging performed or was referred to a general surgical unit prior to obtaining a formal report. Among the patients who had imaging reported, 78% (n = 25/32) had the correct diagnosis, whilst those without a radiology report had a 52% (n = 45/86) diagnostic accuracy. This demonstrates an improved accuracy of diagnosis or reduced error rate of 26% when a scan report is available (p = 0.01). Conclusion Early, routine CT with formal reporting significantly reduces diagnostic error rates and increases accurate referral. This allows accurate diagnosis and improves patient outcomes.

The use of computed tomography in the management of injury in tertiary emergency departments in Western Australia: Evidence of overtesting?

This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality. A total of 411,155 injury-related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury-related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT. While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi-/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories. The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care.

Brainstorming Our Way to Improved Quality, Safety, and Resident Wellness in a Resource-Limited Emergency Department

PurposeTo implement a more efficient standardized computed tomography (CT) protocoling system for emergency department (ED) patients in order to improve resident work satisfaction and wellness, and decrease lag time between ordering and protocoling a study. Methods and MaterialsResidents recorded lag times between time of order and time of protocol for 176 CT scans between November 2018 and January 2019. Pre- and postintervention resident surveys of 7 questions utilizing a 5-point Likert scale were used to assess the perceived efficiency and overall satisfaction with the protocolling system. CT technologists received a 2-step Standardized ED CT Protocoling Guidance Sheet for common indications and would consult the radiologist for any questions. ResultsLag time between order and protocol averaged 17.8 minutes. Postintervention surveys demonstrated that residents were more satisfied with the new system (100% vs 6.1%), had an overall higher job satisfaction in the ED (91% vs 12.1%), thought the system was more efficient for a single study (100% vs 15.2%) and for an entire shift (100% vs 6.1%), volume of studies was maximized (91% vs 6.1%), and the workflow allowed residents to focus on interpreting studies and communicating findings (91% vs 3%). ConclusionThe implementation of an auto-protocolling system at our institution's ED took a system which was disruptive, inefficient, and unreliable, and eliminated both lag time and variation in time between ordering and protocoling, improving time to final report. It simultaneously decreased interruptions, allowing residents to focus on study interpretation, which increased resident work satisfaction, wellness, and educational benefit.

Turning around cancer: Oncology imaging and implications for emergency department radiology workflow

PurposeOncologic imaging in the emergency department (ED) is frequently encountered, including non-acute scans known as “metastatic workups” or “staging” (referred to as “cancer staging computed tomography (CT) exams”). This study examines the impact of oncologic staging CT exams on ED imaging turnaround time (TAT), defined as the time from the end of the CT exam to a final signed radiologist report, as well as order to scan completion time. MethodsA retrospective review was conducted of all adult patients presenting to an urban, quaternary academic medical center ED from February 2016 to September 2017, who had CT imaging ordered, performed, and interpreted in the ED imaging department. CT exams containing institution-specific cancer descriptors were included. After excluding all acute exams, cancer staging CT exams were compared to a matched cohort of non-oncologic ED CT exams to evaluate median TAT and order to scan completion time using a log transformed multivariable linear regression. ResultsAdjusting for age and CT body part, cancer staging CT exams were associated with an independently statistically significant increased median log TAT compared to non-oncologic ED CT exams (114.5 min [IQR 112] versus 69 min [IQR 67], respectively, p < .0001) and an independently statistically significant increased median log initial order to scan completion time (166 min [IQR: 89] vs 119 min [IQR: 93], p < .0001). ConclusionOncology patients receiving non-acute metastatic workup scans in the ED have a significantly longer TAT compared to non-oncologic ED CT exams as well as longer order to scan completion times.

Abstract WP92: Radiologist Inter-rater Reliability of Prehospital Alberta Stroke Program Early CT Scores on a Mobile Stroke Unit

Introduction: The computed tomography (CT) capabilities of mobile stroke units (MSUs) may facilitate prehospital triaging of patients with suspected large-vessel occlusion directly to thrombectomy-capable centers. However, little is known about the reliability of radiological interpretation of early ischemic changes on prehospital CTs. Methods: We identified all patients transported by the NewYork-Presbyterian MSU to Weill Cornell Medical Center with the diagnosis of acute ischemic stroke, transient ischemic attack, or stroke mimic between October 3, 2016 and December 31, 2017. All patients underwent noncontrast head CT on board the MSU using a CereTom® scanner. As controls, we matched these patients 1:1 by diagnosis to patients who were transported by standard ambulance and underwent noncontrast brain CT in our emergency department (ED) over the same period. Two neuroradiologists, blinded to patients’ characteristics and final diagnosis, independently calculated Alberta Stroke Program Early CT Scores (ASPECTS) on all scans. Weighted percent agreement and Cohen’s κ were used to assess inter-rater reliability, and paired t-tests were used to compare these metrics between MSU and ED scans. Results: Among 46 MSU patients and 46 ED patients, 52% had a diagnosis of acute ischemic stroke, 46% a diagnosis of stroke mimic, and 2% a diagnosis of transient ischemic attack. For ASPECTS score as a continuous outcome, the weighted inter-rater agreement was 98% for MSU scans versus 96% for ED scans (mean difference, 2%; 95% CI, -1% to 5%) and the weighted κ was 0.49 for MSU scans versus 0.54 for ED scans (mean difference, -0.05; 95% CI, -0.61 to 0.51). For ASPECTS score categorized as 0-4, 5-7, or 8-10, the weighted inter-rater agreement was 99% for MSU scans versus 97% for ED scans (mean difference, 2%; 95% CI, -2% to 7%) and the weighted κ was 0.66 for MSU scans versus 0.55 for ED scans (mean difference, 0.10; 95% CI, -0.87 to 1.08). Conclusions: In a sample of 96 patients, which limited our power to detect small differences, we found no substantial difference in the inter-rater reliability of ASPECTS scores obtained from MSU CTs versus ED CTs.

Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries

To determine the effect of providing risk estimates of clinically important traumatic brain injuries and management recommendations on emergency department (ED) outcomes for children with isolated intermediate Pediatric Emergency Care Applied Research Network clinically important traumatic brain injury risk factors. This was a secondary analysis of a nonrandomized clinical trial with concurrent controls, conducted at 5 pediatric and 8 generalEDs between November 2011 and June 2014, enrolling patients younger than 18 years who had minor blunt head trauma. After a baseline period, intervention sites received electronic clinical decision support providing patient-level clinically important traumatic brain injury risk estimates and management recommendations. The following primary outcomes in patients with one intermediate Pediatric Emergency Care Applied Research Network risk factor were compared before and after clinical decision support: proportion of ED computed tomography (CT) scans, adjusted for age, time trend, and site; and prevalence of clinically important traumatic brain injuries. The risk of clinically important traumatic brain injuries was known for 3,859 children with isolated findings (1,711 at intervention sites before clinical decision support, 1,702 at intervention sites after clinical decision support, and 446 at control sites). In this group, pooled CT proportion decreased from 24.2% to 21.6% after clinical decision support (odds ratio 0.86; 95% confidence interval 0.73 to 1.01). Decreases in CT use were noted across intervention EDs, but not in controls. The pooled adjusted odds ratio for CT use after clinical decision support was 0.73 (95% confidence interval 0.60 to 0.88). Among the entire cohort, clinically important traumatic brain injury was diagnosed at the index ED visit for 37 of 37 (100%) patients before clinical decision support and 32 of 33 patients (97.0%) after clinical decision support. Providing specific risks of clinically important traumatic brain injury through electronic clinical decision support was associated with a modest and safe decrease in ED CT use for children at nonnegligible risk of clinically important traumatic brain injuries.

Sports-Related Concussions in Children: Differences in Care and Expectations When Seen in an Emergency Department Versus a Sports Medicine Clinic.

Patient and parent expectations can potentially influence management of care. We compared expectations in the diagnosis of concussion between patients who presented to a pediatric emergency department (ED) and those who presented to a sports medicine clinic, and if there was a difference in computed tomography (CT) scans performed. Head-injured athletes aged 8 to 18 years presenting to a pediatric ED and a sports medicine clinic were enrolled. Both groups completed questionnaires on their understanding of concussion and expectations of care. Charts were then reviewed. Forty patients were enrolled in the study: 23 from a pediatric ED and 17 from a sports medicine clinic. Forty-one percent of athletes received a head CT in the pediatric ED versus 12% of those in the clinic population with no abnormal findings (P = 0.04). Forty-one percent of athletes and 48% of parents in the pediatric ED setting reported that a CT was "necessary" to diagnose concussion versus 18% in both groups from the clinic (P = 0.12, P = 0.07). Athletes presenting to the clinic were more likely to have been evaluated by an athletic trainer after the injury than those presenting to the pediatric ED (80% vs 23%, P = 0.004). Patients and parents who presented to a pediatric ED for sports-related head injury had a trend toward higher expectations of a CT scan being necessary to diagnose concussion and did have a higher rate of CT scans performed. Education of athletes and parents engaging in organized sports may be worthwhile to assist in setting expectations in diagnosis of concussion.

Long-term changes in computed tomography and ultrasound utilization in a pediatric emergency department

ObjectiveMany studies have proposed reducing unnecessary use of computed tomography (CT), and ongoing studies in pediatric populations are aiming to decrease radiation dosages whenever possible. We aimed to evaluate the long-term changes in the utilization patterns of CT and ultrasound (US) in pediatric emergency departments (PEDs).MethodsThis retrospective study reviewed the electronic medical data of patients who underwent CT and/or US in the PED of a tertiary referral hospital from 2000 to 2014. We compared the changes in utilization patterns of brain and abdominal CT scans in pediatric patients and analyzed changes in abdominal US utilization in the PED.ResultsDuring the study period, 196,371 patients visited the PED. A total of 12,996 brain and abdominal CT scans and 12,424 abdominal US were performed in the PED. Comparison of CT use in pediatric patients before and after 2007 showed statistically decreasing trends after 2007, expressed as the coefficient values of the differences in groups. The numbers of brain and abdominal CT scans showed a significant decreasing trend in children, except for abdominal CT in adolescents. The abdominal US/CT ratio in the PED showed a statistically significant increase (2.68; 95% confidence interval, 1.87 to 3.49) except for the adolescent group (5.82; 95% confidence interval, -2.06 to 13.69).ConclusionOverall, CT use in pediatric patients has decreased since 2007. Pediatric US use has also shown a decreasing trend; however, the abdominal US/CT ratio in pediatric patients showed an increasing trend, except for adolescents.

57 Emergency Department Computed Tomography in Early Acute Pancreatitis

57 Emergency Department Computed Tomography in Early Acute Pancreatitis

Practices and attitudes towards radiation risk disclosure for computed tomography: survey of emergency medicine residency program directors.

The purposes of this study were to evaluate the frequency with which emergency physicians involved in residency leadership disclose potential malignancy risks from computed tomography (CT), assess comfort with these discussions, and evaluate factors influencing risk disclosure. We surveyed emergency medicine residency program directors and associate/assistant directors. Primary outcome was the proportion who "almost always" or "most of the time" discussed potential risks. Two hundred and seventy-four (50.6%) of 542 eligible physicians responded. There were 82.1% (95% CI 76.8%, 86.6%) who reported almost always or most of the time discussing potential risks for patients ≤18years; proportions for adults 19-40, 41-65, and >65years were 50.6% (95% CI 44.4, 56.7%), 20.7% (95% CI 16.0, 26.0%), and 5.2% (95% CI 2.9, 8.5%), respectively (test for trend, p<0.001). The proportion reporting being "extremely" or "very" comfortable discussing risks was 57.1% (95% CI 51.1, 63.2%). Patient/family CT request that the physician felt was not indicated was of "very high" or "high" importance for driving risk discussions in 86.4% of respondents. For 75.5%, patient/family query about radiation risks was of "high" or "very high" importance. Among 57.4% of respondents, the patient being elderly and/or having a reduced life expectancy was of "high" or "very high" importance in the decision not to discuss risk. Emergency physicians involved in residency leadership report frequently disclosing potential malignancy risks from CT at frequencies inversely proportional to patient age. About half are comfortable with discussions, and many discussions are driven by patient requests. Opportunities exist to optimize and standardize emergency department CT radiation risk disclosure practices.

Clinical information available during emergency department imaging order entry and radiologist interpretation.

The objective of this study was to evaluate the proportion of Emergency Department (ED) radiology examinations ordered or interpreted prior to a documented clinical assessment. We collected 600 retrospective consecutive ED cases consisting equally of patients whose first ED imaging examination was computed tomography (CT), radiography (XR), or ultrasonography (US). For each patient, the following times were documented: ED arrival, ED departure, ED length of stay (LOS), imaging order entry, image availability, radiology report availability, triage note, ED provider note, and laboratory results. Mean age was 44.2, 66.5% female, and mean ED LOS was 326.2min. ED LOS was longer for patients who received CT versus XR (343.9 vs. 311.3; p=0.029). In 25.5% of XR, 10% of CT, and 8% of US cases, the imaging exam was completed before the ED provider note was started. In 20.5% of XR, 6.5% of CT, and 6% of US cases, the radiologist did not have the ED provider note available prior to completing their diagnostic interpretation. In 33.4% of all cases and 57.5% of XR cases, incomplete clinical documentation (triage note, provider note, lab results) was available during radiology report creation. CT and US exams more frequently had clinical data available prior to radiologist interpretation than XR (p<0.0001). Radiologist turn-around-time was unaffected by clinical information availability. Eight percent of ED CT and 10% of ED US examinations were ordered and completed before documented clinical assessment. Thirty-three percent had incomplete clinical assessment performed prior to image interpretation. Further investigation is needed to determine impact on interpretation accuracy.

The Association Between Physician Empathy and Variation in Imaging Use.

Variation in emergency physician computed tomography (CT) imaging utilization is well described, but little is known about what drives it. Physician empathy has been proposed as a potential characteristic affecting CT utilization. The objective was to describe empathy in a cohort of emergency physicians and evaluate its association with CT utilization. We also sought to compare emergency physician performance on an empathy psychometric test with performance on other psychometric tests previously proposed as predictors of CT utilization. This cross-sectional study included two parts: 1) a secondary analysis of emergency department (ED) CT imaging utilization data in a large health system from July 2013 to June 2014 and 2) a survey study of the cohort of physicians responsible for this imaging using four psychometric scales: the Jefferson Scale of Empathy (JSE), a risk-taking subset of the Jackson Personality Index (RTS), the Stress from Uncertainty Scale (SUS), and the Malpractice Fear Scale (MFS). The study included data and physicians from four EDs: one urban, academic ED, two community, and one free-standing. A hierarchical, mixed-effects regression model was used to evaluate the association between emergency physician performance on the four scales and risk-adjusted CT imaging utilization. The model incorporated physician-specific CT utilization rates adjusted for propensity scores that were calculated using over 500 patient-level variables via random forest methods, physician demographics, and a random provider effect to account for the clustering of observations. CT variation analysis included 113,517 patients seen during the study period by the 74 eligible emergency physician survey respondents; 20,972 (18.5%) of these patients had at least one CT. The survey response rate was 74 of 82 (90.2%). Correlation coefficients between JSE and the other scales were not statistically significant. In subset analysis, there was a trend toward a physician's number of years in practice and RTS score contributing to CT utilization for traumatic head CT. There were no significant associations between performance on any of the psychometric scales and CT utilization. Performance on the JSE, RTS, SUS, or MFS was not predictive of risk-adjusted CT utilization in the ED. The underlying physician-based factors that mediate interphysician variation remain to be clearly identified.

The Impact of a Preauthorization Policy on the After-hours Utilization of Emergency Department Computed Tomography Imaging

We evaluated the effects of a streamlined emergency department (ED) policy for CT ordering, pre- and postimplementation, on the completed imaging study rates of all after-hours computed tomography (CT) studies. The study hypothesis was that a streamlined CT ordering process would increase the utilization rates of ED CT. A prospective cohort study was used to estimate the effect of enhancing a preauthorization policy for after-hours CT studies requested through the ED, performed between January 1 and June 30, 2013, and the postimplementation period, performed between January 1 and June 30, 2014. Inclusion criteria were all CT chest, CT abdomen/pelvis, musculoskeletal, neurological, and neuroangiographic examinations performed by ED physicians on adult patients. Pre- and postintervention examination imaging study rates were compared. The period following implementation of the preauthorization policy was associated with a statistically significant increase in utilization for most subtypes of CT examinations (CT chest, CT abdomen/pelvis, and musculoskeletal CT studies), with the exception of neurological examinations, which showed a significant decrease. This study demonstrates a trend toward increased utilization of CT resources after implementation of an ED preauthorization policy with most study types showing significantly increased utilization. In the case of neurological examinations, a potential "substitution effect" was observed, whereby the rates of neuroangiographic studies showed a marked increase, offsetting the decrease in general neurological examinations performed. Departments considering implementation of preauthorization policies should weigh carefully the benefits of ED workflow efficiencies against the potential harms of increased CT use.

Traumatic brain injuries and computed tomography use in pediatric sports participants

BackgroundChildhood sports-related head trauma is common, frequently leading to emergency department (ED) visits. We describe the spectrum of these injuries and trends in computed tomography (CT) use in the Pediatric Emergency Care Applied Research Network. MethodsThis was a secondary analysis of a large prospective cohort of children with head trauma in 25 Pediatric Emergency Care Applied Research Network EDs between 2004 and 2006. We described and compared children 5 to 18 years old by CT rate, traumatic brain injury (TBI) on CT, and clinically important TBI (ciTBI). We used multi-variable logistic regression to compare CT rates, adjusting for clinical severity. Outcomes included frequency of CT, TBIs on CT, and ciTBIs (defined by [a] death, [b] neurosurgery, [c] intubation >24 hours, or [d] hospitalization for ≥2 nights). FindingsA total of 3289 (14%) of 23082 children had sports-related head trauma. Two percent had Glasgow Coma Scale scores less than 14. 53% received ED CTs, 4% had TBIs on CT, and 1% had ciTBIs. Equestrians had increased adjusted odds (1.8; 95% confidence interval [CI], 1.0-3.0]) of CTs; the rate of TBI on CT was 4% (95% CI, 3%-5%). Compared with team sports, snow (adjusted odds ratio, 4.1; 95% CI 1.5-11.4) and nonmotorized wheeled (adjusted odds ratio, 12.8; 95% CI, 5.5-32.4) sports had increased adjusted odds of ciTBIs. ConclusionsChildren with sports-related head trauma commonly undergo CT. Only 4% of those imaged had TBIs on CT. Clinically important TBIs occurred in 1%, with significant variation by sport. There is an opportunity for injury prevention efforts in high-risk sports and opportunities to reduce CT use in general by use of evidence-based prediction rules.What is known about this subject: Pediatric sports-related head injuries are a common and increasingly frequent ED presentation, as is the use of CT in their evaluation. Little is known about TBIs resulting from different types of sports activities in children.What this study adds to existing knowledge: This study broadens the understanding of the epidemiology of Pediatric TBIs resulting from different sports activities through a prospective assessment of frequency and severity of ciTBIs and ED CT use in a large cohort of head-injured children in a network of pediatric EDs.