Scan Requests Research Articles

Magnetic resonance imaging of the internal auditory meatus for vestibular schwannoma in ENT practice: a retrospective analysis with literature and guidelines review.

Magnetic resonance imaging scans of the internal acoustic meatus are commonly requested in the investigation of audio-vestibular symptoms for potential vestibular schwannoma. There have been multiple studies into protocols for requesting magnetic resonance imaging for vestibular schwannoma, but none have been reported based on UK National Institute for Health and Care Excellence guidelines for investigating audio-vestibular symptoms. This study intended to identify the local magnetic resonance imaging detection rates and patterns of vestibular schwannoma, and to audit the conformity of scan requests with the National Institute for Health and Care Excellence guidelines, with a review of relevant literature. A retrospective analysis of 1300 magnetic resonance imaging scans of the internal acoustic meatus, compared against National Institute for Health and Care Excellence guidelines, was conducted over two years. Sixteen scans were positive for vestibular schwannoma, with a detection rate of 1.23 per cent. All positive cases fit the guidelines; three of these could have been missed using other criteria. A total of 281 requests did not meet the guideline criteria but revealed no positive results, supporting the use of National Institute for Health and Care Excellence guidelines in planning magnetic resonance imaging scans for audio-vestibular symptoms.

Health Insurance Ownership and Quality of Computed Tomography Requests: Experience from a Peripheral Referral Hospital in Cameroon.

Background Health insurance ownership facilitates access and minimizes financial hardship after utilization of healthcare services such as computed tomography (CT). Understanding the rational utilization of CT by people with health insurance can help optimize the scheme and provide baseline information for a national universal health coverage program. Objective To assess the relationship between health insurance ownership and the appropriateness of requests for CT in a peripheral referral hospital in Cameroon. Methods A survey of CT users was conducted during which information on health insurance ownership was collected and the request forms for CT assessed for appropriateness using the American College of Radiologists (ACR) Appropriateness Criteria®. Results We consecutively enrolled 372 participants of which 167 (45%) were females. The median age (range) was 52 (18–92) years. Thirty-eight out of 370 participants reported having health insurance (10.3%; 95% confidence interval (CI): 7.2%–13.4%). Twenty-nine out of 352 CT scan requests (8.2%; 95% CI: 5.3–11.0) were judged to be “inappropriate.” The proportion of inappropriate scan requests was higher amongst people with health insurance compared to those without health insurance (18.4% vs. 7.0%; χ2 = 5.8; p=0.02). In the logistic regression analysis, health insurance ownership was associated to the appropriateness of CT requests in the univariate analysis only (OR = 0.33; 95% CI: 0.13–0.84; p=0.020). Conclusions Inappropriate requests for CT were low but nevertheless associated to health insurance ownership. The continuous sensitization and training of physicians would help minimize potential wasteful utilization of resources.

Direct Access and Skill Mix Can Reduce Telephone Interruptions and Imaging Wait Times: Improving Radiology Service Effectiveness, Safety and Sustainability

Unnecessary telephone calls to reporting radiologists impede organizations' workflow and may be associated with a higher chance of errors in reports. We conducted a prospective study in two cycles, which identified vetting plain CT heads as the most common reason for these calls and vetting CT urinary tracts (KUB) was also frequent. Clear vetting and protocolling guidelines exist for both of these scans, which do not routinely require discussion with a radiologist. Therefore, our approach was to create new flow diagrams to allow radiographers to directly accept routine requests for plain CT head and CT KUB scans in- and out-of-hours. After this intervention, incoming calls to radiology for vetting CT heads decreased by 30% and for vetting CT KUBs by 100%. The average wait time between CT head request and scan completion was reduced by 40%. The number of CT head and CT KUB scans performed remained stable. In future, maximizing the benefit of direct access in-patient imaging pathways will rely on effective and sustained communication of the protocols to the junior clinical staff rotating through the organization, as they were responsible for requesting the vast majority of tests.

503 Clinical Frailty Score (CFS) Vs Antibiotics, Time to Surgery and Time to Computerised Tomography (CT) Scan in An Emergency Surgical Population

Abstract Introduction Frail patients have increased mortality after surgery. However, it is not known if pre-operative process measures such as antibiotic administration, time to CT and time to surgery are influenced by patient frailty. Method The Emergency Laparotomy and Laparoscopy Scottish Audit (ELLSA) assessed outcome after emergency surgery across Scottish hospitals (November 2017 – October 2018). Frailty was measured using the 7-point Clinical Frailty Score (CFS). Outcome measures were antibiotic provision for sepsis, admission to CT time, admission to surgery time, CT request to performance time and CT request to surgery time. Results 1302 patients (median age 63 years [IQR 49-74]; 49% male) with complete data were included. Median time from admission to CT and surgery increased between those with CFS 1 to 6/7 from 597 to 1724 minutes (p < 0.0001) and 1556 to 4120 minutes (p < 0.0001) respectively. Time from CT request to surgery also significantly increased with CFS (p < 0.042). There was no significant association between CFS and antibiotic administration or CT request to performance. Conclusions Frail patients have to wait longer for CT scan requests and surgery, but frailty was not associated with antibiotic administration or delays in CT request to performance time. Possible explanations include frailty-related challenges making correct diagnoses and optimal management plans.

The degree and appropriateness of computed tomography utilization for diagnosis of headaches in Ghana

IntroductionHeadache is a common and sometimes debilitating medical condition. Patients presenting with no neurologic anomaly, nontraumatic primary headache require careful evaluation before neuroimaging. National Guidelines standardizing exploitation of Computed Tomography (CT), the most utilized imaging modality in this clinical scenario, has not been established in Ghana, a developing country with limited healthcare resources. The country has not also adopted existing guidelines such as the National Institute for Health and Care Excellence (NICE) of the United Kingdom or the Appropriateness Criteria (AC) of the American College of Radiologists (ACR). The purpose of this review was to analyze the propensity of CT utilization for diagnosing headaches against the AC of the ACR and discuss some of the socio-economic inferences thereof. MethodsThis study retrospectively reviewed CT imaging records and clinical data of all patients referred for head CT scans between 1st January 2016 and 31st December 2018 at five major health facilities (four tertiary government hospitals and one private hospital) across Ghana. We isolated all head CT scans performed for the diagnosis of headache for analysis. We analyzed the type of presenting headache, CT findings, gender distribution, pattern of referrals, and head CT appropriateness against the AC of the ACR. ResultsA total of 44,218 patients were referred to the five facilities for head CT secondary to diverse indications for the period. All non-trauma cases were 41.7%; trauma cases were 31.6%, the majority (72.3%) were from road traffic accidents. The majority (64.9%) of trauma casualties were males. A total of 11,806 (26.7%) patients were referred for a head CT scan for the diagnosis of headache. The private hospital recorded the highest referrals for head CT scan for diagnosis of headache. The gender distribution of all headache patients was 57.6% females, and 42.4% were males. The age distribution showed 19.3% were children, 71.2% were adults, and the aged constituted 9.4%. The results showed 2.8% significant cranial CT findings of all reviewed headache patients. Pathological findings among the cohort of children were 0.6%.The sources and pattern of referrals showed 57.3% were from the Outpatient Department, 26.6% from the Emergency Department, in-patients’ referrals were 9.4%, and specialist consultation was 7.1%. Analysis of CT scans performed against the AC of the ACR, showed 69.0% of headache patients were likely scanned inappropriately. ConclusionsThere is a need to implement international best practice guidelines or develop a national neuroimaging policy to protect patients. Unjustified CT utilization for diagnosis of headaches exposes patients to unnecessary ionizing radiation that can instigate cancer and unnecessary expenditure. Head CT scan for some headache patients with normal neurologic findings may be unnecessary in an emerging country like Ghana. Clinicians must, therefore, be discerning in CT scan requests for the diagnosis of headache.

91 Mrs Bad Bones: Impact of COVID-19 on Secondary Prevention of Fragility Fractures

IntroductionManagement of osteoporosis is an important consideration for neck of femur fracture patients due to the morbidity and mortality it poses, and the significant financial burden to the NHS. Orthogeriatric teams input is invaluable in coordinating secondary fragility fracture prevention. The COVID-19 pandemic resulted in the rapid restructuring of healthcare teams and led to the redeployment of the orthogeriatricians to assist with the influx of medically unwell patients. This study explored the impact COVID-19 had on secondary fragility fracture prevention.MethodA retrospective audit looking at the prescription of vitamin D/calcium supplements, bone-sparing medications, and DEXA scan requests in consecutive neck of femur fracture patients admitted to a trauma and orthopaedic unit pre- and post- UK lockdown in response to the pandemic. A re-audit was conducted following the implementation of our new mnemonic, “MRS BAD BONES”: Medication Review Rheumatology/Renal Advice Smoking Cessation Blood tests Alcohol limits DEXA scan Bone-sparing medications Orthogeriatric review Nutrition Exercise Supplements.ResultsData for 50 patients was available in each phase. The orthogeriatric team reviewed 88% of patients pre-lockdown falling to 0% due to redeployment, before recovering to 38% in the post-intervention period. Upon lockdown there was a significant drop in the prescription of vitamin D/calcium supplements from 81.6% to 58.0% (p = 0.0156); of bone-sparing medications from 60.7% to 18.2% (p = 0.0037), and DEXA scan requests from 40.1% to 3.6% (p = 0.0027). Following the implementation of our mnemonic, there was a significant increase in the prescription of vitamin D/calcium supplements to 85.7% (p = 0.0034), bone-sparing medications to 72.4% (p = 0.0002) and DEXA scan requests to 60% (p < 0.0001).ConclusionCOVID-19 had a major impact on the secondary prevention of fragility fractures in this population. The “MRS BAD BONES” mnemonic significantly improved the management and could be considered for use in a wider setting.

The role of ultrasonography in the management of undescended testes. A 6 year review.

Background: Undescended Testis (UDT) is a common condition that has a potential to cause infertility and may become malignant if not treated surgically in time. Ultrasound is requested by different specialties for diagnosis of UDT before referring to a pediatric urology clinic. Objectives: To evaluate the trends for Ultrasound Scan (USS) requests by particular specialties before referral to a surgical team and to assess the sensitivity and specificity of ultrasound in accurately localizing UDT compared to per operative findings and its impact on the management plan. Methods: We reviewed all the patient between 1st of January 2014 to 1st of January 2019, who were referred to our paediatric urology department for UDT and had an USS testes before referral. Patients with ambiguous genital, hydrocele and redo orchidopexy were excluded. We recorded age at referral, referring specialty, their findings on clinical examination, the USS findings, and per operative findings. The results were expressed as mean/median, percentages, sensitivity, specificity and positive and negative predictive value. Results: We received 670 referrals for UDT to our clinic during this period. Among these 207 patients (31.04%) had an USS done before referral to us. There were nearly equal number of referrals made by the main specialties, which included neonatology, general paediatrics and family medicine. All the decisions as regards to surgery were based on the clinical examination in outpatient and the surgical approach of either open or laparoscopy was based on examination under anaesthesia irrespective of USS findings. The sensitivity and specificity of ultrasonography for correctly diagnosing a testis in the groin was 87.79% and 72.13%, in the abdomen 70.73% and 96.08% and for vanished testes 87% and 94.8% respectively when compared to per operative findings. USS missed diagnosed 43 out of 101 normal testes as either in the groin n=41(16.87%) or abdomen n=2(2.81%). This practice cost our hospital US$ 10350 (US$ 50 per scan). Conclusion: The use of ultrasound does not aid significantly in the accurate diagnosis or management of undescended testes and incur unnecessary additional cost to the health system. Physicians should refrain from requesting ultrasound for localization of testes before referral to surgical team.

Clinical governance in radiologic practice: Evaluating the appropriateness of radiologic investigation considering patient clinical information using the radiology request form

Introduction: Clinical governance in radiology is an improved quality assurance program where the patient well-being is the central focus concerning radiologic service using the radiology request form (RRF). Methodology: The study was a 6-month descriptive study conducted from January 2020 to June 2020. A total of 2053 request forms were collated retrospectively and evaluated to ascertain the appropriateness of the clinical information with the investigation requested. A 3 stage Likert scale of appropriate somewhat appropriate and inappropriate was used and the data analyzed using the statistical package for the social sciences (SPSS) IBM Corp. version 23.0 (Armonk, NY: USA). The results were expressed in percentages and frequencies and presented in tables and charts. Results: Of the 2053 request forms, X-rays constitute 32.54% while ultrasound scans and computed tomography (CT) investigations constitute 43.21% and 5.46%, respectively. Clinical information was indicated in 51.39% of the RRF, out of which 75.95% of the clinical information were adequate while 13.93% were not in keeping with the investigation. Ultrasound scan request had the highest inappropriate clinical information (54.68%) followed by plain radiography request (41.73%) whereas all the CT request was in tandem with the investigation. Conclusion: There are occasional clinical information and radiologic request mismatch. This may be due to the filling of the RRF by medical interns or nonmedical personnel such as allied health workers with less knowledge on radiologic imaging modalities. The audit recommends proper supervision of young clinicians and continues medical education concerning the rational use of imaging modality.

Potentially inappropriate brain CT-scan requesting in the emergency department: A retrospective study in patients with neurologic complaints.

Background:Potentially inappropriate brain CT scan requesting in the emergency department imposes extra charges to the healthcare system and patients. Besides, the unnecessary radiation exposure may cause irreparable damage to the patient. In this study we investigated the percentage of potentially inappropriately conducted brain CT scan for different chief complaints in non-traumatic patients presented to our emergency department.Material and methods:160 patients aged over 18 years old with chief complaints other than trauma, referred to the emergency department of Imam Hossein Hospital (Tehran, Iran), were enrolled in this study. Data were collected from medical records; the inclusion criteria was patients older than 18 years with chief complaint other than trauma.Results:160 people aged 18 to 100 years old enrolled in this study, 83 (51.87%) were male and 77 (48.13%) were female. There was no statistically significant difference in terms of potentially inappropriate brain CT between different age groups. Percentage of potentially inappropriate CT according to chief complaints were as follows: 4.8% for dysarthria, 0% for right and left hemiplegia, 9.1% for decreased level of consciousness, 30% for nausea and vomiting, 41.7% for generalized weaknesses, 0% for seizures, 55.6% for vertigo, 25% for headache, and 57.7% for other complaints. There was a statistically significant association between chief complaints and potentially inappropriate brain CT scan requests (p-value = 0.001).Conclusion:Considering the significant percentage of potentially inappropriate brain CT scan requests for non-traumatic patients in the setting of emergency department, it is critical for healthcare policymakers to propose practical guidelines and supervise their application. (www.actabiomedica.it)

Utility, Appropriateness of Request and Report of Computed Tomography Scan for the Diagnosis of Paranasal Sinuses Pathologies in a Sub-Saharan Africa Urban Setting

Background: Computed tomography (CT) Scan is the imaging of choice for the diagnosis of sino nasal (SN) pathologies in sub-Saharan African setting. However, it is often requested by non experienced practitioners. We aimed to describe the utility and the appropriateness of CT Scan request forms and results in the diagnosis of SN pathologies. Method: We conducted a retrospective cross-sectional study in four health facilities in Yaoundé, Cameroun, from October 2018 to September 2019. All patients to whom SN CT Scan was performed were called for an appointment. After informed consent, data on the appropriateness and conformity of the request form were collected and compared to the guidelines of the French society of radiology. CT Scan results were also collected and the quality of the report was evaluated. Results: A total of 206 SN CT Scan request forms and reports were included, with a mean patient age of 37.7 ± 16.1 years. The request form was conformed to guidelines in 8.3% of cases and was found appropriate in 62.6% of cases. No CT Scan report had all the items required, and 159 (77.2%) reports were useful. The most common diagnosis in patients with abnormal results was chronic sinusitis (49.5%) and SN polyp or polyposis (19.4%). Conclusion: Most of SN CT Scan requested were appropriate and useful. However, the conformity of request forms and reports to the guidelines is low. Suggesting the need for capacity building for the diagnosis of SN pathologies especially for non specialists like general practitioners and nurses.

A Real-World Study of Cerebral 99mTc-TRODAT-1 Single-Photon Emission Computed Tomography (SPECT) Imaging of the Dopamine Transporter in Patients with Parkinson Disease from a Tertiary Hospital in Brazil.

BackgroundStudies on the routine clinical use of dopamine transporter (DAT) imaging have largely been conducted in Europe and the United States. In this real-world study, we investigated the use of cerebral 99mTc-TRODAT-1 SPECT imaging of DAT in patients with Parkinson disease (PD) at a tertiary hospital in Brazil.Material/MethodsWe included 119 patients with suspected PD or clinically unclear parkinsonism who underwent brain scintigraphy with 99mTc-TRODAT-1 during a 3-year period. Additionally, a brief interview was conducted with the physician who requested the scan to determine the usefulness of the method in clinical decision-making.ResultsRegarding the scan requests, most were intended to evaluate or confirm dopaminergic denervation (69%), distinguish PD from essential tremor (10%), or distinguish degenerative parkinsonism from drug-induced parkinsonism (6%). Data analysis showed that scintigraphy with 99mTc-TRODAT-1 was useful in 85% of cases, changing the management of 75% of the patients who underwent a scan. The majority of physicians who requested the scan were neurologists, and 54% were self-reported movement disorder specialists. An inappropriate use of DAT imaging was seen in 5% of cases.ConclusionsThis study demonstrated that brain scintigraphy with the DAT ligand 99mTc-TRODAT-1 may influence diagnostic or therapeutic interventions, meaning that Brazilian physicians who requested the exam have taken in vivo DAT results into account at the time of clinical decision-making.

Secondary Prevention of Hip Fragility Fractures During the COVID-19 Pandemic: Service Evaluation of "MRS BAD BONES".

BackgroundManagement of osteoporosis is an important consideration for patients with femoral neck fractures due to the morbidity and mortality it poses. The input of orthogeriatric teams is invaluable in coordinating secondary fragility fracture prevention. The COVID-19 pandemic resulted in the rapid restructuring of health care teams and led to the redeployment of orthogeriatricians.ObjectiveThis study aimed to determine the impact COVID-19 had on the secondary prevention of fragility fractures among patients with femoral neck fractures, and to optimize management in this population.MethodsA retrospective audit was conducted of patients with femoral neck fractures before and after the lockdown in response to the COVID-19 pandemic in the United Kingdom. A reaudit was conducted following the development of our new mnemonic, “MRS BAD BONES,” which addressed key factors in the assessment and management of osteoporosis: medication review, rheumatology/renal advice, smoking cessation; blood tests, alcohol limits, DEXA (dual energy X-ray absorptiometry) scan; bone-sparing medications, orthogeriatric review, nutrition, exercise, supplements. The Fisher exact test was used for comparison analyses between each phase.ResultsData for 50 patients were available in each phase. The orthogeriatric team reviewed 88% (n=44) of patients prelockdown, which fell to 0% due to redeployment, before recovering to 38% (n=19) in the postintervention period. The lockdown brought a significant drop in the prescription of vitamin D/calcium supplements from 81.6% (n=40) to 58.0% (n=29) (P=.02); of bone-sparing medications from 60.7% (n=17) to 18.2% (n=4) (P=.004), and DEXA scan requests from 40.1% (n=9) to 3.6% (n=1) (P=.003). Following the implementation of our mnemonic, there was a significant increase in the prescription of vitamin D/calcium supplements to 85.7% (n=42) (P=.003), bone-sparing medications to 72.4% (n=21) (P<.001), and DEXA scan requests to 60% (n=12) (P<.001).ConclusionsThe redeployment of the orthogeriatric team, due to the COVID-19 pandemic, impacted the secondary prevention of fragility fractures in the study population. The “MRS BAD BONES” mnemonic significantly improved management and could be used in a wider setting.

Decreasing the number of authorization denials in an academic medical oncology practice.

212 Background: Prior authorizations in medical oncology generate additional work and subsequent stress to providers, contributing to physician burnout. Denials of payments can also impact patient care and lead to loss of revenue for the institution. In 2018, first pass denial rates averaged 8.41% per month at our institution. Imaging/scans denials created the majority of this additional work for providers. We aimed to decrease the monthly first pass denial rate average of oncology scans by 25% by May 31, 2020. Methods: Following the creation of a process map of the current prior authorization process and a cause and effect diagram, we identified many factors that could not be controlled (i.e. Insurance company policies). We subsequently created a priority/pay-off-matrix using factors that we could control. Introducing standardized order template for oncology scans was identified as a high impact and feasible countermeasure. Plan-do-study-act cycles (PDSA) plan was developed using this countermeasure to achieve our aim. PDSA 1 included creating template for order entry, educating the nurse partners and advance practice providers (APPs). PDSA 2 included educating physicians and measuring the compliance rate of the template. PDSA 3 addressed the barriers for compliance and education on resources was provided. PDSA 4 included education of the prior authorization staff and reinforcement of template use. A sustainability plan created consisting of a designated RN liaison for review of peer-to-peer requests for oncology scans. Results: PDSA 1: 100% of the nurse partners and APPs were educated. PDSA2: 80% of physicians were educated and 32.8% compliance rate of template use. PDSA 3: 39.2% compliance. PDSA 4: 95% of the radiology prior authorization staff was educated. While our compliance rate for the standardized order template use did increase, we identified many other opportunities to improve the process. Unfortunately, due to COVID-19 pandemic outbreak, resources have been temporarily allocated to relief efforts and the sustainability plan continues to be a work in progress. Conclusions: Peer to peer requests for imaging/scans following authorization denials consume time and effort of providers contributing to burnout and potentially impacting patient care. While many factors cannot be controlled, standardizing ordering process and educating the involved personnel may decrease the number for peer to peer requests. ASCO’s quality training program process helped our institution identify a provider controlled barrier and helped standardize this approach.

Appropriateness of Emergency CT Utilization During the Initial Peak of the COVID-19 Pandemic.

Appropriateness of Emergency CT Utilization During the Initial Peak of the COVID-19 Pandemic.

Reducing length of stay for patients presenting to general surgery with acute non-surgical abdominal pain.

Acute abdominal pain is a common surgical presentation. We previously found that over the last decade, more patients were admitted to hospital with non-surgical diagnoses (e.g. gastroenteritis, constipation and non-specific abdominal pain) and length of stay and use of imaging (mainly computed tomography scan) for these patients increased. This study aimed to reduce length of stay and use of imaging for patients admitted with non-surgical abdominal pain. A prospective study was undertaken in a tertiary centre evaluating length of stay and use of additional imaging in patients with a non-surgical diagnosis after a quality improvement intervention was implemented. A total of 454 patients were included; 204 (44.9%) presented with non-surgical abdominal pain. During the study period, a significant reduction in computed tomography scan requests was observed (38.5-25.0%, P = 0.037) and an increasing proportion of these patients were discharged within 12 h (33.3-57.1%, P = 0.018). The number of re-presentations remained unchanged (P = 0.358). The study intervention increased the proportion of patients with non-surgical diagnoses that were successfully discharged within 12 h and reduced the use of additional imaging in this group. This may lead to improved use of health care resources for patients with more urgent diagnoses.

Diagnostic Accuracy of Point-of-Care Ultrasound Integrated intoClinical Examination for Acute Diverticulitis: A Prospective Multicenter Study.

Diverticulitis is a common cause of abdominal pain and CT scan is commonly used for its diagnosis in the emergency department (ED). The diagnostic performance of point-of-care ultrasound (POCUS) integrated into a clinical exam for diverticulitis is still not established. We evaluate the accuracy of clinical-sonographic assessment for the diagnosis of diverticulitis and whether POCUS could improve the selection of patients needing CT scan for complicated diverticulitis. This is a multicentric observational study involving adult patients suspected of having diverticulitis presenting at 4 EDs. 21 sonographer physicians were asked to diagnose diverticulitis and complicated diverticulitis based on clinical-sonographic assessment. The final diagnosis was established by two reviewers, blinded to POCUS, based on data collected during the one-month follow-up comprehensive CT scan. Among 393 enrolled patients, 218 (55.5 %) were diagnosed with diverticulitis and 33 (8 %) had complicated diverticulitis. The time to diagnosis by the sonographer physicians was shorter compared to standard care (97 ± 102 vs. 330 ± 319 minutes, p < 0.001). Clinical-sonographic assessment showed optimal sensitivity (92.7 %) and specificity (90.9 %) for diverticulitis. However, the sensitivity (50 %) for complicated diverticulitis was low. The sonographer physician would have proceeded to CT scan in 194 (49.4 %) patients and the CT scan request compared to the final diagnosis of complicated diverticulitis demonstrated 94 % sensitivity. Clinical-sonographic assessment is rapid and accurate for the diagnosis of diverticulitis. Even if POCUS has low sensitivity for complicated diverticulitis, it can be used to safely select patients needing CT.

Audit of CT head request appropriateness for patients referred from emergency department

Introduction: Considering the usefulness and relative ease of Computerized Tomography (CT) based diagnosis, the propensity to request it in the Emergency Room setting when at times it is not really indicated can become an issue.&#x0D; Objective: To audit use of CT imaging in the emergency department of Rehman Medical Institute by evaluating the clinical practice for CT referral and compliance with clinical guidelines by NICE (National Institute for Health and Care Excellence).&#x0D; Materials &amp; Methods: This study was conducted at Radiology Department of Rehman Medical institute Peshawar in Oct-Dec 2019 on 100 patients referred for computed tomography (CT) head scans from the emergency department (ED), mostly performed outside normal working hours. Clinical record and CT reports of patients who had their CT head scans done between 1 January 2018 and September 2019 were reviewed. The imaging record of included patients was reproduced from the Picture Archiving and Communication system (PACS) and laboratory data were reviewed through the Hospital Management Information System (HMIS). Clinical details were reviewed to assess risk factors satisfying NICE criteria for a CT scan in those with head injuries. An urgent CT head scan request was deemed appropriate if it led to an immediate change in patient management. Appropriateness of the requests according to the various guidelines was also evaluated. The NICE guideline 176 was used as a standard of care. Data were entered and analyzed using Microsoft Excel.&#x0D; Results: For suspected brain injuries at least one of the NICE criteria was fulfilled by 84 patients, and 3 or more criteria by 16 patients with a history of head injury; 81% scans were both requested and performed in afternoon and night (between 1700 hrs and 0800 hrs). Most (70) patients were males; ages of patients were from 1- 90 years, most being 51-60 years. Most common presenting complaint was altered consciousness (85%); 51% of the advised CT scans were reported normal, 10% had skull fractures (base 2%, vault 8%), 13% extra-axial hemorrhages, 7% contusions, 7% only scalp hematoma, 6% intracerebral hemorrhages. 2% had infarcts and 2% were cerebral abscesses. Common change in patient management included intracranial bleed requiring urgent neurosurgical intervention and hemorrhagic stroke being ruled out. CT head scans also facilitated early discharge of the patients with head injuries and headache from the hospital.&#x0D; Conclusion: All (100%) patients had CT head in compliance with NICE guidelines and 81% of these were performed in off hours.&#x0D; Keywords: Head; Tomography; Craniocerebral Trauma.

P81 The impact of musculoskeletal ultrasound on the referral of patients with suspected inflammatory arthritis from primary care

Abstract Background Musculoskeletal ultrasound (MSUS) is a helpful adjunct to clinical history and examination in the assessment of patients with suspected early inflammatory arthritis (EIA). Whereas MSUS is used widely by rheumatologists, data regarding the extent to which general practitioners (GPs) utilise MSUS in the assessment of patients with suspected EIA remain lacking. In this service evaluation, we aimed to quantify the MSUS workload originating from primary care, and its impact on the referral pathway of patients with suspected EIA. Methods We studied all patients ≥16 years of age who had an MSUS of the hands and wrists performed by the radiology department at the Queen Elizabeth Hospital (Gateshead, UK) between 1st January and 31st December 2018, and where the scan request originated from a GP within primary care. Electronic records were retrospectively reviewed to ascertain the scan request clinical details, radiology report, and subsequent referral of the patient for rheumatology review. The study was registered with the Trust Clinical Improvement Office. Results 189 patients were scanned: 137 (72%) female, median (IQR, range) age 56 (43-65, 16-91) years. Ultrasonographic abnormalities (synovial hypertrophy, synovitis and/or tenosynovitis) were observed in 31/87 (36%) of suspected EIA patients, and 22/102 (22%) patients without suspicion of EIA, with subsequent referral to rheumatology in 24 and 4 cases from each group respectively. Of the 24 patients with suspected EIA who were referred for rheumatological assessment, 7 were subsequently diagnosed with EIA (one seropositive rheumatoid arthritis [RA], three seronegative RA, two unspecified IA, one reactive arthritis) with a median (range) time from MSUS request to rheumatology referral of 36 (-5 - 58) days. None of the 4 patients referred from the non-EIA group were diagnosed with an inflammatory arthritis. Conclusion MSUS is widely used by GPs within our region for the assessment of suspected EIA, despite local and national guidelines supporting referral without imaging within 3 days of presentation. Furthermore, we show evidence that GPs interpret scan reports within the individual patient clinical context, with rheumatology referral less likely where the clinical suspicion of EIA is low. Normal MSUS findings contributed to avoidance of referral in 56/87 (64%) of suspected EIA cases, substantially reducing EIA referrals to secondary care. However, MSUS requests within primary care also contributed towards a delay in referral for a small number of patients with confirmed EIA, which we plan to address by signposting to local EIA referral guidelines within the radiology request system. A prospective study of MSUS in the triaging of EIA referrals to secondary care, combined with a qualitative study of the impact of MSUS on GP decision making, are warranted to better understand the potential impact of MSUS in the primary care setting for improved patient care and resource allocation. Disclosures K.F. Baker None. E. Fatone None. J. Hamilton None.

Management of reduced fetal movement: A comparative analysis of two audits at a tertiary care clinical service

ObjectivesReduced fetal movement (RFM) is a commonly presenting worrisome complaint, both for mothers and attending clinicians. The aim of this study was to review the management of RFM before and following the implementation of new hospital guideline and to determine pregnancy outcomes following single vs repeated consultations with complaints of RFM. We also compared the standards in our old and new trust guidelines against published guidance from the Royal College of Obstetricians and Gynaecologists (RCOG). Study DesignThis retrospective cohort study was conducted between June -November 2016 (audit 1) and July– December 2018 (audit 2).All women with a non-anomalous singleton pregnancy, attending the Day Assessment Unit of the Jessop Wing Hospital Sheffield UK with a primary presentation of perceived RFM after 24 weeks of gestation were included. The electronic maternity database was used to collect information regarding their presentations and pregnancy outcomes. Adherence to the old and the new local guidelines for the respective epochs of the assessment were reviewed by two independent observers using the Appraisal of Guidelines for Research and Evaluation (AGREE) 11 tool. ResultsA total of 1775 women presented with RFM during the two study periods. Of these, 632 attended with more than 1 presentation of RFM (35.6 %). There were 3 stillbirths; all diagnosed at the first presentation with RFM.In the second audit, prevalence of RFM increased by 10 %, CTG documentation improved by 1% and ultrasound scan requests decreased by 6.6 %.Women with more than one episode of RFM were more likely to be younger, smokers, nulliparous, have raised BMI, had a higher IOL rate and had more ultrasound scans compared to those with one episode. However, neonatal outcome, onset of labour and mode of delivery remained unchanged between the two groups.While the RCOG guideline was superior to both (old and new) guidelines, the overall scores increased in the new guideline by 22 %. ConclusionAfter implementing the new guideline, the re-audit demonstrates a reduction in the number of requested ultrasound scans without any compromise on the perinatal outcome.

AB264. Emergency department requests for gynaecology scans

AB264. Emergency department requests for gynaecology scans