Patient preferences and acceptable risk for computed tomography in trauma

Rodriguez, Robert M.; Henderson, T.; Ritchie, A.; Langdorf, Mark I.; Raja, Ali S.; Silverman, Eric C.; Schlang, J.; Sloane, Bryan; Ronan, C.E.; Anderson, Craig L.; Baumann, Brigitte M.

doi:10.1016/j.injury.2014.03.011

Cited by 22 publications

(22 citation statements)

References 24 publications

(32 reference statements)

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“…Along with the presentation of radiation risk and cost information, provision of likelihood of injury data such as ours should also advance the movement toward shared patient–physician decision‐making with regard to CT. We have demonstrated that most patients wish to be informed of the risks and costs of CT and that they would often choose to forego chest CT when the chances of finding life‐threatening injury are low . In this regard, trauma providers may present alert, lower‐risk patients with estimates of the likelihood that chest CT will show an injury and then discuss the risk/benefit ratios of chest CT directly with the patients involved.…”

Section: Discussionmentioning

confidence: 99%

Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria

Raja

Mower

Nishijima

et al. 2016

Academic Emergency Medicine

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Objectives: The use of chest computed tomography (CT) to evaluate emergency department patients with adult blunt trauma is rising. The NEXUS Chest CT decision instruments are highly sensitive identifiers of adult blunt trauma patients with thoracic injuries. However, many patients without injury exhibit one of more of the criteria so cannot be classified "low risk." We sought to determine screening performance of both individual and combined NEXUS Chest CT criteria as predictors of thoracic injury to inform chest CT imaging decisions in "non-low-risk" patients.Methods: This was a secondary analysis of data on patients in the derivation and validation cohorts of the prospective, observational NEXUS Chest CT study, performed September 2011 to May 2014 in 11 Level I trauma centers. Institutional review board approval was obtained at all study sites. Adult blunt trauma patients receiving chest CT were included. The primary outcome was injury and major clinical injury prevalence and screening performance in patients with combinations of one, two, or three of seven individual NEXUS Chest CT criteria.Results: Across the 11 study sites, rates of chest CT performance ranged from 15.5% to 77.2% (median = 43.6%). We found injuries in 1,493/5,169 patients (28.9%) who had chest CT; 269 patients (5.2%) had major clinical injury (e.g., pneumothorax requiring chest tube). With sensitivity of 73.7 (95% confidence interval [CI] = 68.1 to 78.6) and specificity of 83.9 (95% CI = 83.6 to 84.2) for major clinical injury, abnormal chest-x-ray (CXR) was the single most important screening criterion. When patients had only abnormal CXR, injury and major clinical injury prevalences were 60.7% (95% CI = 52.2% to 68.6%) and 12.9% (95% CI = 8.3% to 19.4%), respectively. Injury and major clinical injury prevalences when any other single criterion alone (other than abnormal CXR) was present were 16.8% (95% CI = 15.2% to 18.6%) and 1.1% (95% CI = 0.1% to 1.8%), respectively. Injury and major clinical injury prevalences among patients when two and three criteria (not abnormal CXR) were present were 25.5% (95% CI = 23.1% to 28.0%) and 3.2% (95% CI = 2.3% to 4.4%) and 34.9% (95% CI = 31.0% to 39.0%) and 2.7% (95% CI = 1.6% to 4.5%), respectively. Conclusions:We recommend that clinicians check for the six clinical NEXUS Chest CT criteria and review the CXR (if obtained). If patients have one clinical criterion (other than abnormal CXR), they will have a very low risk of clinically major injury. We recommend that clinicians discuss the potential risks and benefit of chest CT in these cases. The risks of injury and major clinical injury rise incrementally with more criteria, rendering the risk/benefit ratio toward performing CT in most cases. If the patient has an abnormal CXR, the risks of major clinical injury and minor injury are considerably higher than with the other criteria-chest CT may be indicated in cases requiring greater anatomic detail and injury characterization.

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Section: Discussionmentioning

confidence: 99%

Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria

Raja

Mower

Nishijima

et al. 2016

Academic Emergency Medicine

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“…We have demonstrated that most patients prefer to discuss the risks and costs of CT whenever possible and that they will often choose to forego CT in scenarios in which there is a low risk of injury. 33 The shared decision model is less suitable for patients who have two or more criteria, and who consequently have an increased risk of injury and greater benefit from diagnostic CT imaging.…”

Section: Summary Recommendations and Discussionmentioning

confidence: 99%

“…Furthermore, addressing this issue from the standpoint of patient-centered practice in one of our satellite studies, we demonstrated that patients wish to discuss risks and costs of CT and are willing to accept a small risk of missed injury in lower risk scenarios. 33 …”

Section: Limitationsmentioning

confidence: 99%

Selective chest imaging for blunt trauma patients: The national emergency X-ray utilization studies (NEXUS-chest algorithm)

Rodriguez

Hendey²,

Mower

2017

The American Journal of Emergency Medicine

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Chest imaging plays a prominent role in blunt trauma patient evaluation, but indiscriminate imaging is expensive, may delay care, and unnecessarily exposes patients to potentially harmful ionizing radiation. To improve diagnostic chest imaging utilization, we conducted 3 prospective multicenter studies over 12 years to derive and validate decision instruments (DIs) to guide the use of chest x-ray (CXR) and chest computed tomography (CT). The first DI, NEXUS Chest x-ray, consists of seven criteria (Age > 60 years; rapid deceleration mechanism; chest pain; intoxication; altered mental status; distracting painful injury; and chest wall tenderness) and exhibits a sensitivity of 99.0% (95% confidence interval [CI] 98.2-99.4%) and a specificity of 13.3% (95% CI, 12.6%-14.0%) for detecting clinically significant injuries. We developed two NEXUS Chest CT DIs, which are both highly reliable in detecting clinically major injuries (sensitivity of 99.2%; 95% CI 95.4-100%). Designed primarily to focus on detecting major injuries, the NEXUS Chest CT-Major DI consists of six criteria (abnormal CXR; distracting injury; chest wall tenderness; sternal tenderness; thoracic spine tenderness; and scapular tenderness) and exhibits higher specificity (37.9%; 95% CI 35.8–40.1%). Designed to reliability detect both major and minor injuries (sensitivity 95.4%; 95% CI 93.6–96.9%) with resulting lower specificity (25.5%; 95% CI 23.5–27.5%), the NEXUS CT-All rule consists of seven elements (the six NEXUS CT-Major criteria plus rapid deceleration mechanism). The purpose of this review is to synthesize the three DIs into a novel, cohesive summary algorithm with practical implementation recommendations to guide selective chest imaging in adult blunt trauma patients.

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“…Emergency department (ED) use of computerized tomography (CT) has increased threefold in the past two decades without corresponding increases in the incidence of hospital admissions or diagnoses of life‐threatening illness . CT scanning exposes patients to potentially harmful ionizing radiation, as well as risks associated with intravenous contrast exposure with chest and abdominal/pelvis CT .…”

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confidence: 99%

Feasibility of Informed Consent for Computed Tomography in Acute Trauma Patients

Moore

Patel

Zuabi

et al. 2017

Academic Emergency Medicine

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Background/Objective Computed tomography (CT) is common for trauma victims, but is usually done without informing patients of potential risks or obtaining informed consent. The objective of this study was to determine the feasibility of two elements (time and normal level of alertness) necessary for informed consent for CT in adult trauma patients. Methods We conducted this prospective observational, two-phase cohort study at two urban, Level 1 trauma centers. In the first phase, we determined the median time needed to obtain informed consent for CT by performing sham consent on 11 injured patients at each site. In the second phase, we observed all adult trauma activation cases that presented during specified time blocks and recorded Glasgow Coma Scale (GCS) scores and the time available for consent (TAC) for CT—defined as the time between the end of the secondary trauma survey and when the patient left the resuscitation room to go to CT. We defined, a priori, feasible consent cases as those in which the patient had a GCS of 15 and a TAC > the median sham consent time at that site. Results The median times for sham CT consent at the two sites were 3:36 and 2:09 minutes:seconds (range 1:12 – 4:54). Of the 729 trauma patients enrolled during phase two, 646 (89%) had a CT scan, and of these 646 patients, 461 (71.4% [95% CI 67.8 – 74.7%]) met feasible consent criteria. Of the 185 patients who failed to meet feasible consent criteria, 171 (92.4%) had a GCS < 15, 1 (0.5%) had a TAC < the sham consent time, and 13 (7.0%) had both. Conclusion We found that informed consent for CT was likely feasible in over two-thirds of acute, adult trauma patients.

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Patient preferences and acceptable risk for computed tomography in trauma

Cited by 22 publications

References 24 publications

Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria

Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria

Selective chest imaging for blunt trauma patients: The national emergency X-ray utilization studies (NEXUS-chest algorithm)

Feasibility of Informed Consent for Computed Tomography in Acute Trauma Patients

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