Scenarios to improve CT head utilization in the emergency department delineated by critical results reporting

Abstract

Purpose Increasing use of advanced imaging in the emergency department (ED) has resulted in higher cost without better outcomes. Our goal was to evaluate the yield of CT head exams by scenario to guide efforts at improving patient selection. Methods We performed a retrospective study at an academic medical center over 4 years (1/1/2014-12/31/2017). The chief complaint, imaging order, and exam result text were obtained for all adult ED encounters. For the 50 most common chief complaints leading to CT head exams, the ratio of exams to total encounters and ratio of critical results to imaging studies were calculated. Significant difference in "yield" was assessed via binomial test. Results Over 708,145 adult ED encounters, 58,783 CT head exams were ordered, with an overall critical result yield of 8.0%. The three most common chief complaints had higher yield (p < 0.05): altered mental status (9.8%), fall (9.7%), and new headache (10.1%). Lower yield (p < 0.05) was found for 19 chief complaints: dizziness (6.2%), falls in patients > 65 years old (7.1%), syncope (5.3%), seizure with known epilepsy (4.8%), chest pain (3.7%), head injury (4.9%), headache re-evaluation (7.0%), alcohol intoxication (2.5%), fatigue (6.5%), headache-recurrent or in the setting of known migraines (5.2%), hypertension (4.4%), lethargy (5.8%), loss of consciousness (5.3%), migraine (3.2%), psychiatric evaluation (2.9%), near syncope (4.6%), drug problem (3.1%), symptomatically decreased blood sugar (3.2%), and suicidal (1.7%). ConclusionOur study provides a priority list of low yield scenarios of CT head use for improvement of patient selection.

Head computed tomography for elderly patients with acute altered mental status in the emergency setting: value for decision-making and predictors of abnormal findings

“…The diagnostic yields in those previous studies were higher than those in our selected population by 10% to 40%. 27,31,38 Our low diagnostic yield also differs from that of a retrospective study of 170 patients referred to a geriatric unit for confusion. 19 That previous study considered confusion, decreased alertness, and seizure, and its diagnostic yield was higher than in our setting: about 18.0% of their 68 patients had an intracranial cause of confusion.…”

“…14 A recent retrospective ED study over 4 years found a high diagnostic yield (9.8%) for head CT performed for AMS, but that rate decreased to 5.3% when considering a disorder of consciousness alone. 38 A recent review of 294 ED patients recommended that neuroimaging be ordered for confused patients with new focal signs, suspected traumatic brain injury, suspected encephalitis, or no identifiable cause for delirium. 27 When their analysis was confined to 280 cases of acute isolated AMS, the diagnostic yield of CT was even lower (3%) than in our setting.…”

Use of Computed Tomography of the Head in Patients With Acute Atraumatic Altered Mental Status

“…Of 26 studies, 11 were performed in the ED, 5 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 3 in the ICU, 20 , 21 , 22 4 in an inpatient unit, 23 , 24 , 25 , 26 and 8 in mixed settings. 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 Fifteen studies were performed in the US, 5 , 10 , 11 , 18 , 20 , 22 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 33 , 34 and 4 in Europe 13 , 16 , 21 , 31 ( Table ). The studies were appraised using the Joanna Briggs Institute quality assessment.…”

“… 2 , 3 However, in the subgroup analysis of the studies in the US and Europe, the use of CTH in Europe was not different from that in the US despite socialized medicine and presumed fewer medical-legal concerns. Tu et al 5 reported that AMS accounted for the highest frequency of CTH ordered in the ED in a single health system study; 46% of CTH studies were ordered for AMS alone, with a 10% yield. Computed tomography of the head comprised 38% of all CT studies ordered in the ED and 8% of total ED visits.…”

“…In a previous study, CTH was ordered for almost half of the patients who presented with AMS and confusion in the ED, with a yield of only approximately 9%. 5 Similarly, in another study, an estimated one-third of the CT studies were performed on the head, and 75% were performed in the hospital setting. 2 Some studies suggest that the use of CTH has increased markedly in the US during the past 2 decades.…”