Emerg Radiol (2007) 13:181–185 DOI 10.1007/s10140-006-0531-7

ORIGINAL ARTICLE

Appropriateness of out-of-hours CT head scans Vinod Ravindran & Devesh Sennik & Rod A. Hughes

Received: 26 May 2006 / Accepted: 26 July 2006 / Published online: 23 November 2006 # Am Soc Emergency Radiol 2006

Abstract This study was conducted to evaluate the appropriateness of the out-of-hours computed tomography (CT) head scans (scans performed outside normal working hours) in a large district general hospital in the United Kingdom. CT scan request forms and CT reports of adult patients were reviewed who had their CT head scans done between 1700 and 0900 h the next day and all weekend and national holidays in the study period of 4 months. Information regarding change in the patient management resulting from CT scan was extracted from review of patients’ case notes. An urgent CT head scan request was deemed appropriate if it led to an immediate change in a patient’s management. Appropriateness of the requests according to the various guidelines was also evaluated. One hundred and twenty-one patients were included in the study. Majority (70%) of the scans were requested by the emergency department. Eighty-one (66%) scans were both requested and performed between 1700 and 2200 h. Immediate change in management of 80% patients occurred. In 20 (17%), the change in management occurred only after 0900 h the next day and in 4 (3%), management did not change at all. Common scenarios involving change in patient’s management included intracranial bleed requirAn Editor’s comment on this paper is available at http://dx.doi.org/ 10107/s10140-006-0532-6 and a reply to the comment is available at http://dx.doi.org/10107/s10140-006-0533-5. V. Ravindran (*) : D. Sennik : R. A. Hughes Department of Medicine, St Peter’s Hospital, Guildford Road, Chertsey KT 16 0PZ, UK e-mail: [email protected] Present address: V. Ravindran 14 Wyndham Close, Sutton, Surrey SM 2 6JF, UK

ing urgent neurosurgical intervention and hemorrhagic stroke being ruled out. Out-of-hours CT head scans also facilitated early discharge of the patients with head injuries and headache from the hospital. This retrospective study has found that a high proportion of out-of-hours CT head scans were appropriate and led to change in the patient’s immediate medical care. Keywords Radiography appropriateness . Out of hours . Computed tomography (CT) . Head

Introduction A variety of reasons including the increased patient throughput, anxiety over possible missed diagnosis, and the perceived availability of 24 h investigations contribute to the demand for out-of-hours (defined as those times when department is open only for emergency patients) computed tomography (CT) head scans in hospitals across United Kingdom. This has led to an increase in the radiographer on-call costs; difficulties in obtaining patient escorts, increasing portering needs and increased input from the radiologists. The Royal College of Radiologists (RCR) is concerned that unrealistic workload on radiologists will lead to fatigue resulting in errors in daytime performance. The RCR recommends, “Only those examinations which will affect immediate patient management during out-ofhours should be performed” [1]. The Ionising Radiation (Medical Exposure) Regulations 2000 [IR (ME) R] which is an statutory instrument implemented by the UK department of health requires that all medical radiation exposure should be justified and medical practitioners should be aware of the efficacy of the radiological examination where evidence is available [2]. For these

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reasons, audit of the out-of-hours radiology practices has been recommended [3]. If studies demonstrate that many of out-of-hours CT head scan contribute little to decisions on immediate patient management, it might be possible to limit them without compromising quality of care. Our institution is a large district general hospital with catchment population of 360,000 and it has full accident and emergency (A&E), acute medical, and surgical services in addition to being a center for dealing with trauma. Four hundred and thirty-four out-of-hours CT head scans were performed in year 2004 in our hospital, averaging 36 scans every month. We conducted a retrospective study to evaluate the appropriateness of out-of-hours CT head scanning in our institution. Based on aforementioned recommendations, we assessed whether out-of-hours (defined as between 1700 and 0900 h the next morning on weekdays and all weekends and national holidays) CT head scans made a difference to the patient’s management, and whether the change in management occurred before the next available in-hours routine examination, i.e., before 0900 h. We also assessed whether out-of-hours CT head scans request complied with relevant guidelines of the National Institute for Clinical Excellence (NICE), the Royal College of Physicians (RCP), and the British Infection Society (BIS) in patients with seizures, head injuries, cerebrovascular accident, and suspected meningitis [4–7].

Materials and methods A list of adult patients who had out-of-hours CT head scans from 1st September 2004 to 31st December 2004 was obtained from the database of the department of radiology of our hospital. We included patients who had their CT head scans requested and performed out of hours. For data collection, we reviewed CT scan request forms and CT scan reports (both from the electronic patient administration system). Information provided on the CT scan request forms was crosschecked by review of the patient’s clinical notes. From clinical notes, we obtained information on date and time when the doctor who requested the CT scan assessed the patient and date and time when the CT scan was subsequently requested, performed, and results were recorded on the patient’s case notes. Analysis of the clinical indication for CT head scan and any resultant change in the patient’s management and its time were carried out. An urgent CT head scan was deemed appropriate if it led to an immediate change in a patient’s management. We analyzed compliance with relevant national clinical guidelines of the UK regarding urgent CT head scans in patients with seizures, head injuries, cerebrovascular accident, and suspected meningitis. Two of the authors independently assessed compliance with guidelines solely

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based on the information available in the clinical notes and CT head scan request forms and arrived at the same conclusion in all cases.

Results A total of 121 patients had out-of-hours CT head scans and met the entry criteria during the study period of 4 months (average 30 scans every month). Eighty-five (70%) scans were requested by the A&E department, 34 (28%) scans by the department of medicine, and two (1.5%) by other departments. Only three (2.5%) scans were requested on in patients. Eighty-one (66% of the total 121) scans were both requested and performed between 1700 and 2200 h. CT scan reports (conveyed by the reporting consultant radiologist to the CT scan requesting doctor) were noted in 113 (93%) case notes. Twenty-one CT head scans (17%) were found to be abnormal and they were reported as demonstrating subarachnoid hemorrhage (eight patients), acute hydrocephalus (one patient), subdural hemorrhage (three patients), anterior communicating artery aneurysm (one patient), and acute infarcts (eight patients). Head injuries, headaches, and cerebrovascular accidents were the most frequent indications for head CT (Table 1). CT head scans with both normal and abnormal results led to immediate change in 97 (80%) patients’ management. Of these 97 patients, 51 patients were discharged from the hospital, 8 were transferred to tertiary care center for urgent neurosurgical intervention, 4 were deemed unsuitable for intervention by the relevant neurosurgical teams, and 35 patients were appropriately managed after intracranial bleed was ruled out. In 20 (17%), the change resulted after 0900 h the next day and in 4 patients (3%), management did not change at all. All CT head scans in patients with head injuries and seizures complied with relevant guidelines (Table 2). Compliance was much less (76%) in patients with cerebrovascular accidents (CVA). No scans for suspected meningitis complied with the British Infection Society’s guidelines. All requests, which complied with relevant guidelines, led to immediate change in the patient management.

Discussion There is evidence that radiology and pathology tests sometimes fail to contribute to the clinical decisions about diagnosis and management [8, 9]. Costs and appropriateness of emergency X-rays has been subject of previous studies [10–13]. In this study, we chose to evaluate appropriateness of out-of-hours CT head scans because of

Emerg Radiol (2007) 13:181–185 Table 1 Clinical indications for out-of-hours CT head

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Main symptoms/indications

Total

Normal results

Abnormal results

Management changed

Management unchanged/ delayed

Head injuries Road traffic accident Assault Alcohol related Fall Headaches Nonspecific acute headache Subdural hemorrhage Subarachnoid hemorrhage Cerebrovascular accident Blackout/collapse Cognitive decline Before lumbar puncture Seizures Transient ischemic attack Unsteadiness/falls Miscellaneous Total scans (%)

27 8 5 4 10 29 14 5 10 30 6 5 6 7

26 8 5 3 10 21 14 3 4 22 4 4 6 6 7 3 1 100 (83%)

1 0 0 1 0 8 0 2 6 8 2 1 0 1 7 0 0 21 (17%)

26 8 4 4 10 27 14 3 10 22 6 3 6 4 0 3 0 97 (80%)

1 0 1 0 0 2 0 2 0 8 0 2 0 3 0 0 0 24 (20%)

3 1 121

the complexity of this investigation, which requires a trained CT radiographer to perform it and a radiologist to report, unlike emergency radiographs. In this study, we assessed whether out-of-hours CT head scans made a difference to the patient’s management, and whether the change in management occurred before the next available in-hours routine examination. We did not attempt to classify the change in management as significant or minor. We evaluated whether the CT head scan result answered the questions and concerns raised by the doctor who requested the investigation leading to immediate change in the management irrespective of the appropriateness of the management change itself. In our study, a large proportion (80%) of out-of-hours CT head scans led to immediate change in patients’ management; however, this was not achieved in all patients. Where clinical suspicion was present, the scan results formed the basis of immediate change in patient management reflecting ideal clinical practice. Sixty-seven percent of the out-of-hours head scans were performed between 1700 and 2200 h. This highlights the

fact that for most hospitals in UK, the “normal” practical working hours extends till 2200 h. The A&E department appears to be busy during these hours leading to increase demand on the radiology services. CT head scans to investigate headaches resulted in relatively higher number of abnormal results (8 abnormal CT head scans out of total 15 scans requested) when there was a clinical suspicion of either subdural or subarachnoid hemorrhage (SAH). In this study, where either SAH or subdural hemorrhage was suspected, patients had significant “red-flag” symptoms and signs [14]. In patients presenting with nonspecific acute severe headache with normal neurological examination, a normal CT head contributed equally well to immediate patient management. A recent prospective study assessed emergency physicians in their pretest accuracy for predicting SAH and their comfort in not ordering either CT or lumbar puncture (LP). It was concluded that physicians were moderately able to discriminate SAH from the other causes of acute severe headache in patients with normal neurological examination [15]. We believe that input from experienced physicians

Table 2 CT head scans: compliance with relevant clinical guidelines Main symptoms/indications

Total

Guidelines

Complied (%)

Management changed (%)

Unchanged/delayed

Head injuries Cerebrovascular accident Seizures (epilepsy) Meningitis Total scans (%)

27 30 7 6 70

NICE RCP NICE BIS –

27 (100) 23 (76) 4 (57) 0 (0) 54 (77)

26 (96) 22 (73) 4 (57) 6 (100) 58 (83)

1 8 3 0 12 (17)

NICE National Institute for Clinical Excellence, RCP Royal College of Physicians, BIS British Infection Society

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would be important where uncertainty exists regarding the indication for urgent CT head in this group of patients. The NICE head injury guidelines recommend that CT head scan should replace skull X-ray and patients should be observed, admitted, or discharged as appropriate [5]. In our study, all patients presenting with head injuries had CT head in compliance with NICE guidelines and in almost all immediate change in management resulted even though only one out of 27 patients had abnormalities on the CT. It is generally agreed that implementation of NICE guidelines would lead to a two- to fivefold increase in the CT head scan rate in UK hospitals and a significant proportion would be out of hours. Reduction in the skull X-ray and admission would probably offset these costs without compromising patient care and outcome [16, 17]. The Royal College Of Physicians of UK guidelines for stroke recommend urgent brain imaging if the patients have one or more of the following: on anticoagulation, known bleeding tendency, depressed level of consciousness, progressive or fluctuating symptoms, papilledema, neck stiffness or fever, and severe headache at onset. It also recommends that brain imaging should be undertaken as soon as possible in all patients within 24 h at most of onset unless there are good clinical reasons for not doing so [6]. In our study, seven patients with cerebrovascular accidents did not require urgent out-of-hours CT head scan according to the RCP guidelines. However, as they were performed within first 24 h of presentation in all patients, they were appropriate based on the recommendations. On the contrary, none of the out-ofhours CT head scans on patients with transient ischemic attacks (TIA) appeared justified and could have been avoided. A recent study has found that performing CT head before lumbar puncture (LP) in patients with suspected meningitis is a common practice within the UK [18]. This is of doubtful value in excluding raised intracranial pressure (ICP). A normal CT head scan does not exclude raised ICP and if there are no clinical contraindications to LP, a CT head scan is not necessary beforehand [7, 19]. A recent study from Canada found that inappropriate diagnostictreatment sequence (CT head scan then LP then antibiotics) was one of the factors responsible for door-to-antibiotic time of more than 6 h in adult patients with bacterial meningitis [20]. In our study, patients with suspected meningitis did not have clinical contraindications for LP; therefore, urgent CT head scans were unnecessary. All six patients were given antibiotics before CT. Immediate change in management occurred in other categories (blackout/collapse, cognitive decline, unsteadiness/falls) when CT head scan confirmed or excluded sinister pathology when reasonable clinical suspicion existed. This study could be criticized as having a retrospective design and involving relatively small numbers of patients. It can also be argued that some of the patients included in this

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study would not have had out-of-hours CT head scans in the first instance if guidelines had been adhered to. Studies similar to this become important tools in identifying areas of ambiguities in the local practice, which often has national significance. We believe that the cases included in this study are typical of any UK hospital (and possibly of many hospitals across the developed world) and the study highlights the potential need for putting robust and evidencebased uniform practices in place locally. We recommend that formal teaching and discussion of national guidelines for ordering CT scans in various clinical scenarios should be included in the existing teaching program for doctors involved in providing acute medical care.

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