scholarly journals P015: Implementing the Canadian CT Head Rule in a community emergency department

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S83-S83
Author(s):  
G. Bock ◽  
R. Setrak ◽  
S. Freeman
Keyword(s):  
Emergency Department ◽  
Demographic Data ◽  
Ct Scans ◽  
P Value ◽  
Relative Reduction ◽  
Exclusion Criteria ◽  
Head Ct ◽  
Preliminary Results ◽  
Ct Head ◽  
Significant Injury

Introduction: The Canadian CT Head Rule (‘the rule’) is widely used across the country and its use is specifically recommended by Choosing Wisely Canada. Studies in Canadian hospitals have shown appropriate declines in CT scans when decision tools have been made readily available and useable at the point of care. Research into the implementation of the Canadian CT Head Rule in particular has shown that barriers to its use include an inability to accurately recall each criteria and forgetting to attempt to apply the rule altogether. In an attempt to provide our clinicians with effective access to the rule, we modified CT requisitions and order procedures to facilitate the use of the rule for every head CT in our emergency department (ED). Methods: A quality improvement (QI) approach was used to pilot, implement, and evaluate the modified CT requisition at our hospital. Several Plan-Do-Study-Act cycles involving stakeholders in the hospital resulted in iterative changes to the requisition leading to the implemented version. The new requisition required physicians to indicate which rules or exclusion criteria were met and this was made mandatory for all head CTs ordered. Demographic data was collected on all patients presenting to the ED on age, gender, CTAS level, disposition, and length of stay. Data on which exclusion criteria were appropriate, the rules met leading to CT scans, whether each requisition was used appropriately, and whether there was a significant injury found was collected for each patient receiving a head CT after implementation. Results: In our primary outcome (% of ED visits receiving a head CT), preliminary results have demonstrated a relative reduction in head CT ordering of 10.9%. Our study at completion is powered to detect a ~10% relative change in ordering behaviour, and a Chi square of the data to date yields a P-value of 0.0147. There are no significant differences in visit volume or any of the demographics collected to date. Final results including analysis are anticipated in March, 2016. Conclusion: Preliminary results on this simple, no-cost intervention are very promising. The reduction in head CTs ordered suggests that with mandated access to an easy-to-use, well validated decision tool, ED physicians have been able to confidently defer scans that have a very low risk of having any significant injury present, reducing cost, radiation exposure, and perhaps time in department.

DOZ047.42: The value of rigid tracheobronchoscopy for the diagnosis of tracheomalacia in esophageal atresia patients

2019 ◽  
Vol 32 (Supplement_1) ◽  
Author(s):  
I P Aanen ◽  
B Pullens ◽  
J van Rosmalen ◽  
R M H Wijnen
Keyword(s):  
Sensitivity And Specificity ◽  
Esophageal Atresia ◽  
Surgical Intervention ◽  
Medical Center ◽  
Primary Repair ◽  
Demographic Data ◽  
P Value ◽  
Inclusion Criteria ◽  
Exclusion Criteria ◽  
Low Sensitivity

Abstract Aim of the Study The aim of this study is to evaluate routine airway endoscopy prior to the closure of the trachea-esophageal fistula (TOF) and esophageal atresia (EA) repair in a tertiary medical center concerning pre- and postoperative tracheomalacia. Methods We evaluated all patients with EA born between 2013 and 2016 who underwent routine rigid tracheobronchoscopy (TBS) before primary repair of the EA at our center. Inclusion criteria included peroperative rigid TBS performed by an otolaryngologist. Exclusion criteria included impossibility to determine pre- and or postoperative TM (because of logistic or medical reasons). Demographic data, comorbidities, surgical intervention, TBS findings, and subsequent surgical management were analyzed. Main Results Twenty-four patients with EA were included in this study. Eight of the 24 patients developed postoperative TM. Of these 8 patients with TM, 5 were diagnosed at the preoperative TBS (62.5%). Of the 16 patients without postoperative TM, there were 6 patients (37.5%) with peroperative diagnosed TM. So the sensitivity and specificity of routine airway endoscopy prior to EA-repair are, respectively, 62.5% (CI 30.4%–86.5%) and 62.5% (CI 38.5%–81.6%). Concerning postoperative TM, there is a significant higher appearance in females versus males (P-value 0.021). There was no significant causality between mean gestational age, birth weight, type of EA, type of surgery (open or thoracoscopic), presence of gastroesophageal reflux disease, and the appearance of postoperative TM. Conclusions Preoperative TBS can be useful for the evaluation of tracheoesophageal fistula but has a low sensitivity and specificity to detect postoperative TM.

scholarly journals Reduction of paediatric head CT utilisation at a rural general hospital emergency department

2020 ◽  
Vol 29 (11) ◽  
pp. 912-920
Author(s):  
Jeffrey Paul Louie ◽  
Joseph Alfano ◽  
Thuy Nguyen-Tran ◽  
Hai Nguyen-Tran ◽  
Ryan Shanley ◽  
...  
Keyword(s):  
Emergency Department ◽  
Head Injury ◽  
Rural Community ◽  
Emergency Departments ◽  
Control Charts ◽  
Intervention Period ◽  
Head Ct ◽  
Pediatric Injury ◽  
Ct Utilization ◽  
Ct Head

BackgroundBlunt head injury is a common pediatric injury and often evaluated in general emergency departments. It estimated that 50% of children will undergo a head computed tomography (CT), often unnecessarily exposing the child to ionizing radiation. Pediatric academic centers have shown quality improvement (QI) measures can reduce head CT rates within their emergency departments. We aimed to reduce head CT utilization at a rural community emergency department.MethodsChildren presenting with a complaint of blunt head injury and were evaluated with or without a head CT. Head CT rate was the primary outcome. We developed a series of interventions and presented these to the general emergency department over the duration of the study. The pre and intervention data was analysed with control charts.ResultsThe preintervention and intervention groups consisted of 576 children: 237 patients with a median age of 8.0 years and 339 patients with a median age of 9.00 years (p=0.54), respectively. The preintervention HCT rate was 41.8% (95% CI 35.6% to 48.1%) and the postintervention rate was 27.7% (95% CI 23.3% to 32.7%), a decrease of 14.1% (95% CI 6.2% to 21.9%, p=0.0004). During the intervention period, there was a decrease in HCT rate of one per month (OR 0.96, 95% CI 0.92 to 1.00, p=0.07). The initial series of interventions demonstrated an incremental decrease in HCT rates corresponding with a special cause variation.ConclusionThe series of interventions dispersed over the intervention period was an effective methodology and successfully reduced HCT utilisation among children with blunt head injury at a rural community emergency department.

Acute traumatic brain injury presentations and the use of head CT scans in the Emergency Department

2020 ◽  
Author(s):  
Alice Rogan ◽  
Vimal Patel ◽  
Jane Birdling ◽  
Harnah Simmonds ◽  
Jessica Lockett ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Injury ◽  
Nice Guidelines ◽  
Head Ct ◽  
Ct Head ◽  
Acute Traumatic Brain Injury ◽  
Observational Design ◽  
Clinically Significant ◽  
Significant Injury

Abstract Objective: The use of CT head scanning for traumatic brain injury (TBI) is a vital diagnostic tool, guided by risk stratification tools. This study aims to review the use of CT head scans for TBI in two Australasian Emergency Departments (ED) in New Zealand.Methods: Retrospective observational design of patients referred for head CT from ED to exclude a significant intracranial injury between 1st September 2018 and 31st August 2019. Clinical data were collected regarding presenting patterns, identification of injuries on CT scan and adherence to CT guidelines.Results: Out of 425 cases reviewed, a clinically significant injury was identified in 41 (10%) patients. Patients who reported loss (32% vs 20% p < 0.05) or possible loss of consciousness (34% vs 22% p < 0.05) and had GCS < 13 (17% vs 8%, p < 0.05) or focal neurology (10% vs 3%, p < 0.05) were more likely to have a significantly intracranial injury on CT. Interestingly, 17 (41%) patients with significant injury were GCS 15 with no focal neurology. NICE guidelines were adhered to in 364 (86%) patients. In the 14% of cases that did not meet guideline criteria, all CT head scans were negative.Conclusion: CT head scans are a valuable tool in TBI and guidelines successfully identify those with significant intracranial injuries. However, the rate of significant injury for the total population requiring head CT remains low, with over 90% of head CTs in the population normal, despite high guideline compliance perhaps identifying a role for novel objective tests in ED guidelines internationally.

Syncope and head CT scans in the emergency department

2005 ◽  
Vol 12 (1-2) ◽  
pp. 44-46 ◽  
Author(s):  
Pierre Giglio ◽  
Edward M. Bednarczyk ◽  
Karen Weiss ◽  
Rohit Bakshi
Keyword(s):  
Emergency Department ◽  
Ct Scans ◽  
Head Ct

scholarly journals MP25: The role of advanced imaging in the management of benign headaches in the emergency department: a systematic review

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S73 ◽  
Author(s):  
R. Lepage ◽  
L. Krebs ◽  
S.W. Kirkland ◽  
C. Alexiu ◽  
S. Campbell ◽  
...  
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Ct Scans ◽  
Secondary Headache ◽  
Advanced Imaging ◽  
Ct Utilization ◽  
Weighted Median ◽  
Ct Head ◽  
Study Population ◽  
Headache Patients

Introduction: Headache is a common emergency department (ED) presentation. Benign (i.e., non-pathological) headaches are particularly common, including exacerbations of chronic migraine, tension, and cluster headache. Several studies have reported concerns over the frequent use of advanced imaging, specifically computed tomography (CT), in the ED management of benign or primary headache presentations. This systematic review examined the proportion of adult ED benign headache presentations who receive a CT(head). Methods: Eight bibliographic databases and the grey literature were searched. All studies reporting the proportion of benign headache patients receiving a CT(head) in the ED were eligible for inclusion. Studies which included a secondary headache population of 15% of their total study population or less where eligible for inclusion. Two reviewers independently assessed study inclusion and completed quality assessment and data extraction. Weighted medians were calculated for the primary and secondary outcomes, as appropriate. Results: The search returned 2,444 unique citations, of which 20 met the inclusion criteria (21 patient groups were analyzed). The majority of the studies were descriptive in nature and conducted in North America. The reported proportion of benign headache patients receiving a CT(head) varied considerably (range: 2.06-67.21%); with a weighted median of 30.0% (interquartile range: 30.0, 30.0). Studies published in 2000 or later (18/21 groups) were found to have a higher weighted median percentage compared to those published pre-2000 (p=0.016). Neither the country of origin nor the proportion of patients with secondary headache included within the study population had a significant effect on CT utilization. Of the three studies which reported the discharge diagnosis of all patients, sub-arachnoid hemorrhage was discovered in 2/241 (0.83%) of CT scans. Conclusion: Considerable variation in CT utilization for benign headache ED presentations exists and estimates indicate that more than a quarter of patients receive a CT(head). Overall, these CT scans rarely identify significant pathology, suggesting imaging may be safely reduced. Further research is required to identify interventions which can safely and effectively reduce unnecessary imaging among headache presentations.

Is Head Computerized Tomography Indicated for the Workup of Headache in Patients with Intact Neurological Examination

2018 ◽  
Vol 80 (5-6) ◽  
pp. 341-344
Author(s):  
Lilach Goldstein ◽  
Tamar Laytman ◽  
Israel Steiner
Keyword(s):  
Emergency Department ◽  
Ct Scans ◽  
Neurologic Examination ◽  
Head Ct ◽  
The Past ◽  
Radiation Induced Cancer ◽  
Radiation Induced ◽  
Clinically Significant ◽  
Rule Out

Introduction: The use of neuroimaging as part of the initial workup in the emergency department (ED) for patients with atraumatic headache is increasing, whereas the proportion of cases in which clinically significant intracranial pathology is detected is decreasing. In the last few decades, the exposure to medical ionized radiation from utilization of computer tomography (CT) increased dramatically, raising concern about radiation-induced cancer. Different guidelines were suggested to address the role of neuroimaging in the investigation of adult patients presenting to the ED with nontraumatic headache. Materials and Methods: We retrospectively evaluated data from all consecutive patients who underwent a head CT in the ED for the evaluation of headache during 2015. Patients were included only if a normal neurologic examination was documented. Results: In total, 422 patients were included. About 43.4% of scans were normal. Most abnormal findings were sinusitis (148 patients, 35%) or ischemic changes. Seven CT scans (1.6%) showed clinically significant findings requiring an immediate change in management. Conclusion: A normal neurologic examination, even when performed by a neurologist, does not rule out a significant secondary cause for headache. A CT scan in the ED is indicated for patients presenting with severe nonremitting headache who never had neuroimaging in the past.

scholarly journals MP48: Head computerized tomography overuse in adults with mild traumatic brain injury in a single Quebec emergency department

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S60-S60
Author(s):  
S. Thibault ◽  
V. Gélinas ◽  
S. Turcotte ◽  
A. Pépin ◽  
R. Renald ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Emergency Department ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Low Risk ◽  
Ct Scans ◽  
Administrative Database ◽  
Rater Reliability ◽  
Head Ct ◽  
History Of

Introduction: Choosing Wisely Canada has reported rates of unnecessary head computed tomography (CT) scans for low-risk mild traumatic brain injury (mTBI) patients in Ontario and Alberta ranging from 14% to 46%. Local data for Quebec is currently not available. We sought to estimate the overuse of CT scans among adults with mTBI in the emergency department (ED) of a single level II trauma center in Quebec. Methods: We performed a retrospective chart review of adults who visited the ED of Hôtel-Dieu de Lévis from 04/01/2016 to 03/31/2017. Using an administrative database (Med-GPS, Montreal), we randomly sampled ED patients aged over 18 that had an initial Glasgow Coma Scale score of 13 to 15 and had suffered from a mTBI in the last 24 hours. We excluded patients with an unclear history of trauma, a bleeding disorder/anticoagulation, a history of seizure, any acute focal neurological deficit, a return visit for reassessment of the same injury, unstable vital signs, or a pregnancy. Data was extracted by two reviewers who analyzed separate charts. They used the Canadian CT Head Rule (CCHR) to determine relevance of CT scans. Overuse was determined if a patient without any high or medium risk CCHR criteria underwent a scan. A third reviewer verified a 10% random sample of the data extraction for each primary reviewer and inter-rater reliability was assessed using the kappa statistic. Results: From the 942 eligible mTBI patients, we randomly selected 418 patient charts to review, of which 217 met all inclusion and exclusion criteria (56% were men and the mean age was 48 years old (SD = 21)). Among included patients, 101 were determined as low risk. The overuse proportion was 26% (26/101), 95% CI [18-35]. Two CT scans were assessed as abnormal, but none revealed life-threatening injuries and only one was considered clinically significant with a subdural hematoma of 9 mm. Inter-rater reliability was substantial to perfect (kappa = 0.6 and 1.0) for each primary reviewer. Conclusion: We identified head CT scan overuse in this ED. This will support local quality improvement initiatives to reduce unnecessary head CT scans for adults with mTBI.

scholarly journals RADIATION DOSE TO THE EYE AND POTENTIAL OCCURRENCE RADIATION- INDUCED CATARACT FOLLOWING COMPUTED TOMOGRAPHY (CT) HEAD EXAMINATION

2021 ◽  
Vol 21 (2) ◽  
pp. 1-7
Author(s):  
Muhammad Ikhmal Naim Mohd Hilal ◽  
Rekha Ganesan ◽  
Norhashimah Mohd Norsuddin ◽  
Mohd Izuan Ibrahim ◽  
Said Mohd Shaffiq Said. Rahmat ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Absorbed Dose ◽  
Pitch Factor ◽  
Exclusion Criteria ◽  
Head Ct ◽  
Tube Potential ◽  
Tube Current ◽  
Ct Head ◽  
Radiation Induced ◽  
Ct Brain

The eye is a radiosensitive organ that lies within the scan range during Computed Tomography (CT) of the head. The utilization of the head CT is increasing with growing concern about the chances of development of cataract which induces by ionising radiation. This research aimed to calculate eye absorbed dose and to study the potential occurrence of radiation induces cataracts between CT Brain and CT Temporal. A total of 399 set data were obtained retrospectively according to inclusion and exclusion criteria. 364 patients underwent CT Brain while 35 patients’ data obtained for CT Temporal. The scanning parameters such as tube current, tube potential, pitch factor, beamwidth, filter, revolution time, and filter were recorded. Eye absorbed dose was significantly different (p<0.05) between CT brain (49.07±10.08mGy) and CT temporal (25.72 ± 6.12mGy). None of the analysed data exceeded the eye threshold dose recommended by ICRP 2012. However, as expected, the cumulative eye absorbed dose was increased as the frequencies of the scan increase. The highest number of repeated scans is five times with cumulative dose was recorded as 278.27mGy. In conclusion, the eye absorbed dose is higher in CT Brain compared to CT Temporal and has potential for induction of cataract in the future especially with the patient that undergoes repeated CT examination.

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