Breaking News (2013)

FigureMore than a third of trauma patients transferred to a trauma center received at least one preventable repeat CT scan, yielding an average additional dose of radiation of about 21.5 mSV, about half that said to be associated with elevated cancer risk in adults. The prospective observational cohort study published in the December 2012 edition of the Journal of Trauma and Acute Care Surgery is not the first to document the problem with unnecessary repeat CT scans among transferred patients, but it is the first to quantify the estimated additional radiation dose per patient resulting from those repeat CTs. (2012;73[6]:1564.) All repeat scans done for clinical indications, such as monitoring an intracranial bleed, were excluded from the study, said lead author Alvin Jones, MD, a third-year orthopedics resident at the Robert C. Byrd Health Sciences Center of West Virginia University, whose Jon Michael Moore Trauma Center, a level I facility, was the site of the study. A total of 211 trauma patients who had had previous CT scans were transferred to the trauma center from other institutions during the four-month study period. Of these, 82 (38.9%) had at least one additional scan that the authors categorized as unnecessary falling into one of six categories: technical problem (such as difficulty opening images); image problem (poor quality image or image done without contrast), reporting problem (patient arrived without a report or with a discrepancy between the report's findings and what the trauma team saw on the images); consult request/convenience (a consult team requested a repeat scan); unintentional error (such as a mistaken order by a junior physician); and missing data. By far the most common reasons for repeat CTs, Dr. Jones said, were technical, imaging, and reporting problems. Taken together, these accounted for about 75 percent of the unnecessary repeat scans. Dr. Jones said consult teams often called for a repeat CT scan (the reason for about 13.4% of the repeats) because they weren't confident that they would be able to find the original images when they needed them. “Patients will come in from an outside facility with a CD that has the images, and multiple consult services may need to see it,” he said. “There are multiple ways to lose that CT in transit, so the consult team wants a scan of their own that's easily accessible in our system.” Dr. Jones' findings came as no surprise to Rajan Gupta, MD, the chief of trauma and acute care surgery at Dartmouth-Hitchcock Medical Center in New Hampshire, who published a similar study in the Journal of Trauma, combining a retrospective chart review with a prospective study. (2010;69[2]:253.) Ninety-eight of 243 CT scans (40%) performed at local hospitals were repeated upon transfer to Dartmouth-Hitchcock. About 58 percent of patients transferred had CT scans repeated there. Head CT scans were usually repeated for clinical indications, such as monitoring an intracranial bleed, Dr. Gupta said, and spinal images were more likely to be repeated because of inadequate technique, specifically a lack of reconstruction. “Normally, CT scans are done in an axial format, but you can manipulate the software to do sagittal and coronal reconstructions,” Dr. Gupta said. “Smaller hospitals either didn't know or didn't have the technology to do that.” The most common reason for repeat abdominal and chest CT scans was also inadequate technique, but in these cases, it was usually a lack of contrast that posed the problem. “It might have been usable at a lower-level institution, but most level I centers require a more sensitive scan to accurately identify and grade injuries,” he said. These unneeded repeat scans do not just expose patients to excessive doses of radiation, but also cost a lot of money, an average of more than $450 per patient for each repeat CT, according to Dr. Gupta's study. So what is the solution? Dr. Gupta said better imaging guidelines are needed. Right around the time Dr. Gupta's study was published, the New Hampshire Trauma Medical Review Committee issued Guidelines for the Imaging of the Trauma Patient, a series of detailed, evidence-based directives that even include how to set the dials on the machine. He said technology also should be improved to facilitate image sharing between trauma centers and referring institutions. “Right after I published this paper, three to four companies contacted me about cloud-based storage solutions for imaging,” Dr. Gupta said. “They wanted a fair amount of money, so instead we decided to invest in more servers and enhance our own PACS system. Now, over 30 hospitals that interface with ours can transfer imaging files to us electronically, and we can look at the images before the patient even arrives.” Dr. Jones' hospital adopted a similar solution. “We have a new picture archive system called ImageGrid that allows us to directly scan outside images into our system,” he said. The hospital's IT department developed a translation program called Alchemy for formats that were incompatible to scan into the system. “Some hospitals in our community can now automatically send us images as well, so we don't even need a CD.” Level I trauma centers also must educate community hospitals and lower-level trauma centers on imaging protocols. “On virtually a case-by-case basis, if there's a problem with a scan, we call the program that sent us the patient and explain it to them,” Dr. Gupta said. “If you know you're going to transfer the patient to a level I based on the clinical information you have, then do just enough imaging to ensure safe transport. Don't feel obligated to image everything, as there's a high chance it will be repeated. We also explain that if they are going to do the imaging, this is the way we need them to do it and this is the evidence for it.” Taken together, these interventions should significantly reduce unnecessary repeat CTs, both physicians said. Dr. Gupta has begun reviewing data at his hospital to present at a national meeting later this year, and said he expects to describe a significant reduction. Dr. Jones is also preparing to repeat his study starting in August so he can match any seasonal trauma pattern that appeared in the previous dataset. “We spend so much money on health care, and everyone is looking for ways to cut down on wasteful spending, while at the same time our patients are concerned about their exposure to radiation, especially the younger patients, because they have a higher chance of living to see the consequences,” he said. “This is an area where emergency departments can address both of these problems.” Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.