Education for ER staff could reduce repeat CT scans of kids

Well-prepared emergency personnel who have protocols for transferring and accepting DICOM CDs containing emergency CT scans of injured children can substantially reduce the number of repeat exams required, according to a study in the October issue of the Journal of Pediatric Surgery.

CT exams help emergency physicians in community and rural hospitals who see few cases of pediatric abdominal trauma to make an accurate diagnosis and provide appropriate triage. When children are transferred to specialized trauma centers, they're frequently accompanied by DICOM CDs of their images.

But problems can arise when these CDs aren't transferred to the appropriate personnel at the trauma center. If this occurs, children sometimes get repeat scans at the new facility, conferring an additional radiation burden to patients and additional costs to the healthcare system.

Pediatric surgeons and radiologists at North Carolina Children's Hospital at the University of North Carolina at Chapel Hill wanted to assess the scope of the problem by reviewing records of children who were transferred from 37 predominantly community hospitals from 2002 to 2007 (J Pediatr Surg, October 2010, Vol. 45:10, pp. 2019-2024).

They started with more than 900 pediatric trauma patients who were transferred to the hospital's level I trauma center; of these, 382 were younger than 16 and were diagnosed with blunt trauma. Almost half of this group had not had any emergency CT scans performed.

The researchers chose to focus on the 199 patients who received CT scans at the hospital where they were initially admitted. The percentage of patients who had CT scans taken at the referring hospital skyrocketed from 2002 (6.7% of the total admitted that year) to 2004 (24% of the total). The percentage by year dropped from 2005 to 2007, to 17% in 2007.

Almost one-fourth of the children who had a CT scan performed at the hospital where they were initially admitted arrived at the trauma center without any images. Emergency physicians ordered a repeat CT exam for 19 (or 43%) of these 44 patients.

These 19 patients and an additional 21 patients who had arrived with images from the initial CT exam had repeat CT exams ordered by trauma center emergency room physicians and surgical residents. The exams were ordered based on an incorrect assumption that they were required by trauma center protocols. Radiologists identified significant intra-abdominal injuries on the repeat CT scans of 14 of the 30 patients.

Additional CT scans were appropriately ordered for six other patients whose images accompanied them, according to lead author Steven Cook, MD, from the division of pediatric surgery. The scans were ordered to assess changes in vital signs or patient condition and, in one case, because the images from the initial scans were inadequate.

The authors estimated that the 36 pediatric patients who underwent two CT exams were exposed to a total radiation dose of 10 mSv. The group also estimated that the repeated CT scans resulted in $110,000 of additional patient charges.

The authors did not criticize the original admitting emergency physicians for ordering CT scans. They pointed out that physicians in rural areas who are not highly experienced in pediatric trauma may depend upon the findings of abdominal CT exams for triage.

However, they were critical of the fact that 44 patients arrived without DICOM CDs or films. They suggested that if transfer of CT images were required as a condition of reimbursement to the originating hospital, or an additional payment was made if images were transferred with the patient, emergency department staff might be more incentivized.

The authors also strongly recommended that a radiologist, not an emergency physician, review the CT images of a transferred patient. Radiologists did not review images for 25% of the patients who were admitted with the exams. Had a radiologist interpreted these exams, some of the patients might not have had to undergo repeat CT scans.

The authors' conclusions and recommendations: Training and communication are needed between referring hospitals, the paramedics and nurses transferring the patients, and pediatricians and emergency physicians at trauma centers to guarantee that imaging is conducted properly and that images are transferred. Repeat CT exams, with their high radiation dose, could be avoided for many young patients.

By Cynthia E. Keen staff writer
October 18, 2010

Related Reading

Emergency CT scans may delay pediatric patient transfers, August 6, 2010

CT can rule out abdominal injuries after blunt trauma in kids, June 10, 2010

CT delivers 91% of total pediatric ER radiation dose, April 14, 2010

Copyright © 2010

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