18 August 2011

Reversing the trend

Well, this is satisfying. Over the years, in our ER we have mirrored the nationwide trend and have significantly increased the utilization of CT scans across the board. The reasons are manifold. Some cite malpractice risks, and indeed in our large group we have had one lawsuit for a pediatric head injury and another for a missed appendicitis which probably did contribute. But, in my opinion, there have been many other drivers of the increased use. For one, CTs have gotten way, way better over the last 15 years, which quite simply has made them a better diagnostic tool. They've also gotten way faster. As the facilities have invested in CT scanners, they have increased their capacity and increased their staffing, so the barriers to their use have rapidly diminished. I am so old that I remember when ordering a CT involved calling a radiologist and getting their approval! No more of that, I can tell you.

But a couple of years ago, we really started paying attention (perhaps belatedly) to the risks of increased exposure to radiation, especially for kids. And at that point, we began a concerted effort to reduce the use of CT scans in children. I pulled the numbers today, and here are the results:




(patients <14 y/o, all types of CT scans)

A 40% reduction from the peak utilization. Not too shabby. We were at about the national average at our peak -- studies show that CT scans were ordered about 6% of the time for pediatric ED visits. How did we make the change? Mostly by paying attention to it and talking about it a lot to our medical staff. We made it a journal club, we presented it multiple times at our department meetings. This is, by the way, a pretty significant commitment of limited resources, since we typically have only about 2 hours of clinical education time with our docs per month, and every time we brought it up, it was at the expense of some other topic. We also developed pediatric abdominal pain algorithms which utilized ultrasound and surgical consultation above CT scanning, and we emphasized the CT-sparing clinical decision-making rules for head injury.

Are we still "too high"? I don't know, because I don't know where it optimum rate of CT is. It's not zero, not at a trauma center, and sometimes there are belly pain cases that really do need imaging beyond ultrasound. I'm content with the relative reduction we have achieved so far, and hope we can improve on it as all the docs gain comfort with the radiation-minimizing technique. Some docs are always slow to change their ways, or persistently risk-averse (and test-happy). Maybe more data will come out to guide us in further reducing unnecessary scans.

Or, American medicine being what it is, maybe we'll just wind up ordering more MRIs.

1 comment:

emergencymedicineireland.com said...

we still ring radiologists about every CT... sigh...