The Rate of Normal findings Vs Abnormal findings in Trauma CT’s done at AAH: Do we

need to assess our current practice?

KEY PERFORMANCE AND QUALITY INDICATORS

22/08/2016AL Ain Hospital

Clinical Imaging InstituteCT Scan Department

By: Fathima Hasan MohamedSenior radiographer

Introduction:

• Computed Tomography( CT ) is increasingly used in the evaluation of trauma patients. The use of CT in trauma has increased dramatically over the last two decades.

• The term “ Trauma CT” means CT of the brain to the mid-femurs ( face optional)

• Our facility uses a 64 slice scanner to perform Trauma CT procedures.

Introduction

• An urgent Trauma CT is required for the rapid diagnosis of life threatening injury which requires prompt intervention.

• Literature shows that CT is an excellent tool to show specific anatomical injury and is excellent at showing vessel injury and active bleeding and its use has improved patient outcomes.

Introduction

• Ionising radiation from CT can increase lifetime cancer risk, especially in the very young.

• CT exposes the patient to significant doses of radiation and concern arises about the possible biological effects of these cumulative radiation doses.

Clinical Imaging Institute/CT section

Key Performance Indicator : The Rate of Normal findings Vs Abnormal findings in Trauma CT’s done

at our institute.Objectives: To analyze the number of normal findings from

Trauma CT done and show the impact on patient dose.Audit Plan: AnnuallyPlace of study: CT Scan Section/Clinical Imaging Institute/Al Ain

Hospital.Duration of study: 4 months of the year was chosen( every

quarter)

Sample size: 197 patients were evaluated in this study.

Method

• Patients who had Trauma CT were identified through the Cerner online worklist and clinical history and reports through PACS.

• Data was compiled in excel format.(see excel sheet) and descriptive analysis was performed.

• Study was focused on adult male and female patients < 35years and children < 12 years.

• Our organization uses a 64 slice scanner to perform Trauma CT.

Data Analysis & Result :

Data Analysis & Result :

Data Analysis & Result :

• Percentage(%)• 55% = men< 35 years• 8%= women<35 years• 6.5%= children

Data Analysis & Result :

Discussion

• The aim of this clinical audit was to describe that the greater percentage of Trauma CT’s ordered by ER physicians are normal and to identify gaps to reduce these large amounts of radiation exposure to patients.

• This is the first clinical audit from CT and although we focused on just 4 months, the findings are still useful to improve service delivery at our hospital.

Discussion

• Ionising radiation exposure:• Benefit to the patient must outweigh the risk

with increased radiation exposure from CT compared tp conventional radiography.

• Lifetime potential cancer risk may be significant especially in young patients.

• Is the benefit of of the diagnostic accuracy of whole-body CT worth the potential risk?

Discussion:

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION

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What is the dose from CT? How high?

The effective dose in chest CT is in the order of 8 mSv (around 400 times more than chest radiograph dose) and in some CT examinations like that of pelvic region, it may be around 20 mSv

The absorbed dose to tissues from CT can often approach or exceed the levels known to increase the probability of cancer as shown in epidemiological studies

Discussion

• Organ doses in CT• Breast dose in thorax CT may be as much as

30-50 mGy, even though breasts are not the target of imaging procedure.

• Eye lens dose in brain CT, thyroid in brain or in thorax CT and gonads in pelvic CT receive high doses

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION

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Tissues in the field although they are not the area of interest for the procedure

Lens of the eye Breast tissue

Discussion

• Radiation exposure to the abdomen and pelvis is most significant when calculating whole-body effective radiation dose.

• Exposure to thyroid, breast and gonads carry a relatively high potential cancer risk.

• Therefore consideration of the need for whole-body CT is essential to prevent unnecessary harm.

Discussion: Dose report

Discussion:

• CT dose index ( CTDI )- represents the dose in a single slice.

• Dose report displays the dose length product ( DLP ) index, which represents the integrated radiation dose for a specific CT examination. The DLP is then multiplied by conversion factors for different areas of the body to determine the effective dose in millisieverts to the entire body.

Recommendations

• For ordering of Trauma CT, decision guidelines should be put in place and followed- 20-40% of CT’s can be avoided.

• Trauma CT should not replace careful clinical examination and should only be used only in appropriate patients (severely injured).

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Actions for physician & radiologist…

• Justification: Ensure that patients are not irradiated unjustifiably.

• The physician is responsible for weighing the benefits against risks.

• Physicians need to understand the radiation doses of imaging modalities.

• Clinical guidelines advising which examinations are appropriate and acceptable should be available to clinicians and radiologists.

• Clinician has the responsibility to thoroughly communicate information on patient condition to the radiologist.

What can we do in Clinical Imaging Institute?

• Be more proactive: Need to involve non-imagers- training on

radiation dose and possible risks. Need to educate all involved in the management of the trauma patient.

Control- SAY NO!Engage our community- patient information

leaflets.

Recommendations• Trauma CT workflow:Trauma management from two centers in UAE:

Rashid Hospital (Dubai) - poly-trauma patient received in A/E go throw a series of steps:• 1- Initial screening and physical examinations in resuscitation unit. • 2- Full body scan using a Statscan (Lodox) machine will performed on the patient in resuscitation

unit.• 3- Statscan (Lodox) protocol includes: • · AP full Body (from head to toe) • · Lateral Head and Cervical Spine • · Lateral Full Spine • 4- After the initial management, Patient will be sent to CT unit. • 5- CT scan poly-trauma protocol will be performed, including:• · CT Brain, Face and Cervical Spine • · CT Chest, Abdomen, Pelvis, Dorsal and Lumber • 6- Patient will then sent back to resuscitation to complete his treatment •

Statscan machine (Lodox Systems)

Statscan Images

Recommendations

• Tawam Hospital – Multitrauma CT policy:• Indications for Trauma CT:1. High energy trauma with clinical suspicion of

severe internal injury.2. Any significant history with a Revised Trauma

Score of 10 or less on arrival in ED.

Recommendations

• Contraindications for immediate Trauma CT1. Hemodynamic instability.

2. Un-resuscitated patient.

3. Airway is not safe.

4. Low oxygen saturation.

Recommendations

• Prior to performing a Trauma CT:

• Do x-ray of chest (supine in ED).

Recommendations

Conclusions

• We should evaluate our current practice that if a trauma patient’s GCS is 14 or 15/15 and the patient is stable( BP, Pulse and respiration), do we really need to subject the patient to Trauma CT? The patient may have had a trauma which is trivial and not high energy.

• Is it not better to wait and observe these patients and subject to Trauma CT if needed?

• Do we need to revisit our protocol for the ordering of Trauma CT examinations?

Acknowlegements:

• CT Radiographers: Pulapadi Somanathan, Monir Khan, Illyn Bregonia.

• Radiology Manager: Mr Anthony Bedson for his continuous support.

References:

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION

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Web sites for additional information on radiation sources and effects

• European Commission (radiological protection pages): europa.eu.int/comm/environment/radprot

• International Atomic Energy Agency: www.iaea.org

• International Commission on Radiological Protection: www.icrp.org

• United Nations Scientific Committee on the Effects of Atomic Radiation: www.unscear.org

• World Health Organization: www.who.int

Further References:

• Control of patient dose- Al Ain Hospital policy manager.