A recent study published in the Annals of Emergency Medicine on the rapid increase in CT scans being performed in Emergency Rooms (ER) paired with the decline in hospital admission rates between 1996 and 2007, got me thinking. During this time, the number of CT scans being performed increased by 330 percent, while the rate of those admitted following a CT scan decreased from 26 percent in 1996 to 12.1 percent in 2007. Does this mean that more patients are receiving unnecessary radiation exposure? Well… not necessarily.
The article points out a conflict about the use of CT in ER patients. Remember that practicing medicine in an ER is very different from a physician’s office. Patients are more acutely ill and ER congestion can be marked. Plus, time spent in the ER is very expensive.
In our study of patients presented to an ER with low to moderate risk chest pain, we found that a negative triple rule out CT resulted in shortening the stay by over 20 hours and cutting the cost of the ER encounter by 50%. Further, discharging a patient to home if their CT was negative was a safe practice.
Therefore, under the right circumstances, the use of CT in ER patients can be very effective. Our challenge is – through outcomes research – finding those right circumstances.
For more information on emergency medicine at UW, please see here.
Aunt Minnie recently reported on a study that found that when emergency room personnel are knowledgeable about protocols for transferring and accepting DICOM CDs – which contain images of emergency CT scans of injured children – there is a decrease in the number of repeat (unnecessary) exams performed.
However, the authors of the study said that problems arise when CDs aren’t transferred to the appropriate personnel, leading to unnecessary exams (and unnecessary radiation exposure) even when a CD exists, according to the article.
Another approach – one which we follow – is to set up pre-existing VPN communication networks so studies can be directly downloaded (quickly), without the need for CDs. These often arrive before the transfer of the patient. They are set up with the sites that refer more than 5 patients per year. Here we have about 200 such connections to other healthcare facilities, which is great for all medical records as well as the images from radiology.
A recent study found that the use of CT scanners and other advanced imaging machines in U.S. hospital emergency departments “tripled between 1998 and 2007, resulting in higher costs and longer emergency room stays,” according to an article by blogger Julie Steenhuysen.
Lead researcher Dr. Frederick Korley of Johns Hopkins Medicine in Baltimore said his team noticed “a really significant increase [in usage] without a corresponding increase in the diagnosis of life-threatening illness.” He said this suggest that there is a “potential amount of overuse or use that is not directly yielding any meaningful clinical results.”
Actually, the use of all CT and MR from any source more than doubled during that time period.
Emergency rooms are under great pressure to diagnose or rule out serious conditions quickly, since every ER in the country is swamped with patients – many of whom cannot get to other forms of care. What is inappropriate in some settings may be appropriate in the ER setting.
In our study of patients with low-risk chest pain who had a cardiac CT early in their ER visit, patients were discharged 20 hours faster and with a 40 percent cost reduction compared to similar patients who had a workup without cardiac CT.
So it really depends on the indication.