Keywords:
Cost-effectiveness, Audit and standards, CT, Trauma, Neuroradiology brain, Emergency, Haemorrhage
Authors:
A. Parasuramar; SA/AU
DOI:
10.1594/ranzcr2018/R-0079
Conclusion
Outcome from ED:
Outcome from ED was determined from EPAS notes.
This was used to determine whether the scan had an impact on clinical decision making.
Given that radiographers,
nursing staff and a radiology registrar were called into the hospital after-hours,
it is important to determine the necessity of these Head CTs. This is where clinical deicision rules such as the Canadian Head CT Rule can help risk stratify patients.
Canadian Head CT Rule:
One of the indications for Head CTs was when the examining clinical felt that a Head CT was required despite the patient not filling any of the pre-conceived criteria.
In this study,
this was 30% of patients presenting with head trauma and none of these had any intracranial pathology.
Whilst this may be contentious due to the small sample size,
it is reasonable to conclude that many of those CT Heads may not have been necessary after-hours.
Limitations:
In the original study in the Lancet (2001),
where the CCHR was devised,
patients were excluded if on Warfarin or had bleeding disorders.
Direct Oral Anticoagulants (DOACs) such as the direct thrombin inhibitors and factor Xa inhibitors including apixaban,
dabigatran and rivaroxaban had not been conceived at this time.
In most institutions these are regarded in the same fashion as Warfarin and warrant immediate Head CTs in the setting of head trauma.
It is also worth noting that monotherapy with individual anti-platelet agents such aspirin or clopidogrel is not an indication for Head CTs according to the CCHR.
There is,
however,
some contention in the literature pertaining to dual anti-platelet therapy (DAPT) and whether this should be part of the criteria for an immediate Head CT.
In this audit 3 patients were on DAPT and none had pathology.
Conclusion:
CCHR should be routinely used to reduce the number of CT heads for traumatic presentations in the emergency department.
This is particularly important at hospitals where 24 hour radiology services are not available,
given the extra cost of calling in staff after-hours.