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Journal Club. 8 March 2012 Siegfried Perez, MD Research Registrar, GCH Accident and Emergency Dept. Emergency Physicians’ Diagnostic Imaging Ordering Practice: A Pilot Survey. Preliminary Results: Convenience sample of 24 doctors working in a tertiary emergency department

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journal club

Journal Club

8 March 2012

Siegfried Perez, MD

Research Registrar, GCH Accident and Emergency Dept

emergency physicians diagnostic imaging ordering practice a pilot survey
Emergency Physicians’ Diagnostic Imaging Ordering Practice: A Pilot Survey

Preliminary Results:

  • Convenience sample of 24 doctors working in a tertiary emergency department
  • Conducted between 9 Jan 2012 to 22 Jan 2012
  • 9 resident level, 3 consultant level, 12 registrars
emergency physicians diagnostic imaging ordering practice a pilot survey1
Emergency Physicians’ Diagnostic Imaging Ordering Practice: A Pilot Survey

Questions:

1. Self assessment of inappropriate imaging:

  • 95.8% of respondents admitted to inappropriate imaging
emergency physicians diagnostic imaging ordering practice a pilot survey2
Emergency Physicians’ Diagnostic Imaging Ordering Practice: A Pilot Survey

2. Reasons for inappropriate imaging:

  • Requirement / request from inpatient specialty: 54% of respondents - these are mostly surgical specialties (general surgery, obstetrics and gynaecology)
  • Pre-ordered from triage: 16.7% of respondents (this was a comment mostly from residents)
  • Patient or parental anxiety / request / reassurance: 50% of respondents
emergency physicians diagnostic imaging ordering practice a pilot survey3
Emergency Physicians’ Diagnostic Imaging Ordering Practice: A Pilot Survey

2. Reasons for inappropriate imaging:

  • Diagnosis unclear / exclude other rare causes: 16.7% of respondents
  • Told by a senior in ED:  20.8% of respondents (mostly from residents)
  • Asked to sign an xray form prior to seeing a patient: 4.2% of respondents
  • GP request: 4.2% of respondents
  • Legal/ forensic: 4.2% of respondents
emergency physicians diagnostic imaging ordering practice a pilot survey4
Emergency Physicians’ Diagnostic Imaging Ordering Practice: A Pilot Survey

3. Most common presenting complaint where inappropriate imaging is ordered (more than one can be cited)

  • Headache: 4.2% of respondents
  • Head injuries: 4.2% of respondents
  • Limb / trauma injuries: 25% of respondents
  • Nontraumatic Abdominal pain: 25% of respondents
  • Chest pain: 25% of respondents
  • SOB: 25% of respondents
  • Back pain: 8.3%
emergency physicians diagnostic imaging ordering practice a pilot survey5
Emergency Physicians’ Diagnostic Imaging Ordering Practice: A Pilot Survey

4. Knowledge of at least 1 clinicalpredictionrule:

  • 54% wereable to recall a specificclinicalpredictionrule and havesomeworkingknowledge of it
clinical question construction
Clinical question construction

Population:

Elderly patients presenting with undifferentiated nontraumatic abdominal pain to the emergency department

Intervention:

Early emergency department abdominopelvicCT

Outcome:

ED and hospital length of stay, and 1 month morbidity and mortality

journal search
Journal Search
  • Search strategyMedline 1946-03/12 using the Ovid interface and The Cochrane Library, Issue 2 of 12, 2012-Feb
journal search1
Journal Search
  • Medline:[expAbdominal Pain/di, mo, ra, su, us [Diagnosis, Mortality, Radiography, Surgery, Ultrasonography]] AND [elderly.mp. or Aged] AND [diagnosis/ or diagnostic imaging/ or tomography, x-ray computed/ or imaging, three-dimensional/ or early diagnosis]
  • Cochrane:[Abdominal pain] AND [Elderly] AND [computed tomography]
journal search2
Journal Search
  • Search OutcomeAltogether 385 papers were found in Medline and 0 in Cochrane, of which 380 were irrelevant or of insufficient quality. All relevant papers are summarised in atable.
journal summary 1
Journal Summary #1
  • Strömberg, Cecilia, Gunnar Johansson, and Anders Adolfsson. “Acute Abdominal Pain: Diagnostic Impact of Immediate CT Scanning.” World Journal of Surgery 31, no. 12 (September 26, 2007): 2347–2354.
journal summary 2
Journal Summary #2
  • Ng, Chaan S, Christopher J E Watson, Christopher R Palmer, TeikChoon See, Nigel A Beharry, Barbara A Housden, J Andrew Bradley, and Adrian K Dixon. “Evaluation of Early Abdominopelvic Computed Tomography in Patients with Acute Abdominal Pain of Unknown Cause: Prospective Randomised Study.” BMJ : British Medical Journal 325, no. 7377 (December 14, 2002): 1387–1389.
journal summary 3
Journal Summary #3
  • Ragsdale, Luna, and Lauren Southerland. “Acute Abdominal Pain in the Older Adult.” Emergency Medicine Clinics of North America 29, no. 2 (May 2011): 429–448.
journal summary 4
Journal Summary #4
  • Esses, David, Adrienne Birnbaum, Polly Bijur, Sachin Shah, AleksandrGleyzer, and E.J Gallagher. “Ability of CT to Alter Decision Making in Elderly Patients with Acute Abdominal Pain.” The American Journal of Emergency Medicine 22, no. 4 (July 2004): 270–272.
journal summary 5
Journal Summary #5
  • Abujudeh, Hani H, RathachaiKaewlai, Pamela M McMahon, William Binder, Robert A Novelline, G. Scott Gazelle, and James H Thrall. “Abdominopelvic CT Increases Diagnostic Certainty and Guides Management Decisions: A Prospective Investigation of 584 Patients in a Large Academic Medical Center.” American Journal of Roentgenology 196, no. 2 (February 1, 2011): 238–243.
comments
Comments:
  • In elderly patients presenting to the ED with undifferentiated abdominal pain, does an early protocol driven CT Abdominopelvic decrease ED and hospital length of stay, and 1 month morbidity and mortality?
  • Each study has its own merits and weaknesses – yes, CT abdo does help in decision-making for elderly patients, but it terms of timing – no answer yet.
  • All studies were based on physician’s decision to CT, not on a protocol.
  • No single study was able to answer the question.
bottomline
Bottomline:
  • No good evidence to suggest early CT less than 24 hours changes management, maybe 24 hours
  • Given time constraints in the ED and hospital bed availability, should we have a policy for early CT abdo in elderly patients (within 4 hours of triage)?
  • Will this benefit our patients?
things to do
Things to do:
  • Define who is an elderly / older patient - >50 or >65?
  • Define an early Abdo CT – within 4 hours? Within 1 hour?
  • Define what is an undifferentiated abdominal pain? All elderly patients potentially have a different diagnosis than initially thought due to age-related changes in physiology, use of medications, multiple co-morbidities
  • Define “a protocol” what to consider in a patient’s history and physical examination?
reference
Reference:
  • Strömberg, Cecilia, Gunnar Johansson, and Anders Adolfsson. “Acute Abdominal Pain: Diagnostic Impact of Immediate CT Scanning.” World Journal of Surgery 31, no. 12 (September 26, 2007): 2347–2354.
  • Ng, Chaan S, Christopher J E Watson, Christopher R Palmer, TeikChoon See, Nigel A Beharry, Barbara A Housden, J Andrew Bradley, and Adrian K Dixon. “Evaluation of Early Abdominopelvic Computed Tomography in Patients with Acute Abdominal Pain of Unknown Cause: Prospective Randomised Study.” BMJ : British Medical Journal 325, no. 7377 (December 14, 2002): 1387–1389.
  • Ragsdale, Luna, and Lauren Southerland. “Acute Abdominal Pain in the Older Adult.” Emergency Medicine Clinics of North America 29, no. 2 (May 2011): 429–448.
  • Esses, David, Adrienne Birnbaum, Polly Bijur, Sachin Shah, AleksandrGleyzer, and E.J Gallagher. “Ability of CT to Alter Decision Making in Elderly Patients with Acute Abdominal Pain.” The American Journal of Emergency Medicine 22, no. 4 (July 2004): 270–272.
  • Abujudeh, Hani H, RathachaiKaewlai, Pamela M McMahon, William Binder, Robert A Novelline, G. Scott Gazelle, and James H Thrall. “Abdominopelvic CT Increases Diagnostic Certainty and Guides Management Decisions: A Prospective Investigation of 584 Patients in a Large Academic Medical Center.” American Journal of Roentgenology 196, no. 2 (February 1, 2011): 238–243.