Rising utilization of CT in adult fall patients

Utility of Torso Imaging for Elderly Patients Sustaining Ground-Level Falls

INTRODUCTION

Computed tomography (CT) of the torso has become increasingly common for assessment of fall patients in the emergency department. Some data suggest that older adults (≥65) may benefit from torso imaging more than younger patients. We sought to evaluate the usage and utility of CT imaging for elderly patients presenting after ground-level falls (GLFs) from 1 meter or less at our level 1 trauma center.

METHODS

Patients ≥18 presenting with GLF in 2015-2019 were included. Data were obtained through chart and trauma registry review. Descriptive statistics were used to summarize the use of CT imaging for patients younger than versus older than 65 y old. Three multivariate logistic regression models with age as a continuous, binary (<65 versus ≥65), or categorical (in multiples of 5) variable were used to investigate whether age is associated with an increased identification of traumatic injury not previously suspected or known based on physical exam (PE) or plain radiograph after GLF.

RESULTS

A total of 522 patients <65 and 673 patients ≥65 y old were included. Older patients were significantly more likely to receive screening chest radiograph, screening pelvic radiograph, brain CT, and neck CT (all P < 0.001), but not torso (chest, abdomen, and pelvis) CT (P = 0.144). On multivariate logistic regression, age was not significantly associated with an increased odds of identification of traumatic injury after torso CT (continuous: adjusted odds ratio [aOR] = 1.01, 95% confidence interval [CI] = 0.99-1.03, P = 0.379; binary: aOR = 0.86, 95% CI = 0.46-1.58, P = 0.619; categorical: aOR = 1.03, 95% CI = 0.94-1.14, P = 0.453). A positive PE was the only variable associated with significantly increased odds of having an abnormal torso CT scan in all models. Only two patients ≥65 y old had injuries identified on torso CT in the context of a negative PE and negative screening imaging.

CONCLUSIONS

The rate of torso injury identification in patients sustaining GLF is not associated with age, but is strongly associated with positive PE findings. In the subset of elderly GLF patients without positive torso PE findings, more conservative use of CT imaging could decrease health-care utilization costs without compromising patient care.

The Florida Geriatric Head Trauma CT Clinical Decision Rule

BACKGROUND

Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults.

METHODS

We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort.

RESULTS

Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention.

CONCLUSIONS

The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

The clinical implications of using a low threshold for computed tomography scans in older patients presenting with a proximal femur fracture

PURPOSE

Current guidelines recommend a low threshold for computerized tomography (CT) scanning in older patients presenting with low-energy trauma (LET). With the ageing of the population, this results in increased use of healthcare resources and costs. We aim to assess (1) the number of CT scans performed as part of the initial trauma screening, (2) their traumatic clinical implications, and (3) their non-traumatic clinical implications.

METHODS

A retrospective study in patients ≥ 70 years presenting at a Dutch trauma centre with a proximal femur fracture following a LET between 2021 and 2022. We collected data concerning demographics, Clinical Frailty Scale, Injury Severity Score, number of CT scans and whether the results of these scans altered clinical management.

RESULTS

We included 278 patients. Median age was 83.0 years (IQR 77.0-89.0), median ISS was 9 (IQR 9-10) and, most common mechanism of injury was a ground level fall (n = 159, 57.2%). In 49 patients (17.6%) one or more CT scans were performed. These scans did not reveal co-existing traumatic injuries altering clinical management. In 2 patients (0.7%) incidental findings were found that immediately affected treatment.

CONCLUSION

Our study concludes that (1) approximately one in five patients with a proximal femur fracture received a CT scan as part of the initial trauma screening, resulting in (2) no traumatic and (3) minimal non-traumatic clinical implications. Therefore, a restrictive policy can be justified in patients with no additional clinical signs or symptoms and admission to the hospital. Further prospective research would be valuable to confirm our results.

Automated patient centering of computed tomography images and its implementation to evaluate clinical practices in three hospitals in Indonesia

Purpose: This study aims to develop a software tool for investigating patient centering profiles of axial CT images and to implement it to evaluate practices in three hospitals in Indonesia.

Methods: The evaluation of patient centering accuracy was conducted by comparing the center coordinate of the patient’s image to the center coordinates of the axial CT image. This process was iterated for all slices to yield an average patient mis-centering in both the x- and y-axis. We implemented the software to evaluate the profile of centering on 268 patient images from the head, thorax, and abdomen examinations taken from three hospitals.

Results: We found that 82% of patients were mis-centered in the y-axis (i.e., placed more than 5 mm from the iso-center), with 49% of patients placed 10–35 mm from the iso-center. Most of the patients had a tendency to be placed below the iso-centers. In head examinations, patients were more precisely positioned than in the other examinations. We did not find any significant difference in mis-centering between males and females. We found that there was a slight difference between mis-centering in adult and pediatric patients.

Conclusion: Software for automated patient centering was successfully developed. Patients in three hospitals in Indonesia had a tendency to be placed under the iso-center of the gantry.

Physical exam is not an accurate predictor of injury in geriatric patients with low-energy blunt trauma - A retrospective cohort study

Background

When evaluating trauma patients, many centers perform computed tomography of the head, cervical spine, chest, abdomen, and pelvis, the so-called “pan-scan.” Here, we evaluate the utility of physical exam against pan-scan in geriatric patients who sustained ground-level falls.

Methods

We performed a single-centered retrospective cohort review of consecutive patients from the trauma registry of a large, urban Level 1 trauma center. Inclusion criteria were registration during the 2019 calendar year, age ≥65, mechanism of fall from either sitting or standing, and performance of “pan-scan” at time of assessment. The sensitivity, specificity, positive and negative predictive values of the physical exam for significant injuries were calculated. The effect of such injuries on disposition from the emergency department and hospital were determined.

Results

An initial query for patients age ≥65 yielded 1280 patients. After exclusion of patients who did not undergo pan-scan or who had GCS <14, 751 patients were included in analysis. Median age was 84 years old. 351 patients had at least one injury identified on pan-scan. Physical exam was determined to have a sensitivity of 0.69 when compared to pan-scan as a gold standard. Patients with injury identified on CT scan had significantly more admissions, mortalities, and ICU and OR requirements.

Conclusion

Approximately half of all patients were found to have at least one injury on pan-scan. Physical examination was insensitive at identifying such injuries which ultimately altered patient management, disposition, and outcomes. Pan-scan is recommended in this vulnerable population.

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A selective approach to CT scan may not be appropriate for elderly patients with low-energy blunt falls.

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Approximately half of all elderly patients who fall from sitting or standing have at least one traumatic injury.

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Traumatic injuries alter the hospital course and disposition of elderly fall patients.

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Physical exam is neither sensitive nor specific enough to detect these injuries.

Changing Patterns in Midwestern Farm Trauma: A Retrospective Comparative Analysis

OBJECTIVES

The objective is to determine if injury patterns on agricultural workplaces have changed over time.

METHODS

Retrospective chart review of farm trauma in Fargo, ND, from 2006 to 2020. Results were compared to historical results from La Crosse, WI, from 1978 to 1983. Patient charts with ICD location and external cause code relating to "farm" were included in the study. Frequencies and relative percentages were computed for each categorical variable. Chi-square tests were performed to determine which categories were significantly different from one another.

RESULTS

Injuries on farms from 395 patients from 2006 to 2020 were compared to injuries from 375 patients from 1978 to 1983. Average age of patients in 2006-2020 was 48 compared to 36 for 1978-1983. There were fewer ISS 1-9, more ISS 10-24, and similar ISS > 25 from 2006 to 2020 compared to 1978-1983. Falls doubled in 2006-2020, 132 compared to 67 in 1978-1983. Injuries from tractors were fewer in 2006-2020, and 63 compared to 89 in 1978-1983. Neurological injuries almost doubled in 2006-2020 compared to 1978-1883, 126 and 61, respectively. All the aforementioned temporal differences were statistically significant with P value < .0001. There were 9 deaths from 2006 to 2020 and 8 deaths from 1978 to 1983.

CONCLUSION

Injuries on farms today occur in older patients with higher injury severity scores and are more likely to have neurological injuries compared to data from 1978 to 1983. These changing patterns in injuries can help to provide education, direct farm safety programs, and help triage resources to critical access hospitals that care for this patient population.

A novel methodology to train and deploy a machine learning model for personalized dose assessment in head CT

OBJECTIVES

To propose a machine learning-based methodology for the creation of radiation dose maps and the prediction of patient-specific organ/tissue doses associated with head CT examinations.

METHODS

CT data were collected retrospectively for 343 patients who underwent standard head CT examinations. Patient-specific Monte Carlo (MC) simulations were performed to determine the radiation dose distribution to patients' organs/tissues. The collected CT images and the MC-produced dose maps were processed and used for the training of the deep neural network (DNN) model. For the training and validation processes, data from 231 and 112 head CT examinations, respectively, were used. Furthermore, a software tool was developed to produce dose maps from head CT images using the trained DNN model and to automatically calculate the dose to the brain and cranial bones.

RESULTS

The mean (range) percentage differences between the doses predicted from the DNN model and those provided by MC simulations for the brain, eye lenses, and cranial bones were 4.5% (0-17.7%), 5.7% (0.2-19.0%), and 5.2% (0.1-18.9%), respectively. The graphical user interface of the software offers a user-friendly way for radiation dose/risk assessment. The implementation of the DNN allowed for a 97% reduction in the computational time needed for the dose estimations.

CONCLUSIONS

A novel methodology that allows users to develop a DNN model for patient-specific CT dose prediction was developed and implemented. The approach demonstrated herein allows accurate and fast radiation dose estimation for the brain, eye lenses, and cranial bones of patients who undergo head CT examinations and can be used in everyday clinical practice.

KEY POINTS

• The methodology presented herein allows fast and accurate radiation dose estimation for the brain, eye lenses, and cranial bones of patients who undergo head CT examinations and can be implemented in everyday clinical practice. • The scripts developed in the current study will allow users to train models for the acquisition protocols of their CT scanners, generate dose maps, estimate the doses to the brain and cranial bones, and estimate the lifetime attributable risk of radiation-induced brain cancer.

AOSpine Global Survey: International Trends in Utilization of Magnetic Resonance Imaging/Computed Tomography for Spinal Trauma and Spinal Cord Injury across AO Regions

The aim of this study was to determine the current trends in magnetic resonance imaging (MRI)/computed tomography (CT) utilization for spine trauma in various clinical scenarios. We conducted a survey across six AO regions and preformed pair-wise comparisons between responses obtained from different AO regions. The survey was sent to 5813 surgeons and had a 9.6% response rate with the majority being orthopedic followed by neurosurgeons. In a neurologically intact patient, the predominant imaging modality for all AO regions was CT. For patients with spinal cord injury (SCI), the predominant choice for all AO regions was CT + MRI + x-ray except North America, which was CT + MRI; pair-wise comparisons revealed significant differences involving LATAM (Latin America) versus (Asia-Pacific [APAC], Europe [EU], and Middle East [MEA]) and APAC versus (LATAM and North America [NA]). In a patient with incomplete SCI (ISCI) who presented within 4 h and had CT, the predominant choice for all AO regions was "forgo MRI and proceed to operating room (OR)." Similar to ISCI, in a patient with complete SCI, the predominant option for all AO regions was the same as ISCI, but the range was lower. Pair-wise comparisons noted significant differences between MEA and APAC, with both exhibiting differences compare to NA, LATAM, and EU for complete and ISCI. Most AO regions obtained post-operative MRI only if there was a new deficit. In summary, decisions about the use of a particular imaging modality across AO regions appears to be influenced by the neurological status of the patient upon admission and the presence of neurological deficits post-surgery. Type of residency training and fellowship training did not have an influence on choosing the appropriate imaging modality for both intact and impaired patients. Further study is needed to determine whether accessibility to MRI would change surgeons' attitude toward obtaining MRI in patients with SCI.

Impact of guidelines for the management of minor head injury on the utilization and diagnostic yield of CT over two decades, using natural language processing in a large dataset

OBJECTIVES

We investigated the impact of clinical guidelines for the management of minor head injury on utilization and diagnostic yield of head CT over two decades.

METHODS

Retrospective before-after study using multiple electronic health record data sources. Natural language processing algorithms were developed to rapidly extract indication, Glasgow Coma Scale, and CT outcome from clinical records, creating two datasets: one based on all head injury CTs from 1997 to 2009 (n = 9109), for which diagnostic yield of intracranial traumatic findings was calculated. The second dataset (2009-2014) used both CT reports and clinical notes from the emergency department, enabling selection of minor head injury patients (n = 4554) and calculation of both CT utilization and diagnostic yield. Additionally, we tested for significant changes in utilization and yield after guideline implementation in 2011, using chi-square statistics and logistic regression.

RESULTS

The yield was initially nearly 60%, but in a decreasing trend dropped below 20% when CT became routinely used for head trauma. Between 2009 and 2014, of 4554 minor head injury patients overall, 85.4% underwent head CT. After guideline implementation in 2011, CT utilization significantly increased from 81.6 to 87.6% (p = 7 × 10-7), while yield significantly decreased from 12.2 to 9.6% (p = 0.029).

CONCLUSIONS

The number of CTs performed for head trauma gradually increased over two decades, while the yield decreased. In 2011, despite implementation of a guideline aiming to improve selective use of CT in minor head injury, utilization significantly increased.

KEY POINTS

• Over two decades, the number of head CTs performed for minor, moderate, and severe head injury gradually increased, while the diagnostic yield for intracranial findings showed a decreasing trend. • Despite the implementation of a guideline in 2011, aiming to improve selective use of CT in minor head injury, utilization significantly increased, while diagnostic yield significantly decreased. • Natural language processing is a valuable tool to monitor the utilization and diagnostic yield of imaging as a potential quality-of-care indicator.

History and physical exam predictors of intracranial injury in the elderly fall patient: A prospective multicenter study

OBJECTIVES

A prior single-center study demonstrated historical and exam features predicting intracranial injury (ICI) in geriatric patients with low-risk falls. We sought to prospectively validate these findings in a multicenter population.

METHODS

This is a prospective observational study of patients ≥65 years presenting after a fall to three EDs. Patients were eligible if they were at baseline mental status and were not triaged to the trauma bay. Fall mechanism, head strike history, headache, loss of consciousness (LOC), anticoagulants/antiplatelet use, dementia, and signs of head trauma were recorded. Radiographic imaging was obtained at the discretion of treating physicians. Patients were called at 30 days to determine outcome in non-imaged patients.

RESULTS

723 patients (median age 83, interquartile range 74-88) were enrolled. Although all patients were at baseline mental status, 76 had GCS <15, and 154 had dementia. 406 patients were on anticoagulation/antiplatelet agents. Fifty-two (7.31%) patients had traumatic ICI. Two study variables were helpful in predicting ICI: LOC (odds ratio (OR) 2.02) and signs of head trauma (OR 2.6). The sensitivity of these items was 86.5% (CI 73.6-94) with a specificity of 38.8% (CI 35.1-42.7). The positive predictive value in this population was 10% (CI 7.5-13.3) with a negative predictive value of 97.3% (CI 94.4-98.8). Had these items been applied as a decision rule, 273 patients would not have undergone CT scanning, but 7 injuries would have been missed.

CONCLUSION

In low-risk geriatric fall patients, the best predictors of ICI were physical findings of head trauma and history of LOC.

Is a "Pan-Scan" Indicated in the Older Patient with a Ground Level Fall?

Routine full-body CT "pan-scan" use in older patients after ground level falls (GLFs) is of questionable benefit. Retrospective review of new diagnosis & changes in management in patients >55 years with Glasgow Coma Scale of 15 after a GLF who received a pan-scan (routine head, cervical spine/neck, chest abdomen, and pelvis CT). Head CT results were considered separately; results described in the following paragraph pertains to cervical spine/neck, chest, abdomen, and pelvis CT. One hundred and fifty-two patients received pan-scans; 96 (63%) had new findings. Thirty-five (23%) resulted in a minor change and three (2%) in a major change in management, defined as a procedural intervention. This included tube thoracostomy in one patient and cervical spine surgery in two. A further eight patients required the use of a cervical collar. In all patients requiring intervention, there were clinical signs present that should have led to directed CT scan of area of concern. Routine pan-scans in stable, alert older patients after a GLF result in new findings in most patients, with primarily nonprocedural interventions for these additional findings.

The Impact of a Preauthorization Policy on the After-hours Utilization of Emergency Department Computed Tomography Imaging

RATIONALE AND OBJECTIVES

We evaluated the effects of a streamlined emergency department (ED) policy for CT ordering, pre- and postimplementation, on the completed imaging study rates of all after-hours computed tomography (CT) studies. The study hypothesis was that a streamlined CT ordering process would increase the utilization rates of ED CT.

MATERIALS AND METHODS

A prospective cohort study was used to estimate the effect of enhancing a preauthorization policy for after-hours CT studies requested through the ED, performed between January 1 and June 30, 2013, and the postimplementation period, performed between January 1 and June 30, 2014. Inclusion criteria were all CT chest, CT abdomen/pelvis, musculoskeletal, neurological, and neuroangiographic examinations performed by ED physicians on adult patients. Pre- and postintervention examination imaging study rates were compared.

RESULTS

The period following implementation of the preauthorization policy was associated with a statistically significant increase in utilization for most subtypes of CT examinations (CT chest, CT abdomen/pelvis, and musculoskeletal CT studies), with the exception of neurological examinations, which showed a significant decrease.

CONCLUSIONS

This study demonstrates a trend toward increased utilization of CT resources after implementation of an ED preauthorization policy with most study types showing significantly increased utilization. In the case of neurological examinations, a potential "substitution effect" was observed, whereby the rates of neuroangiographic studies showed a marked increase, offsetting the decrease in general neurological examinations performed. Departments considering implementation of preauthorization policies should weigh carefully the benefits of ED workflow efficiencies against the potential harms of increased CT use.