Does a patient really need this CT scan?
Four times as much advanced imaging, either CT scans or magnetic resonance imaging, was done in EDs in 2008 compared with 10 years prior, according to a recent report from the Centers for Disease Control and Prevention.1
Concerns are growing that many of these tests are, in fact, unnecessary. "This causes the patient unneeded exposure to radiation," says Delores Alexander, RN, BSN, clinical supervisor for emergency and trauma services in the pediatric ED at St. John's Mercy Medical Center in St. Louis, MO. "It also delays the patient's disposition and slows throughput in the ED. This, in turn, increases length of stay and patient dissatisfaction. That causes more stress for both the patient and the staff."
"Astronomical" dose
Stephen R. Pitts, MD, MPH, an ED attending physician at Emory University Hospital Midtown in Atlanta, says "there has been a real revolution in the use of advanced imaging, just in the last decade. Plain X-rays have been essentially replaced by CT scans."
Pitts says that while it is tempting to simply obtain another scan in patients with chronic problems, "the total radiation dose can become astronomical over time and raise the risk of cancer."
ED nurses should be aware that "not all CTs are equal," according to Pitts. "Emergency head CTs are usually done without contrast in the ED, so they are very quick turnaround."
It is critical to have these done within minutes of the patient's arrival if stroke or transient ischemic attack is suspected, says Pitts. Abdominal CTs can be done equally quickly if they are being done strictly to evaluate for kidney stones.
However, CT scans of the abdomen with contrast are "a very different story," says Pitts. Coordinating an abdominal CT with contrast can be difficult and full of pitfalls, and an ED nurse often is the person most able to ensure a smooth sequence of events, he says.
"These tests are true turnaround killers and magnets for medical errors," says Pitts. "Properly timed oral contrast is required for a patient a dicey situation requiring course corrections if the patient vomits." Also, a resulted creatinine level and a short peripheral intravenous line instead of a central line also are necessary for the timed contrast infusion, he says.
"Finally, someone must be aware when all of these things have been done, so that the patient can be taken to CT at a time when the scanner is available," says Pitts. "Because oral contrast so often delays these scans, they are often signed out from shift to shift. This is a major risk factor for subsequent medical errors."
Suggest alternatives
What if you are working with a physician who routinely orders unnecessary tests to avoid litigation issues?
Alexander says, "You should speak up. You most likely won't get that physician to change his mind, but you will know you did the right thing for your patient."
Pitts recommends consulting with the physician to see if the amount of ionizing radiation is really necessary or if the CT could be skipped if it was done recently or replaced with plain films, with ultrasound, or with MRI.
"It would be nice to make CT limbo a thing of the past and even nicer to stop exposing so many people to these large doses of radiation," says Pitts.
3 steps to minimize delays
If the patient must get scanned, Pitts says to minimize the impact on patient flow with these practices:
Avoid contrast when possible.
"This is often simply a matter of getting radiology on board with the ED and becoming confident with reading non-contrast studies," Pitts says.
Have a policy in place for radiology to administer the oral contrast, transport the patient, and to do a bedside creatinine.
With this system, the radiologist reports results directly to the ED physician at the moment the image is read. "If the patient was there recently, look up his or her creatinine," advises Pitts.
Avoid multiple visits back to the scanner, such as performing studies with and without contrast.
"Often, MRI is an alternative," says Pitts. "If imaging will take a long time, encourage the physician to admit the patient to the hospital or observation unit."
Reference
- National Center for Health Statistics. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD. 2010.
Sources
For more information on diagnostic testing in the ED, contact:
- Delores Alexander, RN, BSN, Emergency Medicine, St. John's Mercy Medical Center, St. Louis, MO. Phone: (314) 251-9625. E-mail: [email protected].
- Stephen R. Pitts, MD, MPH, Emergency Department, Emory University Hospital Midtown, Atlanta. Phone: (404) 686-3845. E-mail: [email protected].
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