NICE Guidelines for C-Spine Imaging: Real Life Impact

Transcription

1 NICE Guidelines for C-Spine Imaging: Real Life Impact Poster No.: C-1367 Congress: ECR 2017 Type: Scientific Exhibit Authors: D. Weinberg, I. Djoukhadar, G. Potter; Salford/UK Keywords: Trauma, Audit and standards, MR, CT, Head and neck, CNS DOI: /ecr2017/C-1367 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Aims and objectives The National Health Service (NHS) in England is facing ever-increasing demand, and emergency departments in the financial year of treated over 365,000 patients with head injuries comprising a significant proportion of overall attendances. 1 Very few of these patients have cervical-spine (C-spine) injuries, however cervical-spine radiology is a low-cost procedure that adds significantly to healthcare costs through its popular use. The National Institute for Health and Care Excellence (NICE) produced guidance (CG176) in 2014 on patients sustaining head injury undergoing CT (Computed Topography) C-spine imaging. 2 Much of the basis for the NICE guidance was developed from two key decision rules: The National Emergency X-Radiography Utilization Study (NEXUS) included five items and a subsequent validation study of 34,069 trauma patients demonstrated that the low risk criteria had a sensitivity of 99.6 percent and a specificity of 12.9 percent for detecting cervical-spine injury. 3-4 The Canadian C-spine rule (CCR) for radiography in alert and stable trauma patients was developed by Stiell et al in 2001, aimed at permitting more selective ordering of c-spine radiography, more rapid exclusion of c-spine injury for patients, and to improve healthcare cost savings. 5 The sensitivity and specificity of the CCR was found to be 99.4% and 45.1% respectively. 5 The NICE Guidance includes multiple risk factors (Figure 1) for patients sustaining head injuries. These include specific clinical features, which would restrict CT C-spines to a subset of patients with head trauma. However, the inclusion of patients above the age of 65 and those sustaining a dangerous mechanism of injury substantially increases the number of patients qualifying for a CT C-spine. Of note, the guidelines state that CT C-spine scans should be performed within 1 hour of the risk factor being identified. Further, the guidelines stipulate that a C-spine x-ray should be performed initially in a proportion of patients with head injury. The aim of this audit was to investigate patients presenting to the emergency department with head injury undergoing CT head and C-spine imaging against NICE clinical guidance (CG176). Page 2 of 12

3 Objectives 1. To determine the number of patients with head injury receiving CT C-spine imaging in accordance with NICE Guidance and specific indications for scans. 2. To investigate the number of patients with acute C-spine injuries identified on CT C-spine imaging and correlate this with clinical state. 3. To investigate the number of patients receiving subsequent MR C-spine imaging and whether these identified additional acute injuries. 4. To establish the number of patients receiving C-spine x-rays prior to CT. 5. To investigate whether patients are receiving CT C-spine imaging within the recommended time frame of 1 hour. Images for this section: Fig. 1: NICE Guidance for head injury patients undergoing CT C-Spine imaging. The National Institute for Health and Care Excellence (NICE), Head injury: early assessment and management. London: NICE. Page 3 of 12

4 Methods and materials A retrospective study was carried out at Salford Royal Hospital - a major trauma and neurosurgical centre, over a three-month period from January to March 2016 inclusive (n=107, Figure 2). Inclusion criteria Patients presenting to the emergency department with head trauma Patients receiving CT head and CT C-spine scans Exclusion criteria Polytrauma (patients receiving additional CT imaging to head and C-spine) Patients were identified using coding for CT head and C-spine scans on CRIS (Clinical Research Information System). Those presenting to the emergency department were further examined. Data collected based on scan requests was correlated with NICE Guidance. Further evaluation of patient notes was carried out to determine the following: 1. Documented clinical evidence qualifying CT C-spine in accordance with NICE Guidance in patients with no clear indication from scan requests. 2. Documented clinical evidence of C-spine pain/tenderness in (i) patients over the age of 65 (ii) patients with non-indicated CT C-spine scans determined from scan requests and clinical notes (iii) patients with acute C-spine injuries. Images for this section: Page 4 of 12

5 Fig. 2: Methods - Salford/UK Page 5 of 12

6 Results Demographics 67 (62.6%) male, 40 (37.4%) female Mean age 58 years CT C-Spine Indicated? 1. From examination of CT C-spine scan requests: 82/107 (76.6%) - indicated 25/107 (23.4%) - no clear indication Based on the radiology requests, we correlated CT C-spine indications with specific NICE criteria (Figure 3). Age above 65 years was found to be the main indication (47.8%) followed by Glasgow Coma Score (GCS) below 13 (16.7%) and motor vehicle accidents (12.2%). Eight patients had multiple indications for CT C-spine. 2. Further examination of clinical notes: Documented clinical indication in 10/25 (40%) patients with scan requests demonstrating no clear indication Patients aged >65 as sole indicator for CT C-spine (n=37): 24/37 (64.9%) had no C-spine tenderness 3. Compiling the findings: Compiling these results (Figure 4), we can conclude that 68/107 (63.6%) of patients were indicated Acute Injuries CT C-spine: 5/107 (4.7%) o Vertebral fracture (n=3) o Clavicle fracture (n=1) o Laryngeal cartilage fracture (n=1) 4 out of these 5 CT C-spines were indicated Scan with no clear indication: laryngeal cartilage fracture CT head: 26/107 (24.3%) Page 6 of 12

7 Vertebral fractures: correlation with clinical notes: All patients demonstrated clinical evidence: o Neck pain (n=1) o C-spine tenderness (n=2) The accuracy of the NICE Guidance for the 107 patients in this study is detailed in Figure 5. The sensitivity was 100% (95% confidence interval). The specificity was 38% (95% confidence interval, 29-48). The negative predictive value 100%. Subsequent MRI C-Spine Imaging 13/107 (12.1%) CT C-spines were indicated in 12/13 (92.3%) patients Main reason for subsequent MRI: Abnormal CT C-spine (Figure 6) Additional acute soft tissue/ligamentous injuries (Figure 6): Yes 6/13 (46.2%) No 7/13 (53.8%) Patient with no clear indication for CT C-spine: no acute injury on MRI C-Spine X-Rays The majority of patients had no previous C-Spine x-rays (Figure 6) Yes 2/107 (1.9%) o Subsequent CT C-spine as x-rays inadequate: normal o Subsequent CT C-spine - no clear indication: normal No 105/107 (98.1%) CT C-Spine Timings Most patients received CT C-spine scans within 1 hour of request (Figure 6): 97/107 (90.7%) within 1 hour of request 10/107 (9.3%) > 1 hour of request Examination of clinical notes for delayed scans: Reason not identified (n=7) Prioritisation of other trauma patients (n=1) Patient absconded (n=1) Page 7 of 12

8 Images for this section: Fig. 3: CT C-spine indications according to NICE criteria. - Salford/UK Page 8 of 12

9 Fig. 4: Compiling the findings: examination of clinical notes revealed that less CT C-spine scans were indicated when compared to initial examination of scan requests. - Salford/UK Fig. 5: Accuracy for NICE Guidance on CT C-spine imaging (n=107). - Salford/UK Page 9 of 12

10 Fig. 6: Reasoning for patients undergoing subsequent MR C-spine imaging (A) MR pickup rate for additional acute soft tissue or ligamentous injuries (B) CT C-spine timings from original request (C) Number of patients undergoing C-spine plain radiography prior to CT (D). - Salford/UK Page 10 of 12

11 Conclusion Key Findings The majority (62.6%) of CT C-spine scans were indicated in accordance with NICE Guidance, however 95.3% demonstrated no acute injuries. Over one third of patients had no indication for CT C-spine - none had a traumatic spinal injury o 87.2% of these had no C-spine tenderness 24 of 37 patients receiving CT C-spine for age > 65 as sole indicator had no C-spine tenderness o None of these patients had acute injuries 3 of 107 patients had a traumatic spinal injury on CT C-spine (vertebral body fractures) o All of these patients had neck pain/c-spine tenderness 24.3% of patients had an acute intracranial injury on CT head 13 of 107 patients had subsequent MRI C-spine o The majority were performed based on normal CT C-spines o Under half (46.2%) demonstrated additional acute injuries 2 of 107 patients received C-spine x-rays prior to CT 90.7% of patients received CT head/c-spine scans within 1 hour Future Work Better compliance with the NICE guidelines is required, and practitioners should state clearly in their scan requests the specific clinical indications for CT C-spines. We aim to investigate our findings further by extending this study over a full year, with potential to expand the study across multiple trauma centres throughout the United Kingdom by utilising pre-existing national databases. Page 11 of 12

12 Personal information Daniel Weinberg, Academic Foundation Doctor, Salford Royal NHS Foundation Trust. Ibrahim Djoukhadar, Senior Clinical Fellow, Department of Neuroradiology, Salford Royal NHS Foundation Trust. Gillian Potter, Consultant Neuroradiologist, Department of Neuroradiology, Salford Royal NHS Foundation Trust. References 1. Hospital Episode Statistics Analysis. Health and Social Care Information Centre (2016). Accident and Emergency Attendances in England Health and Social Care Information Centre. 2. The National Institute for Health and Care Excellence (NICE), Head injury: early assessment and management. London: NICE. 3. Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;21(12): Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X- Radiography Utilization Study Group. N Engl J Med. 2000;343:94-9 Normal 0 false false false EN-US JA X-NONE 5. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS,Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26): Page 12 of 12