Computed tomography in the emergency department

Patients across the United States are exposed to excessive radiation levels due to multiple, and often unnecessary, medical tests. Overuse of radiation from computed tomography (CT) is projected to contribute to 29,000 future cases of cancer in the United States.

CT imaging of the head, neck, chest, abdomen and pelvis have led to significant improvements in the diagnosis of disease and injury. The value of CT scanning to diagnose injury, cancer and other health problems is undisputed. However, a national study of CT utilization in United States emergency departments (ED) demonstrates significant growth in CT use.

In 1995, 2.8 percent of ED patients received a CT scan during the course of an ED visit. In 2007, this increased to 13.9 percent. This represents an approximate six-fold increase in CT utilization with an annual growth rate of 14.2 percent (Radiology. 258(1):164-173, 2011 Jan).

Additionally, emergency department physicians are generally unaware of the risk of radiation exposure from CT scans. A 2012 study demonstrated that fewer than 30 percent of ED physicians possess accurate knowledge of the lifetime cancer risk attributable to radiation (Am J Roentgenol. 199(6):1328-36, 2012 Dec.).

In 2010, the Food and Drug Administration (FDA) announced an initiative to reduce unnecessary radiation exposure from medical imaging. Studies suggest that 30 to 50 percent of medical imaging examinations are not medically necessary (Radiology, 257(1):240-245, 2010 Oct). The FDA initiative includes a recommendation that organizations utilize multiple strategies to promote the appropriate use of medical imaging.

The American College of Emergency Department Physicians and the American College of Radiologists have both published detailed evidence-based guidelines that direct appropriate utilization of various imaging and diagnostic modalities. Awareness, education and quality improvement activities in Arkansas EDs can promote appropriate utilization of CT imaging and reduce unnecessary radiation exposure and the associated risks.

Doctors need to be aware of the radiation levels in the imaging tests they perform and of how many previous CT tests the patient has already had. Patients should keep track of their own radiation levels and keep a personal record of any CT tests or other radiation-heavy tests they have taken.

By being aware of radiation levels in medical exams and asking patients about their exam history, doctors can take the first step in protecting their patients from unnecessary radiation exposure

Remember: Radiation dose is cumulative. Significant radiation doses to children and young adults are associated with increased lifetime risk of cancer.

Strategies for success

Reducing radiation exposure during CT (children)

  • Develop pediatric-specific protocols for imaging with a focus on minimal dose necessary to obtain a quality image.
  • Image with radiation only when medically necessary. When ordered appropriately, the risk to benefit medical imaging is excellent. Use alternative modalities (ultrasound or MRI) when appropriate.
  • Scan only the affected region. Develop protocols for follow-up examinations (e.g., follow-up of an incidental lung nodule does not require a full chest CT).
  • Scan once only. Multiphase scans are rarely indicated in children.
    Involve clinical staff in quality improvement initiatives relative to ordering of medical imaging studies.
  • Arkansas Children’s Hospital has developed pediatric-specific imaging protocols. For information about these, you may call and speak with a Pediatric CT Technologist / Radiology Technologist at 501-364-1308.

Reducing radiation exposure during CT (adults)

Improve systems

  • Follow Meaningful Use Stage 2
  • Adhere to Joint Commission CT Imaging Standards

Educate staff

  • Educate emergency department staff:
    • Specific imaging protocols for pediatric/adults
    • Radiation exposure awareness
    • “As low as reasonably achievable” a statement by the American College of Radiology
    • The patient’s rights and the five “rights” of imaging
  • Routinely check medical records for previous imaging studies
  • Routinely questions patients about other imaging workups
  • REMEMBER: Radiation dose is cumulative. Significant radiation doses to children and young adults are associated with increased lifetime risk of cancer.

Educate patients

  • Provide patient educational materials
  • Utilize teach back
  • Educate patients/parents/ caregivers on importance of providing imaging history

Web resources

Computed Tomography (CT) imaging of the head, neck, chest, abdomen and pelvis have led to significant improvements in the diagnosis of disease and injury. The value of CT scanning to diagnose injury, cancer and other health problems is undisputed. However, a national study of CT utilization in United States Emergency Departments (ED) demonstrates significant growth in CT use. In 1995, 2.8% of ED patients received a CT scan during the course of an ED visit. In 2007, this increased to 13.9 %. This represents an approximate 6-fold increase in CT utilization with an annual growth rate of 14.2%. (Radiology. 258(1):164-173, 2011 Jan). Additionally, Emergency department physicians are generally unaware of the risk of radiation exposure from CT scans. A 2012 study demonstrated that fewer than 30% of ED physicians possess accurate knowledge of the lifetime cancer risk attributable to radiation (Am J Roentgenol. 199(6):1328-36, 2012 Dec.).

 

Provider resources

FDA - U.S. Food and Drug Administration

Joint Commission
Revised requirements for diagnostic imaging services:

AAPM computed tomography radiation does education slides

Radiation dose report

American College of Radiology (ACR)

Practice guidelines

Computed tomography (CT) guidelines

ACR Practice Guidelines for Performing and Interpreting Diagnostic Computed Tomography:

American College of radiology computed tomography guidelines

American College of Emergency Medicine

ACEP clinical policies

Acute abdominal pain CT or US?

ACEP clinical policies

CT use in the ED soared in past decade

Imaging exposes many to worrisome doses of radiation

Alarming number of CTs ordered in some patients

Management of suspected appendicitis

US emergency physicians order too many computed tomography scans—or do they?

Emergency department computed tomography utilization in the United States and Canada

Additional articles and resources

Heavy use of CT scans raises concerns about patients' exposure to radiation - Kaiser Health News

Website developed by the American College of Radiology (ACR) and Radiology Society of North America (RSNA)

Most parents underestimate potential risk of CT scans

Imaging patients with acute abdominal pain

The American Association of Physicists in Medicine - 6/7/2012.

Recent issue of Scientific American examines CT scans and risk of cancer
The July 2013 issue of Scientific American examines research methodology to predict future cancer risk associated with CT scans. - 7/9/2013

PowerPoint for pediatric radiation

Resources/articles/case studies

Radiation protection and dose monitoring/ Lippincott Williams & Wilkins

Information on diagnostic imaging

Radiation risks and pediatric computed tomography (CT): A Guide for Health Care Providers

Penn-developed electronic medical record tool cuts down on unnecessary CT scans in emergency room patients with abdominal pain.

EMPRACTICE improving care through evidence (GUIDELINES SUBSCRIPTION)

Safety issues in pediatric imaging

Hospital pediatric check list

Campaign poster

Patient resources

Image wisely - radiation safety awareness for adults diagnostic imaging

Image gently- The Alliance for Radiation Safety in Pediatric Imaging

Study examines parental understanding of potential CT risk
A recent study in Pediatrics found that half of parents are aware of the potential increase in future cancer risk associated with pediatric CT scans. - 7/8/2013