- Email: [email protected]
The use of CT trauma protocols for patients with head injury in a major trauma centre
S16
Abstract / Clinical Radiology 69 (2014) S11eS22
had been appropriately requested by the radiologist but not performed and the patients were recalled. 1st action plan: These results were discussed at a local radiology meeting to ensure that radiologists request STIR when spondyloarthropathy is suspected. The results were then used in the formation of a new MRI protocol for the scanning of spondyloarthropathy, in order to reduce the chance that STIR will fail to be performed in the future. Imaging of the cervical spine injury in elderly patients Authors: Divyashree Mysore*, Sharath R. Hosmane, Reda Braham Background: The RCR and NICE recommends developing local protocol for primary imaging modality for cervical spine (CSPN) assessment of blunt cervical injury in elderly patients (>65 yrs). Literature suggests young elderly (65 e 75yrs) are less likely to need further imaging than old elderly (>75yrs). Distinction reflects observed differences in functional decline, trauma mortality rates and osteoporosis Standard, indicator and target: Standard: 100% images should be technically adequate Aims: Assess adequacy of CSPN x-rays in patients ¼ />65yrs Assess difference in young elderly (65 e 75 yrs) and old elderly (>75yrs) patients Methodology: CSPN x-rays from 1/1/2011 to 31/3/2013, requested for blunt injury from A&E for patients ¼ />65yrs were obtained from PACS Results of 1st audit round: 193 CSPN x- rays were performed with mean age of 78 years 78.8% of the images were of adequate quality and 21.2% CSPN x-rays were inadequate to diagnose CSPN injury. 35pts in old elderly group had inadequate CSPN x-rays compared to 6pts in young elderly group (p ¼ 0.005). 37.3% patients had CT CSPN following x-rays of CSPN for reasons of inadequacy (21.2%), inconclusive (11.4%) and abnormal (4.7%) 1st action plan: The results were presented in clinical governance meeting. The adequacy criteria was presented to increase awareness. The radiologists were advised to mention in report if x-rays are inadequate. It was agreed to have low threshold to perform CT spine in elderly patients, especially in patients aged >75 yrs. Re-audit will be performed Traumatic knee pain e adequacy of clinical information with reference to the Ottawa knee rules Authors: Bilal A. Sethi*, Karen A. Duncan, John Lee Background: Acute knee injuries are common presentation but not all require knee x-rays. The Ottawa Knee rules (OKR) state that for patients presenting with a history of knee trauma knee radiographs are only required if - age 55 yrs or older, - tenderness at head of fibula, - isolated tenderness of patella, - inability to flex knee to 90 - inability to bear weight both immediately and in the emergency department (ED) Standard, indicator and target: All knee x- ray requests for traumatic knee pain should be in line with OKR and provide adequate clinical information including point tenderness. Indicator: Percentage of referrals providing adequate clinical information with reference to the Ottawa knee rules Target 95% compliance. Methodology: Retrospective review of ED referral details as supplied electronically, for patients who were referred for knee imaging. Results of 1st audit round: 100 consecutive knee x-ray referrals from ED were analysed, covering period from 02-30/11/2013.
* * * *
Guarantor Guarantor Guarantor Guarantor
and and and and
correspondent: correspondent: correspondent: correspondent:
Divyashree Mysore Bilal A. Sethi Nik M. Nik-Hussin Tharunniya Vamadevan
36 excluded Adequate information ¼ 38 Inadequate information ¼ 25 Only 60% of knee x-ray requests for traumatic knee pain provided adequate clinical information with reference to OKR. 1st action plan: Presented at ED meeting highlighting areas of non compliance. Following steps taken: i) Knee examination demonstration in ED teaching session ii) Introducing OKR during junior doctors induction. iii) agreement to improve documentation and clinical information on referrals. Results of 2nd round: Currently in the process of re-auditing. Chest staging in head and neck cancer patients: a multicentre regional audit Authors: Nik M. Bonington
Nik-Hussin*, Claire
Barker, Niranjan
Desai, Suzie
Background: The chest is the commonest metastatic site for laryngopharyngeal cancers. The incidence of a 2nd synchronous tumour in the thorax is between 4-30%. Sensitivity and specificity for detecting lung nodules is 100% and 95% for CT vs 33% and 97% for chest radiography. The Northwest Head & Neck Cancer Guidelines advocate CT thorax for staging prior to the multidisciplinary meeting to ensure efficient and timely management. The audit aimed to assess adherence to regional guidelines. Standard, indicator and target: Standard: Northwest Head & Neck Imaging Guidelines. Indicator: New patients should have a pre-MDT CT thorax. Target: 100% Methodology: Multicentre retrospective audit. New patients referred to the regional MDTs from August-December 2013 were identified from prospectively derived databases of the South and Central Manchester NHS Trusts and Pennine Acute Trust MDTs. Retrospective review of imaging on PACS was performed. Data was analysed as a combined cohort to reflect regional practice. Results of 1st audit round: 151 patients were identified. 70.2% had appropriate chest imaging prior to the MDT. 14.5% only chest radiography.11.3% had imaging of the chest after the MDT and prior to surgery. Of these patients 7 patient had a chest radiograph and 10 patients had preoperative CT. 4.0% had no chest imaging performed before or after the MDT. The target of 100% was not achieved. 1st action plan: The results of the audit were presented at each Regional MDT. Re-audit will be undertaken in a year. The use of CT trauma protocols for patients with head injury in a major trauma centre Vamadevan*, Authors: Tharunniya Macmullen-Price, Ian Craven
Daniel
Warren,
Jeremy
Background: Leeds Teaching Hospitals recently became a Major Trauma Centre with a subsequent increase in trauma imaging. Standardised head trauma protocols were introduced in September 2013 stating a volume acquisition with 5mm soft tissue and 1mm bony reformats sent to PACS. Supervising Consultants were concerned that bony reformats were unavailable at the time of reporting - either a discrepancy of the Radiographer or on-call Radiologist. The audit originated following a discrepancy of a missed skull base fracture on 3 mm reconstructions that later became apparent on higher resolution imaging (case will be shown).
Abstract / Clinical Radiology 69 (2014) S11eS22
S17
Standard, indicator and target: The target was to achieve 100 % compliance to the protocol. Methodology: From November 2013 retrospective data was collected on 100 consecutive patients admitted to Leeds General Infirmary with either isolated head injury or major trauma (when a head trauma CT is mandatory). Results of 1st audit round: Out of 100 patients, 94% had adequate imaging sent to PACS. 4% had 2 mm thickness or greater and 2% had no bony reconstructions. 1st action plan: The data was presented to the on-call Radiographers. Results of 2nd round: Data was collected prospectively from 100 consecutive patients from January 2014 using the same criteria. 94% had 1mm bony reconstructions (or thinner); 1 had 3mm and 5 had no bony reconstructions. 2nd action plan: No improvement was demonstrated. We have now presented our data to the Radiologists to underline the importance of reporting with the appropriate datasets in trauma.
Methodology: A CRIS search was performed identifying 50 consecutive pre-operative CUS between 01/09/12-31/10/13. Clinical requests, saved images and radiologists’ reports were reviewed for indication and compliance with imaging standards. All patients were included. Results of 1st audit round: 84% (standard 100%) of patients had an appropriate indication for CUS. 94% (standard 100%) of scans matched the minimum technical standard. It was also noted that 96% of patients also had a pre-operative renal ultrasound of which only 48% were indicated. 1st action plan: Agreed action plan: 1. Prompt review of local guidelines for pre-operative cranial and renal ultrasound in CHD. 2. Re-distribution of technical imaging standards to radiologists. Re-audit in 1 year after implementation of action plan.
Paediatric trauma imaging e how well do we do?
Authors: Susan C. Shelmerdine*, Basrull Bhaludin, Wing Yan Mok, Liam Woods, Valmai Cook
A pain in the neck! Too many normal paediatric cervical spine CTs in trauma?
Authors: Cheng Fang*, Anushka Patchava, Saira Haque Background: Trauma is a leading cause of childhood death. Accurate diagnosis is essential for clinical management. Careful thought must be given prior to exposing children to CT due to significant long term risks. This audit assesses how we image children following major trauma in an emergency setting. Standard, indicator and target: The British Society of Pediatric Radiology imaging protocol for paediatric trauma and NICE guidelines are used as the standards. Plain cervical spine (C-spine) film should be used to exclude bony injury. CT C-spine is only indicted if plain film is abnormal. Thoracic CT is indicated in penetrative chest wall injury or if the chest x-ray shows significant injury. CT abdomen is only indicated if the mechanism of injury is significant or there are clinical concerns such as abdominal tenderness/ distension, bleeding and hypovolaemia. Methodology: Primary imaging requests including CT head, C-spine films, CT C-spine and CT chest, abdomen were audited against the standards in all paediatric traumas (age 0-16 years) for 6 months. Results of 1st audit round: 90 cases were reviewed. All CT head requests were justified. CT C-spines were performed in 5 patients despite normal plain films, which were all normal. 4 of 5 of CT chest requests followed BSPR guidelines. 10 of 11 CT abdomen followed guidelines. 1st action plan: We will raise awareness of a child specific approach to assess paediatric trauma in an emergency setting through regular teaching. Visual aid of paediatric imaging pathways will be made available. Audit of pre-operative cranial ultrasound in congenital heart disease Authors: Andrew Macallister*, David Grier Background: Cranial ultrasound (CUS) is a quick, non-invasive imaging technique used to assess the infant brain. There is a clear technical standard for minimum imaging requirements. It is commonly used in the pre-operative assessment of congenital heart disease (CHD). Certain CHDs are commonly associated with structural or pathological brain abnormalities. Standard, indicator and target: CUS had not previously been audited in our department. We aimed to assess practice against national and local guidelines. 1.100% of pre-operative CUS in CHD should have an indication from the Bristol Royal Children’s Hospital guidelines (local), 2.100% of scans should have at least 5 sagittal and 6 coronal images saved to PACS (National).
* * * *
Guarantor Guarantor Guarantor Guarantor
and and and and
correspondent: correspondent: correspondent: correspondent:
Cheng Fang Andrew Macallister Susan C. Shelmerdine Ai-Lee Chang
Background: CT cervical spines contribute approximately 60x higher dosage to the thyroid than x-rays. NICE guidelines (1) state CT should be reserved where radiographs are inadequate, abnormal, in presence of severe head/multi-region trauma or neurological deficit. Previous local audits demonstrated no abnormal CTs in 1996-7 and 1 in 2002-2003 demonstrating rotatory atlanto- axial subluxation, which was also visible on plain radiography. Are we increasing the number of nonindicated paediatric CTs? Standard, indicator and target: 100% of patients should meet NICE guidelines. Methodology: All CT cervical spines of patients aged <18 years were reviewed. Preceding radiograph findings and indications for CT were analysed. Results of 1st audit round: May 2008 - June 2012 (49 months), 52 CTs performed. 26 (50%) cases met imaging guidelines. 1 abnormality (18 year old motorcycle accident with C7 fractures). 1st action plan: Results presented at local governance meeting with review of diagnostic pitfalls and demonstration of optimal radiographic technique. Commitment to CT reduction was agreed. Results of 2nd round: July 2012 - April 2014 (21 months), 13 CTs performed (8 localized scans to site of pain). 9 (69%) cases met guidelines for imaging. All CTs normal. 50% reduction in CT use. 2nd action plan: Guaranteed next day paediatric MRI cervical spine service in presence of normal plain radiograph instead of CT planned. A reduction in CT can be effected. Practical guidance for DGHs is required, particularly for those outsourcing out of hours work. Knowledge of radiation exposure in common examinations amongst radiology department staff
radiological
Authors: Ai-Lee Chang*, Sophie Wood, Dorothy Keane Background: Ionising radiation (Medical Exposure) regulations 2000 and 2006 (IR(ME)R) impose a responsibility on imaging departments to ensure that all exposures to ionising radiation are justified and doses are optimised. Standard, indicator and target: All radiology department staff should have knowledge of relevant radiation doses for commonly performed examinations. 50% awareness of dose estimation per chest x-ray equivalent. Methodology: Questionnaire with 14 questions. Results of 1st audit round: November 2012 Responders 54/70(77%)
Abstract / Clinical Radiology 69 (2014) S11eS22
had been appropriately requested by the radiologist but not performed and the patients were recalled. 1st action plan: These results were discussed at a local radiology meeting to ensure that radiologists request STIR when spondyloarthropathy is suspected. The results were then used in the formation of a new MRI protocol for the scanning of spondyloarthropathy, in order to reduce the chance that STIR will fail to be performed in the future. Imaging of the cervical spine injury in elderly patients Authors: Divyashree Mysore*, Sharath R. Hosmane, Reda Braham Background: The RCR and NICE recommends developing local protocol for primary imaging modality for cervical spine (CSPN) assessment of blunt cervical injury in elderly patients (>65 yrs). Literature suggests young elderly (65 e 75yrs) are less likely to need further imaging than old elderly (>75yrs). Distinction reflects observed differences in functional decline, trauma mortality rates and osteoporosis Standard, indicator and target: Standard: 100% images should be technically adequate Aims: Assess adequacy of CSPN x-rays in patients ¼ />65yrs Assess difference in young elderly (65 e 75 yrs) and old elderly (>75yrs) patients Methodology: CSPN x-rays from 1/1/2011 to 31/3/2013, requested for blunt injury from A&E for patients ¼ />65yrs were obtained from PACS Results of 1st audit round: 193 CSPN x- rays were performed with mean age of 78 years 78.8% of the images were of adequate quality and 21.2% CSPN x-rays were inadequate to diagnose CSPN injury. 35pts in old elderly group had inadequate CSPN x-rays compared to 6pts in young elderly group (p ¼ 0.005). 37.3% patients had CT CSPN following x-rays of CSPN for reasons of inadequacy (21.2%), inconclusive (11.4%) and abnormal (4.7%) 1st action plan: The results were presented in clinical governance meeting. The adequacy criteria was presented to increase awareness. The radiologists were advised to mention in report if x-rays are inadequate. It was agreed to have low threshold to perform CT spine in elderly patients, especially in patients aged >75 yrs. Re-audit will be performed Traumatic knee pain e adequacy of clinical information with reference to the Ottawa knee rules Authors: Bilal A. Sethi*, Karen A. Duncan, John Lee Background: Acute knee injuries are common presentation but not all require knee x-rays. The Ottawa Knee rules (OKR) state that for patients presenting with a history of knee trauma knee radiographs are only required if - age 55 yrs or older, - tenderness at head of fibula, - isolated tenderness of patella, - inability to flex knee to 90 - inability to bear weight both immediately and in the emergency department (ED) Standard, indicator and target: All knee x- ray requests for traumatic knee pain should be in line with OKR and provide adequate clinical information including point tenderness. Indicator: Percentage of referrals providing adequate clinical information with reference to the Ottawa knee rules Target 95% compliance. Methodology: Retrospective review of ED referral details as supplied electronically, for patients who were referred for knee imaging. Results of 1st audit round: 100 consecutive knee x-ray referrals from ED were analysed, covering period from 02-30/11/2013.
* * * *
Guarantor Guarantor Guarantor Guarantor
and and and and
correspondent: correspondent: correspondent: correspondent:
Divyashree Mysore Bilal A. Sethi Nik M. Nik-Hussin Tharunniya Vamadevan
36 excluded Adequate information ¼ 38 Inadequate information ¼ 25 Only 60% of knee x-ray requests for traumatic knee pain provided adequate clinical information with reference to OKR. 1st action plan: Presented at ED meeting highlighting areas of non compliance. Following steps taken: i) Knee examination demonstration in ED teaching session ii) Introducing OKR during junior doctors induction. iii) agreement to improve documentation and clinical information on referrals. Results of 2nd round: Currently in the process of re-auditing. Chest staging in head and neck cancer patients: a multicentre regional audit Authors: Nik M. Bonington
Nik-Hussin*, Claire
Barker, Niranjan
Desai, Suzie
Background: The chest is the commonest metastatic site for laryngopharyngeal cancers. The incidence of a 2nd synchronous tumour in the thorax is between 4-30%. Sensitivity and specificity for detecting lung nodules is 100% and 95% for CT vs 33% and 97% for chest radiography. The Northwest Head & Neck Cancer Guidelines advocate CT thorax for staging prior to the multidisciplinary meeting to ensure efficient and timely management. The audit aimed to assess adherence to regional guidelines. Standard, indicator and target: Standard: Northwest Head & Neck Imaging Guidelines. Indicator: New patients should have a pre-MDT CT thorax. Target: 100% Methodology: Multicentre retrospective audit. New patients referred to the regional MDTs from August-December 2013 were identified from prospectively derived databases of the South and Central Manchester NHS Trusts and Pennine Acute Trust MDTs. Retrospective review of imaging on PACS was performed. Data was analysed as a combined cohort to reflect regional practice. Results of 1st audit round: 151 patients were identified. 70.2% had appropriate chest imaging prior to the MDT. 14.5% only chest radiography.11.3% had imaging of the chest after the MDT and prior to surgery. Of these patients 7 patient had a chest radiograph and 10 patients had preoperative CT. 4.0% had no chest imaging performed before or after the MDT. The target of 100% was not achieved. 1st action plan: The results of the audit were presented at each Regional MDT. Re-audit will be undertaken in a year. The use of CT trauma protocols for patients with head injury in a major trauma centre Vamadevan*, Authors: Tharunniya Macmullen-Price, Ian Craven
Daniel
Warren,
Jeremy
Background: Leeds Teaching Hospitals recently became a Major Trauma Centre with a subsequent increase in trauma imaging. Standardised head trauma protocols were introduced in September 2013 stating a volume acquisition with 5mm soft tissue and 1mm bony reformats sent to PACS. Supervising Consultants were concerned that bony reformats were unavailable at the time of reporting - either a discrepancy of the Radiographer or on-call Radiologist. The audit originated following a discrepancy of a missed skull base fracture on 3 mm reconstructions that later became apparent on higher resolution imaging (case will be shown).
Abstract / Clinical Radiology 69 (2014) S11eS22
S17
Standard, indicator and target: The target was to achieve 100 % compliance to the protocol. Methodology: From November 2013 retrospective data was collected on 100 consecutive patients admitted to Leeds General Infirmary with either isolated head injury or major trauma (when a head trauma CT is mandatory). Results of 1st audit round: Out of 100 patients, 94% had adequate imaging sent to PACS. 4% had 2 mm thickness or greater and 2% had no bony reconstructions. 1st action plan: The data was presented to the on-call Radiographers. Results of 2nd round: Data was collected prospectively from 100 consecutive patients from January 2014 using the same criteria. 94% had 1mm bony reconstructions (or thinner); 1 had 3mm and 5 had no bony reconstructions. 2nd action plan: No improvement was demonstrated. We have now presented our data to the Radiologists to underline the importance of reporting with the appropriate datasets in trauma.
Methodology: A CRIS search was performed identifying 50 consecutive pre-operative CUS between 01/09/12-31/10/13. Clinical requests, saved images and radiologists’ reports were reviewed for indication and compliance with imaging standards. All patients were included. Results of 1st audit round: 84% (standard 100%) of patients had an appropriate indication for CUS. 94% (standard 100%) of scans matched the minimum technical standard. It was also noted that 96% of patients also had a pre-operative renal ultrasound of which only 48% were indicated. 1st action plan: Agreed action plan: 1. Prompt review of local guidelines for pre-operative cranial and renal ultrasound in CHD. 2. Re-distribution of technical imaging standards to radiologists. Re-audit in 1 year after implementation of action plan.
Paediatric trauma imaging e how well do we do?
Authors: Susan C. Shelmerdine*, Basrull Bhaludin, Wing Yan Mok, Liam Woods, Valmai Cook
A pain in the neck! Too many normal paediatric cervical spine CTs in trauma?
Authors: Cheng Fang*, Anushka Patchava, Saira Haque Background: Trauma is a leading cause of childhood death. Accurate diagnosis is essential for clinical management. Careful thought must be given prior to exposing children to CT due to significant long term risks. This audit assesses how we image children following major trauma in an emergency setting. Standard, indicator and target: The British Society of Pediatric Radiology imaging protocol for paediatric trauma and NICE guidelines are used as the standards. Plain cervical spine (C-spine) film should be used to exclude bony injury. CT C-spine is only indicted if plain film is abnormal. Thoracic CT is indicated in penetrative chest wall injury or if the chest x-ray shows significant injury. CT abdomen is only indicated if the mechanism of injury is significant or there are clinical concerns such as abdominal tenderness/ distension, bleeding and hypovolaemia. Methodology: Primary imaging requests including CT head, C-spine films, CT C-spine and CT chest, abdomen were audited against the standards in all paediatric traumas (age 0-16 years) for 6 months. Results of 1st audit round: 90 cases were reviewed. All CT head requests were justified. CT C-spines were performed in 5 patients despite normal plain films, which were all normal. 4 of 5 of CT chest requests followed BSPR guidelines. 10 of 11 CT abdomen followed guidelines. 1st action plan: We will raise awareness of a child specific approach to assess paediatric trauma in an emergency setting through regular teaching. Visual aid of paediatric imaging pathways will be made available. Audit of pre-operative cranial ultrasound in congenital heart disease Authors: Andrew Macallister*, David Grier Background: Cranial ultrasound (CUS) is a quick, non-invasive imaging technique used to assess the infant brain. There is a clear technical standard for minimum imaging requirements. It is commonly used in the pre-operative assessment of congenital heart disease (CHD). Certain CHDs are commonly associated with structural or pathological brain abnormalities. Standard, indicator and target: CUS had not previously been audited in our department. We aimed to assess practice against national and local guidelines. 1.100% of pre-operative CUS in CHD should have an indication from the Bristol Royal Children’s Hospital guidelines (local), 2.100% of scans should have at least 5 sagittal and 6 coronal images saved to PACS (National).
* * * *
Guarantor Guarantor Guarantor Guarantor
and and and and
correspondent: correspondent: correspondent: correspondent:
Cheng Fang Andrew Macallister Susan C. Shelmerdine Ai-Lee Chang
Background: CT cervical spines contribute approximately 60x higher dosage to the thyroid than x-rays. NICE guidelines (1) state CT should be reserved where radiographs are inadequate, abnormal, in presence of severe head/multi-region trauma or neurological deficit. Previous local audits demonstrated no abnormal CTs in 1996-7 and 1 in 2002-2003 demonstrating rotatory atlanto- axial subluxation, which was also visible on plain radiography. Are we increasing the number of nonindicated paediatric CTs? Standard, indicator and target: 100% of patients should meet NICE guidelines. Methodology: All CT cervical spines of patients aged <18 years were reviewed. Preceding radiograph findings and indications for CT were analysed. Results of 1st audit round: May 2008 - June 2012 (49 months), 52 CTs performed. 26 (50%) cases met imaging guidelines. 1 abnormality (18 year old motorcycle accident with C7 fractures). 1st action plan: Results presented at local governance meeting with review of diagnostic pitfalls and demonstration of optimal radiographic technique. Commitment to CT reduction was agreed. Results of 2nd round: July 2012 - April 2014 (21 months), 13 CTs performed (8 localized scans to site of pain). 9 (69%) cases met guidelines for imaging. All CTs normal. 50% reduction in CT use. 2nd action plan: Guaranteed next day paediatric MRI cervical spine service in presence of normal plain radiograph instead of CT planned. A reduction in CT can be effected. Practical guidance for DGHs is required, particularly for those outsourcing out of hours work. Knowledge of radiation exposure in common examinations amongst radiology department staff
radiological
Authors: Ai-Lee Chang*, Sophie Wood, Dorothy Keane Background: Ionising radiation (Medical Exposure) regulations 2000 and 2006 (IR(ME)R) impose a responsibility on imaging departments to ensure that all exposures to ionising radiation are justified and doses are optimised. Standard, indicator and target: All radiology department staff should have knowledge of relevant radiation doses for commonly performed examinations. 50% awareness of dose estimation per chest x-ray equivalent. Methodology: Questionnaire with 14 questions. Results of 1st audit round: November 2012 Responders 54/70(77%)