Anyone who has been to a surgery morbidity and mortality conference understands the cultural bias behind the desire to “pan-scan” all trauma patients. If an injury is missed, and the body part wasn’t scanned, someone is going to need to stand up and look foolish.
However, this article describes a trauma center in Boston that made a concerted effort to reduce CT scanning. They came up with fifteen evidence-based guidelines for various scans and made a consensus to use these decision instruments to assist in their assessment for need for CT. And, as you might expect, they identified significant reductions in CT scanning during their study period – 37% total reduction in number of CT scans. If 37% doesn’t sound like a big enough number, perhaps the $1.1M absolute difference in brain, chest, and abdomen/pelvis scan costs is enough to get your attention.
However, they have rather some weaknesses. They state there were “no missed injuries”, which is unusual because every study of CT in trauma patients fails to achieve 100% sensitivity – even in patients with liberal use of CT. Then, they do have twice as many “complications” in their evidence-based scan group, as well as three times as many 30-day readmissions. I’m not sure each complication follows from the scanning strategy, but it is an oddly significant difference.
Interestingly, they excluded patients who did not survive 24 hours. Perhaps it complicated their abstraction process, but it is of slightly greater clinical interest to evaluate for potential missed injuries that resulted in immediate demise, rather than the misses that resulted in slightly longer-term morbidity.
“Evidence-based guidelines are equivalent to a liberal computed tomography scan protocol for initial patient evaluation but are associated with decreased computed tomography scan use, cost, and radiation exposure”
www.ncbi.nlm.nih.gov/pubmed/22929486