Pediatr Radiol (2014) 44 (Suppl 3):S409–S413 DOI 10.1007/s00247-014-3122-x
IMAGE GENTLY ALARA CT SUMMIT: HOW TO USE NEW CT TECHNOLOGIES FOR CHILDREN
Why and when to use CT in children: perspective of a pediatric emergency medicine physician Karen Frush
Received: 11 February 2014 / Revised: 2 July 2014 / Accepted: 10 July 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract The Emergency Department is a risk-laden environment for clinicians caring for children. A number of factors can increase the risk of medical errors and adverse events, including lack of standardized medication dosing because of size variation in the pediatric age range, unique physical and developmental characteristics of children that affect treatment strategies, and the inability of young or non-verbal children to provide a medical history or to clearly communicate pain and other symptoms. The Emergency Department (ED) setting is often hectic and chaotic, with lots of interruptions. Many EDs lack the pediatric-specific supplies deemed essential for managing pediatric emergencies, and long hours or overnight shifts, while necessary for maintaining 24-hour emergency services, can cause provider fatigue that can lead to increased medical errors. It is in this environment that ED physicians make decisions about the use of CT scans in children, often without evidence-based guidelines to help them weigh risks and benefits. Although recent efforts have raised the awareness of the risk of exposure to radiation, many pediatric providers and families lack adequate information to guide decisions about the use of CT. Pediatricians and emergency physicians need to collaborate with radiologists to maintain current knowledge of the risks and benefits of CT scans, to advocate for pediatric protocols and evidence-based guidelines, and to engage families in decisions regarding the evaluation and treatment of pediatric patients in the Emergency Department.
Keywords Emergency department . Computed tomography . Assessment . Risk factors . Pediatric K. Frush (*) Department of Pediatrics, Duke University School of Medicine, DUMC, Box 3701, Durham, NC 27710, USA e-mail: [email protected]
Introduction Health care is a risky business. It has now been almost a decade and a half since the seminal Institute of Medicine report that between 45,000 and 98,000 people die each year from adverse events such as health care acquired infections, adverse drug events and procedure-related errors . More recent studies suggest that the number is probably 10 times greater, and even more people experience harm related to health care . Much has been written about the risks specific to children in today’s health care environment, especially in the Emergency Department setting [3–6]. In 2006 the Institute of Medicine published a report on the future of emergency care in the U.S. health system . One component of this report, titled “Emergency Care for Children: Growing Pains,” noted that children represent approximately 27% of all emergency visits, and 80% of these visits are to non-children’s hospitals . Of all Emergency Departments in the country, only 6% have all the supplies deemed essential for managing pediatric emergencies, and about half of all emergency departments have 85% of these supplies . In addition to supplies, clinicians in the ED need to maintain a strong pediatric knowledge base and competencies. Because a minority of patients in most general EDs is in the pediatric age group, ED nurses and providers may lack familiarity with some types of pediatric emergencies, and the cognitive and technical skills learned during professional training can deteriorate quickly without practice. Similarly, a small proportion of emergency medical calls and transports are for pediatric patients, so many emergency medical service providers also lack regular exposure to pediatric emergencies. Compounding the concern of deterioration of pediatric competencies without much practice is the fact that pediatric continuing education is not required for many emergency medical service providers. Further, pediatric testing and
treatment patterns vary widely across emergency medical service providers and emergency departments, and much of this variability could be from a lack of evidence to guide practice patterns . Pediatric patient safety experts have identified several factors in caring for children that may increase the risk of an adverse event [7–9]. These include lack of standardized dosing because of size variation in the pediatric age range, unique physical and developmental characteristics of children that affect treatment strategies, and the inability of young or non-verbal children to provide a medical history or to clearly communicate pain and other symptoms. Caring for children in the Emergency Department may be especially high risk because of a number of environmental and human factors . The ED setting is often hectic and chaotic, with lots of interruptions and a frequent need to calm frightened and anxious children and parents. Fluctuations in volume can be challenging, especially when large numbers of patients with relatively minor illnesses or injuries tie up limited resources and distract providers and staff from more urgent and emergent patient needs . Lack of equipment and supplies can add to the stress of providers trying to multitask and prioritize patient acuity, and long hours or overnight shifts, while necessary to maintain 24-hour emergency services, can cause further stress and fatigue that can lead to increased medical errors . Communication errors among health care providers are a common cause of adverse events , and there are many challenges to effective communication and teamwork in the ED setting. ED staff and providers often come and go at different times throughout the day because of varying shift duration and strategies to optimize department financial performance such as flex staffing. This leads to numerous patient hand-offs that are often brief and interrupted as well as decision-making by multiple providers. Information from consultants and in-patient teams can get lost or misinterpreted among the myriad individuals involved in one patient’s care. Verbal orders, which are often necessary at the time of a true emergency, lead to increased risk of a communication error caused by lack of redundancy or a double-check mitigation strategy . Additional challenges include communication barriers with children, which can be caused by the developmental age of the child and also by language barriers and cultural differences between the child and parents, and ED providers. Studies have shown that non-English-speaking patients might be a high risk group in terms of medical errors . It is in this often hectic and distracting ED environment that children are evaluated for serious illnesses and injuries and decisions about the use of medical imaging, specifically CT scans, are made.
Pediatr Radiol (2014) 44 (Suppl 3):S409–S413
CT scans in pediatric patients in the emergency department Imaging is an important component of care provided to children in the ED, and there are many benefits of CT scans, including more accurate diagnosis of common conditions such as appendicitis and more efficient treatment of children with closed head injuries and multiple trauma. Emergency physicians and pediatric emergency medicine physicians have come to rely on CT as a vital component of rapid diagnostic evaluation of children in the ED, and many hospitals now have CT scanners located either in the Emergency Department or in close proximity, making scans more accessible. The speed of newer scanners has reduced imaging time to only seconds or a few minutes for many studies, thus decreasing the need for sedation even in young children. The ability to eliminate risks of sedation, including respiratory depression and drug interactions, while maintaining the quality of CT images  makes the use of CT scans an attractive choice for ED providers. It should not be surprising, then, that the use of CT scans increased markedly over the last decades. During a 14-year period between 1995 and 2008, researchers found that the number of visits to EDs by children that included a CT scan increased 5-fold (from 0.33 million to 1.65 million), even though the total number of ED visits during the same time period remained relatively constant . The most common complaints for which CT scans were obtained included head injury, abdominal pain and headache . There was a similar but slightly smaller increase in the use of CT scans in adults evaluated in EDs across the United States during the same time period . Overall, CT scans were obtained in approximately 3.2% of ED visits in 1996, and by 2007 the rate had risen to nearly 14% . During the last couple years the use of CT scans in children has peaked and begun to decrease . This may be a result of an increased awareness of the risk of CT scans in children, driven primarily by the Society for Pediatric Radiology and others, through the ALARA (as low as reasonably achievable) approach, which focused national attention on the issue of radiation dose and provided education for the health care community through collaborative conferences and educational offerings. Additionally, the Image Gently campaign (www.imagegently.org), an educational and advocacy initiative of the Alliance for Radiation Safety in Pediatric Imaging, reached out to parents and pediatric providers to raise awareness of opportunities to lower radiation dose in the imaging of children. The Web site promotes informed decision-making, consideration of risks and benefits, and advocacy for the use of childspecific protocols to limit radiation dose when CT scans are performed in children.
Pediatr Radiol (2014) 44 (Suppl 3):S409–S413
Why and when emergency department providers order CT scans: closed head injuries Closed head injury is one of the most common types of childhood injury, resulting in more than 500,000 ED visits each year by patients 14 years and younger . Traumatic brain injury is a leading cause of death and disability in U.S. children, accounting for approximately 2,685 deaths and 37,000 hospitalizations annually . The major benefit of CT scans in children with closed head injury is early identification of those with clinically important traumatic brain injury because these children require acute management, most often emergent neurosurgery. Unnecessary CT imaging, however, could expose children to the potential risk of cancer later in life, and traumatic brain injuries have been found in less than 10% of CT scans in children with minor head trauma . Considering the lack of evidence to guide decision-making regarding use of CT scans in children with closed head injuries, Kuppermann and colleagues  in the PECARN network conducted a large multicenter study and published their results in 2009. The primary aim of the study was to derive and validate prediction rules for clinically important traumatic brain injury to identify children with blunt head trauma who were at very low risk and for whom CT scans might be unnecessary . Researchers derived and validated agespecific prediction rules for two groups of children: those younger than 2 years and those 2 years and older. On the basis of their study of more than 42,000 children at 25 hospital EDs across the United States, researchers stratified children with minor head trauma in these two age ranges into three risk categories. These categories are now used to make decisions related to CT scans . Children who present with altered mental status or signs of skull fracture are at highest risk for traumatic brain injury and should undergo CT scanning . Children who are evaluated for closed head injury and have no clinical symptoms or findings included in the appropriate prediction rule (younger than 2 years or 2 years and older) are at low risk for traumatic brain injury, and most can be safely managed without a CT scan. For the remainder of children who have one or more symptoms or findings included in the predictive rule, the level of risk of traumatic brain injury is not as clear, and clinicians would then use other factors to help determine the need for a CT scan . For example, a child with an isolated headache might be observed for several hours rather than having a CT. Conversely, children who have a combination of findings and symptoms or whose condition is worsening, as well as infants younger than 3 months of age with a closed head injury, should undergo CT scanning. When the prediction rules were used, researchers found that the total number of CT scans obtained per population was
reduced, and no case of traumatic brain injury requiring neurosurgery was missed . Widespread application of these rules has been promoted by pediatric emergency medicine experts and may be helping to limit CT use, thus reducing unnecessary exposure to radiation. The rules can also provide data and information that may be useful to families when considering the risks and benefits of CT scanning in the setting of closed head injuries in children.
CT scans in the setting of pediatric abdominal pain In the setting of pediatric trauma, a prediction rule has been developed through a multi-site study to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom CT could be obviated . Abdominal pain is also a common complaint of children brought to the Emergency Department without a history of trauma, and the primary concern of many pediatric patients, parents and referring physicians in this setting is often “could this be appendicitis?” Once this question has been raised, especially if mentioned by a primary care provider or referring physician, it is difficult for the ED physician to avoid some type of imaging study to provide a definitive answer, even if the clinical evaluation in the ED suggests a different diagnosis. Pediatricians, surgeons and radiologists all agree that the evaluation of children with suspected appendicitis has been greatly enhanced by advances in imaging over the last several decades. Plain radiographs and enemas, the mainstay of evaluation up until 30 years ago, were augmented by ultrasound (sonography) in the mid-1980s and helical CT scans in the mid-1990s . When multidetector-array CT (MDCT) became available in the late 1990s, allowing increased sensitivity and specificity in the evaluation of appendicitis, this became the preferred imaging modality of ED providers and the use of CT scans rose markedly [22, 23]. As CT use has risen over the last decade, so has the discussion and debate over the risk and benefits of CT as clinicians have tried to balance the increased diagnostic performance of a scan with its potential risk from radiation exposure. Of concern is the fact that abdominal and pelvic organs are more radiosensitive than brain tissue, and children’s tissues are more radiosensitive than adults’. Although the exact risk of cancer later in life from a single CT scan cannot be determined, all clinicians and child advocates would agree that it is important to avoid any increased risk, and thus any exposure to radiation, when there is a safer alternative. The use of US, or sonography, is a common alternative to CT scans, especially in cases of suspected appendicitis in nonobese children . The major benefits, in addition to avoiding exposure to radiation, are that US is noninvasive and does not require intravenous or enteral contrast material,
as CT scans often do in children. The biggest problem, however, is that sonography is not as sensitive and specific in diagnosing appendicitis as CT scans and can sometimes lead to equivocal findings or a delay in diagnosis . Further, US can sometimes be technically difficult and it is highly operator-dependent, requiring the presence of an experienced radiologist or sonographer. In some hospitals, then, US is available at only certain times of the day or week, or it may not be available at all. This could change as emergency physicians gain more experience with US techniques and training. Some emergency medicine programs are now offering fellowship training in sonography, and perhaps the ED physicians who complete this year-long training will gain the skills and experience they need to use ultrasound successfully in the evaluation of suspected appendicitis in children. Currently a staged imaging approach (i.e. starting with sonography and going on to CT when the sonogram is inconclusive), assuming appropriate imaging expertise, is a very defensible, cost-effective and radiation-conscious strategy for evaluation .
Strategies to improve patient safety in pediatric imaging Limiting the number of CT scans in children through the use of evidence-based guidelines and alternate imaging modalities is a strategy that can be used to improve patient safety and avoid unnecessary radiation exposure, as well as potential complications from sedation. Emergency physicians, pediatricians and surgeons must work collaboratively to limit CT scans when appropriate, and all these providers should engage parents (and the patient directly, if he or she is old enough) in developing evaluation and treatment plans in the ED. Engaged parents (and patients), defined as those who work collaboratively with providers to share information, make decisions and adhere to jointly agreed-upon treatments, believe they have an important role to play in their child’s care . Dr. Don Berwick, the former Director of the Centers for Medicaid and Medicare, has said that in a truly patient-centric system, patient engagement equates with the maxim “nothing about me without me,” thus, any component of the health care system that affects the patient must include the patient . This manner of thinking, then, extends the idea of shared decision-making with parents to shared responsibility for processes and outcomes, after consideration of the risks and benefits involved in the care plan. In the setting of the ED, for example, it can be difficult for the emergency physician to achieve “shared decision-making” with parents or to convince them that their child can be safely managed without a CT scan if they’ve been told to “go to the ED and get a CT” by another physician. Ideally, parents should be advised that the child needs to be evaluated for abdominal pain or a mild closed head injury in the ED, and emergency providers can then
Pediatr Radiol (2014) 44 (Suppl 3):S409–S413
share appropriate clinical information, including a discussion of risks and benefits with parents, so that they may arrive, together, at a shared decision related to diagnosis and treatment of the child. Although radiation exposure is a potential risk that must be considered when choosing an imaging modality, CT is a powerful diagnostic tool, and there are many clinical situations involving children in the ED in which the benefits of a scan outweigh the risk. In these circumstances, the best safety strategy is to reduce radiation exposure by ensuring that the CT exam is customized, or optimized, to the size of the child and the indication of the study. Pediatricians and emergency physicians can advocate for safe scanning by working with radiology colleagues to assure focused exams, shielding of reproductive organs or other strategies to lower dose to the gonads, and use of advanced CT equipment and protocols that can reduce the radiation dose, or exposure, for each child. Parents can also advocate for such safety strategies, as well as participate as active partners when potential diagnostic and treatment plans for their child are discussed among the members of the ED team. Pediatricians can assist this effort by informing families of the risk and benefits of CT scans and referring them to patient-friendly information sources such as the Image Gently web site. All physicians involved in the care of children in the ED will do well by focusing on patient safety and compelling benefits of the evaluation and care plan, while minimizing potential risk.
Conflicts of interest Dr. Frush has no financial interests, investigational or off-label uses to disclose.
References 1. Kohn HT, Corrigan JM, Donaldson MS (2000) To err is human: building a safer health system. National Academies Press, Washington 2. Pronovost PF, Wachter RM (2014) Progress in patient safety: a glass fuller than it seems. Am J Med Qual 29:165–169 3. Institute of Medicine Committee on the Future of Emergency Care in the United States Health System (2006) Hospital-based emergency care: at the breaking point. National Academies Press, Washington, DC 4. Institute of Medicine Committee on the Future of Emergency Care in the United States Health System (2006) Emergency care for children: growing pains. National Academies Press, Washington 5. AAP Committee on Pediatric Emergency Medicine, Krug S, Frush K (2007) Patient safety in the pediatric emergency care setting. Pediatrics 120:1367–1375 6. Joint Commission Resources (2010) American Academy of Pediatrics. In: Krug SE (ed) Pediatric patient safety in the emergency department. Joint Commission Resources, Oakbrook Terrace 7. Miller MR, Pronovost PJ, Burstin HR (2004) Pediatric patient safety in the ambulatory setting. Ambul Pediatr 4:47–54 8. Slonim AD, LaFleur BJ, Ahmed W et al (2003) Hospital-reported medical errors in children. Pediatrics 111:617–621
Pediatr Radiol (2014) 44 (Suppl 3):S409–S413 9. Lannon CM, Koven BJ, Lane France F et al (2001) Principles of patient safety in pediatrics. Pediatrics 107:1473–1475 10. Chamberlain JM, Slonim AD, Joseph JG (2004) Reducing errors and promoting safety in pediatric emergency care. Ambul Pediatr 4:55–63 11. Joffe MD (2006) Emergency department provider fatigue and shift concerns. Clin Pediatr Emerg Med 7:248–254 12. (1998) Special report on sentinel events. Joint commission on accreditation of healthcare organizations. Jt Comm Perspect 18:19–33, 36–42 13. Morey JC, Simon R, Jay GD et al (2002) Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 37:1553–1581 14. Cohen AL, Rivara F, Marcuse EK et al (2005) Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics 116:575–579 15. Larson DB, Johnson LW, Schnell BM et al (2011) Rising use of CT in child visits to the emergency department in the United States, 1995– 2008. Radiology 259:793–801 16. Kocher KE, Meurer WJ, Fazel R et al (2011) National trends in use of computed tomography in the emergency department. Ann Emerg Med 58:452–462 17. Townsend BA, Callahan MJ, Zurakowski D et al (2010) Has pediatric CT at children’s hospitals reached its peak? AJR Am J Roentgenol 194:1194–1196
S413 18. Faul M, Xu L, Wald MM et al (2010) Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA 19. Brain Injury Association. http://www.biausa.org/brain-injurychildren.htm#Incidence. Accessed 8 July 2014 20. Kuppermann N, Holmes JF, Dayan PS et al (2009) Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study. Pediatric Emergency Care Applied Research Network (PECARN). Lancet 374:1160–1170 21. Holmes JF, Lillis K, Monroe D et al (2013) Identifying children at very low risk of clinically important blunt abdominal injuries. Pediatric Emergency Care Applied Research Network (PECARN). Ann Emerg Med 62:107–116 22. Frush DP, Frush KS, Oldham K (2009) Imaging of acute appendicitis in children: EU vs US … or US vs CT? A North American perspective. Pediatr Radiol 39:500–505 23. Doria AS, Moineddin R, Kellenberger CJ et al (2006) US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 241:83–94 24. Broder JS (2011) Radiation risks from diagnostic computed tomography in the emergency department. Ann Emerg Med 57:309–310 25. Awé C, Lin SJ (2003) A patient empowerment model to prevent medication errors. J Med Syst 27:503–517 26. Berwick DM (2009) What ‘patient-centered’ should mean: confessions of an extremist. Health Aff 28:w555–w565