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Computed Tomography in the Emergency Department Setting

Computed Tomography in the Emergency Department Setting There is growing concern that chest computed tomography (CT) and computed tomographic pulmonary angiography (CTPA) for pulmonary embolus (PE) are overused tests, especially in the emergency department (ED).1,2 Vankatesh et al3 looked at adherence to the “National Quality Measure” guidelines for PE—a welcome addition to the PE literature. They prospectively identified 1205 of 5940 patients (32%) who potentially did not require CTPA. However, their discussion only briefly acknowledges that patients present not for a “PE” diagnosis but for cardiopulmonary signs and/or symptoms needing a rapid explanation. Signs and symptoms of PE are notoriously variable and overlap numerous other diseases. Therefore, several estimates of pretest probability have been developed (eg, Wells, Geneva). Still, only a small percentage of imaged patients have a PE (5%-20% in most studies)2,4,5; the remaining 80% to 95% need an alternative diagnosis. Computed tomography provides alternative diagnosis in a significant minority of patients, with some needing immediate attention (eg, pneumonia, cancer, heart failure), while others can be triaged to a non-ED setting.6 It would help place the current results in perspective to know what percentage of patients with avoidable imaging had actionable alternative diagnosis discovered by CT and what percentage of patients who were not imaged had a CT for their symptomatology in the following months. The unstated assumption that “a negative CT is a wasted CT” is not valid either. In patients with multiple comorbidities or potentially important signs and/or symptoms, a negative CT result in the ED is powerful information, permitting early discharge from the ED to other health care providers. When helical CT scanners provided 1 or 4 slices, the CTPA protocol was different than routine contrast-enhanced chest CT. Now, with 16 or more slices, there is little difference in CT technique between CTPA and CT with contrast. Since a CTPA will cover all other conditions diagnosed by chest CT, many clinicians now use CTPA as a generic order when PE is even a remote possibility. Perhaps the question to be asked is “what percentage of CTs ordered out of the emergency room are avoidable?” Perhaps the designation itself (CTPA) should be dropped. In conclusion, establishing national standards for diagnosing PE and encouraging compliance is a big step forward. However, the authors have used a rigid definition of potentially avoidable imaging, not accounting for the vagaries of PE diagnosis and advancing CT scanner technology. Back to top Article Information Correspondence: Dr Goodman, Medical College of Wisconsin/Froedtert Memorial Hospital, 9200 W Wisconsin Ave, Milwaukee, WI 53226-3596 (lgoodman@mcw.edu). Conflict of Interest Disclosures: None reported. References 1. Lee J, Kirschner J, Pawa S, Wiener DE, Newman DH, Shah K. Computed tomography use in the adult emergency department of an academic urban hospital from 2001 to 2007. Ann Emerg Med. 2010;56(6):591-59620619935PubMedGoogle ScholarCrossref 2. Kline JA, Courtney DM, Beam DM, King MC, Steuerwald M. Incidence and predictors of repeated computed tomographic pulmonary angiography in emergency department patients. Ann Emerg Med. 2009;54(1):41-4818838194PubMedGoogle ScholarCrossref 3. Venkatesh AK, Kline JA, Courtney DM, et al. Evaluation of pulmonary embolism in the emergency department and consistency with a national quality measure: quantifying the opportunity for improvement. Arch Intern Med. 2012;172(13):1028-103222664742PubMedGoogle ScholarCrossref 4. Stein PD, Fowler SE, Goodman LR, et al; PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317-232716738268PubMedGoogle ScholarCrossref 5. Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007;298(23):2743-275318165667PubMedGoogle ScholarCrossref 6. van Strijen MJL, de Monyé W, Schiereck J, et al; Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism Study Group. Single-detector helical computed tomography as the primary diagnostic test in suspected pulmonary embolism: a multicenter clinical management study of 510 patients. Ann Intern Med. 2003;138(4):307-31412585828PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Computed Tomography in the Emergency Department Setting

JAMA Internal Medicine , Volume 173 (2) – Jan 28, 2013

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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/2013.jamainternmed.1031
Publisher site
See Article on Publisher Site

Abstract

There is growing concern that chest computed tomography (CT) and computed tomographic pulmonary angiography (CTPA) for pulmonary embolus (PE) are overused tests, especially in the emergency department (ED).1,2 Vankatesh et al3 looked at adherence to the “National Quality Measure” guidelines for PE—a welcome addition to the PE literature. They prospectively identified 1205 of 5940 patients (32%) who potentially did not require CTPA. However, their discussion only briefly acknowledges that patients present not for a “PE” diagnosis but for cardiopulmonary signs and/or symptoms needing a rapid explanation. Signs and symptoms of PE are notoriously variable and overlap numerous other diseases. Therefore, several estimates of pretest probability have been developed (eg, Wells, Geneva). Still, only a small percentage of imaged patients have a PE (5%-20% in most studies)2,4,5; the remaining 80% to 95% need an alternative diagnosis. Computed tomography provides alternative diagnosis in a significant minority of patients, with some needing immediate attention (eg, pneumonia, cancer, heart failure), while others can be triaged to a non-ED setting.6 It would help place the current results in perspective to know what percentage of patients with avoidable imaging had actionable alternative diagnosis discovered by CT and what percentage of patients who were not imaged had a CT for their symptomatology in the following months. The unstated assumption that “a negative CT is a wasted CT” is not valid either. In patients with multiple comorbidities or potentially important signs and/or symptoms, a negative CT result in the ED is powerful information, permitting early discharge from the ED to other health care providers. When helical CT scanners provided 1 or 4 slices, the CTPA protocol was different than routine contrast-enhanced chest CT. Now, with 16 or more slices, there is little difference in CT technique between CTPA and CT with contrast. Since a CTPA will cover all other conditions diagnosed by chest CT, many clinicians now use CTPA as a generic order when PE is even a remote possibility. Perhaps the question to be asked is “what percentage of CTs ordered out of the emergency room are avoidable?” Perhaps the designation itself (CTPA) should be dropped. In conclusion, establishing national standards for diagnosing PE and encouraging compliance is a big step forward. However, the authors have used a rigid definition of potentially avoidable imaging, not accounting for the vagaries of PE diagnosis and advancing CT scanner technology. Back to top Article Information Correspondence: Dr Goodman, Medical College of Wisconsin/Froedtert Memorial Hospital, 9200 W Wisconsin Ave, Milwaukee, WI 53226-3596 (lgoodman@mcw.edu). Conflict of Interest Disclosures: None reported. References 1. Lee J, Kirschner J, Pawa S, Wiener DE, Newman DH, Shah K. Computed tomography use in the adult emergency department of an academic urban hospital from 2001 to 2007. Ann Emerg Med. 2010;56(6):591-59620619935PubMedGoogle ScholarCrossref 2. Kline JA, Courtney DM, Beam DM, King MC, Steuerwald M. Incidence and predictors of repeated computed tomographic pulmonary angiography in emergency department patients. Ann Emerg Med. 2009;54(1):41-4818838194PubMedGoogle ScholarCrossref 3. Venkatesh AK, Kline JA, Courtney DM, et al. Evaluation of pulmonary embolism in the emergency department and consistency with a national quality measure: quantifying the opportunity for improvement. Arch Intern Med. 2012;172(13):1028-103222664742PubMedGoogle ScholarCrossref 4. Stein PD, Fowler SE, Goodman LR, et al; PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317-232716738268PubMedGoogle ScholarCrossref 5. Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007;298(23):2743-275318165667PubMedGoogle ScholarCrossref 6. van Strijen MJL, de Monyé W, Schiereck J, et al; Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism Study Group. Single-detector helical computed tomography as the primary diagnostic test in suspected pulmonary embolism: a multicenter clinical management study of 510 patients. Ann Intern Med. 2003;138(4):307-31412585828PubMedGoogle Scholar

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Jan 28, 2013

Keywords: computed tomography,emergency service, hospital

References