INNOVATION FUND Innovation, Integration, & Implementation Emergency and Critical Care SHOWCASE 2016 INNOVATION FUND Innovation, Integration, & Implementation Emergency and Critical Care SHOWCASE 2016

Evaluation of the utility of neuroimaging among patients presenting to the emergency department with altered behaviour

Emergency and Critical Care

brian_steinhart

Brian Steinhart

 steinhartb@smh.ca

416-864-5095

mcgowanm@smh.ca

416-864-6060 ext 6202

Highlights

There is limited evidence to support the utility and need for a CT or MRI scan of the head in the context of an altered behavior presentation, with findings leading to a change in patient management. In particular, there is no evidence that this test is imperative in the emergency context.  With the potential harm to patients from unnecessary radiation with a CT, chemical sedation and delayed assessment by a consultant, an evaluation of the role of neuroimaging in the ED for this patient population is warranted. In the ED, reducing wait times is imperative at the administrative level and for which we are benchmarked for performance and funding, but as EPs, the overarching goal is to improve patient care and the quality of patient encounters. For these reasons, the purpose of this multicenter study was to explore the use and frequency of neuroimaging in the ED with patients presenting with altered behavior in order to provide evidence to begin discussions to shift the paradigm with specialists to provide care faster and by reducing time to consultation and disposition. Our study of CT head scans for bizarre behavior ED presentations showed that the CT results did not change the clinical management of the patient. Furthermore, awaiting these results prolonged ED length of stay and delayed patient disposition. A prospective trial of a clinical decision tool for ordering CT head scans in these patients is thus warranted.

Abstract

Introduction: The standard approach between Emergency Departments (EDs) and Psychiatric Emergency Services is to medically “clear” a stable patient of organic pathology prior to psychiatric consultation.This study examines the clinical impact of ordering CT head scans for patients presenting with bizarre behaviour.

Methods: A 5-year retrospective chart review was conducted at 3 academic, urban ED sites. Patients ≥18 years of age triaged as “mental health – bizarre behavior” (defined as deviating from normal cognitive behaviour with no obvious cause) with a CT Head scan ordered while under the care of the ED were included. Exclusion criteria were focal neurologic deficits on exam, alternative medical etiology (i.e. delirium, trauma) and/or pre-existing CNS disease. Demographic, administrative, and neuroimaging data were extracted with 10% of charts independently reviewed by a staff Emergency Physician for inter-rater reliability.

Results: 270 cases met study criteria. CT results were unavailable in 3, leaving 267 cases studied. 49% percent were female, average age 51 years old, 59% arrived by police and/or ambulance and 28% were homeless. 1 case had possible acute findings on CT; 108 (41%) had incidental findings (i.e. cerebral atrophy, small hypodensities); none impacted clinical management. Average time to physician assessment was 1 hour 58 minutes (sd 1:17) and time to CT Head completion was 6 hours 50 minutes (sd 7:20) leaving an average of 4 hours 52 minutes awaiting these results. Ultimately 86% of patients were referred to a consultant of which 92% was to Psychiatry.

Conclusions:This retrospective 3 center study of ordering CT Head imaging for a defined subset of ED patients presenting with bizarre behaviour showed no benefit and prolonged LOS by 5 hours.A clinical decision rule needs to be implemented.

Themes & Abstracts

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