Audit of Appropriateness: Brain Scan Use for Paediatric

Headache at the Emergency Department

Lyndon Woytuck1, Meghan Linsdell2, Lawrence Richer2,3

1St. George’s University of London medical programme delivered by the University of Nicosia 2Women’s and Children’s Health Research Institute, University of Alberta, Edmonton, AB, Canada

3Department of Pediatrics, Division of Neurology, University of Alberta, Edmonton, AB, Canada

9 YEAR-OLD GIRL SPLITTING HEADACHE

PURPOSE

• To evaluate appropriateness and outcomes at the emergency department in comparison with best practice for brain imaging in children presenting with headache.

YOU WILL LEARN

• How well the emergency department images children presenting with headache

• That we catch most important diagnoses (i.e. brain tumour)• We overexpose children to radiation• Studies suggest this is common worldwide• We can improve

THE PROBLEM

• Guidance: American College of Radiology Appropriateness Criteria on headache• low risk (usually not appropriate)• high risk (usually appropriate)

• Are the criteria useful / do they match diagnosis?• Can we learn from our mistakes?

METHODS

• Searched ED records: ICD “Headache”• Excluded head trauma in last 7 days

• 645 patient visits over 1 year from Feb 1 2014 – Jan 30 2015• Stollery Children’s Hospital, Edmonton, Canada

• Stratified – “usually NOT appropriate”, “MAYBE appropriate”, “USUALLY appropriate”• Compared imaging results

IMAGING COMPARED TO CRITERIAAppropriateness Rating Category

Number of Cases

Proportion Imaged

Important Abnormalities

Incidental Abnormalities

Usually not appropriate

412 9.7%

n=40, CI 9.3-10%

1.7%

n=7, CI 1.2-2.2%

1.5%

n=6, CI 1.0-1.9%

May be appropriate 156 28%

n=44, CI 27-29%

2.6%

n=4, CI 1.3-3.8%

1.3%

n=2, CI 0.0-2.5%

Usually appropriate 77 56%

n=43, CI 55-57%

30%

n=23, CI 28-32%

5.2%

n=4, CI 2.8-7.6%Table 1. Number of cases sent for neuroimaging

acquisition and relevant findings according to appropriateness rating. Number (n) and 95% confidence intervals (CI) included.

RESULTS

Most patients that presented to the ED with headache did not receive neuroimaging

o CT scans are overusedo Some high risk patients did not receive brain imagingMost cases handled appropriatelyCould make predictions as per Appropriateness Criteria

DISCUSSION

• Compared Hong Kong Study; the Stollery scanned less• Compared to Pakistan Study: similar CT overuse in migraine• Imaging all catches diagnoses, both important and benign pathology• MRI underused – no radiation risk + higher yield, BUT expensive + high demand• Better record-keeping, guidance usage, clinical rules could help!• “Better safe than sorry” + parental anxiety

MISTAKES CLINICIANS MAKE

• Missing warning signs: high risk patients• CT imaging due to anxiety• Not vetting “medium risk” patients• Not referring to guidance

WHAT YOU CAN DO

• Use CT less, and MRI more• Strongly consider past history and aetiology

• Primary or Secondary?• Neuro signs / symptoms?• Red flags?

• Use imaging criteria! ACRAC or local guideline

• Remember: imaging rarely changes diagnosis

THANK YOU!רבה !תודה

QUESTIONS?

woytuck@ualberta.ca