CT Head Scans Yield No Acute Findings and Increase ED Length of Stay in Patients Presenting with Bizarre Behavior

P Ng1 M McGowan1 B Steinhart1, 2

1Department of Medicine, University of Toronto

2Emergency Medicine, St. Michael’s Hospital

Context

Impact of Obtaining CT Head in the ED among Bizarre Behaviour Patients

• Psychiatric presentations represent a growing proportion of Emergency visits

• Collaborative Emergency Department – Psychiatric Emergency Services approach is to “medically clear” (ensure there is no organic cause) stable patients, including blood work and CT Head prior to transfer of care to Psychiatric Emergency Services (PES)

St. Michael’s Hospital, Toronto, ON• Urban, academic, inner city, level-1 trauma centre (ED volume 72,000 in 2012)

~ 10% annual volume increase~ 15 % sheltered and/or homeless~ 20% mental illness and/or addiction

Problem and Issue• Canadian and American Psychiatric Association recommend CT Head with disease

onset despite no studies demonstrating causality

• CT Head scans, most commonly used in the Emergency Department, pose a radiation risk to the patient and may require the use of chemical sedation (medications) or physical restraints to obtain quality neuroimaging

• Are CT Head scans necessary and what is the impact on clinical management and time spent in the Emergency Department?

Impact of Obtaining CT Head in the ED among Bizarre Behaviour Patients

Measurement• Single-site 5-year retrospective review (2007-12) of patients > 18 years of age, triaged

as “mental health – bizarre behaviour” with a CT Head scan while under the care of ED

• “Mental health – bizarre behavior” defined as any deviation from normal cognitive behavior with no obvious external or structural cause

• Exclusion criteria: focal neurologic deficits on exam; alternative medical etiology for bizarre behavior (i.e. delirium, trauma); and/or pre-existing CNS disease

• 10% of all charts were reviewed by a staff Emergency Physician for inter-rater reliability

Table 1. Clinical Administrative Time MetricsPhysician Initial Assessment (PIA)

mean (SD) 1:22 + 1:10 hr

PIA to CT Result mean (SD) 9:09 + 10:37 hrConsult Request n (%) 75 (90%)

Consultant ServicePsychiatry 71 (95%)Internal Medicine 4 (5.3%)

PIA to Consult Request mean (SD) 3:19 + 3:51 hrConsult Request Prior to CT Result

n (%) 47 (57%)

Consult Attend Prior to CT Result n (%) 43 (52%)

Departure DestinationHome 34 (41%)Admit 49 (59%)

Impact of Obtaining CT Head in the ED among Bizarre Behaviour Patients

Contribution to Patient Safety & Quality ImprovementCT Head scans did not yield acute findings

•While there was no change in clinical management of the patient based on CT Head findings, it did potentiate radiation exposure and delayed consultant evaluation, which in turn postpones initiation of definitive management

Acquiring CT Head prolongs ED Length of Stay

•Prolonged length of stay contributes to Emergency Department crowding which increases patient wait times and impairs the evaluation and treatment of patients waiting to be seen

Partners for Knowledge Translation

•Multi-centre review underway with 4 urban, academic Toronto Emergency Departments

•Collaborations with Psychiatry, Neurology, and Medical Imaging are in place to look at evidence-informed patient-centred process improvement

Table 2. Impact on ED Length of Stay and Consult Attending

MD assessment to consult attending

Total ED length of stay

Waiting for CT result prior to assessment

9:09 ± 10:37hr (0:33-68:58)

23:02 ± 17:28hr (1:09-97:59)

Patient seen before CT result 3:19 ± 7:42hr(0:00-97:24)

18:14 ± 18:25hr (0:45-166:30)