There is continued focus on preventing unnecessary CT scans in the ED.1-3 Nevertheless, the practice remains prevalent.

“In the short term, ordering CT scans liberally may protect against litigation. But that is not necessarily good resource utilization or in the best interest of the patient,” says Genevieve Santillanes, MD, an associate professor of clinical emergency medicine at the University of Southern California.

Researchers reviewed 154 CTs and 154 ultrasounds ordered in the ED for abdominal complaints for appropriateness, based on American College of Radiology recommendations.4 More than one-third (36.3%) of the CTs and 84.4% of the ultrasounds were inappropriate.

Isolated minor head trauma; other blunt trauma, such as motor vehicle collisions; abdominal pain; and seizures all lead to overuse of CT scans in children. “Missed appendicitis is one of the more common reasons for malpractice lawsuits after pediatric emergency visits,” Santillanes notes.5

Appendicitis can be difficult to diagnose during the initial ED presentation.6 “Utilization of alternate forms of imaging can be helpful if the indications and limitations are understood,” Santillanes explains.

For example, ultrasound can be useful in the evaluation of pediatric abdominal pain. “But clinicians must understand that if the appendix is not visualized, the ultrasound is nondiagnostic,” Santillanes cautions.

Appendicitis remains a possible diagnosis for that patient. Some hospital appendicitis pathways use ultrasound, followed by focused MRI if the ultrasound is nondiagnostic. “Such pathways can decrease the need for CT scans without increasing liability,” Santillanes explains.

A good shared decision-making discussion between the EP and the family offers some additional legal protection. When children present with undifferentiated abdominal pain or vomiting, Santillanes explains it this way to parents: “While most abdominal pain and vomiting in children is not dangerous and will improve without specific intervention, appendicitis and other abdominal emergencies can present just like a viral illness in the first day or so. But appendicitis or other emergent conditions will declare themselves over the next day.”

Next, she explains what would warrant additional diagnostic testing so families know what to look for (e.g., pain that consistently is in the right lower abdomen, pain that makes it difficult for the child to walk, or any worsening or lack of improvement in a day or two). “Similarly, after trauma, I talk to families about the risk of injury that is not immediately evident,” Santillanes adds. Other recommended interventions:

  • Tell families what should lead them to return;
  • Document the conversation in the chart;
  • List specific return precautions on discharge paperwork.

This makes it clear to families (and to anyone who reviews the ED chart later) why the CT was not ordered during the initial visit. If the provider takes the time to explain this, the family is less likely to be angry if there is a delayed diagnosis. “Without a discussion at the first visit, the family may feel that a CT scan wasn’t ordered because the physician didn’t take the complaint seriously, didn’t care, or rushed the visit,” Santillanes warns. Providers also should document these specifics:

• A clinical decision rule was used (e.g., the Pediatric Emergency Care Applied Research Network for children with minor head trauma or the Pediatric Appendicitis Score).

• The provider believes the long-term risk of radiation is greater than the risk of a missed injury or missed emergent pathology. This makes it clear the provider did not forget to order the CT; in fact, the provider was carefully considering what was best.

“Families, and lawyers, may forget that CT scans can also cause harm, and that we are weighing the potential harm of radiation when making decisions,” Santillanes observes.

• The EP decided to observe the patient for a period. If this is not noted explicitly in the chart, it appears the patient was ignored. Without mention of the need for observation, the chart misleadingly describes a long visit without any interventions or testing. “Time can be a very valuable diagnostic tool,” Santillanes adds.

• The patient was re-evaluated at the end of the observation period. Repeat exams on a patient with minor head trauma might include the parent’s assessment of patient’s mental status, whether the child is tolerating oral intake without vomiting, and presence or absence of severe headache. “It’s a good time to reinforce to the family that the observation period was part of the medical care, not a delay,” Santillanes stresses.

REFERENCES

  1. Elmoheen A, Salem W, Bashir K. Reducing unnecessary CT scan of the head for minor paediatric head injuries at the emergency department. BMJ Open Qual 2021;10:e000973.
  2. Elzinga JL, Dunne CL, Vorobeichik A, et al. A systematic review protocol to determine the most effective strategies to reduce computed tomography usage in the emergency department. Cureus 2020;12:e9509.
  3. Jennings RM, Burtner JJ, Pellicer JF, et al. Reducing head CT use for children with head injuries in a community emergency department. Pediatrics 2017;139:e20161349.
  4. Francisco MZ, Altmayer S, Verma N, et al. Appropriateness of computed tomography and ultrasound for abdominal complaints in the emergency department. Curr Probl Diagn Radiol 2020; Nov 15;S0363-0188(20)30204-8. doi: 10.1067/j.cpradiol.2020.11.004. [Online ahead of print].
  5. McAbee GN, Donn SM, Mendelson RA, et al. Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States. Pediatrics 2008;122:e1282-e1286.
  6. Mahajan P, Basu T, Pai CW, et al. Factors associated with potentially missed diagnosis of appendicitis in the emergency department. JAMA Netw Open 2020;3:e200612.