Choosing Wisely: Research shows low-risk injuries can safely forego abdominal CT imaging

The Hospital for Sick Children (SickKids) is expecting to see the typical rise in child and youth injuries from outdoor activities this summer. CT imaging is widely recognized as a valuable tool to help clinicians rapidly diagnose and manage the care of patients, and new research will help guide clinicians when it’s needed most.

As described in a recently published article in the Canadian Journal of Emergency Medicine, authored by Dr. Suzanne Beno, Emergency Medicine Physician and Medical Co-Director of the Trauma Program at SickKids, robust clinical decision rules have been published on this topic. The literature indicates approximately one-quarter of paediatric patients receiving abdominal CT imaging after this type of trauma are actually at very low risk for intra-abdominal injury (IAI), which includes organs such as the liver and spleen, as well as intestinal injuries. Children are at higher radiation risk from CT imaging compared to adults given their developing organs and longer life expectancy.

“Children may safely forego abdominal CT imaging based upon clinical variables readily available at the bedside,” Beno says. “When all variables are absent, there is a very low risk of an IAI or IAI requiring intervention, meaning there is little reason to subject patients to an unnecessary and potentially harmful test.”

A 2015 registry and chart review by the Trauma Program at SickKids observed that rates of abdominal CT imaging had exceeded published norms, and a significant number of trauma patients imaged were at very low risk for an intra-abdominal IAI. The Trauma Program concluded that safely reducing abdominal/pelvic CT use in low-risk patients was needed.

Resource stewardship, or the safe reduction of tests and treatments that patients do not need, is the goal of Choosing Wisely Canada, an international campaign SickKids joined in 2016. It has been estimated that in health care as many as 30 per cent of all tests and treatments may be unnecessary, add no value, and in some cases can actually lead to harm. CT imaging, despite its many benefits in trauma cases, does result in ionizing radiation exposure and sometimes the need for procedural sedation, which are potential risks, especially to young children. Unnecessary testing utilizes resources that may be needed more by other patients and puts added pressure on the health-care system.

“The Choosing Wisely working group at SickKids provided invaluable support in the preparation and implementation of this project,” Beno says. “The work we’re doing is not only preventing children from being exposed to unnecessary radiation but also optimizing the efficient use of resources.”

Putting research into action

In 2016, a team led by Beno undertook a quality improvement (QI) initiative at SickKids to reduce rates of CT imaging among paediatric assessments following trauma at very low risk of IAI by 20 per cent within a six-month period. A root-cause analysis to assess rising CT rates revealed several factors contributing to overuse, including low familiarity with current literature and clinical decision rules; a trauma culture not aligned with observation or delayed imaging in low-risk patients; and the need for hospital-wide diagnostic imaging guidelines for trauma.

These findings led to the development of a SickKids Trauma Diagnostic Imaging Algorithm and a dedicated CT trauma requisition incorporating the Choosing Wisely criteria for paediatric abdominal trauma imaging based upon robust evidence-based clinical decision rules from both Emergency Medicine and General Surgery. Audit and feedback to providers, along with regular educational sessions were also important in achieving results. Through this QI initiative, the rate of abdominal/pelvic CT in patients at very low risk for IAI decreased from 26.8 per cent to 6.8 per cent. Balancing measures were collected to ensure children with IAI were not being missed, including monitoring for CT scans ordered within 24 hours of admission, return visits within 72 hours, and hospital admissions with newly diagnosed IAI. No clinically significant IAIs were missed as a result of this intervention.

Key takeaways for clinicians

• CT imaging is an important tool for paediatric trauma diagnoses, and when indicated should be performed; however, it is important to minimize the radiation exposure when robust evidence exists to help stratify when children are highly unlikely to have injuries.
• The alternative of abdominal ultrasound has not been shown to have enough sensitivity to replace CT in this setting. Further investigation around contrast-enhanced ultrasound as an example of alternative strategies to CT scanning, is being done and used elsewhere, but is not our standard of care at the present time.
• The results of this study mirror much of the quality improvement work and research that has been published in this field, which all strongly favour a thoughtful and tailored approach to CT imaging in paediatric trauma.