Introduction Whole-body computed tomography (WBCT) is advocated for use in some trauma patients presenting to the emergency department (ED). It is unclear how widespread the use of WBCT is in the UK and the best way to select patients for WBCT remains controversial. The aim of this study was to investigate the current use and nature of WBCT policies in ED in the UK.
Methods A postal questionnaire was devised and distributed to lead doctors of 245 ED in the UK in May 2010. Two further rounds of questionnaires were sent out in June and July to non-responders.
Results 184/245 hospitals responded (75.1%). 41/184 (22.3%) ED had a WBCT policy. 43 (23.4%) further ED indicated that they used WBCT in certain cases, without a formal policy. Hospitals with a WBCT policy saw significantly more trauma cases than those that did not. Most hospitals with a WBCT policy used multiple criteria to decide which patients received WBCT, although there were variations in the timing of CT and in who could request it. Out-of-hours CT scans were less likely to be reported by a consultant radiologist, and reporting times were longer.
Discussion The use of WBCT in the UK is variable, although centres that see more trauma seem more likely to have a WBCT policy. The results do raise concerns about how effectively WBCT can be delivered, especially out of hours, but nationwide plans to reorganise trauma care may potentially affect how and at which ED WBCT is offered in the future.
- emergency care systems
- emergency departments
- major trauma management
- multiple trauma
- whole-body imaging
- wounds and injuries
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- emergency care systems
- emergency departments
- major trauma management
- multiple trauma
- whole-body imaging
- wounds and injuries
There are at least 20 000 cases of major trauma annually in England and blunt force trauma is the most common cause of death among young adults.1 Data from the 2007 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report suggests that more than half of multiple-injured patients in England and Wales received ‘less than good’ care. Poor access to CT and inappropriate utilisation of CT were reasons for suboptimal care in some cases, although the benefits of whole-body computed tomography (WBCT) were not explored in detail in the report.2
However, the use of WBCT to assess injuries in trauma patients is increasing. Patients have been selected for WBCT on the basis of the mechanism of injury,3 ,4 injury pattern,5 or a combination of factors such as mechanism, injury location and abnormal vital signs.6 ,7
One of the perceived benefits of WBCT is the accurate detection of patients' injuries, but good quality data on the diagnostic accuracy of a single-pass WBCT scan are lacking. There are also no conclusive data demonstrating that WBCT has an effect on patient mortality.8 A retrospective database review of 9259 German trauma patients,9 all with an injury severity score of more than 16, suggested that there were more survivors than expected in the group that received WBCT than the group that did not. However, overall differences in the trauma care between the two groups cannot be ruled out, and improved injury detection in the WBCT group may have artificially inflated the injury severity score, potentially masking differences between the two groups. Two other studies that investigated mortality rates in trauma patients found no differences in survival between those who received WBCT and those who did not.10 ,11
There are misgivings about the use of WBCT. It involves greater amounts of ionising radiation than the use of x-rays or targeted CT, and estimates put the excess lifetime risk of fatal cancer from a single WBCT at between one in 1000 and one in 2000.12 ,13 A critically injured patient's actual radiation burden will often be higher when the need for repeat imaging is considered.14 There is further concern that the unnecessary use of WBCT may delay definitive management of serious injuries. In patients urgently requiring operative intervention even small delays in the emergency department (ED) may increase their chances of dying.15
The appropriate selection of patients and the use of WBCT is thus a topic of great importance. Studies differ in their interpretation of the utility of WBCT in effecting significant changes in clinical management,3 ,16 ,17 and a considerable number of WBCT scans may be unnecessary.7 There seems little consensus from the literature about how best to implement WBCT, and for which patients it is most likely to be of benefit.
Little is known about the use of WBCT policies in the UK. The aim of this study was to investigate the current use and nature of WBCT policies in ED in the UK.
A postal survey was sent to lead clinicians in ED. A list of type 1 ED was compiled from three sources: the College of Emergency Medicine (a 2009 list, with thanks to Mr Philip McMillan); NHS Choices website (http://www.nhs.uk/ServiceDirectories/Pages/AcuteTrustListing.aspx, England and Wales only); and from an existing list within our department (England and Wales only). This information was cross-referenced with individual hospital or trust websites when possible to ensure that the data were up to date.
A questionnaire and cover letter was drafted in January 2010. It was reviewed and tested by an ED doctor locally and a slightly revised version was finalised (see supplementary material, available online only).
We believed this study would fall under the remit of ‘service evaluation’ rather than clinical research,18 and this was clarified after communication with both the Sheffield Research Ethics Committee and Sheffield Teaching Hospitals' Research Department and Clinical Effectiveness Unit.
Results from individual ED were anonymised, with the smallest unit of comparison being made at the regional level. The regions compared were Scotland, Wales, Northern Ireland, and each of the 10 strategic health authorities in England.
The questionnaire was distributed during May 2010. Second and third rounds for non-responders were distributed in June and July, respectively.
Basic spreadsheet functions allowed the summation of data for comparison. Data were either categorical (tick box or yes/no answers) or free-text response. When patterns between two sets of ordered categorical data were investigated appropriate 2×2 or larger contingency tables were constructed. In these cases (as appropriate), a χ2 trend for association with p values, or an OR and 95% CI, with p values calculated using Fisher's exact test, were generated. A p value of less than 0.05 was considered statistically significant. Statistical analyses were performed using the InStat programme (Graphpad software, http://www.graphpad.com/instat/).
Questionnaires were sent out to 245 ED. Ten replied indicating that they were minor injury units or otherwise did not receive trauma patients. One hundred and eighty-four of the remaining 235 returned completed questionnaires (78.3%). There was a similar proportion of responses from all of England, Wales, Scotland and Northern Ireland.
The number of trauma patients that each ED reported seeing per week is shown in figure 1. The majority of ED that responded (152/184, 82.6%) saw one trauma patient or less per day.
Only six (3.3%) ED had 24-h consultant presence; 110 (59.8%) had 24-h specialist registrar (SpR)/ST4–6 presence; 173/174 ED (99.4%, 10 non-responders) had 24-h access to CT; 178/184 (96.7%) had an alert policy for their trauma patients.
Forty-one out of 184 (22.3%) respondents indicated that they had a WBCT policy for their trauma patients, with regional variations (tables 1 and 2). Although not specifically asked by the questionnaire, two other ED indicated that they had a policy in development and 43 indicated that they used WBCT in the absence of a formal policy. A total of 86/184 (46.7%) ED, therefore, indicated that the use of WBCT for trauma was acceptable practice.
There was wide variation in the number of trauma patients seen by ED (table 3), although there was a significant association between the increasing number of trauma patients seen and the presence of a WBCT policy (χ2 test for trend 11.63, p=0.0006). Those ED that saw more than one trauma patient per day were more likely than those who saw less than one trauma patient per day to have a WBCT policy (14/32 vs 27/152, OR 3.60, 95% CI 1.60 to 8.12, p=0.0039).
In 31/41 (75.6%) of the ED that had a WBCT policy, at least three criteria were used to determine whether patients were appropriate for WBCT. In all cases in which only one criterion was used (5/41, 12.2%) it was always the presence of multiple injuries. The frequency with which each criterion was used is shown in table 4.
Of the 45 additional ED that indicated that they also used WBCT, but without a formal policy, 36 provided information on the criteria they used to select patients. Again, multiple criteria were used in all but one ED.
ED consultants most often requested WBCT, although, in many circumstances, more junior doctors were allowed to request WBCT. Consultant-only request was permissible in five out of 41 ED that had a formal WBCT policy. None of the ED that had consultant-only requests were those that indicated that they had 24-h consultant presence in the ED. Most of the ED (34/41, 82.9%) with a WBCT policy indicated that they would request that it be performed after completion of the primary survey.
In the vast majority of cases, reporting by a consultant radiologist was usually available in hours (178/184, 96.7%). There was no difference in the likelihood that a consultant would be available to report scans in hours between ED with or without a WBCT policy (39/41 with WBCT policy, 139/143 without WBCT policy, OR 0.56, 95% CI 0.099 to 3.18, p=0.617).
Reporting by a consultant radiologist was usually available in 133/184 hospitals (72.3%) out of hours. In ED with a WBCT policy, consultants reported scans out of hours less often, although this did not quite reach statistical significance (usually reported by consultant in 25/41 with WBCT policy, 108/143 without WBCT policy, OR 0.51, 95% CI 0.24 to 1.06, p=0.077). In 44/184 hospitals (23.9%), reporting was usually done out of hours by SpR/ST4–5 radiologists, and in seven out of 184 (3.8%) the CT scans were sent electronically to an organisation that reported the scans remotely.
Respondents reported that the vast majority of CT scan reports were available within 2 h. In hours, 173/183 (94.5%) were reported within 1 h, and out of hours, 161/183 (88.0%) of CT scans were reported within 1 h (one non-responder). There were no differences in the time to report between hospitals with a WBCT policy and those without one either in hours (χ2 test for trend 0.98, p=0.323) or out of hours (χ2 test for trend 0.08, p=0.772) (see table 5).
Comparison between the times that we were told it took to report CT scans revealed a significantly increased likelihood for an increased time to report out of hours in hospitals without a WBCT policy (χ2 test for trend 4.15, p=0.042), and also overall (χ2 test for trend 3.98, p=0.046), compared with in hours. There was no difference between time to in-hours and out-of-hours reporting for hospitals with a WBCT policy (χ2 test for trend 0.02, p=0.881).
This is the first national-level survey of WBCT use that we are aware of. Most of the existing data about the use of or selection of patients for WBCT are essentially case series. The work from Huber-Wagner et al9 does review WBCT performed across the whole of Germany, but in this article information is provided about the number of departments that use WBCT, the criteria used for patient selection and organisational issues about performing and reporting WBCT.
Most ED saw less than one ‘trauma’ case per day—defined in the questionnaire—so for many ED it is likely that decisions regarding whether or not to carry out WBCT would not be made very often.
Very few ED had a 24-h consultant presence (3.26%). None of the ED with WBCT policies who only allowed consultant requests had 24-h consultant presence, and this might feasibly impact upon the requesting and performing of WBCT out of hours. Efforts are being made to increase consultant presence in the ED and expand the consultant workforce,19 which may be particularly relevant as the majority of severely injured patients do, in fact, attend ED out of hours.2
Less than a quarter of respondents to the survey had a WBCT policy, but all regions had ED that used WBCT. ED seeing a higher volume of trauma were more likely to have a formal WBCT policy, and such centres have been shown in England and Wales to offer a higher standard of care to their trauma patients.2 Perhaps it can also be intuited that ED in the UK with more experience with WBCT manage its use better, but there is no supporting evidence in the literature for this. We do not suggest that the presence of a WBCT policy is the reason for improved care for trauma patients, rather that a policy may be present more often in centres with better systems in place for dealing with the multiply injured patient.
An unanticipated additional finding was the number of ED indicating that they used WBCT, but without a policy. We demonstrated that at least 86 ED had experience with WBCT, but this figure should be viewed with caution. The questionnaire was not specifically designed to record these data, so the actual number of ED using WBCT without a formal policy may be higher.
The finding that most ED with WBCT policies used multiple criteria to select patients for WBCT reflects practice reported elsewhere in Europe.6 ,7 Interestingly, no ED used mechanism of injury alone as criteria for selecting patients for WBCT, which other authors have reported.3 ,4 Most ED would request WBCT after life-saving interventions had been performed (ie, after the primary survey), and such an approach has also been reported previously.20
The role of the radiologist should not be underestimated when considering the need for WBCT. Close cooperation will be needed when making requests and the timely recognition and reporting of injuries may be important to a patient's progress. Increasing specialisation might necessitate the development of a ‘trauma’ radiologist to interpret different types of injury accurately across several different body regions.21
In this study, most CT were reported within 1 h of the request being made, although it is interesting to note that ED with a WBCT policy showed a trend towards longer time to report out of hours. Clearly, hospitals performing WBCT need tried and tested mechanisms to ensure the timely delivery of an accurate and checked report to ED doctors and, when needed, specialty doctors.
It has been reported that diagnostic information can be obtained from WBCT as soon as 19 min after the start of the scanning process. However, this figure was produced under optimum trial conditions with dedicated radiologists beginning to evaluate the CT scans as soon as they were acquired. The scans themselves were re-formatted very quickly.22 The expectation that it is possible to report CT scans accurately as quickly as this in everyday clinical practice may well be unreasonable. Therefore, the finding from this survey that most CT reports for trauma patients are available within 1 h is encouraging, although accurate reporting is more important than early reporting.
This postal questionnaire received a good response rate (78.3%), a rate at which non-response bias is less likely to be a problem,23 although it is possible that those that did not have a WBCT policy or interest in WBCT would be less likely to respond. We attempted to allow for this by looking at the odds of having a WBCT policy by the round in which ED returned a completed questionnaire (data not shown), and found that there was no difference. The use of multiple data sources to compile an up-to-date list of type 1 ED will hopefully have reduced the chance that a department was missed out of the survey, although we did contact some ED that were minor injury units. It is possible that some of the non-responders were also minor injury units. Reminders were sent out to non-responders when it became apparent that the response rate from that round of questionnaires was falling. A more intense follow-up and/or use of other media (eg, e-mail, telephone follow-up) may have yielded a better response rate.24
The survey did not differentiate between the types of CT report issued—ie, verbal or written, provisional or final—or investigate potential differences between provisional and final reports and the impact this may have had on patient care. Furthermore, in hospitals that indicated that CT scans were usually reported by SpR/ST4–5 doctors, it is not clear how often (if at all) such scans were dual-reported or authorised by consultant radiologists.
This survey merely gives a snapshot of current practice regarding WBCT use. It provides no answers on the appropriateness of such use of WBCT, nor on the impact that decisions to use or not to use WBCT have on a patient's care. We did not ask questions about the organisation and delivery of care to trauma patients among hospitals that use WBCT, or the location of the CT room. The NCEPOD report recommended that CT scanners be adjacent to the resuscitation room, but in 2007 this was the case in only 57.4% of hospitals in England and Wales.2 All of these factors will affect the decision to use WBCT and the time required to perform it and get definitive diagnostic information.
The careful selection of patients suitable for WBCT is important, and there seems little consensus in ED that provide WBCT on how to do this. A clinical decision rule, based on features from the history or mechanism of injury, anatomical injury and vital signs, could potentially help identify those patients who would benefit from WBCT.
Concerns about the ability to deliver WBCT effectively, especially out of hours, have been highlighted in this survey, with wide variations in practice. Indeed, variations in overall trauma practice have led to pronounced differences in survival from major trauma in hospitals in England and Wales.25 Nationwide plans to set up regional trauma networks—with a small number of hospitals acting as major trauma centres, supported by other hospitals taking less severely injured patients—are underway in an attempt to improve and homogenise trauma care for the seriously injured patient26 and could potentially save 450–600 lives a year in England alone.1 It will be interesting to see if the nature of WBCT use changes when these networks are fully operational. If a small number of major trauma centres are receiving all of the ‘significant’ trauma, should it be just these centres that are offering WBCT?
This study showed that less than a quarter of UK ED surveyed have a WBCT policy, and practices regarding the use and timing of WBCT and patient selection for WBCT vary widely. The survey has further highlighted concerns about how effectively WBCT can be delivered, particularly out of hours. WBCT needs to be effectively used within a well-organised system of trauma care, and the diagnostic benefits from performing WBCT must be weighed against the possible risks of delaying definitive treatment. Reorganisations in trauma care are planned, and it is possible that the delivery of WBCT will improve as a result.
The authors would like to thank Dr Avril Kuhrt, for providing feedback on the questionnaire design, and Mrs Joanne Casson, for administrative support.
Funding No commercial funding was received for this project. CMS undertook this work as part of a masters degree during an academic clinical fellowship funded by Yorkshire and the Humber Deanery.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.