Ordering CT Heads on the inpatient setting An Update of the Original Project from January 2012 Cost Containment Project DSR II June 2016 Thi Mai, PGY-2

January 2012 Analysis done on 19 patients at LBVA for unnecessary ordering of CT Heads Defined as “ Recent CT (either 1-7 days prior; or within last 2-4 months); for the same indication; with different imaging recommendation on previous CT; or no new indication. Conclusion: 8/19 received CT Head, 5 of those were repeated within 4 months. 3 of those unnecessary Most at fault was ED, although 1 by Medicine team

Objectives To quantify the amount of CT head images ordered by the ED vs the inpatient team To analyze indications of ordering CT head on the inpatient setting To quantify unnecessary or inappropriate CT head orders, defined as: Ordered for ambiguous indication but no neurological deficits documented Repeat ordering within 4 months for same indication Ordered wrong study (ie MRI would have been more appropriate modality)

Background Indications for CT Head include but are not limited to: TBI (traumatic brain injury) Canadian CT head rule or the New Orleans criteria Stroke Acute headache with high-risk features Syncope suspected to be caused by neurogenic etiology Acute encephalopathy with focal neurologic signs MRI is better for soft tissue abnormalities including metastasis, abscess

CT HEAD in TBI

UCI Policy on Falls For an unwitnessed fall or fall with head impact: MD to consider Head CT if the patient has any 3 risk factors (listed below) or history of major bleed Risk factors for intracranial bleed: Elevated INR On anticoagulation Thrombocytopenia Had loss of consciousness during or immediately after the fall Physical exam findings, such as bruises History of previous falls

Methods All 6 inpatient medicine teams at UCI were analyzed on 6/15/16 CT head were found using “F6” option, resulted during current admission and within 30 days Noted if patient has had CT imaging done within 4 months either at UCI or uploaded from OSH ED H&P and inpatient H&P/progress note were read to clarify reasoning for ordering, attention paid on neurologic exam

Results 64 patients on inpatient teams A-G were analyzed Out of 64, 23 patients received CT Head during this admission and within the last month = 35.9% Out of 23, only 1 showed acute changes, 2 showed stable intracranial hemorrhage 9 out of these 23 patients had CT scans within past 4 months, however 6 of these required new CT scan due to code stroke, ICH, or other obvious reason 1 CT scan was repeated within hours of first one, without clear documentation why

Results CT ordersAMSFALLSyncopeStroke r/o malignancy HATotal Med team ED Total % of all CT scans

Results Unnecessary or inappropriate ordering of CT HEAD Total % of all CTs AMSFALLSyncopeStroke r/o malignancy HA Med team10n/a % ED %

Conclusion Out of 64 patients, 35.9% of the time CT head were ordered; more than half of which by the ED Most common reason for ordering was encephalopathy (34.8%), then fall (26.1%) Often times CT Heads were ordered with normal neurological findings CT heads were ordered to rule out metastasis or intracranial malignancy in 3 patients

Conclusion Medicine teams ordered 8 CT scans, of which 2 were inappropriate or unnecessary Compared to previous study, we do a lot better in looking through chart for previous brain imaging Causes of ordering CT Heads inappropriately or unnecessarily were “defensive medicine”, time constraints, incomplete history or neurologic exam, and possibly patient contraindications/intolerance to other imaging study We should improve on ordering CT scans based on clear indications, and perform more thorough neurologic exams