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• W3118543801 abstract "HomeRadiologyVol. 298, No. 3 PreviousNext Reviews and CommentaryFree AccessEditorialUse of Triaging Algorithms to Decrease CT Use Following Blunt Head and Neck TraumaFelipe Munera , Adam MartinFelipe Munera , Adam MartinAuthor AffiliationsFrom the Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital/Ryder Trauma Center, 1611 NW 12th Ave, WW-279, Miami, FL 33136.Address correspondence to F.M. (e-mail: [email protected]).Felipe Munera Adam MartinPublished Online:Jan 12 2021https://doi.org/10.1148/radiol.2021204103MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Farris et al in this issue.Dr Munera is a professor of radiology at the University of Miami Miller School of Medicine, University of Miami Health System (UHealth), and Jackson Memorial Hospital/Ryder Trauma Center. Dr Munera is currently the Medical Director of Radiology Services and Service Chief at UHealth, Vice-Chair for Operations Department of Radiology, and Division Director of ER/Trauma Radiology. Dr Munera is an expert as well as a prolific author on imaging of emergency and trauma. He currently serves on the editorial board of Radiology and previously served on the editorial board of RadioGraphics. Dr Munera is actively involved in several societies, including the ASER, RSNA, and ARRS, where he has held several leadership roles.Download as PowerPointOpen in Image Viewer Dr Martin is an assistant professor of radiology at the University of Miami Miller School of Medicine and Jackson Memorial Hospital. Dr Martin currently works in the emergency and trauma section, lending his expertise to injuries of the head, neck, and spine. As a junior faculty, he has a primary research interest in neuroradiology in the acute setting. Dr Martin is currently a member of several radiological societies, including the RSNA, ARRS, and ASNR.Download as PowerPointOpen in Image Viewer Multidetector CT is frequently and increasingly used in the diagnostic work-up of patients who present to the emergency department following blunt trauma. Undoubtedly, accurate diagnosis of acute head and neck injuries has a critical impact on the management of these patients, and decreased time to multidetector CT has been shown to correlate with decreased morbidity, mortality, and length of hospital stay (1).Given the urgent benefits of multidetector CT in trauma and contemporary practices that emphasize ever-increasing diagnostic precision, it is not surprising that numerous studies have suggested multidetector CT imaging may be overutilized (2); that is, certain patients are undergoing imaging that is unlikely to yield actionable, clinically significant results. In light of the ongoing national attention to health care costs, real-world implementation of processes to triage patients to the most appropriate imaging is welcome. Additionally, reducing excessive imaging has the added benefit of improving radiology workflows and limiting patient exposure to unnecessary ionizing radiation.In this issue of Radiology, Farris et al (3) examined the effect of triaging algorithms on the usage of head and neck multidetector CT imaging following blunt trauma. In their single-institution retrospective review of nearly 9000 adults admitted after blunt trauma, 4030 of the patients were admitted before implementing imaging triage guidelines, while 4969 were admitted after the adoption of these algorithms. The triaging guidelines were developed at the authors’ home institution; three clinically tailored algorithms were created to direct patients to head CT, cervical spine CT, and head and neck CT angiography, respectively.Following the implementation of the triaging algorithms, the percentage of patients that underwent CT of the head and neck decreased. Head CT was performed in 64% of patients before adoption of the algorithm and in only 56% of patients after algorithm implementation.Similarly, cervical spine CT was performed in 60% of patients before the use of the algorithm and in only 49% of patients after implementation of the algorithm. The use of cerebrovascular imaging with CT angiography, however, was not significantly affected following implementation of the algorithms. The authors believed that this absence of effect was the result of the algorithm relying in large part on the results of concomitant CT imaging of the head and cervical spine rather than purely clinical criteria, which did not significantly differentiate it from the prealgorithmic criteria that were also partially based on the results of concomitant imaging studies.Perhaps more importantly, Farris et al found no significant difference in clinical metrics such as length of stay, intensive care unit admission, intensive care unit length of stay, or mortality between the patients admitted before and after adopting the triaging algorithms. These findings suggest that patients triaged with the algorithms experience no additional clinical detriment compared with patients who undergo more liberal imaging without triaging guidelines.By the authors’ admission, a potential concern is the possibility of injuries missed in patients who do not undergo imaging because of the triaging algorithms. To truly investigate this consideration, patients who were not imaged because of the algorithms (but who otherwise would have been imaged before implementing the algorithms) would require delayed imaging to evaluate for occult injuries. Neither this study nor prior studies have attempted such an investigation prospectively, presumably to avoid burdening the patient and health care system with likely negative delayed imaging examination results (4).Farris et al note that the absence of significant differences in clinical metrics between the pre- and postalgorithm groups lends credence to the suggestion that no clinically significant misses were present in the postalgorithm group, although the possibility of an occult, subclinical radiologic injury would remain. We agree with the authors’ use of clinical metrics as a proxy for clinically relevant misses and concede that while clinically trivial radiologic misses may be present in the patients who were not imaged because of the algorithms, no important misses were present in the postalgorithm group. Nevertheless, this does not definitively exclude the possibility of clinically important misses, and prior studies have shown that delay in diagnosis can occur even with liberal multidetector CT use (5). As such, clinicians should remain vigilant in follow-up clinical examinations and maintain a high index of suspicion for occult injuries, particularly in scenarios where imaging was initially withheld due to relatively innocuous clinical presentation.As an additional point for consideration, Farris et al used homegrown algorithms that were primarily based on clinical criteria specifically tailored for evaluation of head and neck injury in the setting of blunt trauma. Although we have no major objections to the algorithms’ criteria, as they do not adhere to any universally accepted set of guidelines, it remains to be seen how other algorithms with more strict or relaxed criteria would affect image utilization and, more importantly, clinical outcomes.Finally, it should be emphasized that all of the patients in this investigation were admitted to the hospital, which allowed Farris et al to evaluate the clinical outcomes between the pre- and postalgorithmically triaged groups, at least for the duration of stay. Certainly, many patients imaged in the emergency department following blunt trauma to the head and neck are not admitted. Assessment of these patients' outcomes remains problematic. While the finding that no patients who underwent imaging triage experienced worse clinical outcomes is encouraging, it is unknown if the same can be said of the patients who were discharged from the hospital. However, we would suspect no difference in clinical outcomes between those discharged after utilization of an imaging triage algorithm and those discharged from a setting with liberal CT use.This investigation is admirable in its large sample size and confidently validates that triaging algorithms significantly reduce head and neck multidetector CT utilization after blunt trauma. While this is not entirely surprising, implementing a diagnostic algorithm in routine clinical practice is often an inconsistent process and may be altered by variables such as attending physician preferences, time constraints, and medical-legal concerns. Farris et al submit that they were unable to quantify how appropriately the algorithms were followed, but despite the likely imperfect adoption, a significant improvement in multidetector CT usage was nonetheless demonstrated in a real-world setting. Furthermore, clinical outcomes were not worsened for the cohort that received less imaging due to the algorithm. This strongly suggests that unnecessary examinations were avoided by implementing the triaging instructions. However, continued studies of algorithmically triaged imaging are warranted to further validate the clinical outcomes of patients and optimize algorithm criteria.Disclosures of Conflicts of Interest: F.M. disclosed no relevant relationships. A.M. disclosed no relevant relationships.References1. Huber-Wagner S, Mand C, Ruchholtz S, et al. Effect of the localisation of the CT scanner during trauma resuscitation on survival -- a retrospective, multicentre study. Injury 2014;45(Suppl 3):S76–S82. Crossref, Medline, Google Scholar2. Levin DC, Rao VM, Parker L, Frangos AJ. Continued growth in emergency department imaging is bucking the overall trends. J Am Coll Radiol 2014;11(11):1044–1047. Crossref, Medline, Google Scholar3. Farris CW, Takahashi C, Baghdanian A, et al. Implementation of Institutional Triaging Algorithms Decreases Head and Neck MDCT Use in Blunt Trauma. Radiology 2021;298:622–629. Link, Google Scholar4. Mahoney E, Agarwal S, Li B, et al. Evidence-based guidelines are equivalent to a liberal computed tomography scan protocol for initial patient evaluation but are associated with decreased computed tomography scan use, cost, and radiation exposure. J Trauma Acute Care Surg 2012;73(3):573–578; discussion 578–579. Crossref, Medline, Google Scholar5. Lawson CM, Daley BJ, Ormsby CB, Enderson B. Missed injuries in the era of the trauma scan. J Trauma 2011;70(2):452–456; discussion 456–458. Crossref, Medline, Google ScholarArticle HistoryReceived: Oct 21 2020Revision requested: Nov 2 2020Revision received: Dec 9 2020Accepted: Dec 14 2020Published online: Jan 12 2021Published in print: Mar 2021 FiguresReferencesRelatedDetailsAccompanying This ArticleImplementation of Institutional Triaging Algorithms Decreases Head and Neck MDCT Use in Blunt TraumaJan 12 2021RadiologyRecommended Articles Implementation of Institutional Triaging Algorithms Decreases Head and Neck MDCT Use in Blunt TraumaRadiology2021Volume: 298Issue: 3pp. 622-629Effect of an Institutional Triaging Algorithm on the Use of Multidetector CT for Patients with Blunt Abdominopelvic Trauma over an 8-year PeriodRadiology2016Volume: 282Issue: 1pp. 84-91Diagnostic Yield and Clinical Utility of Abdominopelvic CT Following Emergent Laparotomy for TraumaRadiology2016Volume: 280Issue: 3pp. 735-742Multidetector CT of Laryngeal Injuries: Principles of Injury RecognitionRadioGraphics2019Volume: 39Issue: 3pp. 879-892Imaging and Management of Blunt Cerebrovascular InjuryRadioGraphics2018Volume: 38Issue: 2pp. 542-563See More RSNA Education Exhibits Overlooked Blunt Bowel and Mesenteric Injuries: Imaging Findings and ImplicationsDigital Posters2020Postmortem Imaging of the Cervical Spine InjuriesDigital Posters2018Rules to Scan By: Criteria for Guiding Imaging Workup in TraumaDigital Posters2019 RSNA Case Collection Type III Odontoid fractureRSNA Case Collection2022Traumatic vertebral artery AV fistulaRSNA Case Collection2020Jefferson FractureRSNA Case Collection2021 Vol. 298, No. 3 Metrics Altmetric Score PDF download" @default.
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