Appropriateness of CT brain scans in patients presenting with mild head injury at an emergency department in Malta

Abstract

Purpose of the study The purpose of the study was to investigate whether CT brain requests and scans performed for patients presenting at accident and emergency (A&E) with mild head injury (MHI) are being performed in line with the recommended guidelines. These include the National Institute for Health and Clinical Excellence (NICE) guidelines and the locally (Malta) adopted guidelines. Additionally, the study explored referrers’ and practitioners’ opinion about the local use of CT for patients presenting with MHI. Methodology A mixed method research design consisting of two sequential phases was adopted for this study. Phase one was a retrospective chart review (RCR) where the data collected included information regarding the justification of CT brain requests for adult patients suffering from MHI. Percentages were drawn from the whole population of CT brain requests. In the second phase, six face-to-face semi-structured interviews were performed with A&E physicians, radiologists, and radiographers to further explore their opinion about factors relating to the justification and appropriateness of CT brain scans performed locally for patients presenting with MHI. Results A total of 894 brain CT scans for patients with MHI were evaluated in phase 1. Based on the NICE guidelines and local guidelines, 60.29% (n=539) and 56.15% (n=502) of the performed scans were not indicated, respectively. These findings suggest considerable over scanning with CT. Following reflexive thematic analysis of the face-to-face interviews conducted during phase 2, four main themes were conceptualised. These were: the lack of adherence to guidelines, the lack of proper justification, the added pressure due to medicolegal aspects and the need to improve the current justification pathway for CT brain. Conclusions Based on this research, it is evident that there is a high percentage of CT overuse for patients presenting with MHI at a local A&E department. By designing systems that aid healthcare professionals in managing uncertainty as to whether a patient would benefit from a CT brain examination, could optimise CT use in MHI.