Everyone who takes care of spine trauma patients at a tertiary referral center is familiar with the difficulties in obtaining and actually viewing images obtained at an outside hospital (OSH) prior to transfer. Sometimes the CD fails to make the trip with the patient, other times it ends up in a resident’s pocket, and occasionally it cannot be opened at all. Any of these scenarios usually results in patients undergoing repeat imaging studies, resulting in unnecessary radiation exposure, increased cost, wasted time, and potentially dangerous transfers of patients with unstable injuries into and out of scanners. Not uncommonly, we see imaging studies repeated even when they are available for viewing—lack of multiplanar reconstructions, poor quality, and incomplete imaging of the injury are common drivers of repeat studies. While physicians who care for spine trauma patients are all too familiar with these scenarios, the magnitude of the problem has never been quantified. On this background, Dr. Bible and his colleagues from Vanderbilt decided to analyze the imaging associated with 1,427 patients with spinal injuries transferred to a Level 1 trauma center over a 51 month period. They found that over 70% of patients had a CT scan imaging at least a portion of the spine at the OSH, and approximately three quarters of these studies were transferred successfully with the patient and were viewable at the trauma center. Fifty percent of the patients whose OSH CT scan was not available to view underwent repeat CT scan compared to 23% of patients whose CT scans had been transferred successfully. While the majority of repeated scans including the spine also included non-spinal anatomy (i.e. head and C-spine, chest and T-spine, abdomen and L-spine), 65 patients had a repeat dedicated spine CT. Most concerning about this was the fact that the rationale for repeating the spine CT scan in 50 of these patients was not clear from chart review, and only 5/65 repeated spine CT scans changed the treatment plan or were required for surgical planning. Decreasing this wasteful and potentially harmful repeat imaging should clearly be a quality improvement priority.
The authors should be congratulated on taking on the daunting task of reviewing over 1,400 charts in an effort to identify areas for improvement at their trauma center. The next step, which will likely be even more difficult, will be for the leaders of this trauma program to identify and implement solutions to this problem. Given that a relatively low proportion of the repeated studies were dedicated spine imaging, the authors will need to identify the reason that so many “traumagrams” (i.e. head and neck, abdomen and L-spine) were repeated. It seems that coordinating care with the OSHs will be essential to having an efficient system that gets the patient the right study at the right institution at the right time. This may mean minimizing imaging at the OSH once an injury that necessitates transfer is identified or possibly encouraging the use of “traumagrams” that allow for the imaging of the spine, head, chest, abdomen, and pelvis with one rather than multiple studies. The authors suggested earlier consultation with the spine service once an injury is identified, which should result in the spine service ordering the studies they actually need rather than having others guess at what they want. Another potential solution is through the use of technology that allows for the electronic transfer of images from the OSH to the trauma center. It seems likely that such technology was not available over the duration of the current study, though it is becoming more prevalent at this point. Developing these links between OSHs and the trauma center will be essential to improving the rate of successful image transfer. Now that the authors have nicely described the scope of this problem, we look forward to the publication of their quality improvement study where they demonstrate how to reduce the rate of unnecessary repeat imaging.
Please read Dr. Bible’s article on this topic in the February 15 issue. Have you attempted to tackle this problem at your institution? If so, let us know about your experience by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor