Directed training facilitates out-of-hours emergency brain scans

By Eleanor McDermid, Senior medwireNews Reporter

An intensive teaching session helps emergency department (ED) physicians to reliably interpret head computed tomography (CT) scans when a radiologist is not on duty, a study shows.

However, the researchers stress the importance of maintaining a database to identify areas where ED staff are misinterpreting CT findings and providing ongoing feedback to rectify problems.

The study was based in a single hospital, and initial training, consisting of a 3-hour tutorial given by a consultant radiologist, was attended by all senior ED staff. Over the following 8 months, these ED staff interpreted 360 head CT scans done out of hours. The scans were reviewed the next morning by a consultant radiologist, who interpreted 40 as abnormal, and agreed with the ED interpretation for 94% of patients.

"In the small number of discordant cases, none of the patients experienced an adverse clinical outcome as defined by not requiring a change in management once the formal report was available," say lead study author Karim Jamal (St Helier's Hospital, UK) and team.

ED staff detected all cases of subarachnoid, subdural, and extradural hemorrhage, but missed one case of intracerebral hemorrhage - multiple small hemorrhages caused by head trauma. They detected five of nine acute infarcts but none of four old infarcts. The infarcts they missed were mostly small lacunar infarcts.

"This has given us a useful insight in designing future teaching sessions," write the researchers in the Emergency Medicine Journal.

The ED staff correctly identified two of seven cases of soft tissue swelling, but missed all three skull fractures and one case of cerebral edema. Overall, the positive predictive value was 91%, showing that ED staff were mostly correct regarding the abnormalities they did identify, but the sensitivity was 53%, showing that they missed nearly half of all abnormalities identified by the radiologists.

However, all patients with missed diagnoses were kept in for observation or admitted, so were still on site when the radiologist's diagnosis became available.

"Emergency physicians need to remember that the clinical status of the patient must never be ignored, irrespective of their CT head findings," says the team.

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