Clinical scoring system may improve yield of head CT of non-trauma emergency department patients
The positive rate of head CT in non-trauma patients presenting to the emergency department (ED) is low. Currently, indications for imaging are based on the individual experience of the treating physician, which contributes to overutilization and variability in imaging utilization. The goals of this study are to ascertain the predictors of positive head CT in non-trauma patients and demonstrate feasibility of a clinical scoring algorithm to improve yield. We retrospectively reviewed 500 consecutive ED non-trauma patients evaluated with non-contrast head CT after presenting with headache, altered mentation, syncope, dizziness, or focal neurologic deficit. Medical records were assessed for clinical risk factors: focal neurologic deficit, altered mental status, nausea/vomiting, known malignancy, coagulopathy, and age. Data was analyzed using logistic regression and receiver operator characteristic (ROC) curves and three derived algorithms. Positive CTs were found in 51 of 500 patients (10.2 %). Only two clinical factors were significant: focal neurologic deficit (adjusted odds ratio (OR) 20.7; 95 % confidence interval (CI) 9.4–45.7) and age >55 (adjusted OR 3.08; CI 1.44–6.56). Area under the ROC curve for all three algorithms was 0.73–0.83. In proposed algorithm C, only patients with focal neurologic deficit (major risk factor) or ≥2 of the five minor risk factors (altered mental status, nausea/vomiting, known malignancy, coagulopathy, and age) would undergo CT imaging. This may reduce utilization by 34 % with only a small decrease in sensitivity (98 %). Our simple scoring algorithm utilizing multiple clinical risk factors could help to predict the non-trauma patients who will benefit from CT imaging, resulting in reduced radiation exposure without sacrificing sensitivity.
KeywordsComputed tomography (CT) Emergency department (ED) Utilization Actionable results Clinical risk factors
Area under curve
Electronic medical records
Posterior reversible encephalopathy syndrome
We thank John Brock for his assistance in the preparation of this manuscript.
Conflict of interest
The authors declare that they have no conflict of interest.
This project was partly supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1 TR000002.
- 1.National Center for Health Statistics (2009) Health, United States, 2009: with special focus on medical technology. National Center for Health Statistics, Hyattsville. Available at: http://www.cdc.gov/nchs/data/hus/hus09.pdf. Accessed 23 Sept 2014
- 3.Gee A (2012) Radiation concerns rise with patients’ exposure. New York Times: A18Google Scholar
- 5.NCRP (2009) 160—ionizing radiation exposure to the population of the United States. National Council of Radiation Protection and Measurements, BethesdaGoogle Scholar
- 12.Daroff RB, Bradley WG (2012) Bradley’s neurology in clinical practice. In: Daroff RB, et al (eds). 6th ed. Elsevier/Saunders, PhiladelphiaGoogle Scholar
- 14.National Institutes of Health. National Institute of Health Stroke Scale. Available at http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf. Accessed 23 Sept 2014