Evidence-Based Imaging Improving the Quality of Imaging in Patient Care Series Editors: L. Santiago Medina · Kimberly E. Applegate · C. Craig Blackmore Aine Kelly Paul Cronin Stefan Puig Kimberly E. Applegate Editors Evidence-Based Emergency Imaging Optimizing Diagnostic Imaging of Patients in the Emergency Care Setting Evidence-Based Imaging Series Editors L. Santiago Medina, Kimberly E. Applegate, C. Craig Blackmore Series Editors L. Santiago Medina, MD, MPH Kimberly E. Applegate, MD, MS C. Craig Blackmore, MD, MPH Editorial Board L. Santiago Medina, MD, MPH Co-Director of Neuroradiology-Neuroimaging, Department of Radiology Director, Health Outcomes, Policy and Economics HOPE Center Miami Nicklaus Children’s Hospital Miami, FL, USA Professor of Clinical Radiology Herbert Wertheim College of Medicine Florida International University Miami, FL, USA Former Lecturer in Radiology Harvard Medical School Boston, MA, USA Kimberly E. Applegate, MD, MS, FACR Professor of Radiology and Pediatrics Director of Practice Quality Improvement Department of Radiology University of Kentucky Children’s Hospital Lexington, KY, USA C. Craig Blackmore, MD, MPH Director, Center for Health Services Research and Department of Radiology Virginia Mason Medical Center Seattle, WA, USA Jeffrey G. Jarvik, MD, MPH Professor of Radiology and Neurological Surgery Adjunct Professor of Health Services and Pharmacy Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA, USA Pina C. Sanelli, MD, MPH Associate Professor of Radiology and Public Health Associate Chairman of Practice Quality Improvement Director, Neuroradiology Fellowship Weill Cornell Medical College NewYork-Presbyterian Hospital New York, NY, USA Aims of the Series Evidence-Based Imaging: Improving the Quality of Imaging in Patient Care series presents the radiologist and clinician with a user-friendly guide to the evidence-based science and the merit behind the diagnostic imaging performed in medicine. This ideal reference gathers contributions by internationally renowned specialists in the field. The series provides a systematic framework for understanding the best imaging choices for patient care. Chapters highlight key points that support the clinical applications, allowing fast access to pertinent information. Topics include patient selection, imaging, strategies, test performance, cost-effectiveness, and applicability. By offering a clear understanding of the science behind the evidence, the book fills a void for radiologists, clinicians, physician assistants, nurse practitioners, residents, fellows, students and others with an interest in medical imaging and a desire to implement an evidence-based approach. More information about this series at http://www.springer.com/series/8865 Aine Kelly • Paul Cronin • Stefan Puig Kimberly E. Applegate Editors Evidence-Based Emergency Imaging Optimizing Diagnostic Imaging of Patients in the Emergency Care Setting Editors Aine Kelly Paul Cronin Department of Radiology Department of Radiology Division of Cardio-Thoracic Radiology Division of Cardio-Thoracic Radiology Michigan Medicine Michigan Medicine Ann Arbor, MI, USA Ann Arbor, MI, USA Stefan Puig Kimberly E. Applegate Department of Diagnostic, Department of Radiology Interventional, and Pediatric Radiology University of Kentucky Children’s Inselspital, University Hospital Bern Hospital University of Bern Lexington, KY, USA Bern, Switzerland Department of Radiology and Neuroradiology Klinik im Park, Hirslanden AG Zurich, Switzerland Evidence-Based Imaging ISBN 978-3-319-67064-5 ISBN 978-3-319-67066-9 (eBook) https://doi.org/10.1007/978-3-319-67066-9 Library of Congress Control Number: 2017964706 © Springer International Publishing AG, part of Springer Nature 2018 This work is subject to copyright. 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Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by the registered company Springer International Publishing AG part of Springer Nature. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland To our patients, who are our best teachers To our students, who are the healthcare providers of tomorrow To the researchers, who made this book possible To our families, friends, and mentors AMK: To my loving family past, present, and future, Paddy, Anita, Paul, Alison, Anna, and Eva PC: To my parents, Brendan and Claire. To my loving and supportive wife, Aine, who makes it all possible and our two children who are truly our pride and joy. To my sister, Alison SP: To my wife, Rosi; my sons, Julian, Simon, and Sebastian; and my grandson, Liam Foreword The practice of emergency radiology encompasses the diagnostic imaging management of acutely ill and injured patients in the emergency setting. It is one of the newest subspecialties of diagnostic radiology and one of the fastest growing. Its growth parallels the escalation in emergency medical practice as emergency departments experience an ever-increasing patient volume each year. Many institutions have experienced an annual growth rate of emergency department volume greater than 5%. The sophistication of emergency imag- ing has also been increasing as trauma surgeons and emergency physicians expect and require the availability of all imaging modalities including radiog- raphy, ultrasound, computed tomography, and magnetic resonance imaging at all hours, every day of the week. Emergency physicians are also requesting rapid turnaround times with final image interpretations available days, eve- nings, and nights. Recent investigations have shown that the timely perfor- mance and interpretation of emergency imaging examinations cannot only increase emergency department throughput, decompressing busy centers, but also contribute to improved patient outcomes and decreased healthcare costs. Emergency radiology as a radiology subspecialty has been experiencing increasing recognition for its advances in patient care. Both the Radiological Society of North America and the American Roentgen Ray Society include educational and scientific programs devoted to emergency imaging at their annual meetings. The American Society of Emergency Radiology (ASER) was established 28 years ago and currently has over 1000 members, a vibrant annual meeting with postgraduate course, and an official journal, Emergency Radiology, established in 1994. The journal has showcased original research relevant to emergency and trauma imaging. Emergency radiology fellow- ships have been established at many academic radiology departments, and an increasing number of radiology trainees are entering the practice of emer- gency radiology. It would appear that the time is most appropriate for a compilation of scholarly communications on evidence-based emergency radiology available in textbook format to assist those in emergency practice. The editors have skillfully accomplished this goal. The text is organized into two main sec- tions beginning with an introductory segment on the principles of evidence- based imaging, appraising the literature critically, emergency imaging information systems, and consequences of inappropriate imaging. The sec- ond segment is comprised of 36 chapters (in 5 subsections) covering common emergency conditions requiring high-quality, state-of-the-art imaging man- vii viii Foreword agement. This unique text is not only intended to educate emergency physi- cians and emergency radiologists but all healthcare workers providing care in the emergency setting. I have no doubt that this task will be successfully accomplished with evi- dence-based emergency radiology. Department of Radiology Robert A. Novelline Massachusetts General Hospital Boston, MA, USA Foreword Emergency physicians often depend on sophisticated imaging for many of the patients evaluated in emergency departments (EDs). In fact, nearly 50% of the 130,000 million annual ED visits in the USA are accompanied by radiological imaging of some type, making the field of emergency radiology one that impacts a large percentage of the US population. While emergency imaging has become more sophisticated over the past decades, allowing cli- nicians access to immediate diagnostic tools, this has also come with costs, both financial and otherwise. As with all tests, sensitivity and specificity are not perfect, leading to under- and overdiagnosis. Although the risks to patients of underdiagnosis are more apparent to clinicians and patients alike, overdi- agnosis has its own insidious and potentially harmful consequences. Incidental findings on radiological images can lead to unnecessary and poten- tially harmful testing and treatment, as well as undue patient anxiety. Concerns regarding radiation exposure from radiography, particularly com- puter tomography (CT), have also come to the forefront in the past decade, with many studies raising concerns over radiation-induced malignancies. Since 1980, the use of CT has increased approximately eightfold. This is of particular concern in children, given their greater sensitivity to radiation than adults, their longer life expectancies during which malignancies can be expressed, and the higher dose of radiation they frequently receive unless the CT scan radiation doses are appropriately adjusted to meet their body sizes. Fortunately, CT use has decreased in recent years for a number of reasons, including the increasing use of ultrasound and other imaging modalities, quality improvement initiatives (which include monitoring and feedback of physician radiology use), and shared decision-making between clinicians and their patients regarding the tradeoffs of performing or avoiding specific imag- ing. Finally, the past decade has seen a sharp increase in the use of clinical decision rules and computer-based clinical decision support tools for the use of emergency imaging. This has led to more rational, evidence-based, and cost-effective use of diagnostic imaging. In addition, the Choosing Wisely Campaign of the ABIM (American Board of Internal Medicine) has been championing evidence-based and cost-effective use of diagnostic testing, including the use of imaging in the ED. One specific example of research and efforts dedicated toward evidence- based imaging comes from the Pediatric Emergency Care Applied Research Network (PECARN), which has made emergency imaging decision rules one of its foci in the last decade given the previous lack of evidence around imag- ix x Foreword ing of injured children. Studies from several countries examining the imple- mentation of the PECARN cranial CT decision rules for children with minor head trauma have demonstrated safe decreased use of CT in these children. In 2015, the Society for Academic Emergency Medicine hosted the Academic Emergency Medicine consensus conference entitled “Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization.” Leaders in emergency medicine, radiology, and health services research and other experts came together to discuss and debate the issues described previously and to develop a consensus research agenda. After much preparation and discussion, six content areas emerged as those of greatest importance and in need of future study. These included the development and validation of clinical decision rules for emergency diagnostic imaging; the use of administrative data for emergency imaging research; patient-centered outcomes research; training, education, and competency; knowledge transla- tion and barriers to imaging optimization; and comparative effectiveness research in alternatives to traditional CT use. Many of the issues considered at that conference are intertwined with the contents of this novel and timely textbook. Evidence-Based Emergency Imaging will undoubtedly serve as an out- standing resource for all clinicians who care for acutely ill and injured adults and children. Within the pages of this text, the reader will find the principles of evidence-based imaging and the specific imaging needed for a variety of emergent conditions. This melding of the principles of radiology, clinical epi- demiology, and health services research will help clinicians identify who to image in the emergency setting, what piece of technology to use, and what issues to consider and anticipate. I greatly welcome and applaud the arrival of this new textbook. Departments of Emergency Medicine Nathan Kuppermann and Pediatrics, University of California, Davis, School of Medicine Sacramento, CA, USA Bo Tomas Brofeldt Endowed Chair, Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, USA PRIME Node, Pediatric Emergency Care Applied Research Network (PECARN), Sacramento, CA, USA Pediatric Emergency Research Networks (PERN), Sacramento, CA, USA