Reasons for ordering computed tomography scans of the head in patients with minor brain injury

Minor brain injury is a frequent condition. Validated clinical decision rules can help in deciding whether a computed tomogram (CT) of the head is required. We hypothesized that institutional guidelines are not frequently used, and that psychological factors are a common reason for ordering an unnecessary CT.

Physicians at the emergency department of a tertiary care hospital completed an anonymous questionnaire before ordering a CT of the head for a patient presenting with a GCS of 13-15 after a head trauma.

Over a period of 10 months, 1018 CTs of the head were performed in patients presenting with a GCS of 13-15 after a head trauma; 168 (16.5%) questionnaires were completed. The most four common reasons for ordering a CT were "to confirm/rule out traumatic intracranial lesion" (in 94% of all questionnaires), "to expedite diagnosis" (63%) "guidelines" (58%) and "fear of missing a traumatic intracranial lesion" (50%). A positive answer for "fear of being sued" was declared in 21%, and "pressure from the patient or his relatives" in 8% of all questionnaires. Of 71 questionnaires without "guidelines" as a positive answer, there were 40 (56%) positive answers of "fear of missing a traumatic cerebral lesion".

Besides guidelines, fear of missing a traumatic intracranial lesion played a role in ordering head CTs. Although the physicians had been instructed in the use of guidelines, including validated clinical decision rules, this did not prevent them from ordering unnecessary CTs.