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Emergency Department Use of Computed Tomography for Children with Ventricular Shunts
Todd A Florin1, Paul L Aronson2, Matthew Hall3
1Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
Insights
Half of emergency department visits for children with ventricular shunts involved cranial computed tomography (CT) scans, showing significant hospital variation. Strategies are needed to reduce unnecessary CT utilization and radiation exposure in these pediatric patients.
Area of Science:
- Pediatric neurosurgery
- Radiology
- Health services research
Background:
- Children with ventricular shunts frequently require emergency department (ED) visits.
- Cranial computed tomography (CT) is commonly used in the ED for evaluating these children.
- There is a need to understand CT utilization patterns and associated radiation exposure.
Purpose of the Study:
- To quantify the rates and variability of ED cranial CT utilization in children with ventricular shunts.
- To estimate the cumulative effective radiation dose from these CT scans.
- To assess the relationship between CT utilization and shunt revision.
Main Methods:
- Retrospective longitudinal cohort study of 1319 children (0-18 years) with initial shunt placement.
- Analysis of 6636 ED visits from 2003-2013 across 31 hospitals using the Pediatric Health Information System.
- Multivariable regression to model factors influencing CT utilization and shunt revision within 7 days.
Main Results:
- Cranial CT was performed in 49.4% of ED visits for children with ventricular shunts.
- Significant hospital-level variation in CT utilization was observed, with some patients receiving ≥10 CTs.
- Median cumulative effective radiation dose was 7.2 mSv overall, and 33.4 mSv for those receiving ≥10 CTs.
Conclusions:
- Cranial CT utilization in the ED for children with ventricular shunts is high and highly variable across hospitals.
- Strategies to identify children at risk for shunt malfunction are crucial to reduce unnecessary CT scans and radiation exposure.
- Standardizing care pathways may mitigate overuse of diagnostic imaging in this vulnerable population.
Objectives:
To quantify rates and variation in emergency department (ED) cranial computed tomography (CT) utilization in children with ventricular shunts, estimate radiation exposure, and evaluate the association between CT utilization and shunt revision.
Study Design:
Retrospective longitudinal cohort study of ED visits from 2003-2013 in children 0-18 years old with initial shunt placement in 2003. Data were examined from 31 hospitals in the Pediatric Health Information System. Main outcomes were cranial CT performed during an ED visit, estimated cumulative effective radiation dose, and shunt revision within 7 days. Multivariable regression modeled the relationship between patient- and hospital-level covariates and CT utilization.
Results:
The 1319 children with initial shunt placed in 2003 experienced 6636 ED visits during the subsequent decade. A cranial CT was obtained in 49.4% of all ED visits; 19.9% of ED visits with CT were associated with a shunt revision. Approximately 6% of patients received ≥10 CTs, accounting for 37.2% of all ED visits with a CT. The mean number of CTs per patient varied nearly 20-fold across hospitals; the individual hospital accounted for the most variation in CT utilization. The median (IQR) cumulative effective radiation dose was 7.2 millisieverts (3.6-14.0) overall, and 33.4 millisieverts (27.2-43.8) among patients receiving ≥10 CTs.
Conclusions:
A CT scan was obtained in half of ED visits for children with a ventricular shunt, with wide variability in utilization by hospitals. Strategies are needed to identify children at risk of shunt malfunction to reduce variability in CT utilization and radiation exposure in the ED.
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