Heetderks-Fong Elizabeth
University of Maryland School of Nursing, Baltimore.
Adv Emerg Nurs J. 2019 Apr/Jun;41(2):172-182. doi: 10.1097/TME.0000000000000240.
The American College of Radiology (ACR) developed Appropriateness Criteria (ACR-AC) for diagnostic imaging to reduce overuse and promote high-yield, cost-effective, evidence-based decision-making. For adult headaches, there are 16 variants with specific imaging recommendations. Headache accounts for 4.5% of emergency department (ED) visits, and 61% are chronic. Imaging for headaches has increased in the past 2 decades, with intracranial pathology diagnoses going down. Evidence suggests that there is poor knowledge of the ACR-AC among advanced practice nurses (APNs) and nonradiologist physicians. The ACR-AC recommendations were examined using the Health Care Cost and Utilization Project State Emergency Department Data (HCUP SEDD) from Maryland in 2013. Imaging proportions were examined, as well as differences between residency program hospitals and hospitals that have APNs in the ED. Of the 11,109 chronic headache visits, a quarter underwent computed tomography ([CT]; 26.9%) and 3.6% underwent magnetic resonance imaging (MRI); the ACR-AC does not recommend use of either of these in patients with chronic headache. There were significant practice differences related to hospital teaching and whether APNs were employed in the ED or not. For patients with posttraumatic headache, there were no significant differences in practice. Computed tomography was used in 76.4% of posttraumatic headache visits. It is unknown whether the ACR-AC are being used in the ED, and there is variability in following the recommendations. Posttraumatic headache protocol is well established in the ED, but chronic headache continues to be a problem in imaging overuse despite recommendations. Radiological education, including the ACR-AC, as well as radiation dosing and exposure information should be part of APN, physician, and registered nurse education, as well as continuing education. Continuing education is critical for adherence to the ACR-AC, as the recommendations are complex and continuously evolving. In addition, to minimize overuse of CT in headaches, the ACR-AC should be integrated into clinical decision support to promote best imaging practices.
美国放射学会（ACR）制定了诊断成像的适宜性标准（ACR-AC），以减少过度使用，并促进高收益、具有成本效益的循证决策。对于成人头痛，有16种变体及具体的成像建议。头痛占急诊室就诊病例的4.5%，其中61%为慢性头痛。在过去20年中，头痛成像检查有所增加，但颅内病变的诊断率却在下降。有证据表明，高级执业护士（APN）和非放射科医生对ACR-AC的了解不足。利用2013年马里兰州的医疗保健成本与利用项目州急诊室数据（HCUP SEDD）对ACR-AC建议进行了研究。检查了成像比例，以及住院医师培训项目医院和急诊室配备APN的医院之间的差异。在11109例慢性头痛就诊病例中，四分之一接受了计算机断层扫描（CT；26.9%），3.6%接受了磁共振成像（MRI）；ACR-AC不建议对慢性头痛患者使用这两种检查。在医院教学以及急诊室是否雇佣APN方面存在显著的实践差异。对于创伤后头痛患者，实践中没有显著差异。76.4%的创伤后头痛就诊病例使用了CT。尚不清楚急诊室是否采用了ACR-AC，并且在遵循建议方面存在差异。创伤后头痛方案在急诊室已得到很好的确立，但尽管有建议，慢性头痛在成像过度使用方面仍然是一个问题。包括ACR-AC在内的放射学教育，以及辐射剂量和暴露信息，应成为APN、医生和注册护士教育以及继续教育的一部分。继续教育对于遵守ACR-AC至关重要，因为这些建议复杂且不断演变。此外，为尽量减少头痛患者CT的过度使用，应将ACR-AC纳入临床决策支持，以促进最佳成像实践。
