Marin Jennifer R, Tyler-Kabara Elizabeth C, Anderson Casey, Butler Gabriella, Charles Shaquille, Furtado Andre, Rosen Johanna R
Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
Division of Pediatric Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
Pediatr Qual Saf. 2021 Jul 28;6(4):e441. doi: 10.1097/pq9.0000000000000441. eCollection 2021 Jul-Aug.
Children with ventricular shunts undergo frequent neuroimaging, and therefore, radiation exposures, to evaluate shunt malfunctions. The objective of this study was to safely reduce radiation exposure in this population by reducing computed tomography (CT) and increasing "rapid" magnetic resonance imaging (rMRI-shunt) among patients warranting neuroimaging for possible shunt malfunction.
This was a single-center quality improvement study in a tertiary care pediatric emergency department (ED). We implemented a multidisciplinary guideline for ED shunt evaluation, which promoted the use of rMRI-shunt over CT. We included patients younger than 18 years undergoing an ED shunt evaluation during 11 months of the preintervention and 25 months of the intervention study periods. The primary outcome was the CT rate, and we evaluated the relevant process and balancing measures.
There were 266 encounters preintervention and 488 during the intervention periods with similar neuroimaging rates (80.7% versus 81.5%, = 0.8.) CT decreased from 90.1% to 34.8% (difference -55.3%, 95% confidence interval [CI]: -71.1, -25.8), and rMRI-shunt increased from 9.9% to 65.2% (difference 55.3%, 95% CI: 25.8, 71.1) during the preintervention and intervention periods, respectively. There were increases in the mean time to neuroimaging (53.1 min; [95% CI: 41.6, 64.6]) and ED length of stay (LOS) (52.3 min; [95% CI: 36.8, 67.6]), without changes in total neuroimaging, 72-hour revisits, or follow-up neuroimaging.
Multidisciplinary implementation of a standardized guideline reduced CT and increased rMRI-shunt use in a pediatric ED setting. Clinicians should balance the reduction in radiation exposure with ED rMRI-shunt for patients with ventricular shunts against the increased time of obtaining imaging and LOS.
患有脑室分流管的儿童需要频繁进行神经影像学检查，因此会受到辐射照射，以评估分流管故障。本研究的目的是通过减少计算机断层扫描（CT）并增加“快速”磁共振成像（rMRI-分流管）检查，来安全地减少这一人群的辐射暴露，这些检查适用于因可能的分流管故障而需要进行神经影像学检查的患者。
这是一项在三级医疗儿科急诊科（ED）进行的单中心质量改进研究。我们实施了一项针对急诊科分流管评估的多学科指南，该指南提倡使用rMRI-分流管检查而非CT检查。我们纳入了年龄小于18岁的患者，这些患者在干预前11个月和干预研究期间25个月内在急诊科接受分流管评估。主要结局是CT使用率，我们还评估了相关的过程和平衡措施。
干预前有266次就诊，干预期间有488次就诊，神经影像学检查率相似（80.7%对81.5%，P = 0.8）。在干预前和干预期间，CT使用率分别从90.1%降至34.8%（差异-55.3%，95%置信区间[CI]：-71.1，-25.8），rMRI-分流管检查使用率从9.9%增至65.2%（差异55.3%，95%CI：25.8，71.1）。神经影像学检查的平均时间（53.1分钟；[95%CI：41.6，64.6]）和急诊科住院时间（LOS）（52.3分钟；[95%CI：36.8，67.6]）有所增加，而总的神经影像学检查、72小时复诊或随访神经影像学检查没有变化。
在儿科急诊科环境中多学科实施标准化指南可减少CT检查并增加rMRI-分流管检查的使用。临床医生应在减少患有脑室分流管患者的辐射暴露与使用急诊科rMRI-分流管检查之间进行权衡，同时要考虑到获取影像的时间增加和住院时间延长的问题。
