BC Computed Tomography (CT) Prioritization Guidelines

Transcription

1 BC Computed Tomography (CT) Prioritization Guidelines I. Preamble 1) Prioritization Levels were originally selected, for simplicity, to match those designed for MRI examinations (BCRS MRI P4P October 2010). The prioritization now assigned has been adopted from the Canadian Association of Radiologist's national designation Five Point Classification System (see Appendix A). Wording, where possible, has been replicated to allow application of principles across modalities. 2) It should be understood that these are guidelines, and as such are designed to apply in general terms. These guidelines are intended for use by radiologists/imaging departments for the prioritization of CT requests and are not the responsibility of the ordering physician. These guidelines should not be applied rigidly to each case, as varying clinical situations, specific patient factors, and other parameters may shift a particular indication from one priority level to another. Access to CT scanners at some sites (especially smaller hospitals with limited technologist availability) will have an impact on the ability to respond to emergent/urgent CT requests. As such, the guidelines should therefore not replace clinical judgment or physician-- to-- physician discussion in these situations nor are these guidelines intended as performance markers on any particular radiologist or imaging department. 3) The clinical questions or scenarios provided within each of the prioritization level tables are broad examples, and are not meant to encompass all requirements for CT scan examinations. Centres may offer specialty CT imaging not reflected in the examples listed. 4) The examples provided should not be interpreted as suggestions that CT is the preferred imaging modality for a given clinical question (i.e. investigation of suspected spinal cord compression in which MRI is preferred when available). 5) Requisitions for CT scans will be evaluated for appropriateness and will be prioritized with radiologist oversight using institutionally accepted mechanisms. Highest priority (P1) will be given to examinations that are most likely to impact positively on patient management and outcome when history and physical examination indicate a potentially unstable and serious medical condition. Medical situations that are less acute, as specified in the attached documentation, will be assigned Priority 2 (P2) or Priority 3 (P3). Follow-- up studies on patients with stable findings, or with lesions in which progression is expected to be slow, will be given the lowest level of Priority 4 (P4). PRIORITY LEVEL P1 P2 P3 P4 CLINICAL EXAMPLE An examination immediately necessary to diagnose and/or treat life---threatening disease. Such an examination will need to be done either stat or not later than the day of the request. An examination indicated within one week of a request to resolve a clinical management imperative. An examination indicated to investigate symptoms of potentially life threatening importance. An examination indicated for long---range management or for prevention. SUGGESTED WAIT TIMES Immediately to 24 hours maximum 7 calendar days maximum 30 calendar days maximum 60 calendar days NOTE: This guideline document is not designed to be all-- inclusive. The ultimate responsibility for prioritization rests with the attending radiologist after consultation with the referring physician. Guidelines need to be interpreted in context of each individual's needs, as there may additional factors to consider such as risk of CIN with iodinated contrast, as well as factors such as age and pregnancy status.

2 Priority 1 (P1) <24 hours BC Computed Tomography (CT) Prioritization Guidelines This category is defined by examinations immediately necessary to diagnose and/or treat life--- threatening disease. Such an examination will need to be done either stat or not later than the day of the request. Decreased or altered level of consciousness TIA/Stroke Headache acute: suspected subarachnoid hemorrhage +/--- CTA Acute stridor NYD Intracranial venous thrombosis Acute trauma to head, facial bones, spine Infection --- neck or intracranial Dissection/Carotid or Vertebral Acute orbital mass or inflammation with imminent visual loss Acute SOB Mediastinitis Acute aortic dissection Acute pulmonary embolism Major trauma Abdominal aorta aneurysm rupture Surgical abdomen (appendicitis, diverticulitis, perforation, bowel ischemia) Renal colic Complications --- postop, abdomen Biopsies/Drainages Acute spinal trauma Cord compression, cauda equina syndrome Discitis / osteomyelitis, suspected (if MRI contraindicated) Fractures/Pre-- op evaluation (acute) Necrotizing fasciitis Acute vascular insufficiency to extremity: CTA evaluation Pediatric Non-- accidental trauma, suspected Congenital Cystic Adenomatoid Malformation / Diaphragmatic Hernia suspected on plain film ( Hip --- post-- op dislocated (ped) Infection --- fungal in immuno-- compromised patients (pediatric) T-- cell lymphoma (usually associated with airway compromise) Cyanotic Congenital Heart Disease

3 Priority 2 (P2) --- maximum 7 calendar days This category includes examinations indicated within one week of a request to resolve a clinical management imperative. Head and Neck malignancy (pre-- op) 1st staging Post-- op neurosurgical patients --- in absence of acute deterioration Orbital Pathology includes new visual symptoms, foreign body and/or acute proptosis Progressive shortness of breath Hemoptysis, increasing in frequency and volume Lung disease --- acute interstitial Lymphadenopathy, hilar Mediastinal mass Pre-- op evaluation of lung mass (+/--- guided biopsy): staging Metastatic pre-- op workup Tumor --- abdomen, search for primary Pancreatitis, complications Malignant Disease --- staging prior to Treatment Solid organ masses --- intra-- abdominal --- characterization Workup of asymptomatic abdominal mass (+/--- guided biopsy) Fractures without neurovascular Sx in which a decision re surgery is required Assess progress of healing if not conclusive on radiography Osteomyelitis (MRI contraindicated) Tumor --- primary bone or soft tissue Tumor -- Musculoskeletal --- Biopsy Pediatric Mass, pediatric evaluation Oncology (pediatric) --- staging or investigation of mass Acyanotic congenital heart disease Craniosynostosis Seizure, first onset (pediatric)

4 Priority 3 (P3) maximum 30 calendar days This category includes examinations indicated to investigate symptoms of potentially life threatening importance. Psychoses --- acute onset --- 1st episode Headaches (recently worsening or soft neurologic findings) Sellar pathology (MRI not available) Seizures, 1st documented Cholesteatoma (inflammatory process middle ear) Hematoma --- chronic subdural, suspected Hearing loss or tinnitus Chronic headache without neurological findings Non-- acute psychiatric assessment Non-- resolving pneumonia on CXR Atypical chest pain in low risk patient (coronary CTA) Renal --- cysts vs. tumors Adrenal mass, incidental finding Pre-- op evaluation of aneurysms Suspected tumor recurrence Unexplained chronic abdominal pain or weight loss Inflammatory Bowel Disease: CT enterography Pain, abdominal --- unexplained chronic Chronic mesenteric ischemia Back pain with objective neurological findings (radiculopathy) Joint pathology, pre-- op localization

5 This category includes cases where an examination is indicated for long range management or for prevention. CTA for aneurysms asymptomatic (family history) Dementia Sinus disease without intracranial complication TMJ pathology Post-- surgical follow-- up (i.e. meningioma resection; pituitary adenoma Rx)as directed by referring clinician Lung disease --- chronic interstitial Bronchiectasis Aneurysm/dissection follow-- up without CXR or symptomatic changes Characterization or follow-- up of small pulmonary nodule Pulmonary Embolus --- chronic Routine follow-- up of treated malignancy History of, or high risk of, colonic polyps (CT colonography) Follow-- up for aneurysm growth Hernia without acute symptoms Renal stone burden Back pain with no objective neurological findings Post-- operative spine with chronic pain Characterization of arthritis, gout Assessment of painful prosthesis Monitoring of multiple myeloma, bone mets where radiographs are inadequate CTA evaluation of chronic vascular insufficiency Pediatric Leg Length, femoral version, tibial torsion

6 IV. Appendix Appendix A Priority Priority Category Definitions Maximum Time Interval Target Priority 1 (P1) Emergent: an examination necessary to diagnose P1: Same day maximum 24 hours and/or treat disease or injury that is immediately threatening to life or limb. Note: for emergent / life-- threatening conditions, some patients require imaging in even less than an hour and these decisions are based on the clinical team s judgment. Priority 2 (P2) Urgent: an examination necessary to diagnose P2: maximum 7 calendar days and/or treat disease or injury and/or alter treatment plan that is not immediately threatening to life or limb. Based on provided clinical information, no negative outcome related to delay in treatment is expected for the patient if the examination is completed within P2: maximum 14 calendar days National Maximum Wait Time Access Targets for Medical Imaging 3 the benchmark period. Priority 3 (P3) Semi-- urgent: an examination necessary to P3: maximum 30 calendar days diagnose and/or treat disease or injury and/or alter treatment plan where provided clinical information requires that the examination be performed sooner than the P4 benchmark period. Priority 4 (P4) Non-- urgent: an examination necessary to P4: maximum 60 calendar days diagnose and/or treat disease or injury where, based on provided clinical information, no negative long-- term medical outcome related to delay in treatment is expected for the patient if the examination is completed within the benchmark period. Specified Procedure Date The MRI or CT Scan appointment date requested by the ordering physician for the purpose of disease surveillance. It is recommended to track performance against specified dates, as poor performance in P1-- P4 categories may alter performance in this category creating a serious concern in patient care for which strategies should be developed. Source: Canadian Association of Radiologists National Maximum Wait Time Access Targets for Medical Imaging (MRI and CT).