Vetting requests for body computed tomography

Abstract

The aim of this study was to assess the process and outcome of hospitalised patients (inpatients) for whom whole-body CT was requested but not performed. For 6 months the reasons why CT was not performed were recorded, together with relevant discussions with clinicians. Subsequent referrals for alternative investigations were noted. The eventual outcome of the patients was monitored via the patients' records. Eighty-three (8%) of 1001 inpatient requests were identified for which body CT was not performed after an electronically generated request. Fifty-five requests were not accepted by the radiology department during the vetting process for a variety of reasons (often more than one): criteria used for rejection often overlapped and included referrals outside national guidelines (n = 20), better alternative investigations (n = 29), time constraints (n = 19), over-zealous requests (n = 17) and clinicians' erroneous interpretation of preceding imaging investigations (n = 9). Sixteen CT exams were cancelled by a clinician. An additional 12 exams were not performed for miscellaneous non-medical reasons. In no case could a patient's death be ascribed to CT not being performed. Most (981 of 1001, 98%) CT requests comply with current guidelines, disproving a perception that many radiological referrals are inappropriate. In our health care system radiologists have to turn down some appropriate CT referrals due to a lack of CT capacity. Although lack of CT contributed to delay in diagnosis, no patient died as a direct result of not having CT.

Radiologists’ responses to inadequate referrals

“…Radiologists' response of seeking more information from the clinician takes time, but direct contact between clinician and radiologist can facilitate appropriate examinations and improve patient care [1]. Returning referrals may be less time-consuming, but clinicians may respond by adjusting the clinical information or by gaining approval for a doubtful referral elsewhere [32]. Changing the imaging investigation without contacting the clinician may be more effective and better for the patient, but may upset the clinician [33].…”

Patient dose considerations in computed tomography examinations

“…A number of documents have been published containing information on the clinical indications for CT in order to assist referring physicians to come to an informed decision on whether they should prescribe a CT exam, in the case that they may be in doubt [40][41][42] . While CT is a valuable tool within the diagnostic chain, there are many cases where a CT examination is not actually necessary [43] . Alternative radiation-free imaging modalities, such as ultrasound and MRI, should be used instead, when they may provide the same or even better diagnostic information than CT [44] .…”