Selected topic: Emergency radiology
Frequency and Follow-up of Incidental Findings on Trauma Computed Tomography Scans: Experience at a Level One Trauma Center

Presented as a poster at the Society for Academic Emergency Medicine Annual Meeting, San Francisco, May 2006.
https://doi.org/10.1016/j.jemermed.2008.01.021Get rights and content

Abstract

Objectives: Incidental findings found on computed tomography (CT) scan during the Emergency Department evaluation of trauma patients are often benign, but their presence must always be communicated to patients, who should be referred for follow-up care. Our objective was to quantify the frequency of these incidental CT findings in trauma patients. A secondary goal was to determine how often these lesions were communicated to patients and how often patients were referred for follow-up. Methods: We performed a retrospective chart review of 500 consecutive patients presenting as trauma activations. Subjects received head, chest, or abdomen/pelvis CT scans at our hospital. Patients were identified using our trauma registry. Final CT reports were examined and discharge summaries were reviewed for basic demographics. Scans with incidental findings prompted detailed secondary review of discharge summaries to determine follow-up. Investigators reviewed incidental findings and classified them into three groups by clinical importance, using predetermined criteria. Results: Of the 500 patient charts identified for review, 480 (96%) were available, yielding 1930 CT reports for analysis. Incidental findings were noted in 211 of 480 (43%) patients and on 285 (15%) of the 1930 CT studies performed for the 480 patients. Of available patient records, only 27% of patient charts had mention of the finding in the discharge summary, had documentation of an in-hospital workup, or had documentation of a referral for follow-up. Most-concerning lesions, such as suspected malignancies or aortic aneurysms, accounted for 15% of all incidental findings and were referred for follow-up in only 49% of cases. Conclusions: Incidental findings were noted in 15% of trauma CT scans. Follow-up was poor, even for potentially serious findings. Further studies should examine the long-term outcome of patients with these findings.

Introduction

Computed tomography (CT) has become the preferred means for diagnosis of many types of injury in trauma patients. Although the increased use of CT scan may improve the immediate diagnosis of traumatic injury in these patients, one consequence has been the increased frequency of incidental findings discovered in the course of initial trauma work-up.

Incidental findings—findings on CT that are unrelated to the original purpose of the scan—are problematic because they may prompt additional diagnostic testing and potentially dangerous diagnostic interventions. At the same time, it is possible that CT scanning may contribute to the serendipitous discovery of serious illness. Failure to appropriately manage incidental findings presents significant medico-legal exposure, and places the patient's health at risk.

We examined a series of trauma patients receiving CT imaging to determine: 1) What is the frequency of incidental findings discovered on trauma CT scans at our center? 2) How seemingly clinically significant are these findings? 3) How often is documented referral to outpatient or inpatient follow-up performed? This study attempts to report the number of findings uncovered during the routine course of trauma scanning, and whether our system is robust enough to ensure follow-up. We do not report the results of any follow-up.

Section snippets

Study Design and Setting

This study was a retrospective chart review of patients presenting as trauma activations to our Level I trauma center, which has a trauma admission volume of over 4000 patients annually. In this hospital, after the patient has undergone initial trauma evaluation, the trauma team determines if CT scanning is required. The CT images are initially reviewed by a senior resident or staff radiologists, and a final read is subsequently issued by the staff radiologist.

Selection of Participants

Investigators accessed the

Results

Of the 500 patient charts identified for review, 480 (96%) were available, yielding 1930 CT reports for analysis. The median age of the trauma cohort was the third decade of life; the median age of patients with incidental findings was the fourth decade of life (only decade of life could be abstracted due to HIPAA blinding requirements). Sixty-three percent of all reviewed patients were male; 54% of those with incidental findings were male. The median age of patients with incidental findings

Discussion

In this study, 43% of patients presenting to our trauma center had at least one incidental finding discovered during trauma evaluation. Such prevalence echoes high rates previously reported in the literature. In a retrospective study conducted at a California Level I trauma center, the overall ratio of incidental findings was 34.1% in men and 27.6% in women (1). In another study of incidental findings found on ED-ordered abdominal spiral CTs, investigators reported incidental findings in 47% of

Conclusions

The performance of a large number of CT scans during the evaluation of trauma at our center has generated a large number of incidental findings. These findings vary in importance, but all should be communicated to the patient and some require referral to primary care physicians or specialists for follow-up. In our system, documentation of incidental findings and follow-up instructions was poor. Effective management of incidental findings will require a rigorous quality-control system. This

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