(In)appropriate neurosurgical consultation.
OBJECTIVE
Whether or not a patient could benefit from a computed tomography (CT) scan and/or the evaluation by a neurosurgeon requires judgment by a clinician of the risk of clinical deterioration. To assess this clinical process we aimed to determine how many of the consultations to the Neurosurgical department (NSG) of UC Davis are appropriately indicated for neurosurgical input or management. Secondly, we investigated how CT is used in the University of California Davis Medical Center (UCDMC) in NSG consults of head injured patients compared to a validated and highly sensitive decision making tool, the Canadian CT Head Rule (CCHR).


METHODS
Patients were enrolled in this prospective study if they presented to a department of UCDMC other than neurosurgery and when, consequently, the NSG was consulted. The emergency consultations were categorized into three groups: head injury, spine injury and others. Subsequently, the appropriateness of the consultations was evaluated based on the need for evaluation determined by the likelihood of clinically important intracranial lesions for head injury and by the likelihood of clinically important spinal cord injury or spinal cord instability for spine injury. Of the head injured patients with a CT scan the appropriateness of the scan was determined by way of the CCHR.


RESULTS
Between 21 July and 15 August 2008 99 consultations were included: 32 patients with head injuries, 29 with spine injuries, 34 with other diseases and 4 not sufficiently documented patients. 23 classified inappropriate, 69 appropriate and 7 remained unclassified. Of the head injured patients, 10 (31.2%) had gotten a CT scan that was classified inappropriate.


CONCLUSIONS
NSG receives 3-4 requests for consultations per day from the other services of UCDMC, of which one is of questionable validity and one of the three CT scans for head injury is not necessary. These results suggest the use of the CCHR in UCDMC would improve patient care and could result in large health-care savings, while there would also be less radiation exposure.
van Essen
Thomas Arjan
TA
Department of Neurological Surgery, University of California Davis Medical Center, 4860 Y St., Suite 3740, Sacramento, CA 95817, United States. t.vanessen@erasmusmc.nl
Heeringa
Jorn Jesse
JJ
Muizelaar
Jan-Paul
JP
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001927:Brain Diseases / Q000000981:diagnostic imaging / Q000601:surgery; D002140:California; D002648:Child; D002675:Child, Preschool; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging / Q000601:surgery; D003625:Data Collection; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000000981:diagnostic imaging / Q000601:surgery; D009493:Neurosurgery / Q000592:standards* / Q000706:statistics & numerical data; D018579:Patient Selection; D012017:Referral and Consultation; D018570:Risk Assessment; D013124:Spinal Injuries / Q000000981:diagnostic imaging / Q000601:surgery; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D055815:Young Adult