Evaluating head CT referral quality and appropriateness in an Italian emergency department: a monocentric retrospective study.

Abstract

Objectives: To analyze the quality and appropriateness of head CT referrals from the emergency department (ED) of a single hospital in Italy.

Materials and methods: A quality care study was designed to retrospectively identify consecutive head CT referrals generated from the ED of a tertiary hospital between January 1 and April 30, 2022. Referral quality was assessed using the Reason for Exam Imaging Reporting and Data System (RI-RADS), while referral appropriateness was evaluated according to the American College of Radiology (ACR) criteria.

Results: We included 2908 imaging requests, of which 620 (21%) were adequate (RI-RADS A or B) and 2288 (79%) were inadequate (RI-RADS C or D) in terms of quality. In 410 cases, it was not possible to evaluate the appropriateness of the requests according to the ACR guidelines due to the lack of clinical data. Among the 2498 evaluable requests, 25% were classified as usually not appropriate. Of the requests with RI-RADS A or B, 84% were appropriate. Conversely, among the evaluable requests with RI-RADS C or D, the percentage of appropriate requests dropped to 70%. Of all patients with inappropriate requests, 98% did not suffer from acute cerebral diseases according to imaging, with headache and syncope being the primary clinical indications. Analysis of positivity rates revealed a significant difference between appropriate and inappropriate CT scans (11% vs 1%; p-value < 0.001).

Conclusion: The recent increase in head CT scan requests in the ED is not completely justified and could be mitigated by improving the quality and appropriateness of referrals.

Critical relevance statement: Excessive head CT requests in the ED cause needless radiation, pollution, and costs. Integrating guidelines and prospective justification with clear documentation in patient records, along with improved staff training and a no-blame culture, are key to reducing unnecessary imaging.

Key points: RI-RADS scores the quality, while the ACR criteria assess the appropriateness of imaging referrals. Most ED head CT requests lacked quality (especially lacking a specific diagnostic question) and were often clinically inappropriate. Appropriate head CT indication strongly predicted finding acute cerebral pathology on imaging.