NCEPOD: Trauma - Who Cares? - London Health Programmes

CHAPTER 7 - Management of circulationfor which a discrepancy was found between the casenotesand A&E questionnaire. Three hundred and ninety threepatients had a CT alone and 90 patients had a CT plusanother investigation. Other investigations for haemorrhage,such as FAST, were performed alone on 66 patients.With advances in CT scanning it is possible to obtainrapid and detailed information on injuries and site ofhaemorrhage. If CT scanning is appropriately co-located withthe emergency department and suitably staffed, then thisimaging modality has the potential to provide information onall but the most unstable patients. There is now emergingliterature showing the use of whole body CT scanning inthe multiple injured patient can reveal unsuspected injuries,locate the source of haemorrhage, speed up defi nitive careand reduce additional unnecessary investigations. Wholebody multi-sliced CT scanning with contrast should becomeroutine in the patient with multiple injuries. There is probablyno role for chest x-ray, pelvic x-ray and other plain fi lms if thepatient is to undergo whole body CT scanning as these plainfi lms will delay defi nitive investigation.The advisors assessed the necessity of a CT scan forhaemorrhage, for each patient. Table 59 shows thesedata and demonstrates that there was general agreementbetween the clinical decisions and the advisors’ opinions.However, in 21/457 (4.6%) cases advisors judged that a CTscan was performed unnecessarily. In addition it was judgedthat in 30/309 (9.7%) cases a CT scan was indicated, butwas not performed.Table 59. Advisors’ opinion on the necessity of aCT scan for haemorrhageCTscanCT necessaryYes No Subtotal InsufficientdataTotalYes 436 21 457 26 483No 30 279 309 3 312Total 466 300 766 29 795Time to CT scanningIn those cases where the time to CT scan could bedetermined from the casenotes, the average time taken for aCT scan after arrival in hospital was 138 minutes (2.3 hours)in those patients who only had a CT scan to investigatehaemorrhage and 181 minutes (3.0 hours) in patients whohad a CT scan and another investigation.Long time delays to the CT scanner frequently occurred(Figure 27). This is likely to have major clinical implicationsand ultimately be detrimental to patient outcome. Therefore,hospitals admitting severely injured patients must providemore timely access to this important imaging modality.Timeliness of CT scanningIn 55/254 cases, the clinician completing the A&Equestionnaire indicated that there was a delay to CTscanning. Twenty out of these 55 delays were due theinstability of the patient. The remaining 35 cases weredelayed due to organisational factors.Awaiting radiology staff was a major source of delay (Figure28). This occurs as it is unusual for any hospital in the UKto have resident CT radiographers, unlike North America,Australasia, the Far East or mainland Europe where thiswould be considered normal. The lack of the timely presenceof CT radiography staff is a major issue and an apparentweakness of the multidisciplinary team required to providerapid defi nitive care to the severely injured patient.Even the cases where the reason for delay was cited as‘patient instability’ may be contributed to organisationalfactors: consultant involvement was variable (especially out ofhours) and junior medical staff may have been more reticentthan consultants to move potentially unstable patients to theCT scanner. Furthermore, the location of the CT scanner may74