Background: CT Head imaging for patients with altered mental status is a common procedure that many clinicians utilize to establish a diagnosis. As health care costs rise, practitioners are becoming more conscious about ordering costly imaging studies that are unlikely to change management. The purpose of the study is to determine when obtaining CT imaging in patients with altered mental status during a rapid response (RR) is appropriate. Analysis of the data may help provide a pathway for clinicians to follow to order CT Heads when appropriate to optimize resources and minimize cost burden on the healthcare system.
Methods: We performed a retrospective chart review of the 258 medical rapid responses that were called for “altered mental status” at a large urban/suburban tertiary care hospital over the course of one year. In the subset of these patients who had non-contrast CT Head scans ordered during the rapid response, we assessed whether the test was helpful to the diagnosis of the mental status change, and whether it led to an intervention. Several data points were gathered to categorize these patients, including their comorbidities, reason for admission, and previous history of known neurological disease.
Results: Our study found that of all the rapid responses for altered mental status, 57 patients had a CT head scan ordered during the course of the event. Of those, only four (7%) resulted in positive findings that produced information helpful in eliciting the etiology of the patient’s mental status change. In the remaining 53 patients who were scanned, the CT head provided no diagnostic value to the patient’s mental status change (93%). Three of the patients whom had positive findings had known neurological disease (2 cases of hematoma and 1 case of metastatic malignancy with brain involvement). Only one patient among all 57 patients (1.6%) led to an intervention (craniotomy following evolving subdural hematoma).
The results show that 75% of patients with positive CT findings either already had evidence of neurological disease prior to admission, or were admitted with a neurological diagnosis. Of the 57 patients with CT head scans ordered, 34 of them had no known history of a neurologic comorbidity. Only 1 patient in this cohort (2.9%) had an imaging study that provided diagnostic value.
Conclusions: In hospitalized patients without history of neurological disease who develop acute altered mental status, non-contrast CT head imaging provide low diagnostic yield. The next step of this project is to form a model for when to order CT head scans during a rapid response, so that the cost-conscious clinician can use the algorithm to maximize resources within the hospital and to decrease costs of unnecessary testing.