Assessment of CT-Ordering Behavior After In-Patient Falls on the Neurosurgery Ward

Introduction: Neurosurgery patients are at higher risk of falls given the morbidity associated with their neurological disease. A non-contrast CT scan of the head is commonly ordered to rule out new intracranial pathology, despite being associated with increased cost, radiation exposure, and no change in clinical outcomes. As the Canadian healthcare system faces continued challenges in expenditure, physicians must focus on cost-effective strategies to deliver healthcare. We analyze our institution’s experience with in-patient falls on the Neurosurgery ward to assess the impact of our therapeutic interventions.

Methods: All in-patient falls on the Neurosurgery ward within a four-year period were analyzed with respect to various fall and patient characteristics. Odds ratios (with 95% CI) were calculated to determine which factors were more likely to result in a CT head being ordered and subsequently positive interval findings and change in management.

Results: From the 6,585 patients admitted, 4.95% (n= 326) had an in-patient fall, of which 17% had a repeat CT head (n=50) done. 24% (n=12) of these showed minute interval traumatic hemorrhagic changes with only 1 patient seeing a change in clinical management. Patient factors associated with a higher OR of getting a CT head to investigate their fall were: age greater than 50 (OR = 4.084), intra-cranial hemorrhage (OR = 2.223), and level 3 severity fall (OR = 5.65). Patients with spinal pathology as their admitting diagnosis were less likely (OR = 0.2031) to have a CT head scan. No factors were significantly associated with positive interval changes on CT.

Conclusion : CT scans without positive interval findings may still hold clinical value due to subjectivity in interpretation. However, most CT head scans rarely result in changes in clinical management. Hence, adopting a more conservative approach towards post-fall imaging may have significant cost-savings potential, without the risk of compromising patient care.