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КЛИНИЧЕСКАЯ ЛАБОРАТОРНАЯ ДИАГНОСТИКА
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Original Paper
x-RAYS REFERRAL IN AN EMERGENCY DEPARTMENT
Zohair Jamil Gazzaz - MB, ChB, PhD, Health Research Centre Director, Consultant Diabetes, Al-Noor Specialist Hospital, Makkah, Saudi Arabia; Khalid Obeid Dhafar - FACS, FRCS, Consultant Surgeon, Al-Noor Specialist Hospital, Makkah, Saudi Arabia; Abdul Fatah Sindy, MBBS, MD, Head of Emergency Department, Consultant Emergency Medicine, Al-Noor Specialist Hospital, Makkah, Saudi Arabia; Mian Usman Farooq - MBBs, MSc, Performance Measurement Manager, Al-Noor Specialist Hospital, King Abdullah Medical City, Makkah, Saudi Arabia; Shakeel Ahmad Mian, MBBS, Resident Emergency Department, Al-noor Specialist Hospital, Makkah, Saudi Arabia.
УДК 616-083.98-073.75(532)(045)=111 Оригинальная статья
практика рентгенологического обследования в отделении экстренной помощи
Зохаир Джамил Газзаз - Саудовская Аравия, Мака, Специализированная больница Ал-Нор, директор исследовательского центра здоровья, доктор философии; Халид Обейд Дафар - Саудовская Аравия, Мака, Специализированная больница Ал-Нор, консультант хирургического отделения; Абдул Фата Синди - Саудовская Аравия, Мака, Специализированная больница Ал-Нор, заведующий отделением экстренной помощи, доктор медицины; Миан Усман Фарук - Саудовская Аравия, Мака, Специализированная Больница Ал-Нор, магистр естественных наук; Шакил Ахмад Миан - Саудовская Аравия, Мака, Специализированная больница Ал-Нор, отделение экстренной помощи, врач-ординатор.
Дата поступления - 11.06.2010 г. Дата принятия в печать - 16.09.2010 г.
Gazzaz Zohair Jamil, Dhafar Khalid Obeid, Sindy Abdul Fatah, Farooq Mian Usman, Mian Shakeel Ahmad. X-rays referral in an emergency department // Saratov Journal of Medical Scientific Research. 2010. Vol. 6, № 3. P. 612-614.
This study highlighted referral rate for X-rays with positive findings in an Emergency department of a tertiary care hospital in Makkah, Saudi Arabia.
This was a retrospective review of Emergency department(ED) cards/files of patients visited (ED) of Alnoor Specialist Hospital, Makkah, Saudi Arabia, during the month of April, 2006G.
The total of 660 (22%) out of 2980 ED patients were included in the study and 1472 X-rays of different regions were done for them. Majority 288 (43.3%) were below 24yrs of age while males 372 (56.3%) and Saudis 400 (60%) were predominant. The discharged patients were 572 (86.6%), and 4(0.6%) were died. Six hundred and twenty (93.9%) patients got exposures rang of 1-4 while only four (0.6%) got more than eight exposures to X-rays. It was found that lower limb was exposed 384 times (26%), followed by chest 320 (21.7%). Overall 240 (16.3%) X-rays had positive findings with majority of upper limb 60 (50%) followed by chest 72 (22.5%). Pelvis & perineum had no positive X-ray. Patients from injury & poisoning were predominant 224 (33.9%) followed by respiratory disorders 104 (15.7%).
Eighty four percent X-rays had no positive findings. Majority of X-rays were done for lower limb. Neck, pelvis & perineum X-rays had no positive findings.
Key words: X-ray, Emergency, Radiology, Makkah.
Газзаз Зохаир Джамил, Дафар Халид Обейд, Синди Абдул Фата, Фарук Миан Усман, Миан Шакил Ахмад. Практика рентгенологического обследования в отделении экстренной помощи // Саратовский научно-медицинский журнал. 2010. Т. 6, № 3. С. 612-614.
Исследование по выявлению доли рентгенологических обследований с положительными заключениями, в том числе всех обследований, проводимых в отделении скорой помощи при центральной больнице Мака в Саудовской Аравии. Ретроспективное рассмотрение карточек пациентов, обратившихся в отделение неотложной помощи в течение апреля 2006 г, послужило методом данного научного исследования. Из 2980 экстренных пациентов 660 (22%) приняли участие в исследовании. Были проведены 1472 рентгенологические проЦедуры. Большинство обследованных - 288 (43,3%) человек - в возрасте до 24 лет. Превалировали жители Саудовской Аравии - 400 (60%) человек; 372 (56,3%) пациента - мужского пола. Выписаны из отделения 572 (86,6%) исследуемых. Зарегистрировано 4 (0,6%) случая летального исхода. 620 (93,9%) пациентов подвергались рентгенологическому исследованию от 1 до 4 раз. Четыре (0,6%) человека более восьми раз проходили данную процедуру. Обследование нижних конечностей по частотности составило 384 (26%) раза, обследование грудной клетки - 320 (21,7%) раз. Большинство положительных результатов было отмечено при исследовании верхних конечностей и грудной клетки. Обследование области шеи, таза и промежностей не дало положительных результатов. Пациенты с различными повреждениями и отравлениями превалировали над пациентами с заболеваниями дыхательных путей. Не дали положительных результатов 84% ренгенологических обследований.
Ключевые слова: рентгенологическое обследование, экстренная медицина, рентгенология, Мака.
introduction. Since the discovery of x-rays in 1895, world-wide at a rate of 5 to 10% per year [2-6]. Conven-
the field of diagnostic radiology has grown quickly [1]. tional radiology constitutes more than 80% of the daily
The utilization of radiological investigations is increasing work of any radiology department and thus forms a size---------------------------------------------------------- able amount of effort and cost [7, 8].
Co;:;lSPJod"re::sg,Mi,Ja,nhS;mlMn‘f,U;;man F,r””q “BBS' '" huma" tissue, the ionization by X-rays can cause
Performance Measurement Manager, damage to DNA and cells, but it can also penetrate the
King Abdullah Medical City, body to allow noninvasive visualization of the internal
M°.-SS!^ 21955 anatomy [9]. Contemporary medicine relies heavily on
Fax: +96 6 (02) 5(368ei8i. radiological and medico nuclear investigations and
Source of Financial Support: Hospital Budget procedures. However, the often essential information
^tegoi-y of Article:Original artide. derived from such investigations is obtained at a risk
E-mail: hrd_alnoor@yahoo.com ^
that few doctors are fully aware of. Use of radiation for medical examinations and tests is the largest manmade source of radiation exposure. According to United Nations, an average of 2.4mSv/year radiations come from natural sources. The medical sources of radiation were about one fifth of the natural radiation in 1987, closes to half in 1993, and almost 100% of natural radiation in 1997 in most affluent countries [10] .
Emergency departments are major source of requests for radiographs. The aim of this study was to identify the level of referrals from the emergency department for X-rays and to estimate its overutilization in the sense of suspected positive findings in a tertiary care referral unit, ie Al-noor Specialist Hospital, Makkah, Saudi Arabia.
Methods. This study was performed at the ED of a 520 bed tertiary care referral teaching hospital in Makkah, Saudi Arabia, the Al-Noor Specialist Hospital with an annual average of about 229,200 ED visits. The ED typically contains 72 nurses and a total of 40 doctors, including consultants, specialists and residents. ED doctors could call resident or specialist of the day or on call (ROD, SOD) of all specialties, to take second opinion for the patients with expected admissions or complications. Only the (SOD) could admit a patient as per hospital policy and depending upon the patient's condition. Al-Noor Hospital's ED is fully equipped with a total department area of 2315 m2 having 54 beds in different areas including Triage Area, Adult Care Area (ACA), Ob/Gyne, Critical Care Area (CCA) and Paediatrics Care Area (PCA). This ED also has an Emergency Pharmacy, Radiology Department and Laboratory. There is a surgical facility with an Operation room, and ENT, Eye and Dental procedure rooms are also present for emergency patients.
This is a retrospective study comprising of data collected from emergency department (ED) cards/files of patients who visited the eD during the one month period of April, 2006G. The ED cards were reviewed for age, gender, nationality, no of X-rays advised and their findings, final discharging diagnosis according to International Classification of Diagnosis version-10 (ICD-10) and final outcome. The age was divided into 0-24, 2544, 45-64, >64, gender was expressed as male, female, while nationality was detailed as Saudies, non-saudies. The subjects exposed to X-rays had been enumerated, and body was divide into regions, ie lower limb, upper limb, chest, head, neck, abdomen, thoraco-lumbo-sacral spine, pelvis and premium. Regions were enlisted from smallest to largest number of times they exposed to X-rays. The clinical notes of each X-ray written by radiologist had been reviewed for findings suspected by the ED physician before advising X-rays or findings coherent with his initial working diagnosis considered as positive. Each patient,s final diagnosis was categorized according to ICD-10 and arranged in Major Diagnostic Categories (MDCs). Data was analyzed by using Microsoft excel 2003 version.
We declare that we have no financial or personal relationship(s) which may have inappropriately influenced us in writing this paper.
Results. A total number of 660 (22%) patients out of 2980 had been referred to radiology department for X-ray from ED of alnoor Specialist Hospital during study period. Majority 288 (43.3%) were below 24yrs of age while males 372 (56.3%) and Saudis 400 (60%) were predominant (Table 1).
The discharged patients were 572 (86.6%), and 4 (0.6%) were died. Six hundred and twenty (93.9%) patients got exposures rang of 1-4 while only four (0.6%) got more than eight exposures to X-rays (Table 2).
Table 1
Demographic data
no %
0-24 288 43.6
25-44 208 31.5
Age groups (years) 45-64 112 16.9
>64 52 7.8
M 372 56.3
Gender
F 288 43.6
S 400 60
Nationality N/S 260 40
Table 2
Outcome of Patients
no %
Discharged 572 86.6
Admitted 72 10.9
Outcome DAMA 8 102
Referred 4 0.6
Dead 4 0.6
1-4 620 93.9
no of exposures 5-8 36 5.4
>8 4 0.6
Table 3
Detail of region wise exposure with positive findings
Regions No of X-rays % No of positive X-rays %
1 Lower limb 384.0 26.1 24.0 6.3
2 Chest 320.0 21.7 72.0 22.5
3 Head(skull) 176.0 12.0 32.0 18.2
4 Neck 116.0 7.9 0.0 0.0
5 Abdomen 268.0 18.2 36.0 13.4
6 Upper limb 120.0 8.2 60.0 50.0
7 Thoraco- lumbo-sacral spine 72.0 4.9 16.0 22.2
8 Pelvis & perinium 16.0 1.1 0.0 0.0
Total 1472.0 100.0 240.0 16.3
It was found that lower limb was exposed 384 times (26%), followed by chest 320 (21.7%). Overall 240 (16.3%) X-rays had positive findings with majority of upper limb 60 (50%) followed by chest 72 (22.5%). Pelvis & perineum had no positive X-ray out of 16 (1.1%) (Table 3).
A total of 13 Major Diagnostic Categories (MDCs) were found for the patients and injury & poisoning were predominant (S00-T98) 224 (33.9%) followed by respiratory disorders (J00-J99) 104 (15.7%).Endocrine (E00-E99), neoplasm (C00-D48) and congenital malformation (Q00-Q99) cases were equal, ie 4 (0.6%) (Table 4).
Discussion. It is both ethically and economically desirable to restrict the use of diagnostic medical radiation to only those who will benefit from it. However, patients should not refuse diagnostic tests based on an exagger-
614
клиническая лабораторная диагностика
Table 4
Subjects’ detail according to Major Diagnostic Categories (MDCs)
s/n Major Diagnostic Categories ICD-10 no %
1 Injury, poisoning & certain other consequences of external causes S00-T98 224 33.9
2 Diseases of respiratory system J00-J99 104 15.7
3 Symptoms, signs & abnormal clinical & laboratory findings not elsewhere classified R00-R99 76 11.5
4 Diseases of digestive system K00-K99 60 9
5 Diseases of circulatory system '00-199 52 7.8
6 Diseases of genitourinary system N00-N99 48 7.2
7 External causes of morbidity& mortality V00-Y98 48 7.2
8 Diseases of musculoskeletal system and connective tissue M00-M99 20 3
9 Diseases of nervous system G00-G99 8 1.2
10 Diseases of skin and subcutaneous tissues L00-L99 8 1.2
11 Endocrine, nutritional & metabolic diseases E00-E99 4 0.6
12 Neoplasm C00-D48 4 0.6
13 Congenital malformations, deformities &chromosomal abnormalities Q00-Q99 4 0.6
Total 660 100
ated estimation of the risks because most of these tests involve low doses of radiation. It is probable that risks derived from studies of the atomic bomb survivors, who were exposed to high doses of radiation, overestimate the risks at low doses. No evidence of thyroid cancer, leukemia or non-Hodgkin lymphoma has been found in patients exposed to diagnostic levels of ionizing radiation. For most diagnostic tests, the risks arising from radiation exposure are too small to be observed and the benefits will almost always outweigh the risk. There is increasing evidence that the risks associated with medical diagnostic radiation exposure are substantially less than that predicted from high-dose radiation [11]. Our study was limited, retrospective with one month emergency patients who referred for radiography, ie X-ray contrary to the prospective one of Richards in which, study period was one week with study sample (1436) of whom 637 (44%) were radio graphed, which is higher than our study, ie (22% out of total ED visits). In our study only emergency cards of those patients were studied who got X-ray while in his, all the emergency cards had been studied in detail. His study had been conducted by only emergency departments notes, illustrated that the commonest site of body requiring radiological assessment was extremities (34%) similar to ours [12]. Another study which is of one week, prospective and conducted in three emergency departments in which (31.6%) patients were referred for X-rays and 1231sets of X-rays were done which more than ours, out of these skull X-rays were studied in detail which were 112 (9%) of the total, and only (4.5%) of these were positive which is less than our study which had shown that their emergency doctor's have less ability to predict X-rays outcome than ours [13]. The study of Fry which is a comparison of abnormality rate among the limb X-rays prescribed by the triage nurses and doctors, had shown as a whole abnormality rate (38.6%) lower than ours, on the other hand upper limb positive percentage i.e. (51%) was nearly similar while that of lower limb, ie (31%) was much higher than our study [14]. Morover, in our study patient's complaints were also categorized
according to International Classification for Diagnosis version 10, ie ICD-10 and arranged in Major Diagnostic Categories (MDCs) which is not mentioned in any above study.
Conclusion. X-ray prediction of our accident and emergency physicians were better than other studies but still there is a need of clear guidelines for prescribing X-rays in our ED setup.
Reference
1. Report of a joint IAEA/WHO Expert Committee: The medical uses of ionizing radiation and radioisotopes // WHO Technical Report Series. 492 Geneva: WHO, 1972.
2. Evans K.T. The radiologist’s dilemma // Br. J. Radiol. 1977. № 50. P 299-301.
3. Clinical audit in diagnostic radiology: [Editorial] // Br. Med. J. 1977. № 6085. P 479-480.
4. Hall F.M. Overutilization of radiological examinations // Radiology. 1976. № 120. P 443-448.
5. Reducing tests: [Editorial] // Lancet. 1981. № 2. P 539540.
6. Beentjes L.B., Timmermans C.W.M. Age- and sex-specific radiographic examination frequency in the Netherlands // Br. J. Radiol. 1990. № 63. P 691-697.
7. Palmer P.E.S., Cockshott W.P. The appropriate use of diagnostic imaging: avoidance of the red goggle syndrome // J. Am. Med. Asso. 1984. № 252. P 2753-2754.
8. Racoveau N.T. Towards a basic radiological service // World Health Forum. 1981. № 2. P 521-524.
9. Gingold E.L. Physics of conventional radiography // Katz D.S., Math K.R., Groskin S.A., Radiology secrets. Hanley & Belfast, INC., 1997. P. 1.
10. Picano E. Sustainability of medical imaging: education and debate // Br. Med. J. 2004. № 328. P 578-580.
11. Smart R.C. What are the risks of diagnostic medical radiation? // Med. J. Aust. 1997. № 166. P 589-591.
12. The emergency department: an appropriate referral rate for radiology / PJ. Richards, B. Tins, R. Cherian [et al.] // Clinical radiology. 2002 (57). P. 753-758.
13. Warren R.A., Ferguson D.G. Why do accident and emergency doctors request X-rays? Arch. Emerg. Med. 1984. № 1 (3). P 143-150.
14. Fry M. Triage nurses order x-rays for patients with isolated distal limb injuries: a 12-month ED study // J. Emerg. Nurs. 2001. № 27 (1). P 17-22.
