Background

Diagnostic imaging in the emergency department (ED) is experiencing an upward trajectory in terms of utilisation [1]. The associated effects of ionising radiation, as well as the higher cumulative risk from examinations such as  radiography and computed tomography (CT), are concerning [2]. Imaging referral guidelines empower clinicians to make appropriate imaging referrals by providing imaging recommendations for specific clinical scenarios.

However, different imaging guidelines employed distinct methodologies for their content, resulting in varying imaging recommendations [3,4].  The inclusion and/or exclusion of variables for considerations such as radiation risk, evidence and cost awareness can directly affect the imaging recommendations. Furthermore, these imaging guidelines have variations in their imaging recommendations. This may lead to significant diversity in the emergency care provided and its associated outcomes, such as patient disposition [5].

Methods

This retrospective clinical audit was approved by SingHealth Centralised Institutional Review Board (CIRB) (No. 2020/2941). 

We conducted a retrospective review of cervical spine X-rays and CT scans performed consecutively in a Singapore ED between October 1st and December 31st, 2022. We excluded imaging referrals from general practitioners because we did not have access to the clinical notes for this specific group.

For each imaging referral, the initial clinical diagnosis (reasons for the referral), the ordered procedure, patient demographics (age and gender), ED clinical notes, and radiological reports were extracted from the electronic health records. Based on the clinical diagnosis (reasons for the referral), the ordered procedure, patient demographics (age) and ED clinical notes, each imaging referral was matched with guidelines in ACR AC, ESR iGuide and RCR iRefer, to assess whether the imaging was performed according to the imaging recommendation(s).

We also examined all imaging referral-associated radiological reports for significant positive findings (findings that will impact therapeutic decisions). Three authors reviewed all imaging referrals, resolving disagreements through discussion and consensus.

We performed a descriptive analysis of the data, summarising categorical variables using frequency (percentages) and continuous variables using the mean (standard deviation).  Fisher-Freeman-Halton Exact Test and Fisher’s Exact Test were used to examine if there were any differences in the imaging characteristics among the imaging recommendations within the same imaging referral guidelines, i.e., ACR AC, ESR iGuide, and RCR iRefer. All statistical analyses were performed in SPSS Statistics version 29.0 (IBM SPSS Inc., Chicago, USA).