BASH GPwSI Group Audit: what do we image and why?Steven Elliot

GPwSI Tier 2 Neurology Salford

Aim

Assess adherence to and relevance of

the BASH guidelines on imaging patients with suspected brain tumour

Objectives

Record all patients seen Record numbers of patients scanned Record reasons for scans Reflect on non-guideline scans

Standards

95% of scans would be red or orange flags as stipulated by guidelines

Red flags

Papilloedema New epileptic seizure New onset cluster headache Abnormal findings on examination/neurological

symptoms History of cancer especially lung/breast Significant alteration consciousness, memory,

confusion or co-ordination.

Orange flags

Aggravated by exertion/Valsalva Headache associated with vomiting Headache which has increased in

frequency New onset >50 Headache waking from sleep Confusion

Methods

3 month baseline measurement 2010 Standard audit tool Anonymised collated analysis Reflection and recommendation Personal and/or group re-audit 2011

Baseline results

14 GPwSIs 3month period 895 patients 270 scans (30.16%) 173 (64%) Red or orange flags 54 red flags 16/270 “positive” (5.6%) Average scan rate 32.86%

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6 7 8 9 10 11 12 13

% scan

Seen

Positive

Scanned

Activity

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6 7 8 9 10 11 12 13

Indication

Positive

Indication for scan

010203040506070

Series1

Indication 13

Positive scansIndication 7 Intracranial hypotension Bilateral subdurals Grade 1 Chiari Left orbital abnormality Mild Chiari ChiariIndication 8 Sinus thickeningIndication 9 1cm lesion right temporal lobe Aneurysm Indication 13 CVST Multiple emboli Frontal lobe infarct Aneurysm Infarct left parietal lobe Left parietal infarct Glioma

Conclusions

Not adherent Need for personal reflection Need for group reflection Not clear that guidelines are relevant Need for non-cancer indications What do we do about the anxious patient? True positive rate 1.5%

Planning re-audit

Change scanning habits? Change criteria? Give up!

Suggested criteria 1

New criteria 2 New undifferentiated headache where a pattern

has not emerged after 8 weeks Headache aggravated or precipitated by exertion

or Valsalva manoevre, cough or sex and not migraine

Headache associated with vomiting and not migraine

Headache which has increased in frequency/severity in the last six months despite appropriate treatment

New criteria 3

New headache in age >50 whose onset is less than 6 months ago

Headache that wakes from sleep that is not migraine

Thunderclap headache Patient whose anxiety is not relieved by

explanation and is aware of the implications of incidental findings

New criteria 4

New daily persistent headache Headache suggestive of low intracranial

pressure Recent onset headache in HIV or

immmunocompromised

Re-audit

Suggestions? Agree criteria Repeat recording of activity in January to

March 2012 Any volunteers?