Use of the NEXUS Chest Clinical Decision Instruments to Reduce Unnecessary Chest Imaging in the Blunt Trauma Victim

Blunt trauma patients are often evaluated using chest radiography (CXR) and chest computed tomography (CT). These studies expose patients to ionizing radiation and accrue significant medical costs. Unnecessary imaging studies... [ view full abstract ]

Blunt trauma patients are often evaluated using chest radiography (CXR) and chest computed tomography (CT). These studies expose patients to ionizing radiation and accrue significant medical costs. Unnecessary imaging studies also can reveal incidental findings which may lead to further downstream testing. In order to minimize unnecessary chest imaging in blunt trauma, the NEXUS group derived and validated three clinical decision instruments (DIs) for selective use of CXR and CT in blunt trauma. In their internal validation, the NEXUS Chest, CT-Major, and CT-All DIs each demonstrated extremely high sensitivity and negative predictive value for thoracic injury. However, these DIs have not yet been widely adopted.

In this study, 3263 patients who presented to an urban Level I Trauma Center after blunt trauma were retrospectively reviewed using a systematic data abstraction tool. After exclusion of transferred, expired, eloped and other ineligible patients, 1470 patients were included in the analysis. The NEXUS Chest imaging DIs were each applied and compared to clinical outcomes.

Results of this analysis suggest that usage of the DIs in these patients could have reduced CXR use by 25% and CT use by 3%. Furthermore, application of these tools in these patients would have led to zero missed clinically significant thoracic injuries.

Based on published CDC figures for current use of chest imaging in blunt trauma, these results indicate that the nationwide application of the DIs could reduce the number of chest CTs performed by 200,000 and CXRs by 4.8 million each year. This could prevent the development of over 300 cancers due to ionizing radiation yearly. The cost savings could total $2.1 billion annually and as many as 316,000 downstream studies could be avoided. This study demonstrates that application of these DIs could potentially decrease costs and prevent unnecessary testing without missing clinically significant conditions.