The InSPECTED study

• Research type

  Research Study

• Full title

  Improving the Scaphoid Pathway with Extremity CT in the Emergency Department: The InSPECTED study

• IRAS ID

  274018

• Contact name

  Bev Snaith

• Contact email

  beverly.snaith@nhs.net

• Sponsor organisation

  Mid Yorkshire Hospitals NHS Trust

• Clinicaltrials.gov Identifier

  32914, EuroQoL

• Duration of Study in the UK

  0 years, 4 months, 3 days

• Research summary

  Summary of Research
  The scaphoid is a small bone in the wrist commonly broken during falls, particularly in young men. Clinical examination of the scaphoid performs poorly for identifying scaphoid fractures and the diagnosis relies on imaging. This observational study will evaluate a recently implemented care pathway whereby traditional x-ray imaging is supplemented by extremity cone beam computed tomography (CBCT) at first presentation at the emergency department (ED) to enable early diagnosis or exclusion of scaphoid fracture.
  We will document the care pathway (steps) for patients presenting at the ED with a wrist injury and suspected scaphoid fracture to quantify issues around delivery of this new service model. A key part of the pathway is the clinical examination performed by emergency practitioners and this study will evaluate a clinical screening tool for scaphoid fractures that can guide clinical-decision making.
  To ensure that CBCT is accepted in practice we will evaluate the test on a minimum of 130 patients who have a suspected scaphoid fracture but in whom initial x-rays are normal. The CBCT scan represents local standard practice, but patients will have opportunity to opt of the study if they do not wish for their data to be used. Comparison with a retrospective patient cohort will evidence whether the pathway changes have resulted in earlier diagnosis and reduced healthcare resource utilisation.
  This feasibility study will quantify the number of patients who present with a scaphoid injury, those subsequently diagnosed with a fracture, ED discharge and referral rates, as well as CBCT failures. Follow-up telephone questionnaires with patients will allow us to measure outcomes in a single-centre cohort of patients and draw inferences on health-related quality of life. This feasibility assessment will also help us to evaluate a trial case report form (CRF) for this group and design a multicentre research study.

  Summary of Research
  Improving the Scaphoid Pathway with Extremity CT in the ED: The InSPECTED Study Study contacts: Prof B Snaith, M Harris, S Robertshaw Study supported by: Carestream Health Ltd
  Sponsor: Mid Yorkshire Hospitals NHS Trust PPI input: Protocol development, steering group, dissemination to participants

  The problem: The scaphoid is a small bone in the wrist and often injured following a fall. Fractures can be missed initially and may take some time to be diagnosed, with multiple hospital visits and imaging investigations. This was a research study exploring whether a new imaging technology, cone beam computed tomography (CBCT) could reduce the time to diagnosis, or exclusion, of a scaphoid fracture.
  The research: All patients (≥18 years) presenting between March and June 2020 to the Mid Yorkshire Hospitals NHS Trust with a wrist injury and suspicion of scaphoid fracture could participate. An initial scaphoid X-ray was performed and if normal, they went on to have a CBCT scan of the wrist (the research intervention) for further evaluation. If this scan was also normal, a member of the research team contacted them after two weeks and again at 6 weeks to see if they had recovered as expected or if further clinical review was required. Comparison to a retrospective cohort of 349 patients attending for a scaphoid X-ray during the preceding year was undertaken to confirm the potential for service improvement.
  Results: A total of 68 participants were recruited with 55 having normal or equivocal X-rays and proceeding to CBCT, all scans were completed within 4-days of initial attendance, with an average time to diagnosis of 17 hours. Of these undergoing CBCT, nine (16.2%) had fractures confirmed which were not evident on the initial X-ray. No additional fractures were identified on follow up.
  In 2019 the average time to diagnosis was 13 days, with the longest wait to be told there was a fracture 72 days, and fracture exclusion took up to 90 days.
  Summary: CBCT scans enabled a rapid pathway for the diagnosis or exclusion of scaphoid fractures, and enabled identification of other wrist fractures to facilitate treatment.
  Impact: Based on the new pathway it was identified that in 1 year over 1000 patient hospital visits could be saved, equating to over 170 hours of medical consultant time and approximately 150 wrist casts. Additionally, exclusion of a fracture means earlier return to activities of daily living.
  Further research: Other applications of CBCT for trauma are planned.
  More details: Contact the Chief Investigator - beverly.snaith@nhs.net

• REC name

  East Midlands - Leicester Central Research Ethics Committee

• REC reference

  20/EM/0012

• Date of REC Opinion

  24 Feb 2020

• REC opinion

  Further Information Favourable Opinion