Variation in Computed Tomography Use for Evaluation of Head Injury in a Pediatric Emergency Department
Michael J Miescier1, Nanette C Dudley, Howard A Kadish
1From the *Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine; and †Systems Improvement Department, Intermountain Healthcare, Salt Lake City, UT.
Insights
Pediatric emergency physicians show significant variation in ordering computed tomography (CT) scans for head-injured children. This study highlights differences in CT utilization rates among individual doctors in a hospital emergency department (ED).
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Healthcare Quality Improvement
Background:
- Computed tomography (CT) utilization for pediatric head injuries varies significantly across emergency departments (EDs).
- Understanding physician-level variations in CT use is crucial for optimizing diagnostic strategies in pediatric head trauma.
Purpose of the Study:
- To examine the variation in computed tomography (CT) use among individual attending physicians in a pediatric hospital emergency department (ED) for evaluating head-injured children.
- To identify factors associated with CT utilization in this patient population.
Main Methods:
- Retrospective analysis of an administrative database of children (<18 years) evaluated for head injury between January 2011 and March 2013.
- Exclusion of encounters with trauma team activation or prior head CT, and physicians with low patient volume.
- Analysis of CT rates across 27 ED attending physicians, including pediatric emergency medicine (PEM) fellowship-trained physicians and pediatricians.
Main Results:
- A total of 5340 head injury encounters were analyzed. CT rates varied widely among individual physicians, ranging from 12.4% to 37.3% (mean 28.4%).
- Pediatric emergency medicine (PEM) physicians had CT rates from 18.9% to 37.3%, compared to 12.4% to 31.8% for pediatricians.
- Factors associated with CT use included younger age (<2 years), higher triage acuity, nighttime arrival (10 PM - 6 AM), hospital admission, and evaluation by a PEM physician. Only 8.4% of CTs revealed traumatic brain injury, and 8.2% showed simple skull fractures.
Conclusions:
- Significant variation exists in the use of computed tomography (CT) by individual physicians in a pediatric hospital ED for evaluating head-injured children.
- Physician specialty (PEM vs. pediatrician) and patient factors influence CT ordering patterns.
- Further research is needed to understand the drivers of this variation and its impact on patient outcomes and resource utilization.
Objectives:
Recent research has shown significant variation in rates of computed tomography (CT) use among pediatric hospital emergency departments (ED) for evaluation of head injured children. We examined the rates of CT use by individual ED attending physicians for evaluation of head injured children in a pediatric hospital ED.
Methods:
We used an administrative database to identify children younger than 18 years evaluated for head injury from January 2011 through March 2013 at our children's hospital ED, staffed by pediatric emergency medicine (PEM) fellowship trained physicians and pediatricians. We excluded encounters with trauma team activation or previous head CT performed elsewhere. We excluded physicians whose patient volume was less than 1 standard deviation below the group mean.
Results:
After exclusions, we evaluated 5340 encounters for head injury by 27 ED attending physicians. For individual physicians, CT rates ranged from 12.4% to 37.3%, with a mean group rate of 28.4%. Individual PEM physician CT rates ranged from 18.9% to 37.3%, versus 12.4% to 31.8% for pediatricians. Of the 1518 encounters in which CT was done, 128 (8.4%) had a traumatic brain injury on CT, and 125 (8.2%) had a simple skull fracture without traumatic brain injury on CT. Patient factors associated with CT use included age younger than 2 years, higher triage acuity, arrival time of 10:00 PM to 6:00 AM, hospital admission, and evaluation by a PEM physician.
Conclusions:
Physicians at our pediatric hospital ED varied in the use of CT for the evaluation of head-injured children.
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