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Reducing Head CT Use for Children With Head Injuries in a Community Emergency Department
Rebecca M Jennings1,2, Jennifer J Burtner3, Joseph F Pellicer3
1Divisions of General Pediatrics and Hospital Medicine and rebecca.jennings@seattlechildrens.org.
Insights
A quality improvement project successfully reduced computed tomography (CT) scans for pediatric head injuries in a community emergency department (ED). This initiative lowered CT use from 29% to 17%, promoting evidence-based care.
Area of Science:
- Emergency Medicine
- Pediatrics
- Radiology
- Quality Improvement
Background:
- Computed tomography (CT) use for minor pediatric head injuries remains high in community emergency departments (EDs).
- Clinical decision rules have shown success in reducing CT use in specialized pediatric EDs.
- There is a need to decrease unnecessary CT scans in community EDs where most children receive care.
Purpose of the Study:
- To reduce the rate of CT scans for evaluating pediatric head injury from 29% to 20% in a community ED setting.
- To implement and evaluate a quality improvement (QI) project utilizing a validated head trauma prediction rule.
Main Methods:
- A multidisciplinary team implemented a QI project in a community ED, focusing on a validated prediction rule for traumatic brain injury.
- Decision aids were introduced to improve the application of prediction rules, and barriers to CT use were identified and addressed.
- Statistical process control charts monitored monthly CT scan rates, with a Wald test of equivalence comparing pre- and post-intervention proportions.
Main Results:
- The baseline CT scan rate was 29.2% (n=695) before the intervention.
- Following the QI project, the CT scan rate decreased significantly to 17.4% (n=651) (P < .01).
- Identified barriers included variable provider experience and parental expectations for imaging.
Conclusions:
- A Maintenance of Certification QI project, supported by a children's hospital, effectively decreased unnecessary CT use in a community ED.
- The project facilitated the adoption of evidence-based pediatric care practices in a community setting.
- This demonstrates a successful model for improving pediatric head injury evaluation in non-specialized emergency departments.
Background And Objective:
Clinical decision rules have reduced use of computed tomography (CT) to evaluate minor pediatric head injury in pediatric emergency departments (EDs). CT use remains high in community EDs, where the majority of children seek medical care. We sought to reduce the rate of CT scans used to evaluate pediatric head injury from 29% to 20% in a community ED.
Methods:
We evaluated a quality improvement (QI) project in a community ED aimed at decreasing the use of head CT scans in children by implementing a validated head trauma prediction rule for traumatic brain injury. A multidisciplinary team identified key drivers of CT use and implemented decision aids to improve the use of prediction rules. The team identified and mitigated barriers. An affiliated children's hospital offered Maintenance of Certification credit and QI coaching to participants. We used statistical process control charts to evaluate the effect of the intervention on monthly CT scan rates and performed a Wald test of equivalence to compare preintervention and postintervention CT scan proportions.
Results:
The baseline period (February 2013-July 2014) included 695 patients with a CT scan rate of 29.2% (95% confidence interval, 25.8%-32.6%). The postintervention period (August 2014-October 2015) included 651 patients with a CT scan rate of 17.4% (95% confidence interval, 14.5%-20.2%, P < .01). Barriers included targeting providers with variable pediatric experience and parental imaging expectations.
Conclusions:
We demonstrate that a Maintenance of Certification QI project sponsored by a children's hospital can facilitate evidence-based pediatric care and decrease the rate of unnecessary CT use in a community setting.
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