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A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department
Rakesh S Engineer1, Seth R Podolsky, Baruch S Fertel
1From the Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH.
Insights
A new care path significantly reduced head CT scans for children with minor head injuries. The clinical decision support tool (CDST) and parent discussion aided adherence, with no missed traumatic brain injuries.
Area of Science:
- Emergency Medicine
- Pediatric Care
- Clinical Decision Support
Background:
- The American College of Emergency Physicians' "Choosing Wisely" campaign aims to reduce unnecessary computed tomographic (CT) scans in low-risk minor head injury patients.
- Validated decision rules exist to identify patients who do not require CT scans.
- There is a need for tools to support clinicians in applying these rules and discussing risks with parents.
Purpose of the Study:
- To develop and implement a Pediatric Mild Head Injury Care Path to decrease inappropriate CT utilization.
- To evaluate the effectiveness of a clinical decision support tool (CDST) and a structured parent discussion tool in reducing CT scans.
- To assess adherence to the care path recommendations and identify any missed traumatic brain injuries.
Main Methods:
- A 9-week quality improvement project in pediatric and freestanding emergency departments.
- Interventions included leadership engagement, provider education, a parent discussion tool, and an embedded CDST in the electronic medical record.
- Prospective enrollment of patients where providers used the CDST for decision-making; comparison with 2013 baseline data.
Main Results:
- The CDST was utilized in 77.5% of eligible patients (176/227).
- Adherence to care path recommendations was high (99% in 164 patients).
- Head CT utilization decreased significantly from 62.7% to 22% (OR, 0.17) in patients where the CDST was used; no traumatic brain injuries were missed.
Conclusions:
- A Pediatric Mild Head Injury Care Path is implementable in emergency departments.
- The care path, supported by a CDST and parent discussion, effectively reduces head CT utilization.
- High adherence to CDST recommendations and the absence of missed injuries support the tool's clinical utility.
Introduction:
The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool.
Methods:
A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013.
Results:
The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group.
Conclusion:
A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.
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