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Applying the RE-AIM Framework for the Evaluation of a Clinical Decision Support Tool for Pediatric Head Trauma: A
Ruth M Masterson Creber1, Peter S Dayan2, Nathan Kuppermann3
1Division of Health Informatics, Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York, United States.
Insights
Electronic health record clinical decision support (CDS) tools reduced cranial computed tomography (CT) use in children with minor head trauma. This study evaluated the implementation and maintenance of these TBI prediction rules.
Area of Science:
- Pediatric Emergency Medicine
- Health Informatics
- Clinical Decision Support Systems
Background:
- Overuse of cranial computed tomography (CT) in children with minor blunt head trauma leads to unnecessary ionizing radiation exposure.
- Traumatic brain injuries (TBIs) in children require accurate diagnosis while minimizing radiation risks.
Purpose of the Study:
- To facilitate the nationwide implementation and dissemination of an electronic health record (EHR) clinical decision support (CDS) alert system.
- To reduce the use of CT scans in pediatric patients with minor head trauma.
Main Methods:
- A mixed-methods analysis was conducted, incorporating 38 interviews with healthcare stakeholders and quantitative data.
- The Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework guided the evaluation of the EHR CT CDS tool.
Main Results:
- The EHR CT CDS tool demonstrated a modest reduction in CT rates for 8,067 children with minor head trauma.
- Successful implementation was linked to clinical champions, workflow integration, user training, and perceived tool relevance.
- The tool was well-integrated into institutional culture and practice, showing long-term maintenance.
Conclusions:
- The EHR CT CDS tool effectively supported the reduction of CT use in pediatric head trauma cases.
- Findings provide critical insights for the integration and dissemination of similar decision support tools in emergency departments nationwide.
Background:
The overuse of cranial computed tomography (CT) to diagnose potential traumatic brain injuries (TBIs) exposes children with minor blunt head trauma to unnecessary ionizing radiation. The Pediatric Emergency Care Applied Research Network and the Clinical Research on Emergency Services and Treatments Network implemented TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) to decrease use of CTs in children with minor blunt head trauma.
Objective:
This article aims to facilitate implementation and dissemination of a CDS alert into emergency departments around the country.
Methods:
We evaluated the EHR CT CDS tool through a mixed-methods analysis of 38 audio-recorded interviews with health care stakeholders and quantitative data sources, using the Reach, Efficacy, Adoption, Implementation, and Maintenance framework.
Results:
Reach -: The demographics of participants enrolled in the clinical trial were consistent with national estimates of TBI prevalence. Efficacy-There was a variable and modest reduction in CT rates for the 8,067 children with minor head trauma whose clinicians received CDS. Adoption -: The EHR CT CDS tool was well matched with the organizational mission, values, and priorities of the implementation sites. Implementation- The most important predisposing factors for successful implementation were the presence of an approachable clinical champion at each site and belief that the tool was a relevant, reusable knowledge asset. Enabling factors included an effective integration within the clinical workflow, organizational investment in user training, and ease of use. Maintenance -: Reinforcing factors for the EHR CT CDS tool included a close fit with the institutional culture, belief that it was useful for providers and families, and a good educational and informational tool. As such, the EHR CT CDS tool was maintained in clinical practice long after study completion.
Conclusion:
Data from this mixed-methods study complement findings from the efficacy trial and provide critical components for consideration prior to integration and subsequent dissemination of the EHR CT CDS tool.
Trial Registration:
NCT01453621, Registered September 27, 2011.
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