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Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic
Jennifer R Marin1, Jonathan Rodean2, Rebekah C Mannix3
1Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
Insights
Clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) significantly reduced head computed tomography (CT) use in children. These tools lowered CT scans without negatively impacting patient outcomes.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Informatics
- Radiology Decision Support
Background:
- Mild traumatic brain injury (mTBI) is a common pediatric emergency department diagnosis.
- Head computed tomography (CT) is frequently used for mTBI, but its overuse raises concerns about radiation exposure and cost.
- Clinical guidelines and clinical decision support (CDS) systems are potential tools to optimize CT utilization.
Purpose of the Study:
- To investigate the association between the availability of clinical guidelines and CDS for mTBI and the rate of head CT utilization in pediatric emergency departments.
- To assess the impact of these interventions on secondary outcomes such as emergency department length of stay and revisit rates.
Main Methods:
- A cross-sectional study was conducted using data from 45 pediatric emergency departments between 2015 and 2019.
- Data included children discharged with mTBI. Surveys of clinical directors ascertained the presence and implementation of clinical guidelines and CDS.
- Statistical analysis adjusted for confounders to evaluate the association between guidelines/CDS and CT use.
Main Results:
- Over 216,000 pediatric mTBI cases were analyzed, with CT performed in 20.3% of visits.
- Emergency departments with CDS showed significantly lower odds of CT use (aOR 0.52) compared to those with neither intervention.
- Emergency departments with clinical guidelines also demonstrated lower odds of CT use (aOR 0.83).
Conclusions:
- Clinical guidelines and CDS for mTBI are associated with reduced head CT utilization in pediatric emergency settings.
- The implementation of CDS appears particularly effective in lowering CT rates.
- No significant differences in ED length of stay or revisit rates were observed, suggesting safe implementation.
Objective:
To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT).
Study Design:
We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits.
Results:
There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS.
Conclusions:
Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.
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