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Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic
Andrew J Knighton1, Doug Wolfe1, Angelene Hunt1
1Intermountain Healthcare, Salt Lake City, UT.
Insights
A multimodal strategy improved adherence to clinical pathways for pediatric minor head trauma in emergency departments (EDs). This approach safely reduced computed tomography (CT) scans while maintaining patient safety.
Area of Science:
- Emergency Medicine
- Clinical Implementation Science
- Pediatric Traumatology
Background:
- Minor head trauma is common in children presenting to emergency departments (EDs).
- Adherence to clinical pathways can optimize care and resource utilization.
- Multimodal strategies, including clinical decision support systems (CDSS), may enhance pathway adherence.
Purpose of the Study:
- To evaluate the effectiveness of a multimodal strategy, incorporating a CDSS, in sustaining adherence to a clinical pathway for pediatric minor head trauma.
- To assess the impact of the strategy on computed tomography (CT) scan rates and 72-hour readmissions for clinically important traumatic brain injury.
Main Methods:
- A prospective, hybrid effectiveness-implementation cohort study with a stepped-wedge design was conducted across 21 diverse ED sites.
- The study included 12,670 pediatric minor head trauma encounters from July 2018 to December 2020.
- Multilevel hierarchical modeling analyzed guideline adherence, CT scan rates, and readmissions.
Main Results:
- Implementation of the clinical pathway significantly increased guideline adherence (adjusted odds ratio 1.12) and decreased CT scan rates (adjusted odds ratio 0.96).
- Absolute improvements included a median +2.3% increase in adherence and a median -6.6% reduction in CT scans.
- No 72-hour readmissions with clinically important traumatic brain injury were identified.
Conclusions:
- A multimodal approach, including a CDSS, effectively sustained adherence to a minor head trauma clinical pathway in general EDs.
- This strategy achieved a modest, safe reduction in CT scans for low-risk pediatric patients.
- The findings support the use of such strategies in diverse emergency care settings.
Study Objective:
To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs).
Methods:
Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician.
Results:
During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified.
Conclusion:
Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.
