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Good organizations are not satisfied with good practices. They strive for great practices. Intermountain Healthcare is one of those organizations.
Clinical decision rules have been quite successful for some conditions in reducing unnecessary imaging studies without jeopardizing patient safety. One such condition is minor head trauma. Our multiple columns listed below describe several different clinical decision rules that have been used to help guide clinicians in their decisions about CT scanning in adults with minor head trauma. There are also clinical decision rules for ordering CT scans in pediatric patients with minor head trauma. Intermountain Healthcare (Knighton 2022) was using a clinical pathway based on the PECARN (Pediatric Emergency Care Applied Research Network) risk stratification criteria for clinically important traumatic brain injury. Their Primary Children’s Hospital, which had participated in the development of those criteria, had pretty good compliance with the pathway but compliance at general ED’s in their 21 other system hospitals was not as good.
They initially deployed an intranet-based lookup tool, a care pathway, and a mobile flashcard application across general ED’s. But emergency physicians perceived the retrieval of guideline information as cumbersome and it did not fit well with their workflows.
So, they developed a clinical decision support system to accompany the clinical pathway. Part of it included automated feedback and education (both at the site level and individual physician level). But the major intervention was embedding an easy-to-understand, information-rich graphic “pop-up” alert providing current PECARN risk stratification criteria and supporting evidence, along with a risk assessment prompt linked to a head CT scan order or an “observation” order. (The article has nice screen shots of the “pop-up” alert for children less than 2 years old and those older than 2 years.)
They observed 4% lower odds of ordering a CT scan during the intervention months versus the control months. The CT scan rate remained significantly below the control
Months during the sustainment months (35.4% in the sustainment months versus 38.6% in the control months). As you’d expect a higher percentage yield of abnormalities by doing CT scans only in those children at higher risk, they found CT positivity rates increased from 6.0% during the control months to 9.3% during the sustainment months. CT scans with clinically important findings increased from 9.2% during the control months to 33.3% during the sustainment months. And no 72-hour readmissions with confirmed clinically important traumatic brain injury were identified.
The authors do acknowledge that the alert was only evoked in about half the eligible encounters and they discuss the issue of alert fatigue. However, they surmise that the educational value of seeing the alert led to later improved compliance with the criteria even when the clinicians did not subsequently see the alert.
The “pop-up” alert is a pretty simple tool and this study showed it can have a positive impact on care.
Some of our previous columns on CT scans in minor head trauma:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
November 23, 2010 “Focus on Cumulative Radiation Exposure”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
January 2017 “Still Too Many CT Scans for Pediatric Appendicitis”
March 2017 “Update on CT Scanning after Minor Head Trauma”
September 2017 “Clinical Decision Rule Success”
August 21, 2018 “Delayed CT Scan in the Anticoagulated Patient”
September 21, 2021 “Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective”
December 14, 2021 “Delayed Hemorrhage After Head Trauma in Anticoagulated Patients”
Knighton AJ, Wolfe D, Hunt A, et al. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study. Annals of Emergency Medicine 2022; Published June 23, 2022
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