In our November 10, 2009 Patient Safety Tip of the Week “Conserving Resources…But Maintaining Patient Safety” we extolled the virtues of clinical “rules” that help guide the decisions whether to pursue imaging or not in patients seen in the emergency department. For years, we have used the Ottawa knee and ankle rules in our ED’s and seen the number of knee and ankle x-rays diminish without adversely affecting patient care. The Canadian C-spine rule has recently been shown to reduce utilization of cervical spine imaging without compromising patient safety or outcomes. Use of such rules not only saves costs but it also streamlines ED throughput and helps avoid lengthy waits by patients.
Similarly, there are several “rules” that aid the decision about performing CT scans of the head in patients with minor head trauma. The Canadian CT Head Rule (Stiell 2001) for adults with minor head trauma has been around for about 10 years. The New Orleans Criteria (Haydel 2000) have been around for about the same period and the CHIP Prediction Rule (Smits 2007) is slightly newer. A recent cost-effectiveness analysis for use of these rules in minor head injury (Smits 2010) showed that use of these rules can produce substantial cost savings.
All the above rules were developed and validated in adult populations. There has been no widely-accepted clinical decision rule for CT scanning in children with minor head trauma. Given recent concerns about the dosages of ionizing radiation given to children by CT scans, any rule that would identify which children could safely avoid CT scanning would be very useful. Now a new rule, CATCH (the Canadian Assessment of Tomography for Childhood Head Injury), has been developed as a clinical decision support rule to help identify which children with minor head injury need CT scanning done (Osmond et al 2010). The study derived the CATCH rule from a population of children, aged 0 to 16 years, who presented to the emergency department after minor head trauma with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. The rule now requires validation in other pediatric cohorts If so validated, it holds great potential to help manage pediatric patients with minor head trauma in the ER in a cost-effective way without jeopardizing patient safety.
Stiell IG, Wells GA,Vandemheen K, et al for the CCC Study Group. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357: 1391–96
Haydel MJ, Preston CA, Mills TJ, et al. Indications for Computed Tomography in Patients with Minor Head Injury. N Engl J Med 2000; 343: 100-5
Smits M, Dippel DWJ, Steyerberg EW, et al.Predicting Intracranial Traumatic Findings on Computed Tomography in Patients with Minor Head Injury: The CHIP Prediction Rule. Ann Intern Med. 2007; 146: 397-405
Smits M, Dippel DWJ, Nederkoorn PJ. Minor Head Injury: CT-based Strategies for Management—A Cost-effectiveness Analysis. Radiology 2010; 254: 532-540
Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. Can. Med. Assoc. J., Feb 2010; early release published February 8, 2010 doi:10.1503/cmaj.091421