Implementation of the Canadian CT Head Rule and Its Association With Use of Computed Tomography Among Patients With Head Injury

Abstract

Study objective Approximately 1 in 3 computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the association of implementation of the Canadian CT Head Rule on head CT imaging in community emergency departments (EDs). Methods We conducted an interrupted time-series analysis of encounters from January 2014 to December 2015 in 13 Southern California EDs. Adult health plan members with a trauma diagnosis and Glasgow Coma Scale score at ED triage were included. A multicomponent intervention included clinical leadership endorsement, physician education, and integrated clinical decision support. The primary outcome was the proportion of patients receiving a head CT. The unit of analysis was ED encounter, and we compared CT use pre- and postintervention with generalized estimating equations segmented logistic regression, with physician as a clustering variable. Secondary analysis described the yield of identified head injuries pre- and postintervention. Results Included were 44,947 encounters (28,751 preintervention and 16,196 postintervention), resulting in 14,633 (32.6%) head CTs (9,758 preintervention and 4,875 postintervention), with an absolute 5.3% (95% confidence interval [CI] 2.5% to 8.1%) reduction in CT use postintervention. Adjusted pre-post comparison showed a trend in decreasing odds of imaging (odds ratio 0.98; 95% CI 0.96 to 0.99). All but one ED reduced CTs postintervention (0.3% to 8.7%, one ED 0.3% increase), but no interaction between the intervention and study site over time existed (P=.34). After the intervention, diagnostic yield of CT-identified intracranial injuries increased by 2.3% (95% CI 1.5% to 3.1%). Conclusion A multicomponent implementation of the Canadian CT Head Rule was associated with a modest reduction in CT use and an increased diagnostic yield of head CTs for adult trauma encounters in community EDs.

Tablet-Based Patient-Centered Decision Support for Minor Head Injury in the Emergency Department: Pilot Study

“…Traditional implementation strategies such as CDS can address clinical factors such as a lack of awareness of the evidence [ 37 ]. However, these strategies have had limited success for this decision, likely due to nonclinical factors such as patients’ concerns with their condition and care [ 12 - 15 ]. Findings of this study suggest that patients can be educated and engaged in the ED setting in decisions about CT imaging for low-risk minor head injury using a health information technology interface that supports the clinician-patient relationship (rather than getting in its way) [ 17 , 38 , 39 ].…”

“…Implementing the CCHR with traditional computerized clinical decision support (CDS) has had a modest effect (5%-8%) on decreasing CT use in these patients [ 12 , 13 ]. Since one-third of CTs in minor head injury patients are potentially avoidable and traditional CDS has had limited effect on reducing these scans, it has been hypothesized that nonclinical factors (such as fear of litigation, physician personality, fear of missed diagnoses, financial incentives, paucity of information, and patient expectations) also contribute to CT overuse in these patients [ 14 , 15 ].…”

Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department

“…A significant challenge we encountered during the testing and implementation phase was integrating the checklist into existing workflows, given the busy environment of the ED. Traditionally, the CCTHR has been employed at the point of CT scan order entry, which occurs after the provider–patient interaction has occurred and therefore after the clinician (MD, NP or PA) has already committed to ordering diagnostic imaging 13 16. We felt that providing reminders and cues earlier in the care process would have a bigger impact on nudging clinician behaviour since it would allow them to incorporate the CCTHR as part of their assessment and engage patients in the process before committing to ordering a CT scan.…”

“…The CCTHR is a widely accepted and well-validated clinical decision rule used for ED patients with minor head injuries. Several studies have shown the rule performs better than other clinical decision rules and is highly sensitive at detecting clinically significant head injuries 4 6 13–15. However, the effect of the CCTHR on reducing CT scan utilisation has yielded mixed results, with some studies showing decreased CT use with the CCTHR, while others showing increased use of CT scans post-implementation 6 16…”

“…Major themes identified involve knowledge translation around decision rules, physician comfort and medico-legal concerns with using the CCTHR, patient preference and ease of access to diagnostic imaging 6 17. More recently, Sharp and colleagues used a multimodal intervention that included decision support, leadership buy-in and physician education to decrease CT scan use over during a 6-month period 13. In addition, work done in paediatric head injuries have shown that patient/provider education can reduce overall healthcare utilisation 18.…”