Reducing Computed Tomography Scan Utilization for Pediatric Minor Head Injury in the Emergency Department: A Quality Improvement Initiative

Abstract

Background The validated Pediatric Emergency Care Applied Research Network (PECARN) prediction rules are meant to aid clinicians in safely reducing unwarranted imaging in children with minor head injuries (MHI). Even so, computed tomography (CT) scan utilization remains high, especially in intermediate‐risk (per PECARN) MHI patients. The primary objective of this quality improvement initiative was to reduce CT utilization rates in the intermediate‐risk MHI patients. Methods This project was conducted in a Level I trauma pediatric emergency department (ED). Children < 18 years evaluated for intermediate‐risk MHI from June 2016 through July 2019 were included. Our key drivers were provider education, decision support, and performance feedback. Our primary outcome was change in head CT utilization rate (%). Balancing measures included return visit within 72 hours of the index visit, ED length of stay (LOS), and clinically important traumatic brain injury (ciTBI) on the revisit. We used statistical process control methodology to assess head CT rates over time. Results A total of 1,535 eligible intermediate‐risk MHI patients were analyzed. Our intervention bundle was associated with a decrease in CT use from 18.5% (95% confidence interval [CI] = 14.5% to 22.5%) in the preintervention period to 13.9% (95% CI = 13.8% to 14.1%) in the postintervention period, an absolute reduction of 4.6% (p = 0.015). Over time, no difference was noted in either ED LOS or return visit rate. There was only one revisit with a ciTBI to our institution during the study period. Conclusions Our multifaceted quality improvement initiative was both safe and effective in reducing our CT utilization rates in children with intermediate‐risk MHI.

Interventions to reduce low-value imaging – a systematic review of interventions and outcomes

“…The most commonly targeted patient diagnosis was bronchiolitis [ 48 , 90 , 104 , 112 , 119 ], pulmonary embolism [ 49 , 58 , 60 , 82 , 100 , 102 , 121 , 122 , 125 ], and head injuries [ 67 , 70 , 77 , 79 , 87 , 94 , 101 , 123 , 126 , 127 ]. In studies targeting these complaints, a reduction in use of low-value imaging were reported in 78–80% of the studies, while imaging in lower back pain [ 38 , 45 , 51 , 53 , 54 , 65 , 68 , 71 , 75 , 89 , 115 , 118 ] were reduced in 58% of studies.…”

“…Implementation of multi-component interventions (2 or more components in combination) reportedly reduced the use of low-value imaging among 94% of the included studies [ 40 – 44 , 47 , 48 , 51 , 53 , 56 , 59 , 63 , 72 , 78 , 79 , 81 , 83 , 86 , 87 , 94 , 101 , 104 , 105 , 111 , 115 , 116 , 118 , 120 , 122 , 123 , 126 , 128 ]. Multi-component interventions were found to be more effective when education was one of the components.…”

“…Thus, county of intervention does not affect the result alone. Implementation of guidelines or clinical decision support systems were the most effective single-component interventions [ 37 – 121 , 126 , 128 , 130 ]. Furthermore, 23% of single-component interventions compared to 6% of multi-component interventions showed no statistically significant difference or an increase in the use of low-value imaging.…”

Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases

“…These may result in knowledge gaps with regard to best pediatric practices, partly explaining the increased use of radiographs at these institutions. 45,46,48,59 Radiograph use was highest in hospitals with higher pediatric volumes. This finding differs from the large body of "volumeoutcome" literature suggesting that higher volumes lead to better adherence to guidelines and better outcomes, for both pediatric and adult patients.…”

“…The addition of specific skills or exposure to ED-specific clinical practice guidelines in PEM training may also explain some of the variation. 45,46,48 No studies have specifically evaluated the underlying causes of these differences in low-value radiograph use. Our findings suggest that ED setting and physician specialty training warrant further exploration, perhaps through qualitative studies, to inform future interventions.…”