Use of Clinical Prediction Rules for Guiding Use of Computed Tomography in Adults With Head Trauma

Rivara, Frederick P.; Kuppermann, Nathan; Ellenbogen, Richard G.

doi:10.1001/jama.2015.17298

Cited by 13 publications

(9 citation statements)

References 15 publications

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“…31 This can often be misleading, however, given the aforementioned limitations associated with CT scans. 32 Moreover, the development of effective in-hospital interventions that can help to reduce unnecessary CT scans may be challenging. A randomized trial in Canada found education, hospital policy changes, and real-time reminders were unsuccessful in reducing rates of CT scans in EDs during concussion care.…”

Section: Discussionmentioning

confidence: 99%

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments

Stern

Seichepine

Tschoe

et al. 2017

Journal of Neurotrauma

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Evidence-based clinical practice guidelines can facilitate proper evaluation and management of concussions in the emergency department (ED), often the initial and primary point of contact for concussion care. There is no universally adopted set of guidelines for concussion management, and extant evidence suggests that there may be variability in concussion care practices and limited application of clinical practice guidelines in the ED. This study surveyed EDs throughout New England to examine current practices of concussion care and utilization of evidence-based clinical practice guidelines in the evaluation and management of concussions. In 2013, a 32-item online survey was e-mailed to 149/168 EDs throughout New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine). Respondents included senior administrators asked to report on their EDs use of clinical practice guidelines, neuroimaging decision-making, and discharge instructions for concussion management. Of the 72/78 respondents included, 35% reported absence of clinical practice guidelines, and 57% reported inconsistency in the type of guidelines used. Practitioner preference guided neuroimaging decision-making for 57%. Although 94% provided written discharge instructions, there was inconsistency in the recommended time frame for follow-up care (13% provided no specific time frame), the referral specialist to be seen (25% did not recommend any specialist), and return to activity instructions were inconsistent. There is much variability in concussion care practices and application of evidence-based clinical practice guidelines in the evaluation and management of concussions in New England EDs. Knowledge translational efforts will be critical to improve concussion management in the ED setting.

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Section: Discussionmentioning

confidence: 99%

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments

Stern

Seichepine

Tschoe

et al. 2017

Journal of Neurotrauma

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“…1,2 Better imaging stewardship has the potential to avoid unnecessary radiation exposure, reduce costs, and eliminate the harms of overdiagnosis of “incidentalomas.” 3,4 Reducing avoidable imaging may also decrease the length of emergency department (ED) stays and focus limited time and resources on patients more likely to benefit from ED care. There are multiple clinical decision rules, 5 and their use during the evaluation of patients with head trauma is a recommended clinical strategy 6 by both the American College of Emergency Physicians and the Choosing Wisely campaign. 7 …”

Section: Introductionmentioning

confidence: 99%

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

Sharp

Huang

Tang

et al. 2018

Annals of Emergency Medicine

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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.

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“… 4 For patients with obvious signs of TBI, such as evidence of skull fracture on physical exam, or neurologic changes, obtaining head CTs has clear benefit, as advanced imaging may be necessary to guide medical and neurosurgical interventions. 5 However, for patients without obvious signs of TBI, the decision to perform a head CT requires more deliberation. Many non-clinical factors influence a provider’s decision to obtain a CT in patients with minor head injury.…”

Section: Introductionmentioning

confidence: 99%

Head CT for Minor Head Injury Presenting to the Emergency Department in the Era of Choosing Wisely

DeAngelis

Lou

et al. 2017

WestJEM

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IntroductionThe Choosing Wisely campaign currently recommends avoiding computed tomography (CT) of the head in low-risk emergency department (ED) patients with minor head injury, based on validated decision rules. However, the degree of adherence to this guideline in clinical practice is unknown. The objective of this study was to evaluate adherence to the Choosing Wisely campaign’s recommendations regarding head CT imaging of patients with minor head injury in the ED.MethodsWe conducted a retrospective cohort study of adult ED patients at a Level I trauma center. Patients aged ≥ 18 years who presented to the ED with minor head injury were identified via International Classification of Diseases, 9th Revision, Clinical Modification codes. Medical record abstraction was conducted to determine the presence of clinical symptoms of the NEXUS II criteria, medical resource use, and head CT findings. We used descriptive statistics to characterize the study sample, and proportions were used to quantify guidelines adherence.ResultsA total of 489 subjects met inclusion criteria. ED providers appropriately applied the Choosing Wisely criteria for 75.5% of patients, obtaining head CTs when indicated by the NEXUS II rule (41.5%), and not obtaining head CTs when the NEXUS II criteria were not met (34.0%). However, ED providers obtained non-indicated CTs in 23.1% of patients. Less than 2% of the sample did not receive a head CT when imaging was indicated by NEXUS II.ConclusionED providers in our sample had variable adherence to the Choosing Wisely head-CT recommendation, especially for patients who did not meet the NEXUS II criteria.

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Use of Clinical Prediction Rules for Guiding Use of Computed Tomography in Adults With Head Trauma

Cited by 13 publications

References 15 publications

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments

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

Head CT for Minor Head Injury Presenting to the Emergency Department in the Era of Choosing Wisely

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