Rajan Arora1, Emily N White2, Deborah Niedbala3, Yagnaram Ravichandran1,4, Usha Sethuraman1, Nancy Radovic3, Kristin Watson3, Michele Nypaver5,6. 1. From the, Department of Pediatrics, Division of Pediatric Emergency Medicine, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, USA. 2. the, Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA. 3. the, Department of Quality, Children's Hospital of Michigan, Detroit, MI, USA. 4. the, Department of Pediatrics, Wright State University, Dayton Children's Hospital, Dayton, OH, USA. 5. the, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA. 6. and the, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
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.
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.
Authors: Gabrielle C Freire; Christina Diong; Sima Gandhi; Natasha Saunders; Mark I Neuman; Stephen B Freedman; Jeremy N Friedman; Eyal Cohen Journal: CMAJ Open Date: 2022-10-11