Jennifer R Marin1, Jonathan Rodean2, Rebekah C Mannix3, Matt Hall2, Elizabeth R Alpern4, Paul L Aronson5, Pradip P Chaudhari6, Eyal Cohen7, Stephen B Freedman8, Rustin B Morse9, Alon Peltz10, Margaret Samuels-Kalow11, Samir S Shah12, Harold K Simon13, Mark I Neuman3. 1. Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA. Electronic address: jennifer.marin@chp.edu. 2. Children's Hospital Association, Lenexa, KS. 3. Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA. 4. Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL. 5. Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT. 6. Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the USC, Los Angeles, CA. 7. Division of Pediatric Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children and Department of Pediatrics, Toronto, Ontario, Canada; Institute of Health Policy, Management & Evaluation, The University of Toronto, Toronto, Ontario, Canada. 8. Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. 9. Nationwide Children's Hospital, Columbus, OH. 10. Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA. 11. Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. 12. Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. 13. Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA.
Abstract
OBJECTIVE: To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT). STUDY DESIGN: We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits. RESULTS: There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS. CONCLUSIONS: Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.
OBJECTIVE: To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT). STUDY DESIGN: We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits. RESULTS: There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS. CONCLUSIONS: Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.
Authors: Judy Shan; E Margaret Warton; Mary E Reed; David R Vinson; Nathan Kuppermann; Peter S Dayan; Stuart R Dalziel; Adina S Rauchwerger; Dustin W Ballard Journal: Perm J Date: 2021-11-22