CT Trends After Minor Head Injury Guideline Implementation

Abstract

Source: Corwin DJ, Durbin DR, Hayes KL, et al. Trends in emergent head computed tomography utilization for minor head trauma after implementation of a clinical pathway. Pediatr Emerg Care. 2021;37(9);437-441; doi:10.1097/PEC.0000000000001728Investigators from the Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, conducted a retrospective study to assess changes in neuroimaging among children seen in the ED for mild traumatic brain injury (TBI) following implementation of guidelines designed to reduce unnecessary CT scans. The guidelines, implemented in 2011, were adapted from guidelines published by the Pediatric Emergency Care Applied Research Network (PECARN) that included specific clinical criteria for identifying children at low risk.1 Study participants were patients ≤21 years old seen in the ED at CHOP between 2012 and 2016 with TBI (identified using ICD-9 and ICD-10 codes) with a Glasgow Coma Scale score of 13–15 who were discharged home following evaluation. Data abstracted on these children included demographics, time of day, provider type (general pediatrician, pediatrician emergency physician, or nurse practitioner), whether a CT was obtained, and Emergency Severity Index (ESI) score. ESI scores range from 1–5, with 1 being the most acute. The medical records of a random sample of 10% of patients on whom a CT was obtained were reviewed to assess the reason for obtaining the scan and to classify the child’s risk for intracranial injury based on PECARN criteria. The primary outcome was change in rate of CT utilization during the study period, assessed using Wilcoxon rank sum test for trend. Secondary outcomes included rate of ordering CT scans by provider type, using logistic regression and adjusting for ESI scores.Data were analyzed on 21,129 patients with a mean age of 6.6 years; 62% were male. Overall, CT scans were obtained on 6.3% (95% CI, 5.9%, 6.6%) of these patients. During the study period the rate of CT scan utilization fell from 8.3% in 2012 to 4.9% in 2016 (average decrease 0.9% per year; P <0.001 for trend). After adjusting for ESI score, general pediatricians were more likely to obtain a CT scan than pediatric emergency physicians (OR, 1.37; 95% CI, 1.02, 1.83); there was no difference in likelihood of ordering a CT between nurse practitioners and pediatric emergency physicians (OR, 0.63; 95% CI, 0.33, 1.17). In the 10% random sample of patients on whom CT scans were obtained, 30% met PECARN criteria for being low risk. The most common indications for ordering a CT in children <2 years old were concern for non-accidental trauma and vomiting, while for older patients the most common reasons were parental preference and presence of a scalp hematoma.The authors conclude the rate of CT scan ordering in children with mild TBI decreased after implementation of guidelines designed to reduce unnecessary neuroimaging.Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Clinical pathways (CPWs) are tools to promote evidence-based healthcare delivery and strive to standardize care for a specific clinical problem in a specific population.2 Thus, compliance with a CPW by a diverse swath of healthcare providers is ultimately the best indicator of its relevance and utility. The primary objective of the current well-done study was to assess the pattern of change in CT utilization in discharged children with mild TBI following the implementation of a CPW in a children’s ED.The authors found that for 5 years, the rate of obtaining CT in children discharged with minor TBI declined by 0.9% per year, a statistically significant decrease, without an accompanying increase of LOS in the ED. However, despite these guidelines, 30% of surveyed Electronic Health Records (EHRs) of discharged children were characterized as low risk by the guidelines and still had a CT obtained. When documented in the EHR, the most common indications for obtaining a CT in this population were age specific. For example, in children younger than 2 years, providers were more concerned about the presence of abusive trauma and vomiting, whereas, in children older than 2 years, parental preference and scalp hematomas drove CT utilization. It may be noted that updated PECARN guidelines do not use vomiting as a risk factor, while parental preference is still a consideration in choosing CT over observation.3 The other interesting finding was that general pediatricians were more likely to order a CT compared with emergency medicine providers. Thus, the dissemination of this CPW to general pediatricians would be helpful to reduce CT use further. (See AAP Grand Rounds. 2017;37[6]:68.)4A CPW for the management of minor closed head trauma in children can lead to the reduction in the utilization of head CTs in childrenAbove and beyond decreasing unnecessary use of expensive resources and decreasing length of ED stay, decreased cranial CT frequency in children with minor TBI reduces exposure to potentially harmful ionizing radiation.4