Abstract
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.
Highlights
IntroductionMany non-clinical factors influence a provider’s decision to obtain a computed tomography (CT) in patients with minor head injury
The 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
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%)
Summary
Many non-clinical factors influence a provider’s decision to obtain a CT in patients with minor head injury These include patient expectations, patient and provider anxiety, fear of litigation, fear of missed diagnoses, and desire to expedite diagnoses.[6,7,8] providers may hesitate to order CTs due to concerns such as increased door-to-discharge times, increased length of hospital stay, harm and cost from incidental findings on imaging, and risk of cancer due to exposure to ionizing radiation.[9,10] A balanced approach is required to ensure ordering of head CTs when necessary, while mitigating the potential downsides of over-imaging
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