When a child shows up at the emergency department with a traumatic brain injury, the encounter can often result in a costly head CT scan that provides little value to the patient. But one Philadelphia-based provider may have figured out how to avoid such unnecessary imaging, without disrupting a physician’s workflow.
Einstein Healthcare radiology experts devised a clinical decision support system that may be starting to make a dent in this patient population. In a case study, detailed Tuesday in JACR, scientists said the system boosted the number of brain CT orders considered to be clinically necessary from 57% prior to the intervention up to 76% afterward.
“This study demonstrates that embedding a clinical decision algorithm within the EHR can be an effective method in affecting behavioral change and may be useful in the implementation of other protocol changes that result in the performance of studies that are supported by evidence and are truly necessary, as is promoted by Choosing Wisely,” Joel Y. Sun, MD, Einstein’s chief radiology resident, and colleagues wrote June 23.
Traumatic brain injury is a common concern in U.S. emergency departments, resulting in 812,000 such visits in 2014 alone. CT is the go-to diagnostic tool for significant TBI cases that require intervention, but the large majority of presentations for minor pediatric head trauma result in negative imaging findings, Sun et al. noted. ED providers are often forced to make snap ordering decisions, without the necessary decision support, resulting in added cost and radiation risk to the patient.
To address this issue, the Einstein team built an algorithm using guidance from the Pediatric Emergency Care Applied Research Network on how to handle kids with head trauma who are at a low risk for traumatic brain injury. Despite efforts from the PECARN and Choosing Wisely to address this issue over the years, Sun noted, the use of head CT for trauma among pediatric patients did not decrease between 2007 and 2015.
Einstein’s CDS assistant activates in the electronic health record at the start of a head CT order for any patient under the age of 18. If for head trauma, the system then guides the provider through several steps and places each patient into one of three categories. Those include low risk, with CT not recommended; intermediate risk, with CT recommended only based on other clinical factors such as worsening condition; and high risk, with computed tomography scans deemed necessary.
Sun et al. tested the system’s success by retrospectively comparing one year of using the decision support versus the previous year, prior to implementation. All told, Einstein logged 251 eligible head CT scans for minor pediatric head trauma during the two-year study period. During year one, 56.8% (71 of 125) head examinations fell into the intermediate- or high-risk category. And in year two after the intervention, that number climbed to 76.2% (96 0f 126). That’s a 19.4 percentage-point uptick, with Sun and colleagues labeling compliance after the intervention as “significant.”
Meanwhile, overall rates of head CT ordering for pediatric head trauma remained flat at 5.6% and 5.7% before and after the intervention, respectively. Sun cited a previous analysis noting that even a 15% order rate for such CT scans as commendable, meaning Einstein providers were already ahead of the pack.
“The ordering rate of 5.6% in our network before our intervention suggests that our ED providers already demonstrated high discretion in ordering head CT for minor pediatric head trauma at baseline,” the team noted.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.