Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support

Abstract

The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.

Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource emergency department: A retrospective cohort study

“…Nevertheless, although our baseline rates are comparable to those of a recent QI study conducted in the US, the implementation of PECARN guidelines in our PED had less of an impact on CT use when compared to results reported by Nigrovic et al consisting of a CT scan decrease from 21-15% after implementation and down to 9% through individual provider feedback (24). According to previous studies, a CT rate of less than 15% is achievable for all children with minor blunt head trauma (20,24,25). Knowing that there is substantial variability in adherence to PECARN rules between physicians worldwide (26); some of the physicians working in the pediatric ED section in our institution may have been reluctant to adhere to the rules as their adoption is usually influenced by local practice and culture (36).…”

“…In the literature, implementation studies conducted in different settings achieved mixed results with regards to changing practice. Some studies report no change between implementation and control groups (20,26,27), while others report consistent and substantial decreases in CT imaging rates (23)(24)(25). The change in CT scanning rates appears to be influenced by the baseline CT rates (16,19,33), the preexisting clinician accuracy (27), the medicolegal climate, the inclination for shared decision making with families (25) and the availability of observation units for conservative watchful waiting on intermediate risk patients (20).…”

“…Some studies report no change between implementation and control groups (20,26,27), while others report consistent and substantial decreases in CT imaging rates (23)(24)(25). The change in CT scanning rates appears to be influenced by the baseline CT rates (16,19,33), the preexisting clinician accuracy (27), the medicolegal climate, the inclination for shared decision making with families (25) and the availability of observation units for conservative watchful waiting on intermediate risk patients (20). As such, in settings such as the US and Canada with high baseline CT rates and variability between CT rates (16,19), clinical decision rules may contribute to a safe reduction in CT rates (24,25) but perhaps not in other settings with low CT rates or high clinician accuracy as has been shown in Italy (20) or Australia (33)(34)(35) and in our study.…”

“…Knowing that there is substantial variability in adherence to PECARN rules between physicians worldwide (26); some of the physicians working in the pediatric ED section in our institution may have been reluctant to adhere to the rules as their adoption is usually influenced by local practice and culture (36). In addition, the pediatric patients included in this study were evaluated by physicians with a surgical, emergency or family medicine rather than pediatric or pediatric ED background, which have been reported to have higher CT imaging rates (25). As such, provider related factors might have weakened the impact of PECARN rules implementation on CT scanning rates in our institution.…”

Reduction of Computed Tomography Use for Pediatric Closed Head Injury Evaluation at a Nonpediatric Community Emergency Department

“…In the future we plan to implement the Pediatric Closed Head Injury Assessment Tool at each nonpediatric ED within our health care system through electronic decision support. While not essential, we do feel that electronic decision support may enhance guideline adoption as integration of the PECARN head injury decision tool into the EMR has been shown to also help reduce head CT use in pediatric patients . To broadly monitor the efficacy and safety of the Pediatric Closed Head Injury Assessment Tool at these nonpediatric EDs we are matching the physician‐assigned discharge diagnoses used in this study to ICD‐10 discharge diagnoses to identify future head injury patients without chart review.…”