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. 2015 Jul;136(1):e227-33.
doi: 10.1542/peds.2014-3588.

Quality Improvement Effort to Reduce Cranial CTs for Children With Minor Blunt Head Trauma

Lise E Nigrovic  1 , Anne M Stack  2 , Rebekah C Mannix  2 , Todd W Lyons  2 , Mihail Samnaliev  3 , Richard G Bachur  2 , Mark R Proctor  4
Affiliations

Quality Improvement Effort to Reduce Cranial CTs for Children With Minor Blunt Head Trauma

Lise E Nigrovic et al. Pediatrics. 2015 Jul.

Abstract

Objective: Blunt head trauma is a common injury in children, although it rarely requires surgical intervention. Cranial computed tomography (CT) is the reference standard for the diagnosis of traumatic brain injury but has been associated with increased lifetime malignancy risk. We implemented a multifaceted quality improvement initiative to decrease the use of cranial CT for children with minor head injuries.

Methods: We designed and implemented a quality improvement effort that included an evidence-based guideline as well as individual feedback for children aged 0 to 21 years who present to the emergency department (ED) for evaluation of minor blunt head trauma. Our primary outcome was cranial CT rate, and our balancing measure was any return to the ED within 72 hours that required hospitalization. We used statistical process control methodology to measure cranial CT rates over time.

Results: We included 6851 ED visits of which 4242 (62%) occurred in the post-guideline implementation period. From a baseline CT rate of 21%, we observed an absolute reduction of 6% in cranial CT rate (95% confidence interval 3% to 9%) after initial guideline implementation and an additional absolute reduction of 6% (95% confidence interval 4% to 8%) after initiation of individual provider feedback. No children discharged from the ED required admission within 72 hours of initial evaluation.

Conclusions: An ED quality improvement effort that included an evidence-based guideline as well as individual provider feedback was associated with a reduction in cranial CT rates without an increase in missed significant head injuries.

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Conflict of interest statement

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Figures

FIGURE 1. Key driver diagram for reduction of cranial CT for minor blunt head trauma. PECARN, Pediatric Emergency Care Applied Research Network.
FIGURE 1
Key driver diagram for reduction of cranial CT for minor blunt head trauma. PECARN, Pediatric Emergency Care Applied Research Network.
FIGURE 2. Statistical process control chart showing CT rate over time with control limits. EBG, evidence based guideline.
FIGURE 2
Statistical process control chart showing CT rate over time with control limits. EBG, evidence based guideline.
FIGURE 3. Mean CT rate with 95% CI by quarter for the study institution compared with other 35 comparator hospitals contributing ED data to the PHIS administrative database.
FIGURE 3
Mean CT rate with 95% CI by quarter for the study institution compared with other 35 comparator hospitals contributing ED data to the PHIS administrative database.
See this image and copyright information in PMC

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