Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department

Abstract

Over 90% of patients with head trauma seen in emergency departments (EDs) are diagnosed with minor head injuries. Over-utilisation of CT scans results in unnecessary exposure to radiation and increases healthcare utilisation. Using recommendations from the Choosing Wisely Canada (CWC) campaign and quality improvement (QI) methodology, we aimed to reduce the CT scan rate for head injuries by 10% over a 6-month period.Baseline CT scan rates were determined through a 27-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and Plan-Do-Study-Act (PDSA) cycles, which included (1) improving provider knowledge about the CWC campaign recommendations; (2) testing, refining and implementing a modified Canadian CT Head Rule checklist; (3) developing CWC-themed head injury-specific patient handouts; and (4) feedback on CT scan group ordering rates to providers. Our primary outcome measure was the number of CT scans performed for patients with head injuries. Process measures included the number of checklists completed and ED length of stay (LOS). Our balancing measure was return ED visits within 72 hours (with or without admission).Baseline CT scan rates prior to our interventions was 46.1%. Our QI initiative resulted in a 'shift' in the Statistical Process Control chart of the weekly CT scan rates, associated with the first and second PDSA cycles, resulting in a 13.9% reduction in CT rates during the initial 3 months, and a sustained reduction of 8% at 16 months (p<0.05). Mean ED LOS for all patients with head injuries decreased by 1.5 min (p=0.74). 33% of checklists were completed. 72-hour return visits did not change significantly (p=0.68).Through provider and patient education, and the creation of a user-friendly evidence-based tool, our local QI initiative was successful in achieving long-term reduction in CT rates for patients presenting to EDs with head injuries.

Keywords: PDSA; emergency department; quality improvement.

Figure 1

Ishikawa diagram showing results of root-cause analysis for CT over-utilisation for patients with head injury. CWC, Choosing Wisely Canada.

Figure 2

Canadian CT head rule poster as published by Stiell et al (reproduced with permission). CSF, cerebrospinal fluid; GCS, Glasgow Coma Scale.

Figure 3

CHIMES Checklist developed by the project team, which is based on the Canadian CT head rule in figure 2. The final version of the checklist is shown which was the product of several PDSA cycles resulting in iterative improvements. CSF, cerebrospinal fluid; GCS, Glasgow Coma Scale; MD, medical doctor; NP, nurse practitioner; PA, physician assistant; RN, registered nurse.

Figure 4

High–low process map showing integration of PDSAs 2 and 3 into existing workflows in the emergency department. CWC, Choosing Wisely Canada; MD, medical doctor; RN, registered nurse.

Figure 5

Choosing Wisely Canada–themed patient handout that was developed and implemented based as part of PDSA 3.

Figure 6

Statistical process control p-chart showing changes in CT rates during and after the study period. PDSA cycles indicated by 1=education and dissemination of Choosing Wisely Canada (CWC) Campaign recommendations; 2=introduction of the new CHIMES Checklist; 3=distribution of the CWC patient handout; 4=bi-monthly feedback on CT-scan rates to providers. A ‘shift’ is seen with PDSA cycles 1 and 2, and prior to the start of the ‘passive’ phase.

Figure 7

Statistical process control XmR-chart showing changes in emergency department length of stay during and after the study period. PDSA cycles indicated by 1=education and dissemination of Choosing Wisely Canada (CWC) Campaign recommendations; 2=introduction of the new CHIMES Checklist; 3=distribution of the CWC patient handout; 4=bi-monthly feedback on CT-scan rates to providers. A ‘trend’ towards decreased length of stay is seen with PDSA cycle 3.

Figure 8

Statistical process control p-chart showing rates of return visits to the emergency department for patients discharged with a diagnosis of head injury. PDSA cycles indicated by 1=education and dissemination of Choosing Wisely Canada (CWC) Campaign recommendations; 2=introduction of the new CHIMES Checklist; 3=distribution of the CWC patient handout; 4=bi-monthly feedback on CT-scan rates to providers. An ‘astronomical point’ is seen at week 58.

Figure 9

Statistical process control p-chart showing rates of return visits to the emergency department for patients discharged with a diagnosis of head injury that resulted in an admission to hospital. PDSA cycles indicated by 1=education and dissemination of Choosing Wisely Canada (CWC) Campaign recommendations; 2=introduction of the new CHIMES Checklist; 3=distribution of the CWC patient handout; 4=bi-monthly feedback on CT-scan rates to providers.