Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study

Abstract

Study objective: To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs).

Methods: Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician.

Results: During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified.

Conclusion: Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.

Figure 1.

Pediatric head trauma A, less than 2 years; B, 2 or more years. Derived from 2019 Intermountain CPM, 2019 Pediatric Emergency Care Applied Research Network study (N=42,412) and subsequent substudies. ciTBI, clinically important traumatic brain injury (defined as death, neurosurgery, intubation > 24 hours, admission ≥ 2 nights); CPM, care process model; CT, computed tomography; GCS, Glasgow Coma scale/score; LOC, loss of consciousness; PECARN, Pediatric Emergency Care Applied Research Network; PED, pediatric ED.

Figure 2.

Study population in each step and study period.

Figure 3.

Unadjusted proportion of guideline adherence.

Figure 4.

Unadjusted computed tomography scan rate. The sustainment period coincided with COVID-19 outbreak in 2020. Fewer people sought care during the COVID-19 pandemic, but when they did, it was for a more serious presentation (eg, persistence of symptoms or number of vomiting episodes).