Touchstone Silver: Reducing CT Utilization for Pediatric Patients with Minor Head Trauma

Traumatic brain injury is a leading cause of death and disability in children, and a CT scan is a valuable tool in determining if the brain is bleeding or swollen or if the patient has a skull fracture. In a study published in 2012 in the UK Medical Journal Lancet, a possible link between pediatric CT scans and increased risk of development of brain tumors and leukemia was illustrated.

NHRMC formed a team to re-evaluate the frequency of use of CT scans at NHRMC and our partner hospitals.

The Project

The goal was to reduce unnecessary CT imaging for pediatric patients who present to the ED with minor head trauma.  This is important as CT imaging exposes patients to radiation.

Prior to this project, NHRMC did not have a standard decision-making algorithm for determining if a pediatric patient needed a CT for minor head trauma, a convenient process for monitoring pediatric patients post injury as an alternative for CT, or a consistent organizational message for CT utilization in children.

In the year prior to the launch of this program an average of 76 ED patients per month, ages 17 years and younger, received a CT scan of the head at one of NHRMC’s three Emergency Departments. 

Goals:

1. Reduce CT imaging of the head for pediatric ED patients who present with minor head trauma by at least 10%.
2. Educate ED providers about the Pediatric Emergency Care Applied Research Network guidelines and achieve at least 80% compliance with a stretch goal of 100%.

Objectives:

• Develop standard workflow for pediatric head trauma patients.
• Educate patients, parents, and referring providers about the importance of selective utilization of CT for pediatric patients.
• Develop a process so pediatric head trauma patients can be admitted quickly to NHRMC Pediatrics for observation.

The team built a process in which the nurse educates the patient and parents about the PECARN guidelines. This step helps to establish expectations early in the visit and supports the physician's communication. The physician consults with the patient, and the patient’s parents, reviewing the clinical status of the patient and the recommended pathway based on the presentation of their clinical signs and symptoms.

Once a decision is made using the PECARN guidelines, the patient may receive a CT scan, be admited to Pediatrics for observation or discharged.

The Impact

• There has been a 40% decrease in the number of pediatric head CTs after the project was initiated.
• Compliance with PECARN guidelines by ED providers has improved from 76% since implemenation to consistently above 98%.
• Through the end of October 2018, the reduction of 732 pediatric head CT scans has resulted in an overall decrease in billed charges to our patients of more than $1,488,000 dollars.There has also been a direct cost savings of over $75,000 for NHRMC.
• To date there have been no reported cases of missed injury or poor outcome secondary to this decision making.

Additional Steps

Next, through collaborative efforts with our marketing department, the team worked to educate providers in the outpatient setting.  This helps set the expectation with the parents and patient that when they get to the ED, they may or may not receive a CT scan.

Team Members

• Dr. Bryan Durham, ED Physician
• Dr. David Evans, Radiologist
• Dr. Fernando Moya, Neonatologist and Medical Director Betty Cameron Children's Hospital
  
• Dr. Michael Stoiko, Pediatric Intensivist and Medical Director of Pediatric ICU
• Dr. Chip Williams, Pediatric Gastroenterologist and Medical Director Nunnelee Pediatric Subspecialty Clinic
• Dr. Christopher Sepich, Internal Medicine
• Dr. Lauren Gainor, Pediatric Hospitalist and Medical Director of Inpatient Pediatrics
• James Bryant, Administrator Emergency Services
• Suzie McCabe, Clinical Director Women's and Children's Hospital
• Joshua Tucker, Director of Radiology
• Johnsie Davis, Director of Patient Safety
• Terri DeWees, Trauma Program Director
• Joni Mitchem, Emergency Department PI Coordinator
• Casey Powell, Manager Emergency Department 17th Street Campus
• James Brekhus, Radiology CT Manager
• Carolyn Fisher, Director of Marketing and Public Relations
• Anna Dover, Pharmacy Analyst II
• Jeremy Pollock, Business Application Analyst
• Michael Voorheis, Senior Copywriter
• Pamela Meares, Clinical and Operations Project Analyst
• Alexis Bostic, ED RN
• Amber McVeigh, Clinical Educator Respiratory Therapist
• Cheryl Cummings, ED Patient Assistance Center RN
• Amie Ellis, Manager Emergency Department Orthopedic Campus
• Cara Emerson, Administrative Coordinator Pediatrics/PICU
• Debbie Pendleton, Manager Pediatrics and Pediatric Specialty Services
• Angela Frey, ED Clinical Education Specialist II
• Elizabeth Harris, Education and Development Manager SEAHEC
• Andrea Smith, Pediatrics RN
• Kristen Harrison, ED RN
• Gayle Thear, Clinical Education Specialist II
• James Holtvoigt, Clinical Education Specialist II
• Vanessa Van Gilder, Manager Pediatric Specialty Clinics
• Anne Leggett, ED RN Coordinator
• Alicia May, ED RN