This is the first of 2 quality improvement projects I'll be mentioning this month. The authors here apparently used their work to get credit for Maintenance of Certification from the American Board of Pediatrics, an added bonus!
Source: Jennings RM, Burtner JJ, Pellicer JF, et al. Reducing head CT use for children with head injuries in a community emergency department. Pediatrics. 2017; 139:e20161349. doi:10.1542/peds.2016-1349. See AAP Grand Rounds commentary by Dr. Michelle Stevenson (subscription required).
The premise of this study was straightforward, and highlights probably the biggest hurdle in practicing evidence-based medicine. Once we have high quality evidence showing us a better way to do things, how do we implement this new practice successfully? Here, clinicians at a community hospital partnered with a children's hospital to lessen use of CT scans in pediatric head trauma, implementing well-established management guidelines published several years ago. Of course, minimizing unnecessary tests and treatments is laudable just from a cost and resource utilization perspective, but in this case there is the added bonus of less radiation exposure for such children.
Utilizing standard quality improvement tools, clinicians at the community hospital successfully achieved their goal in lowering head CT scans from their baseline of 29% of children presenting to their emergency department to 17%, over a 15 month period. The study is a very nice example of a straightforward quality improvement practice, which is a different animal than standard clinical research (more about this later in the month). It clearly was a lot of work for all involved; this particular hospital made use of the children's hospital's personnel for data collection and monitoring, which requires a lot of human resources.
I was intrigued with a few of the study details. The investigators tracked individual clinician (ER doctors and physician assistants) and not surprisingly found some individual variation in their use of CT. In fact, 3 of the physicians had increases in their rates of CT use following the quality improvement intervention. I found myself wanting to hear a bit more about what could have caused this; perhaps it's just insignificant variation of the study period time. Also, the investigators did not track clinical outcomes of the children after leaving their facility. Clearly, lowering the CT rate isn't a good thing if dangerous conditions were missed, and such children might have sought care at a different facility later on and thus be missed in this study.
If you've ever had an inclination to learn more about developing a first-rate quality improvement endeavor, read this study. Beginners, as well as those who are more experienced, can also check out the Institute for Healthcare Improvement's Open School online.
