P2.D079: Using a Pediatric Best Practice Guideline to Reduce Head CT Usage in a Community Emergency Department

Purpose/Objectives: Approximately 89 percent of pediatric emergency department (ED) visits occur in general, non-pediatric departments. Affiliated with 15 general, non-pediatric EDs in our system which cares for over 120,000 annual ED visits, our pediatric ED is uniquely positioned to influence pediatric care across our state. With a goal to standardize care and improve pediatric outcomes, we created the Pediatric Emergency Medicine Clinical Effectiveness Team (PEMCET), a collaborative infrastructure to create and distribute pediatric best practices shared with our partner hospitals. One area of focus was pediatric head injuries. It is known that radiation exposure from CTs in childhood increases the lifetime risk of brain cancer. The PECARN head CT guidelines provide strong evidence to determine which children with head injuries are low risk for clinically significant brain injury. A pediatric head injury pathway was created with the aim of decreasing unnecessary head CT usage through improved adherence to PECARN guidelines. Since adherence to these guidelines should decrease unnecessary CT usage, we hypothesized that the implementation of our best practice guideline would increase the percentage of scans with traumatic injuries.

Design/Methods: A pediatric best practice guideline for head injuries was created and approved by PEMCET, affiliated with our institution’s emergency medicine clinical effectiveness council. The best practice guideline encourages providers to utilize the validated PECARN head CT guidelines. Our best practice guideline was distributed to all hospitals within our system. We selected one large community ED to study the impact of the guideline. After distribution of the best practice guideline, education was provided during a department meeting. Patients 18 or less who had a head CT for a traumatic cause were included in the study. Patients were selected from June-September 2022 and then June-September 2023, after the guideline was implemented. Data was also collected regarding mechanism of injury, Glasgow Coma Scale, physical exam findings of basilar skull fracture, vomiting, mental status, headache, and loss of consciousness.

Results: Pre-implementation, 41 pediatric patients with traumatic head injury underwent head CT, Post-implementation, 33 patients underwent head CT. No patients in either group were found to have a skull fracture or intracranial bleed. Documentation of secondary data was inconsistent.

Conclusion/Discussion: Evaluation of children who received head CTs for a traumatic cause at one urban community hospital showed that 74 head CTs were obtained without identification of a single clinically significant head injury. Although we were unable to access any impact of our protocol, this study suggests that many unnecessary head CTs are being obtained. Significant work still needs done to decrease unnecessary pediatric head CT usage in our system. Since documentation of secondary data was inconsistent, further work will focus on implementing a dot phrase that can be shared across the system.