Reducing Head CT Use for Children With Head Injuries in a ... · with head injuries in both the...

Reducing Head CT Use for Children With Head Injuries in a Community Emergency DepartmentRebecca M. Jennings, MD, a, b Jennifer J. Burtner, MD, c Joseph F. Pellicer, MD, c Deepthi K. Nair, MS, b Miranda C. Bradford, MS, b Michele Shaffer, PhD, b Neil G. Uspal, MD, d Joel S. Tieder, MD, MPHa, b

Divisions of aGeneral Pediatrics and Hospital Medicine and dEmergency Medicine, Seattle Children’s Hospital, Seattle,

Washington; bCenter for Clinical & Translational Research,

Seattle Children’s Research Institute, Seattle, Washington;

and cProvidence St Peter Hospital Emergency Department,

Olympia, Washington

Dr Jennings conceptualized and designed the

study, performed and supervised the primary data

abstraction, and drafted the initial manuscript;

Drs Burtner, Pellicer, and Uspal helped design and

implement the quality improvement initiative

and reviewed and revised the manuscript;

Ms Nair designed the data collection instruments,

coordinated and supervised data collection, and

reviewed and revised the manuscript; Ms Bradford

performed data analysis and reviewed and revised

the manuscript; Dr Shaffer helped to plan the data

analysis and reviewed and revised the manuscript;

Dr Tieder provided leadership for the design

and implementation of the quality improvement

initiative and critically reviewed the manuscript;

and all authors approved the fi nal manuscript as

submitted.

DOI: 10.1542/peds.2016-1349

Accepted for publication Oct 24, 2016

Address correspondence to Rebecca M. Jennings,

MD, M/S FA.2.115, PO Box 5371, Seattle, WA 98145-

5005. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,

1098-4275).

Copyright © 2017 by the American Academy of

Pediatrics

FINANCIAL DISCLOSURE: The authors have

indicated they have no fi nancial relationships

relevant to this article to disclose.

Pediatric head trauma is a common

reason to seek emergency department

(ED) care in the United States,

accounting for 650 000 visits per

year. 1 Patients with head trauma

present a diagnostic challenge.

Clinicians need to quickly identify

serious traumatic brain injuries

(TBIs) while limiting the radiation

exposure, sedation risk, and cost

from unnecessary head computed

tomography (CT). Children are

particularly susceptible to the

carcinogenic properties of radiation;

it is estimated that 1 case of leukemia

results from every 5250 head CT scans

performed on children <5 years old. 2

The Pediatric Emergency Care Applied

Research Network (PECARN) created

a validated prediction rule to identify

pediatric patients with blunt head

trauma at very low risk of clinically

important TBI (ci-TBI), who can safely

abstractBACKGROUND AND OBJECTIVE: Clinical decision rules have reduced use of computed

tomography (CT) to evaluate minor pediatric head injury in pediatric

emergency departments (EDs). CT use remains high in community EDs,

where the majority of children seek medical care. We sought to reduce the

rate of CT scans used to evaluate pediatric head injury from 29% to 20% in

a community ED.

METHODS: We evaluated a quality improvement (QI) project in a community ED

aimed at decreasing the use of head CT scans in children by implementing

a validated head trauma prediction rule for traumatic brain injury. A

multidisciplinary team identified key drivers of CT use and implemented

decision aids to improve the use of prediction rules. The team identified and

mitigated barriers. An affiliated children’s hospital offered Maintenance

of Certification credit and QI coaching to participants. We used statistical

process control charts to evaluate the effect of the intervention on monthly

CT scan rates and performed a Wald test of equivalence to compare

preintervention and postintervention CT scan proportions.

RESULTS: The baseline period (February 2013–July 2014) included 695

patients with a CT scan rate of 29.2% (95% confidence interval, 25.8%–

32.6%). The postintervention period (August 2014–October 2015) included

651 patients with a CT scan rate of 17.4% (95% confidence interval,

14.5%–20.2%, P < .01). Barriers included targeting providers with variable

pediatric experience and parental imaging expectations.

CONCLUSIONS: We demonstrate that a Maintenance of Certification QI project

sponsored by a children’s hospital can facilitate evidence-based pediatric

care and decrease the rate of unnecessary CT use in a community setting.

QUALITY REPORTPEDIATRICS Volume 139 , number 4 , April 2017 :e 20161349

To cite: 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(4):e20161349

by guest on October 1, 2020www.aappublications.org/newsDownloaded from

JENNINGS et al

be evaluated without a CT scan. 3

The PECARN guidelines identify

multiple risk factors for ci-TBI for

patients with minor head trauma

(eg, severe mechanism of injury,

loss of consciousness, palpable skull

fracture). Among patients with no

risk factors, the prediction rule has

a high negative predictive value for

ci-TBI of 100.0% for children <2

years old and 99.95% for children ≥2

years old. Since the publication of the

PECARN guidelines, multiple quality

improvement (QI) projects have

achieved significant reduction in

head CT scan rates for pediatric head

injury in academic pediatric EDs, 4, 5

but there have not been similarly

reported efforts in community

settings. It is important to address

head CT use in general EDs because

89% of emergency visits in the

United States for patients <14 years

old are in general EDs 6 and head CT

scan rates are significantly higher

among patients who present to

general EDs (22%) compared with

pediatric EDs (13%).7, 8

Leaders in the study hospital’s

pediatric department and ED

identified pediatric head CT use as

an area for improvement because

the baseline head CT scan rate

was significantly higher than the

rate observed at other general

EDs. 8 The goal of reducing head CT

scans aligned with the Washington

State Hospital Association 100K

Children Campaign, whose aim

is to reduce pediatric radiation

exposure in Washington hospitals. 9

We established a multidisciplinary

team, including nurses, general

pediatricians, and ED physicians, to

identify key drivers of CT use and

implement decision aids to improve

the use of head trauma prediction

rules for pediatric TBI. We used the

Maintenance of Certification (MOC)

Multispecialty Portfolio Program

from an affiliated academic children’s

hospital to provide support and

coaching for the QI project. The aim

was to reduce the rate of head CT

scans for the evaluation of pediatric

head injury in a general ED from

the current median rate of 29% to a

goal median rate of 20% within 12

months.

METHODS

Specifi c Aim

The specific aim of the project was

to reduce the head CT scan rate

among pediatric patients with head

trauma from 29% to 20% within

12 months. We chose 20% because

it is near the published national

average for general EDs. 8 Primary

drivers identified for implementation

of evidence-based care were ED

provider knowledge of head trauma

prediction rules, standard decision

process for CT imaging, and effective

caregiver education about head

trauma and imaging ( Fig 1).

Setting

Providence St Peter Hospital is a

community hospital in Olympia,

Washington, 60 miles from Seattle,

with 12 000 pediatric visits per

year. It is staffed by 24 emergency

medicine and family medicine

trained physicians and 7 physician

assistants (PAs). The PAs see less

acute patients. They see patients

independently and consult with the

ED physicians if they need guidance.

Pediatric hospitalists contracted with

Seattle Children’s Hospital provide

24-hour in-hospital consultation.

The closest pediatric neurosurgical

consultant is 28 miles away.

Seattle Children’s American Board

of Medical Specialties Multispecialty

MOC Portfolio Program was

accredited in 2012 and maintains a

portfolio of approved MOC projects

aimed at improving health outcomes

for children in the Pacific Northwest.

The program provides MOC credit

to >200 physicians per year from

multiple specialties.

The Providence Institutional Review

Board approved this study and

waived participant consent.

Planning the Intervention

We convened a multidisciplinary

team that included leaders (nurses

and physicians) from the ED, trauma

team, pediatric department, and

a regional pediatric hospital MOC

portfolio program. The project

was led by a pediatric hospitalist

and a general ED physician. Seattle

Children’s MOC Portfolio program

provided QI consultation, and

participants were eligible for MOC

credit. The team evaluated the impact

of the interventions on patients <18

years old who presented to the ED

with head injury from February

2013 to October 2015. Improvement

performance, overall and by

individual clinician, was evaluated

monthly via annotated statistical

process control (SPC) charts.

Improvement Activities

Provider Education

The team met and developed

interventions, or secondary drivers,

to address the primary drivers. The

team created an evidence-based

decision support tool, or clinical

protocol, that was adapted from

the PECARN prediction rule. This

protocol was finalized through

feedback with key stakeholders at

multiple planning meetings in July

2014. The QI initiative was then

launched for the ED physicians

during an initial educational meeting

in August 2014, where the PECARN

prediction rule was reviewed and the

new clinical protocol was introduced.

The clinical protocol was posted on

a laminated sheet at each physician

workstation in the ED. Laminated

pocket-sized cards were distributed

to all physicians and PAs. To address

caregiver education, we discussed

possible scripts to use when

discussing head injuries, concussions,

and the role for CT scans with

patients and caregivers.

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PEDIATRICS Volume 139 , number 4 , April 2017

Performance Data

Baseline CT scan rates were reviewed

and compared with national averages

at the stakeholder and ED provider

meetings. The project’s progress was

reviewed every 3 to 4 months at ED

provider meetings, and barriers to

implementation were addressed. An

annotated run chart was updated

monthly, publicly posted in a

common area of the ED, and e-mailed

to providers. Semiannually, clinicians

were privately provided with their

personal CT use rates, benchmarked

to other providers in the group on

a deidentified chart. Only providers

who had treated ≥5 patients

with head injuries in both the

preintervention and postintervention

periods were included.

Subject Identifi cation

We performed a retrospective

medical record review on eligible

subjects during the preintervention

period (February 1, 2013 to July 31,

2014) and postintervention period

(August 1, 2014 to October 31,

2015). We included patients <18

years old at the time of presentation

to the ED with an International

Classification of Diseases, Ninth

Revision, Clinical Modification (ICD-

9-CM) discharge diagnosis code

indicating head trauma (head injury

[959.01], concussion [850.xx],

skull fracture [800.xx–804.xx],

intracranial hemorrhage [851.xx–

853.xx], or other brain injury

[854.xx]). 7 For patients discharged

in October 2015, the International

Classification of Diseases, 10th

Revision discharge codes of

S06.0X0A, S06.0X1A, S06.9X1A,

e3

FIGURE 1Key driver diagram for reduction of head CT scans for pediatric patients with head injury in a community ED.


JENNINGS et al

S09.8XXA, and S09.90XA were

used. Patients with an ICD-9-CM

discharge code indicating comorbid

conditions that might increase

risk for bleeding or brain injury

were excluded. Excluded ICD-9-CM

discharge codes were hemophilia

(286.xx), thrombocytopenia

(287.xx), and ventriculoperitoneal

shunt (V45.2). For October 2015,

the International Classification of

Diseases, 10th Revision discharge

codes of D65–D69.XXX, P54, P61.0,

and Z98.2 were used.

Outcome Assessment

The primary outcome of interest

was the rate of cranial CT imaging

among eligible patients. Covariates

included race, age, sex, and

insurance status (public versus

private). Balancing measures

were readmissions within 72

hours to the index ED to assess

missed cases of ci-TBI, and length

of stay (LOS) to assess changes in

resource utilization. Patients with

an LOS >12 hours were excluded

from the LOS analysis if they were

evaluated by the crisis counselor

for psychiatric comorbidity

after their initial evaluation for

head trauma. The provider was

considered the assigned attending

provider listed in the electronic

medical record (EMR) encounter.

If a patient was evaluated by both

a PA and a physician, the physician

was assigned the role of attending

provider.

Data Analysis

We summarized sample

characteristics by using

appropriate descriptive statistics

for quantitative (mean and SD or

median and interquartile range

[IQR]) and categorical (counts

and percentages) variables. We

calculated preintervention and

postintervention proportions for

CT head imaging. We estimated

95% confidence intervals (CIs)

for CT scan proportions by

using a logit transform and

Huber–White sandwich variance

estimates to account for within-

subject correlation due to repeat

admissions (<5% of patients)

and performed a Wald test of

equivalence for preintervention

and postintervention proportion

estimates. 10, 11 In addition, we

carried out an interrupted

time series analysis based on

autoregressive integrated moving

average models as a sensitivity

analysis to account for potential

secular trends. 12

SPC charts with 1-month time

intervals were constructed to assess

the effect of the intervention on CT

scan rates. We set control limits at 3

SD from the mean and used standard

criteria to identify special causes. 13, 14

Centerline shifts were made when

8 consecutive points fell above or

below the centerline. SPC charts

were constructed with QI Macros

(KnowWare International, Inc,

Denver, CO).

We compared preintervention

and postintervention LOS by

using the Wilcoxon rank-sum

test. For our other balancing

measure, 72-hour readmissions,

we calculated preintervention

and postintervention monthly

readmission proportions.

RESULTS

The baseline period included 695

patients, and the postintervention

period included 651 patients. Four

patients were excluded because

of comorbid conditions (2 in the

preintervention period and 2

in the postintervention period).

The characteristics of our patient

population were similar in the

preintervention and postintervention

groups ( Table 1).

The proportion of head CT scans

declined from 29.2% (95% CI,

25.8%–32.6%) at baseline to

17.4% during the postintervention

period (95% CI, 14.5%–20.2%,

P < .01) ( Fig 2). These results were

consistent with results from the

interrupted time series sensitivity

analysis, which estimated that

monthly CT scan rates dropped

by 12.0% (95% CI, 7.4%–16.5%,

P < .01). Multiple barriers were

identified and addressed by

the team with new or modified

interventions ( Table 2).

The median LOS increased from 1.5

hours in the preintervention period

(IQR 0.9–2.5) to 1.9 hours in the

postintervention period (IQR 1.0–2.8,

P < .01).

There were 13 readmissions

within 72 hours during the study

period, 5 in the preintervention

period and 8 in the postintervention

period. None of these readmissions

were diagnosed with a ci-TBI; 1

patient in the preintervention

period was diagnosed with a

linear, nondisplaced skull

fracture.

During the baseline period,

individual provider rates of head CT

scan usage varied from 4% to 92%.

The majority of providers (22 out

of 28) demonstrated a reduction

in head CT scan rate during the

postintervention period ( Fig 3).

Among physicians, the average

CT scan rate declined from 47.0%

(95% CI, 41.9%–52.1%) at baseline

to 31.4% (95% CI, 26.3%–36.9%)

after intervention, whereas among

PAs the average CT scan rate fell

from 6.6% (95% CI, 4.1%–10.1%)

to 2.5% (95% CI, 1.1%–4.9%).

DISCUSSION

This study demonstrates that

community EDs can implement

evidence-based pediatric care,

particularly when coached by

a regional children’s hospital.

Specifically, we were able to

significantly reduce the rate of head

CT scans in pediatric head injury



patients in a community ED from

29.2% to 17.4% and sustain this

change over 15 months.

Our project was aided by a

multidisciplinary QI team, with

coaching from an academic center

with more QI expertise. Formal

mentoring has been shown to help

successfully implement evidence-

based recommendations and reduce

variation in care in the community

setting. 15 The educational outreach

by a pediatric ED physician

from a site that had successfully

implemented the PECARN rules

probably helped in the adoption of

the intervention. 16

The majority of providers

improved their rate of CT use,

although variation persisted across

providers. Among providers who

had a higher CT scan rate in the

postintervention period, there

were not identifiable reasons

for the increase. We found that

providing feedback to individual

providers about how their

performance compared with

others within our organization

was beneficial. This feedback was

particularly useful in a community

setting. The pediatric-specific

resources available in community

EDs are often not as robust as

in academic pediatric EDs, and

patient populations may differ.

Our providers preferred feedback

within their peer group, instead

of being benchmarked to external

providers.

We had marked improvement in

ordering rates by PAs. Our PAs see

e5

FIGURE 2SPC chart of the proportion of eligible patients in the ED with head trauma receiving a head CT scan from February 2013 through October 2015. LCL, lower control limit; UCL, upper control limit.

TABLE 2 Characteristics of Patients in the Preintervention and Postintervention Time Periods

Characteristic Preintervention, N = 695 Postintervention, N = 651

Age, median (IQR); range 8 (2–13); 0–17 9 (3–14); 0–17

Race, n (%)

White 550 (79.1) 487 (74.8)

Nonwhite 129 (18.6) 124 (19)

Unknown or refused 16 (2.3) 40 (6.1)

Private insurance, n (%) 314 (45.2) 295 (45.3)

Female sex, n (%) 285 (41.0) 265 (40.7)


JENNINGS et al

less acute patients independently,

and we encouraged them to consult

the ED physicians for more acute

patients who may need a CT scan.

PAs can play a critical component in

quality care endeavors and in fact

are now required to incorporate

QI in their MOC process. 17 Our

study demonstrates the importance

of involving nonphysician care

providers in QI processes.

There is a significant lag between

when research is first described

and when it is finally adopted into

clinical practice. 18 Numerous QI

projects in tertiary care pediatric

EDs have sought to increase the use

of evidence-based guidelines. 19 – 21

Yet the majority of pediatric patients

are seen at community hospital

EDs.6 Hospitals that see a smaller

volume of pediatric patients are less

likely to have adopted guidelines to

help guide imaging decision-making

processes for pediatric head trauma

patients. 22 Indeed, head CT scan rates

among pediatric head injury patients

are significantly higher in community

hospitals. 7

There are many barriers to the

adoption of evidence-based pediatric

care in community EDs. Because the

majority of patients seen by general

ED physicians are adults, continuing

medical education programs may

not focus on pediatric care and

there may be no impetus to create

pediatric-specific protocols. The

Joint Commission has implemented

multiple national hospital inpatient

quality core measures, but nearly

all these measures are specific to

adult care. 23 This discrepancy may

lead some community hospitals

to focus all or nearly all of their

QI endeavors on adult care. When

pediatric-specific quality measures

are created, community hospitals

may more readily focus on

pediatric care. We found this

to be the case at our own institution

when the Washington State

Hospital Association included

imaging for pediatric head

trauma among their improvement

efforts. 9 Our community hospital

was able to overcome these

barriers with the help of hospital

leadership support for our

pediatric-specific QI initiative. In

addition, because of the presence

of pediatric hospitalists, we have

hospital-based providers invested

in improving pediatric quality

measures.

Another barrier to the

dissemination of pediatric-

specific evidence encountered

at community hospitals is that

providers may use adult-specific

decision tools for pediatric

patients. We found that before our

intervention, many of our providers

used the Canadian CT Head Rule to

decide whether to image pediatric

patients, even though this decision

tool included only patients ≥16

years old. 24 Pediatric QI efforts

at community hospitals should

emphasize the unique clinical

considerations of pediatric patients

for providers who manage the full

age spectrum. We demonstrate

that the use of pediatric-specific

evidence-based clinical protocols

can improve the use of evidence-

based medicine in community EDs.

The adoption of the PECARN

guidelines is important because

it decreases radiation exposure,

which can lead to cancer, 25

and is cost-effective. Given the

lifetime risk of cancer, imaging is

beneficial only with higher pretest

probability of ci-TBI, such as the

higher-risk patients in the PECARN

guidelines. 26 Unnecessary testing

can lead to incidental findings; of

the patients included in the PECARN

study, 4% who underwent CT scans

were found to have incidental

findings on head CT scans. 27

Incidental findings can result in

additional parental anxiety, testing,

cost, and procedures and often

have unclear clinical significance. 28

Because of the risks associated

with unnecessary testing, many

professional groups have focused

on appropriate use criteria. During

our postintervention period, our

hospital performed 76 fewer CT

scans than we would have if our

preintervention CT scan rate had

continued.

The regional pediatric hospital

facilitated an effective QI project

in a local community hospital by

using MOC credit to encourage

e6

TABLE 1 Barriers to Implementation Identifi ed and Mitigated During Initiative

Barrier Intervention

Discomfort with pediatric

assessment among ED

physicians

1. ED physicians encouraged to consult on-call pediatric hospitalist for

patients with equivocal examination or presentation.

2. PECARN criteria and clinical pathway reviewed at monthly pediatric

hospitalist meeting.

Management of parental

expectations

1. Scripts to use with parents were reviewed at follow-up ED provider

meetings. Providers encouraged to show parents pathway to help

explain risk.

2. Clinical pathway presented at grand rounds with outpatient providers.

Outpatient providers encouraged to explain referral to ED as referral

for additional evaluation, not referral for CT.

Address late adopters 1. Individual provider feedback: ED physicians provided with deidentifi ed

chart to benchmark personal CT scan rate as compared with rest of

group.

Familiarity with PECARN rules 1. Presentation to ED physicians, PAs: Clinical protocol adapted from

PECARN rule and presented at ED physician and PA meetings and grand

rounds.

2. Clinical protocol posted on a laminated sheet at each physician

workstation.

3. Laminated pocket-sized cards with clinical protocol distributed to all

ED physicians and PAs.



participation. Other studies

have shown that offering MOC

credit can increase participation

for QI projects in community

settings. 29 MOC was established

by the American Board of Medical

Specialties to encourage ongoing

improvement in physicians’

knowledge, and improvement

in medical practice to evidence-

based care. 30 In part IV of the

MOC requirements, physicians

participate in approved QI

projects. 29 However, MOC

requirements have been criticized

because they do not always fulfill

practice-specific needs, and

they provide minimal benefit if

not tailored to the practice of

the physician, 30 and so valuable

MOC projects are needed.31

We demonstrate that regional

children’s hospitals can use MOC

requirements to help community

hospitals adopt evidence-based best

practices and improve important

outcomes.

One challenge we encountered was

that we were unable to standardize

the CT ordering process through

a “best practice alert” in the EMR.

Because the community hospital is

part of a larger health system, EMR

changes were difficult to institute.

These changes may have further

decreased our rate of head CT

scans. 32, 33

It is important to note that we

did have a statistically significant

increase in our LOS, 1 of our

balancing measures. This increase

in LOS is probably secondary to

more patients who were observed

after head injury instead of

immediately imaged. The median

LOS increased by only 24 minutes

(from 90 minutes to 114 minutes),

and so the clinical significance of

this increased LOS is unclear. We

think that the benefits of decreased

CT use outweigh the disadvantage

of a longer LOS.

This study has several important

limitations. First, the partnership

with pediatric hospitalists from

the regional pediatric hospital

helped engage and coach multiple

stakeholders in change, and

e7

FIGURE 3CT scan rates for individual providers, among providers who managed ≥5 patients in both the preintervention and postintervention time periods.


JENNINGS et al

this assistance is not available

at many community hospitals.

Therefore, our results may not

be generalizable to community

hospitals that do not have pediatric

hospitalist presence. Second,

although we tracked readmissions

within 72 hours to our hospital,

patients may have been readmitted

to other hospitals. There may

be patients with ci-TBIs that

were missed when we evaluated

readmissions. However, with

proper implementation of PECARN,

the rate of missed ci-TBIs is low. 3, 25

In addition, we evaluated only

absolute CT scan rates and did

not evaluate whether PECARN

was appropriately used with

each encounter, because this

analysis was beyond the scope

of this study. Glasgow Coma

Scale scores were not available

in the EMR for the majority of

the included patients, and so we

were unable to limit our study

population to patients with only

minor head injuries, and we were

unable to compare the head injury

severity in the preintervention

and postintervention patient

populations. We have not

yet demonstrated prolonged

sustainability, but we plan to

continue tracking CT scan rates,

monitoring readmissions, and

engaging the ED providers to

maintain change.

CONCLUSIONS

We demonstrate that a

multidisciplinary MOC QI project

sponsored by a regional children’s

hospital can decrease the rate

of CT use in the evaluation

of pediatric head injury in a

community setting.

e8

ABBREVIATIONS

CI: confidence interval

ci-TBI: clinically important

traumatic brain injury

CT: computed tomography

ED: emergency department

EMR: electronic medical record

ICD-9-CM: International

Classification of

Diseases, Ninth

Revision, Clinical

Modification

IQR: interquartile range

LOS: length of stay

MOC: Maintenance of

Certification

PA: physician assistant

PECARN: Pediatric Emergency

Care Applied Research

Network

QI: quality improvement

SPC: statistical process control

TBI: traumatic brain injury

FUNDING: All phases of this study were supported by Seattle Children’s Hospital Academic Enrichment Fund.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

REFERENCES

1. Kuppermann N. Pediatric head trauma:

the evidence regarding indications

for emergent neuroimaging. Pediatr

Radiol. 2008;38(suppl 4):S670–S674

2. Miglioretti DL, Johnson E, Williams A,

et al. The use of computed tomography in

pediatrics and the associated radiation

exposure and estimated cancer risk.

JAMA Pediatr. 2013;167(8):700–707

3. Kuppermann N, Holmes JF, Dayan

PS, et al; Pediatric Emergency Care

Applied Research Network (PECARN).

Identifi cation of children at very

low risk of clinically-important

brain injuries after head trauma: a

prospective cohort study. Lancet.

2009;374(9696):1160–1170

4. Bressan S, Romanato S, Mion T,

Zanconato S, Da Dalt L. Implementation

of adapted PECARN decision rule for

children with minor head injury in the

pediatric emergency department. Acad

Emerg Med. 2012;19(7):801–807

5. Nigrovic LE, Stack AM, Mannix RC,

et al. Quality improvement effort to

reduce cranial CTs for children with

minor blunt head trauma. Pediatrics.

2015;136(1). Available at: www.

pediatrics. org/ cgi/ content/ full/ 136/ 1/

e227

6. Gausche-Hill M, Schmitz C, Lewis

RJ. Pediatric preparedness of

US emergency departments:

a 2003 survey. Pediatrics.

2007;120(6):1229–1237

7. Mannix R, Bourgeois FT, Schutzman

SA, Bernstein A, Lee LK. Neuroimaging

for pediatric head trauma: do patient

and hospital characteristics infl uence

who gets imaged? Acad Emerg Med.

2010;17(7):694–700

8. Blackwell CD, Gorelick M, Holmes

JF, Bandyopadhyay S, Kuppermann

N. Pediatric head trauma: changes

in use of computed tomography in

emergency departments in the United

States over time. Ann Emerg Med.

2007;49(3):320–324

9. WA State Hospital Association. 100K

Children Campaign. Available at: www.

wsha. org/ quality- safety/ projects/ 100k-

children- campaign/ . Accessed January

11, 2016

10. Huber PJ. The behavior of

maximum likelihood estimates

under nonstandard conditions. In:

Proceedings of the Fifth Berkeley

Symposium on Mathematical Statistics

and Probability. Vol 1. Berkeley,

CA: University of California Press;

1967:221–233

11. White H. A heteroskedasticity-

consistent covariance matrix

estimator and a direct test for

heteroskedasticity. Econometrica.

1980;48(4):817–838

12. Box GEP, Jenkins GM, Reinsel GC. Time

Series Analysis: Forecasting and

Control. 4th ed. Hoboken, NJ: Wiley;

2008

13. Benneyan JC, Lloyd RC, Plsek PE.

Statistical process control as a



tool for research and healthcare

improvement. Qual Saf Health Care.

2003;12(6):458–464

14. Benneyan JC. Use and interpretation of

statistical quality control charts. Int

J Qual Health Care. 1998;10(1):69–73

15. Li J, Hinami K, Hansen LO, Maynard G,

Budnitz T, Williams MV. The physician

mentored implementation model:

a promising quality improvement

framework for health care change.

Acad Med. 2015;90(3):303–310

16. Grol R, Grimshaw J. From best

evidence to best practice:

effective implementation of

change in patients’ care. Lancet.

2003;362(9391):1225–1230

17. Boucher NA, Mcmillen MA, Gould JS.

Agents for change: nonphysician

medical providers and health care

quality. Perm J. 2015;19(1):90–93

18. Trochim W, Kane C, Graham MJ, Pincus

HA. Evaluating translational research:

a process marker model. Clin Transl

Sci. 2011;4(3):153–162

19. Jerardi KE, Elkeeb D, Weiser J,

Brinkman WB. Rapid implementation of

evidence-based guidelines for imaging

after fi rst urinary tract infection.

Pediatrics. 2013;132(3). Available at:

www. pediatrics. org/ cgi/ content/ full/

132/ 3/ e749

20. Murtagh Kurowski E, Shah SS,

Thomson J, et al. Improvement

methodology increases guideline

recommended blood cultures in

children with pneumonia. Pediatrics.

2015;135(4). Available at: www.

pediatrics. org/ cgi/ content/ full/ 135/ 4/

e1052

21. Ambroggio L, Thomson J, Murtagh

Kurowski E, et al. Quality improvement

methods increase appropriate

antibiotic prescribing for childhood

pneumonia. Pediatrics. 2013;131(5).

Available at: www. pediatrics. org/ cgi/

content/ full/ 131/ 5/ e1623

22. Wylie MC, Merritt C, Clark M, Garro

AC, Rutman MS. Imaging of pediatric

head injury in the emergency

department. Pediatr Emerg Care.

2014;30(10):680–685

23. The Joint Commission. Specifi cations

manual for national hospital inpatient

quality measures. Available at: www.

jointcommission. org/ specifi cations_

manual_ for_ national_ hospital_

inpatient_ quality_ measures. aspx.

Accessed August 11, 2016

24. Stiell IG, Wells GA, Vandemheen K, et al.

The Canadian CT Head Rule for patients

with minor head injury. Lancet.

2001;357(9266):1391–1396

25. Nishijima DK, Yang Z, Urbich M, et al.

Cost-effectiveness of the PECARN rules

in children with minor head trauma.

Ann Emerg Med. 2015;65(1):72–80.e6

26. Hennelly KE, Mannix R, Nigrovic

LE, et al. Pediatric traumatic

brain injury and radiation risks: a

clinical decision analysis. J Pediatr.

2013;162(2):392–397

27. Rogers AJ, Maher CO, Schunk JE,

et al; Pediatric Emergency Care Applied

Research Network. Incidental fi ndings

in children with blunt head trauma

evaluated with cranial CT scans.

Pediatrics. 2013;132(2). Available at:

www. pediatrics. org/ cgi/ content/ full/

132/ 2/ e356

28. Jensen MC, Brant-Zawadzki MN,

Obuchowski N, Modic MT, Malkasian

D, Ross JS. Magnetic resonance

imaging of the lumbar spine in people

without back pain. N Engl J Med.

1994;331(2):69–73

29. Gorzkowski JA, Klein JD, Harris DL,

et al. Maintenance of Certifi cation

Part 4 Credit and recruitment for

practice-based research. Pediatrics.

2014;134(4):747–753

30. Cook DA, Holmboe ES, Sorensen KJ,

Berger RA, Wilkinson JM. Getting

maintenance of certifi cation to work:

a grounded theory study of physicians’

perceptions. JAMA Intern Med.

2015;175(1):35–42

31. Levinson W, King TEJ Jr, Goldman L,

Goroll AH, Kessler B. Clinical decisions.

American Board of Internal Medicine

maintenance of certifi cation program.

N Engl J Med. 2010;362(10):948–952

32. Ballard DW, Rauchwerger AS, Reed

ME, et al; Kaiser Permanente CREST

Network. Emergency physicians’

knowledge and attitudes of clinical

decision support in the electronic

health record: a survey-based study.

Acad Emerg Med. 2013;20(4):352–360

33. Sheehan B, Nigrovic LE, Dayan PS,

et al; Pediatric Emergency Care Applied

Research Network (PECARN). Informing

the design of clinical decision support

services for evaluation of children

with minor blunt head trauma

in the emergency department: a

sociotechnical analysis. J Biomed

Inform. 2013;46(5):905–913


DOI: 10.1542/peds.2016-1349 originally published online March 2, 2017; 2017;139;Pediatrics

Miranda C. Bradford, Michele Shaffer, Neil G. Uspal and Joel S. TiederRebecca M. Jennings, Jennifer J. Burtner, Joseph F. Pellicer, Deepthi K. Nair,

Emergency DepartmentReducing Head CT Use for Children With Head Injuries in a Community

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DOI: 10.1542/peds.2016-1349 originally published online March 2, 2017; 2017;139;Pediatrics

Miranda C. Bradford, Michele Shaffer, Neil G. Uspal and Joel S. TiederRebecca M. Jennings, Jennifer J. Burtner, Joseph F. Pellicer, Deepthi K. Nair,

Emergency DepartmentReducing Head CT Use for Children With Head Injuries in a Community

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