scholarly journals P008: Implementation of a voluntary provincial knowledge translation intervention project to improve the appropriateness of CT imaging for patients with mild traumatic brain injury and suspected pulmonary embolism

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S80
Author(s):  
J. Andruchow ◽  
D. Grigat ◽  
A. McRae ◽  
G. Innes ◽  
E. Lang
Keyword(s):  
Traumatic Brain Injury ◽  
Pulmonary Embolism ◽  
Decision Support ◽  
Brain Injury ◽  
Diagnostic Imaging ◽  
Patient Outcomes ◽  
Mild Traumatic Brain Injury ◽  
Emergency Physicians ◽  
Suspected Pulmonary Embolism ◽  
Ct Utilization

Introduction: Utilization of CT imaging has risen dramatically with increases in availability, but without corresponding improvements in patient outcomes. Previous attempts to improve imaging appropriateness via guideline implementation have met with limited success, with commonly cited barriers including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. The objective of this project is to improve CT utilization and appropriateness by addressing common barriers through clinical decision support (CDS) embedded in clinical practice. Methods: This matched-pair cluster-randomized trial saw 12 Alberta EDs with CT scanners randomized to receive CDS for diagnostic imaging. After extensive site engagement to recruit emergency medicine and diagnostic imaging leadership and stakeholders and understand local contexts, half of the sites received CDS for mild traumatic brain injury (MTBI) based on the Canadian CT Head Rule, while the remainder received CDS for suspected pulmonary embolism (PE), including the Pulmonary Embolism Rule-out Criteria (PERC), Wells Score, age-adjusted D-dimer and CT pulmonary angiography (CTPA) use. Hardcopy CT order forms including quantitative decision support, source literature and patient handouts were developed and adapted and integrated into workflow as per local site preference. Regular physician and site report cards on CT utilization and CDS use were also provided. The primary outcome was diagnostic imaging utilization for patients with MTBI and suspected PE. Results: During the study period, 144 emergency physicians at 6 EDs saw 3,278 patients with MTBI and 146 emergency physicians at six matched comparison EDs saw 18,606 patients with suspected PE. Use of CDS was highly variable by site, ranging from 0% to 29% of CT orders for MTBI and from 13% to 75% of CTPA orders for suspected PE. Impact on CT utilization, appropriateness, diagnostic yield is currently under investigation, but is expected to be limited at many sites given the variable adoption of decision support. Conclusion: A comprehensive CDS intervention to improve evidence-based imaging has met with variable uptake. Meaningful and widespread sustained improvements in practice will likely require incentives, accountability measures and leadership authority to enforce change.

scholarly journals MP38: Barriers and facilitators to physician use of computerized clinical decision support for mild traumatic brain injury and suspected pulmonary embolism

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S54-S54
Author(s):  
S. Arnold ◽  
D. Grigat ◽  
J. E. Andruchow ◽  
A. D. McRae ◽  
G. Innes ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Pulmonary Embolism ◽  
Decision Support ◽  
Brain Injury ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Barriers And Facilitators ◽  
Evidence Based ◽  
Emergency Physicians ◽  
Suspected Pulmonary Embolism

Introduction: As utilization of CT imaging has risen dramatically, evidence-based decision rules and clinical decision support (CDS) tools have been developed to avoid unnecessary CT use in low risk patients. However, their ability to change physician practice has been limited to date, with a number of barriers cited. The purpose of this study was to identify the barriers and facilitators to CDS adoption following a local CDS implementation. Methods: All emergency physicians at 4 urban EDs and 1 urgent care center were randomized to voluntary evidence-based CT imaging CDS for patients with either mild traumatic brain injury (MTBI) or suspected pulmonary embolism (PE). CDS was integrated into the computerized physician order entry (CPOE) software and triggered whenever a CT scan for an eligible patient was ordered. Physicians in both the MTBI and PE arms were ranked according to their CDS use, and a stratified sampling strategy was used to randomly select 5 physicians from each of the low, medium and high CDS use tertiles in each study arm. Each physician was invited to participate in a 30-minute semi-structured interview to assess the barriers and facilitators to CDS use. Physician responses were reported using a thematic analysis. Results: A total of 202 emergency physicians were randomized to receive CDS for either MTBI or PE, triggering CDS 4561 times, and interacting with the CDS software 1936 times (42.4%). Variation in CDS use ranged from 0% to 88.9% of eligible encounters by physician. Fourteen physicians have participated in interviews to date, and data collection is ongoing. Physicians reported that CDS use was facilitated by their confidence in the evidence supporting the CDS algorithms and that it provided documentation to reduce medico-legal risk. CDS use was not impeded by concerns over missed diagnoses or patient expectations. Reported barriers to CDS use included suboptimal integration into the CPOE such as the inability to auto-populate test results, it disrupted the ordering process and was time consuming. A common concern was that CDS was implemented too late in workflow as most decision making takes place at the bedside. Physicians did not view CDS as infringing on physician autonomy, however they advised that CDS should be a passive educational option and should not automatically trigger for all physicians and eligible encounters. Conclusion: Physicians were generally supportive of CDS integration into practice, and were confident that CDS is an evidence-based way to reduce unnecessary CT studies. However, concerns were raised about the optimal integration of CDS into CPOE and workflow. Physicians also stated a preference to a passive educational approach to CDS rather than an automatic triggering mechanism requiring clinical documentation.

Association of Clinical Guidelines and Decision Support with CT use in Pediatric Mild Traumatic Brain Injury

2021 ◽  
Author(s):  
Jennifer R. Marin ◽  
Jonathan Rodean ◽  
Rebekah C. Mannix ◽  
Matt Hall ◽  
Elizabeth R. Alpern ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Decision Support ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Clinical Guidelines

scholarly journals MP41: Validity of the Canadian CT head rule age criterion for mild traumatic brain injury

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S55-S55
Author(s):  
N. Fournier ◽  
M. Émond ◽  
N. Le Sage ◽  
C. Gariépy ◽  
E. Fortier ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Univariate Analysis ◽  
Trauma Centre ◽  
Emergency Physicians ◽  
Historical Cohort ◽  
Radiological Data ◽  
Ct Head ◽  
Proposed Modification

Introduction: With a Canadian aging population, the prevalence of mild traumatic brain injury (mTBI) among elderly is increasing and the age criterion of the Canadian CT head rule (CCHR) is challenged by many emergency physicians. We evaluated if increasing the age criterion of the CCHR would maintain its validity. Methods: We conducted an historical cohort study using the medical charts of all patients 65 years old or more who consulted at a Level One Trauma Centre emergency department (ED) for a mTBI between 2010 and 2014. The main outcome measures were clinically important brain injury (CIBI) on Computed Tomography (CT) and the presence of the CCHR criteria. The clinical and radiological data collection was standardized. Univariate analysis was performed to measure the predictive capacities of modified age cut-offs at 70 and 75 years old. Results: Out of the 104 confirmed mTBI in this study, 32 (30,8%) had CIBI on CT scan. Sensitivity and specificity [C.I. 95%] of the CCHR were 100% [89.1 - 100] and 0% [0.0 5.0] for an age criterion of 65 years old and above; 100% [89.1 - 100] and 4,2% [0.9 11.7] for a modified criterion of 70 years old; 100% [89.1 - 100] and 13,9% [6.9 24.1] for 75 years old. Furthermore, for an age criterion of 80 and 85 years old, sensitivity was respectively 90,6% [75.0 98.0] and 75,0% [56.6 88.5]. Conclusion: In our cohort, increasing the age criterion of the CCHR for minor head injury to 75 years old would benefit ED by further reducing CT scans without missing CIBI. A larger prospective study is indicated to confirm the proposed modification.

90 EMFProvider Adherence to Head CT Utilization Guidelines for Mild Traumatic Brain Injury

2011 ◽  
Vol 58 (4) ◽  
pp. S207-S208
Author(s):  
M.J. Morton ◽  
R.E. Rothman ◽  
T. Mundangepfupfu ◽  
T. Zhou ◽  
A. Mohareb ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
Head Ct ◽  
Ct Utilization

The Speech-Language Pathologists' Role in Mild Traumatic Brain Injury for Middle and High School–Age Children: Viewpoints on Guidelines From the Centers for Disease Control and Prevention

2019 ◽  
Vol 28 (3) ◽  
pp. 1363-1370 ◽  
Author(s):  
Jessica Brown ◽  
Katy O'Brien ◽  
Kelly Knollman-Porter ◽  
Tracey Wallace
Keyword(s):  
High School ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Disease Control ◽  
Mild Traumatic Brain Injury ◽  
School Age Children ◽  
School Age ◽  
Speech Language Pathologists ◽  
Control And Prevention ◽  
Centers For Disease Control

Purpose The Centers for Disease Control and Prevention (CDC) recently released guidelines for rehabilitation professionals regarding the care of children with mild traumatic brain injury (mTBI). Given that mTBI impacts millions of children each year and can be particularly detrimental to children in middle and high school age groups, access to universal recommendations for management of postinjury symptoms is ideal. Method This viewpoint article examines the CDC guidelines and applies these recommendations directly to speech-language pathology practices. In particular, education, assessment, treatment, team management, and ongoing monitoring are discussed. In addition, suggested timelines regarding implementation of services by speech-language pathologists (SLPs) are provided. Specific focus is placed on adolescents (i.e., middle and high school–age children). Results SLPs are critical members of the rehabilitation team working with children with mTBI and should be involved in education, symptom monitoring, and assessment early in the recovery process. SLPs can also provide unique insight into the cognitive and linguistic challenges of these students and can serve to bridge the gap among rehabilitation and school-based professionals, the adolescent with brain injury, and their parents. Conclusion The guidelines provided by the CDC, along with evidence from the field of speech pathology, can guide SLPs to advocate for involvement in the care of adolescents with mTBI. More research is needed to enhance the evidence base for direct assessment and treatment with this population; however, SLPs can use their extensive knowledge and experience working with individuals with traumatic brain injury as a starting point for post-mTBI care.

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