Feature Editor: Lori E. Rutman, MD, MPH A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool Rakesh S. Engineer, MD, Seth R. Podolsky, MD, MS, Baruch S. Fertel, MD, MPA, Purva Grover, MD, Heather Jimenez, MD, Erin L. Simon, DO, and Courtney M. Smalley, MD Introduction: The American College of Emergency Physicians embarked on the “Choosing Wisely” campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on val- idated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool. Methods: A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utiliza- tion and head CT reduction was determined for all patients with minor head in- jury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013. Results: The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to rec- ommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence inter- val, 0.12–0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group. Conclusion: A Pediatric Mild Head Injury Care Path can be imple- mented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations. Key Words: pediatric mild head injury, clinical decision support tool, shared decision making, care path utilization, radiation exposure (Pediatr Emer Care 2018;00: 00–00) T raumatic brain injury is a leading cause of death and disability in children worldwide. 1 In the United States, head trauma in patients 18 years and younger results in approximately 7400 deaths, more than 60,000 hospital admissions, and more than 600,000 annual emergency department (ED) visits. The standard tool for diagnosing these injuries in the ED setting has become head computed tomographic (CT) scan. 2 From 1996 through 2008, CT use for pediatric patients presenting to the ED with head injury increased from 10.9% to 34.0%. 3 Inappropriate utilization of radiologic testing increases costs, may increase ED length of stay, and may cause iatrogenic cancer in 1:1500 to 1:3000 pediatric patients undergoing head CT. 4,5 Implementation of the Pediatric Emergency Care Applied Research Network (PECARN) clinical decision rule has been projected to decrease total health care costs, decrease CT use, and result in fewer radiation-induced cancers. 6 The “Choosing Wisely” campaign from the American College of Emergency Physicians first recommendation states: “ Avoid com- puted tomography (CT) scans of the head in ED patients with minor head injury who are at low risk based on validated decision rules. ” Multiple groups have developed clinical decision rules (CDRs) to help providers make informed decisions about children with mild head trauma, including Canadian Assessment of Tomography for Childhood Head injury (CATCH), Children's Head injury Algo- rithm for the prediction of Important Clinical Events (CHALICE), and PECARN. 2,7,8 In an external validation and direct comparison among 1009 patients, only physician practice and PECARN achieved 100% sensitivity. The PECARN CDR was found to have better specificity (62%) over regular physician practice (50%). 9 It was also shown to have better sensitivity than CATCH or CHALICE in a recent study. 10 The PECARN CDR has been successfully imple- mented and externally validated in multiple countries. 11–13 In addi- tion, National Patient Safety Goals (17.01.01) recommends using CDRs in an effort to eliminate unnecessary radiation exposure. 14 Clinical decision support tools (CDSTs) have been shown to in- crease documented adherence to evidence-based guidelines by 56% and decrease inappropriate CT utilization in other evaluations. 15–17 Systematic reviews and meta-analyses have identified several factors that predict success in CDST: incorporation into clinician workflow, computer-based support, automatic prompting, support at the time and location of decision making, provision of recommendations rather than assessments to both patients and practitioners, and sys- tems that require a reason to override recommendations. 18–20 This study implemented the PECARN CDR in a pediatric and freestanding ED to achieve consistent clinical practice in accor- dance with evidence-based guidelines and national recommendations. We hypothesized that a Pediatric Mild Head Injury Care Path, focused on provider education, provision of a structured parent discussion tool to parents, and electronic medical record (EMR)–based CDST, could be developed, implemented, and ultimately reduce inappro- priate head CT utilization. Secondary outcomes included CDST utilization and adherence to CDST recommendations. METHODS We conducted a quality improvement project to reduce inap- propriate head CT utilization through 5 interventions: (1) engage- ment of ED nursing and physician leadership explaining the From the Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH. Disclosure: The authors declare no conflict of interests. Reprints: Courtney M. Smalley, MD, Emergency Services Institute/E19, Cleveland Clinic Health System, 9500 Euclid Ave, Cleveland, OH 44195 (e‐mail: courtney.smalley@gmail.com). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 ORIGINAL RESEARCH-QI Pediatric Emergency Care • Volume 00, Number 00, Month 2018 www.pec-online.com 1 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.