Community EDs cut needless trauma CT using Canadian rule

After implementing an established rule for selecting head CT for trauma patients, a 13-site set of Kaiser Permanente community EDs in Southern California reduced avoidable head CT utilization by 5.3 percent while improving their performance on injury identification, according to a study published online July 21 in Annals of Emergency Medicine.

Adam Sharp, MD, and colleagues describe their work before and after adopting the Canadian CT Head Rule with a multi-pronged approach that combined leadership endorsement, physician education and EHR-embedded clinical decision support.

The team analyzed the cases of 44,947 patients (28,751 preintervention and 16,196 postintervention) who were triaged with trauma over a two-year period ending in 2015.

The last seven months of the study period saw the use of the rule.

A total of 14,633 patients (32.6 percent) received head CTs. The preintervention CT count was 9,758 preintervention versus 4,875 postintervention.

The researchers calculated an absolute reduction in CT use postintervention of 5.3 percent (95 percent confidence interval).

Meanwhile, 12 of the 13 sites reduced their utilization of trauma head CT after implementing the rule.

Importantly, after the intervention, diagnostic yield of CT-identified intracranial injuries, including skull fractures and intracranial hemorrhages, increased by 2.3 percent (95 percent confidence interval), the authors report.

In their discussion, Sharp et al. note that clinical decision support likely played a key role in the success they had with the Canadian rule, adding that their experience “supports the integration of clinical decision support for head trauma into routine practice in modern U.S. emergency departments.”

The authors also point out that the importance of including the Canadian rule in continuing medical education is not well defined.

“Using clinical decision support may be critical to the success in reducing CT use, but the more nebulous effect of leadership, education and other cultural factors requires further investigation,” they write. “Influencing physicians to apply decision rules is complex, and, although our results are favorable, we hypothesize there is still ample room for improvement in the application of the Canadian CT Head Rule in our study EDs. Including other components of implementation strategies, such as audit and feedback, may result in even greater reductions in avoidable CT use.”