530 - Putting our heads together: reducing community ED head CT utilization in pediatric head trauma

Publication Number: 530.6159

Jordan Silberg, Yale-New Haven Children's Hospital, Stamford, CT, United States; Bonnie Mackenzie, Lawrence + Memorial Hospital, Yale New Haven Health, Madison, CT, United States; Cynthia Tucker, Yale-New Haven Children's Hospital, New London, CT, United States; Seth Woolf, Yale School of Medicine, Ansonia, CT, United States; Daniela Hochreiter, Yale School of Medicine, Guilford, CT, United States

Background: Head trauma is a common presenting chief complaint in up to 3% of all visits to the emergency department (ED) for pediatric patients. The PECARN head injury guideline is a validated tool to support clinical decision-making in managing patients with head trauma. In our health system with over 110,000 pediatric ED visits annually, we noted practice variability between patients seen at the tertiary pediatric ED as compared to community EDs regarding head CT utilization for head trauma.

Objective: Our pediatric quality improvement initiative sought to standardize the evaluation for patients with pediatric head trauma at two affiliated community EDs. The primary outcome was to reduce head CT utilization from 23% (site 1) and 27% (site 2) to 15% (tertiary ED) over a 12-month period. Process measures: PECARN adherence and documentation. Balancing measure: missed head traumas, ED visits within 7 days.

Design/Methods: We formed a multidisciplinary QI team with members from both community sites including ED attendings, Pediatric hospitalists, and QI specialist. Using QI methodology, we used a key driver diagram (Image 1), Pareto charts to identify barriers to PECARN adherence, and funnel plots (Image 2) to identify providers with head CT ordering behaviors above peer average. Plan-do-study-act cycles included: dashboard for real-time data feedback, electronic medical record (EMR) based clinical pathway, provider feedback emails, creation of EMR documentation templates, and educational sessions. Concordant with PECARN guidelines, we included patients between 2 months and 18 years of age.

Results: The QI period spanned from January 2023 to September 2024. Baseline data was collected for 23 months prior to the first intervention and demonstrated a baseline of 23% head CT head utilization (site 1) and 27% (site 2) vs a baseline of 15% at the tertiary ED (Image 3). At site 1, special cause was achieved by 3/2023 (8 consecutive data points below the center line): head CT utilization decreased to 11% which has been sustained since. At site 2, we did not observe special cause to date.

Conclusion(s): Head CT utilization was starkly different at two academically affiliated community EDs vs the tertiary ED. While one ED was able to match their utilization with the children’s ED, site 2 has not shown improvement. This is likely due to a larger pool of providers and demographically different patient populations with caregivers less accepting of observation periods. Next steps for site 2 will target shared-decision making with intermediate risk patients and continued provider feedback.

Image 1. Key driver diagram.


Image 2. Site 2 Funnel plot with x-axis: de-identified provider performance; y-axis: % head CTs ordered.


Image 3. p-Chart of head CT utilization at site 1 (left) and at site 2 (right).


Image 1. Key driver diagram.


Image 2. Site 2 Funnel plot with x-axis: de-identified provider performance; y-axis: % head CTs ordered.


Image 3. p-Chart of head CT utilization at site 1 (left) and at site 2 (right).