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It has been suggested that adherence to clinical decision support (CDS) may result in a safe .... board (AllscriptsED, Chicago, IL) and identified potential subjects ...
ORIGINAL RESEARCH CONTRIBUTION

Agreement Between Routine Emergency Department Care and Clinical Decision Support Recommended Care in Patients Evaluated for Mild Traumatic Brain Injury Frederick K. Korley, MD, Melinda J. Morton, MD, MPH, Peter M. Hill, MD, MS, Tichaendepi Mundangepfupfu, MD, Tingting Zhou, Amir M. Mohareb, and Richard E. Rothman, MD, PhD

Abstract Objectives: Emergency department (ED) computed tomography (CT) use has increased significantly during the past decade. It has been suggested that adherence to clinical decision support (CDS) may result in a safe decrease in CT ordering. In this study, the authors quantified the percentage agreement between routine and CDS-recommended care and the anticipated consequence of strict adherence to CDS on CT use in mild traumatic brain injury (mTBI). Methods: This was a prospective observational study of patients with mTBI who presented to an urban academic ED of a tertiary care hospital. Patients 18 years or older, presenting within 24 hours of nonpenetrating trauma to the head, from August 2010 to July 2011, were eligible for enrollment. Structured data forms were completed by trained research assistants (RAs). The primary outcome was the percentage agreement between routine head CT use and CDS-recommended head CT use. CDS examined were: the 2008 American College of Emergency Physicians [ACEP] neuroimaging, the New Orleans rule, and the Canadian head CT rule. Differences between outcome groups were assessed using the chi-square test for categorical variables and the Kruskal-Wallis rank test for continuous variables. The percentage agreement between routine practice and CDS-recommended practice was calculated. Results: Of the 169 patients enrolled, 130 (76.9%) received head CT scans, and five of the 130 (3.8%) had acute traumatic intracranial findings. For all subjects, agreement between routine practice and CDSrecommended practice was 77.5, 65.7, and 78.1%, for the ACEP, Canadian, and New Orleans CDS, respectively. Strict adherence to the 2008 ACEP neuroimaging CDS would result in no statistically significant difference in head CT use (routine care, 76.9%; CDS-recommended, 82.8%; p = 0.17). Strict adherence to the New Orleans CDS would result in an increase in head CT use (routine care, 76.9%; CDS-recommended, 94.1%; p < 0.01). Strict adherence to the Canadian CDS would result in a decrease in head CT use (routine care, 76.9%; CDS-recommended, 56.8%; p < 0.01). Conclusions: There is a 60% to 80% agreement between routine and CDS-recommended head CT use. Of the three CDS systems examined, the only one that may result in a reduction in head CT use if strictly followed was the Canadian head CT CDS. Further studies are needed to examine reasons for the less than optimal agreement between routine care and care recommended by the Canadian head CT CDS. ACADEMIC EMERGENCY MEDICINE 2013; 20:463–469 © 2013 by the Society for Academic Emergency Medicine

From the Department of Emergency Medicine, Johns Hopkins University School of Medicine (FKK, MJM, PMH, RER), Baltimore, MD; the Lincoln Medical and Mental Health Center (TM), Bronx, NY; and the Johns Hopkins University School of Public Health (TZ, AMM), Baltimore, MD. Received August 23, 2012; revision received October 30, 2012; revision accepted November 5, 2012. Presented at the American College of Emergency Physicians Scientific Assembly, San Francisco, CA, October 2011. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Lawrence Lewis, MD. Address for correspondence and reprints: Frederick K. Korley, MD; e-mail: [email protected].

© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12136

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omputed tomography (CT) use in the evaluation of emergency department (ED) patients increased significantly during the past decade.1 This trend has contributed to rising health care costs and increasing patient exposure to ionizing radiation.2,3 However, it is unclear whether the increase in CT utilization is due to an increase of inappropriate use of CT scans. It has been suggested that adherence to evidence-based clinical decision support (CDS) may lead to more judicious use of CT scans in EDs.4,5 The 2001 Institute of Medicine report entitled “Crossing the Quality Chasm” characterized clinicians’ adherence to well-established evidence as “highly uneven.”6 The eval-

ISSN 1069-6563 PII ISSN 1069-6563583

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Korley et al. • AGREEMENT BETWEEN CDS AND ROUTINE ED CARE FOR TBI

uation of subjects with mild traumatic brain injury (mTBI) is one example of a condition for which numerous CDS systems exist to guide emergency physicians (EPs) regarding appropriate use of CT scans.6 The Canadian7 and the New Orleans8 head CT rules are two of the most extensively validated CDS for mTBI.9 The derivation and validation cohorts for these two CDS were composed of patients with blunt head trauma who either had loss of consciousness (LOC), amnesia, or disorientation. However, physicians often suspect acute traumatic intracranial pathology in blunt head injury patients without LOC or amnesia or disorientation. In 2002, the American College of Emergency Physicians (ACEP) authored a widely cited10–12 guideline and revised it in 2008.13 This guideline provides guidance on neuroimaging decision-making in all mTBI patients, including those without LOC or posttraumatic amnesia or disorientation. The 2008 ACEP neuroimaging CDS was formulated based on expert consensus and not on empirically derived data. Therefore, the effect of strict adherence to this CDS on head CT use is unknown. To our knowledge, no prior studies have quantified the gap between routine ED provider practice and CDS-recommended practice. In this study, we determined the percentage agreement between routine ED and CDS-recommended head CT utilization in mTBI patients. We also measured the potential effect of strict adherence to existing CDS on head CT use during the evaluation of mTBI patients. METHODS Study Design This was a prospective observational study of ED patients presenting with acute mTBI. The study protocol was approved by the local institutional review board. Study Setting and Population The study was conducted at an urban academic ED of a tertiary care hospital. The ED, a Level I regional trauma center, sees about 60,000 adult patients annually. We enrolled a convenience sample of subjects 18 years or older, who presented within 24 hours of nonpenetrating trauma to the head, from August 2010 to July 2011. Enrollment occurred on days when a research assistant (RA) was available (most weekdays). During those days, patients who met the study inclusion criteria were approached for consent to be enrolled. Patients who were evaluated for blunt trauma to the head (with or without LOC or posttraumatic amnesia) were eligible for inclusion in the study. We excluded patients with no clear history of trauma, unstable vital signs, obvious depressed skull fracture, a Glasgow Coma Scale (GCS) score of less than 14 on presentation, multisystem trauma, acute focal neurologic deficit, and pregnant patients. Eligibility was verified by treating physicians (supervised emergency medicine residents, board-eligible or board-certified EPs). Although the Canadian head CT CDS included patients with GCS scores of 13 in their study population, these patients were excluded from the study because current practice at the study ED is to obtain

head CT scans on all blunt head injury patients with GCS scores of 13 or less. Study Protocol Treating physicians evaluated mTBI patients in accordance with their routine practice and obtained head CT scans at their clinical discretion. RAs trained by authors (FKK, MJM) reviewed the ED electronic patient tracking board (AllscriptsED, Chicago, IL) and identified potential subjects based on chief complaints that were suggestive of blunt traumatic head injury (fall, assault, head injury, head trauma, or motor vehicle collision [MVC]). After speaking with treating physicians to verify inclusion and exclusion criteria, RAs approached eligible subjects for verbal informed consent. To minimize the chance that the study protocol altered physician practice, RAs approached potential subjects for enrollment only after treating physician evaluation and formulation of a diagnostic plan (as signified by the presence of physician orders or documentation of history or physical examination in the patient’s electronic medical record). A structured data entry form (see Data Supplement S1, available as supporting information in the online version of this paper) was completed for each enrolled subject at the bedside by an RA using the Research Electronic Data Capture (REDCap) electronic data capture tool, hosted at Johns Hopkins University Bloomberg School of Public Health. REDCap is a secure, Web-based application designed to support data capture for research studies.14 Subjects provided RAs with demographic information and additional data related to the history of present illness and review of symptoms. RAs interviewed treating physicians to obtain physical examination data including GCS. RAs did not ask treating physicians whether subjects met the criteria for obtaining head CT scans based on the decision rules evaluated. Two independent EPs reviewed the final head CT results as reported by boardcertified neuroradiologists and categorized them as acute traumatic finding (subdural, epidural, or parenchymal hematoma; subarachnoid hemorrhage; cerebral contusion; or depressed skull fracture) or no acute traumatic finding. Both the independent EP reviewers and the board-certified neuroradiologists were blinded to patient data collected specifically for the purposes of this study. For subjects who did not receive head CT scans during their index ED visits, we performed structured telephone follow-up at 14 to 60 days after enrollment to determine whether they subsequently had any hospital visits and were diagnosed with acute traumatic intracranial findings for the same injuries. Outcome Measures The primary outcome was the percentage agreement between routine head CT use and CDS-recommended head CT use. A secondary outcome was the difference in the proportion of patients who had head CT scans as part of our routine practice to that which would have occurred with strict adherence to each of the CDS systems. Data Analysis We used descriptive statistics to summarize demographic and clinical data. Categorical and continuous

ACADEMIC EMERGENCY MEDICINE • May 2013, Vol. 20, No. 5 • www.aemj.org

variables were summarized as proportions and medians, respectively (data were not normally distributed). Differences between outcome groups were assessed using the chi-square test for categorical variables and the Kruskal-Wallis rank test for continuous variables. A chi-square test was also used to determine whether there was a statistically significant difference between the proportion of patients who received head CT scans during routine ED practice and the recommended proportion that would have received head CT scans if existing CDS systems were strictly adhered to. To quantify the percent agreement between routine head CT use and guideline-recommended head CT use, we added the number of patients for whom both routine care and CDS-recommended care were congruent (recommended CT or did not recommend CT) and divided by the total number of patients. We did not use a kappa statistic, because this statistic assumes that part of the agreement between two raters occurs by chance. This assumption is not valid in this study because CDS recommendations are not affected by chance.

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Power Calculation. The study was powered to measure the percentage agreement between routine practice and CDS-suggested practice with precision. Enrolling 1,329 patients would have allowed us to measure a true percentage agreement of 70% to within 2.5 percentage points with 95% confidence. However, due to limited resources, we enrolled 169 patients. With this sample size, we had the ability to measure a true percentage agreement of 70% to within 7.2 percentage points. RESULTS A total of 169 subjects provided informed consent and were enrolled in the study. Demographic and clinical characteristics of enrolled subjects are presented in Table 1 and Data Supplement S2 (available as supporting information in the online version of this paper; see Tables Data Supplement 2 for the distribution of clinical characteristics according to each CDS investigated). Enrolled patients had demographic characteristics that were similar to those of the source population of

Table 1 Characteristics of Study Population Characteristic Demographics Median age, yr (IQR) Age > 60 yr Age  65 yr Sex Male Female Race African American White Other Had insurance Clinical characteristics Median MAP, mm Hg (IQR) Median heart rate, beats/min (IQR) GCS on presentation 14 15 GCS 2 hours after presentation 14 15 LOC Amnestic to traumatic event Persistent anterograde amnesia Headache present Headache severe Vomiting since traumatic event Vomiting  2 episodes Seizure after traumatic event Taking warfarin/bleeding disorder Trauma above clavicles Drug or alcohol intoxication Suspected open/depressed skull fracture Sign of basal skull fracture Focal neurologic deficit Dangerous mechanism Admitted to hospital

Had CT Scan, n = 130

Did Not Have CT Scan, n = 39

41 (27–62) 34 (26.2) 30 (23.1)

38 (27–51) 1 (2.6) 1 (2.6)

0.16