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Feng T, Ajdari A, Boyle LN, Kannan N, Burd R, Groner JI, Farneth RA, Vavilala MS. Computer Simulation to Assess Emergency Department Length of Stay in Pediatric Traumatic Brain Injury. Pediatr Emerg Care 2024; 40:421-425. [PMID: 38227782 PMCID: PMC11141338 DOI: 10.1097/pec.0000000000003088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
OBJECTIVES Our study aimed to identify how emergency department (ED) arrival rate, process of care, and physical layout can impact ED length of stay (LOS) in pediatric traumatic brain injury care. METHODS Process flows and value stream maps were developed for 3 level I pediatric trauma centers. Computer simulation models were also used to examine "what if" scenarios based on ED arrival rates. RESULTS Differences were observed in prearrival preparation time, ED physical layouts, and time spent on processes. Shorter prearrival preparation time, trauma bed location far from diagnostic or treatment areas, and ED arrival rates that exceed 20 patients/day prolonged ED LOS. This was particularly apparent in 1 center where computer simulation showed that relocation of trauma beds can reduce ED LOS regardless of the number of patients that arrive per day. CONCLUSIONS Exceeding certain threshold ED arrival rates of children with traumatic brain injury can substantially increase pediatric trauma center ED LOS but modifications to ED processes and bed location may mitigate this increase.
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Affiliation(s)
| | - Ali Ajdari
- Harvard Medical School & Massachusetts General Hospital, Boston, MA
| | | | | | - Randall Burd
- Children’s National Medical Center, Washington, DC
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2
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Tian Y, Shultz K, Ryskina K. Emergency department visits by older adults receiving postacute care in skilled nursing facilities. J Hosp Med 2024; 19:40-44. [PMID: 37867290 PMCID: PMC11037473 DOI: 10.1002/jhm.13226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
Skilled nursing facilities (SNF) represent a common postdischarge destination for hospitalized older adults. The goals of SNF care include the completion of extended skilled nursing care and physical rehabilitation to enable patients to safely return home. However, nearly one in four older adults discharged to SNF are rehospitalized and one in five seek care in the emergency department (ED) but are discharged back to SNF. Our aim was to measure the national prevalence and costs to Medicare of ED visits by SNF patients. Of the 1,551,703 Medicare beneficiaries discharged to SNF in 2019, 16.3% had an ED visit within 14 days (n = 253,104). Of those ED visits, 25.5% resulted in a same-day discharge back to SNF (n = 64,472), costing Medicare $24.6 million. Novel care models that can leverage SNF staff and resources while providing rapid diagnostic services are urgently needed.
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Affiliation(s)
- Ye Tian
- Penn Presbyterian Medical Center, Pulmonary and Critical Care Division, Philadelphia, Pennsylvania, USA
| | - Kaitlyn Shultz
- Division of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kira Ryskina
- Division of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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Wilson S, Chen KCJ, Chartier LB, Campbell SG, Dowling S, Upadhye S, Thiruganasambandamoorthy V. Revisiting Choosing Wisely recommendation #1: "Don't order CT head scan in adults and children who have suffered minor head injuries (unless positive for a validated clinical decision rule)". CAN J EMERG MED 2023:10.1007/s43678-023-00515-0. [PMID: 37253996 DOI: 10.1007/s43678-023-00515-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/22/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Samuel Wilson
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
| | - Samuel G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
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Below C, Brianti IC, Parreira JG, Lucarelli-Antunes PDES, Saade N, Golin M, Pivetta LGA, Veiga JCE, Assef JC. Clinical assessment of head injuries in motorcyclists involved in traffic accidents: A prospective, observational study. Rev Col Bras Cir 2022; 49:e20223340. [PMID: 35894390 PMCID: PMC10578845 DOI: 10.1590/0100-6991e-20223340-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/09/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to review the clinical assessment of head injuries in motorcyclists involved in traffic accidents. METHOD prospective observational study, including adult motorcyclists involved in traffic accidents in a period of 12 months. Patients sustaining signs of intoxication were excluded. A modification of the Canadian Head CT Rules was used to indicate computed tomography (CT). Patients not undergoing CT were followed by phone calls for three months. Collected variables were compared between the group sustaining head injuries and the others. We used chi-square, Fisher, and Student's t for statistical analysis, considering p<0.05 as significant. RESULTS we included 208 patients, 99.0% were wearing helmets. Seventeen sustained signs of intoxication and were excluded. Ninety (47.1%) underwent CT and 12 (6.3%) sustained head injuries. Head injuries were significantly associated with Glasgow Coma Scale<15 (52.3% vs. 2.8% - p<0,001) and a positive physical exam (17.1% vs. zero - p<0,05). Four (2.1%) patients with intracranial mass lesions needed surgical interventions. None helmet-wearing patients admitted with GCS=15 and normal physical examination sustained head injuries. CONCLUSION Head CT is not necessary for helmet-wearing motorcyclists admitted with GCS=15 and normal physical examination.
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Affiliation(s)
- Cristiano Below
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Cirurgia - São Paulo - SP - Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | - Isabela Campos Brianti
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | - José Gustavo Parreira
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Cirurgia - São Paulo - SP - Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | - Pedro DE Souza Lucarelli-Antunes
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Cirurgia - São Paulo - SP - Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | - Nelson Saade
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Cirurgia - São Paulo - SP - Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | - Murilo Golin
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Cirurgia - São Paulo - SP - Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | | | - José Carlos Esteves Veiga
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Cirurgia - São Paulo - SP - Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | - Jose Cesar Assef
- - Irmandade da Santa Casa de Misericórdia de São Paulo, Cirurgia - São Paulo - SP - Brasil
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
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5
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Lee C, Beavers J, Pham J, Hackett L, Miller J, Buntine P. Impact of the Canadian CT head rule supplemented by the original published minimum inclusion criteria to assist emergency department clinicians' assessment of patients presenting post fall from residential aged care: a retrospective audit. BMC Geriatr 2022; 22:607. [PMID: 35864470 PMCID: PMC9306092 DOI: 10.1186/s12877-022-03284-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 06/27/2022] [Indexed: 11/12/2022] Open
Abstract
Background A large number of CT brain (CTB) scans are ordered in the ED for older patients with a confirmed or possible head strike but no ongoing symptoms of a head injury. This study aimed to evaluate the effect of the Canadian CT head rule supplemented by the original published minimum inclusion criteria to assist clinician assessment of the need for CTB following minimal trauma fall in patients presenting from residential aged care facilities to a major metropolitan emergency department (ED). Methods This study was conducted as a pre- and post-intervention retrospective audit. The intervention involved implementation of a decision support tool to help clinicians assess patients presenting to the ED following a fall. The tool integrated the Canadian CT Head Rule (CCHR) in conjunction with a simplified set of inclusion criteria to help clinicians define a minimum threshold for a “minor head injury”. Outcome data pertaining to CT brain ordering practices and results were compared over symmetrical 3-month time periods pre- and post-intervention in 2 consecutive years. Results The study included 233 patients in the pre-intervention arm and 241 in the post-intervention arm. Baseline demographics and clinical characteristics were similar in both groups. There was a 20% reduction in the total number of CTB scans ordered following tool implementation, with 134 (57.0%) scans in the pre-intervention group and 90 (37.3%) in the post-intervention group (p < 0.01). The diagnostic yield in the pre- and post-intervention groups was 3.7 and 5.6% respectively (p = 0.52). No variation was observed in medical management between groups, and no patients in either group underwent neurosurgical intervention. Conclusions Use of the CCHR supplemented by the original published minimum inclusion criteria appeared to safely reduce the number of CTB scans performed in residential aged care facility residents presenting to an ED after a fall, with no associated adverse outcomes. A larger study across multiple centres is required to determine widespread efficacy and safety of this tool.
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Affiliation(s)
- Charlene Lee
- Department of Geriatric Medicine, Eastern Health, Melbourne, Australia
| | - Jonathan Beavers
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Jonathan Pham
- Department of General Medicine, Eastern Health, Melbourne, Australia
| | - Liam Hackett
- Eastern Health Clinical School, Monash University, Melbourne, Australia.,Box Hill Hospital Emergency Department, 5 Arnold Street, Box Hill, Victoria, 3128, Australia
| | - Joseph Miller
- Eastern Health Clinical School, Monash University, Melbourne, Australia. .,Box Hill Hospital Emergency Department, 5 Arnold Street, Box Hill, Victoria, 3128, Australia.
| | - Paul Buntine
- Eastern Health Clinical School, Monash University, Melbourne, Australia.,Box Hill Hospital Emergency Department, 5 Arnold Street, Box Hill, Victoria, 3128, Australia
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Chartier LB, Masood S, Choi J, McGovern B, Casey S, Friedman SM, Porplycia D, Tosoni S, Sabbah S. A blueprint for building an emergency department quality improvement and patient safety committee. CAN J EMERG MED 2022; 24:195-205. [PMID: 35107806 PMCID: PMC8808466 DOI: 10.1007/s43678-021-00252-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
The field of quality improvement and patient safety (QIPS) has matured significantly in emergency medicine over the past decade. From standalone, strategically misaligned, and incoherently designed QIPS projects years ago, emergency department (ED) leaders have now recognized that developing a more robust QIPS infrastructure helps prioritize and organize projects for a greater likelihood of success and impact for patients and the system. This process includes the development of a well-defined, accountable, and supported departmental QIPS committee. This can be achieved effectively using a deliberate and structured approach, such as the one described by Harvard Business School Professor John Kotter in his seminal work, “Leading Change.” Herein, we present a blueprint using this framework and include practical examples from our experience developing a robust and successful ED QIPS committee and infrastructure. The steps include how to develop a “burning platform,” select a guiding coalition of leaders, develop a strategic vision and initiatives, recruit a volunteer army of members, enable actions for the committee, generate short-term successes, sustain the pace of change, and, finally, enable the infrastructure to support ongoing improvements. This road map can be replicated by ED teams of variable sizes and settings to structure, prioritize, and operationalize their QIPS activities and ultimately improve the outcomes of their patients.
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Affiliation(s)
- Lucas B Chartier
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada. .,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.
| | - Sameer Masood
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Joseph Choi
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Barb McGovern
- Ryerson University, Daphne Cockwell School of Nursing, Toronto, ON, Canada.,Emergency Department, Trillium Health Partners, Mississauga, ON, Canada
| | - Stephen Casey
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada
| | - Steven Marc Friedman
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danielle Porplycia
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada
| | - Sarah Tosoni
- University Health Network, Quality, Safety & Clinical Adoption, Toronto, ON, Canada
| | - Sam Sabbah
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
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Chen KCJ, Thiruganasambandamoorthy V, Campbell SG, Upadhye S, Dowling S, Chartier LB. Choosing Wisely Canada: scratching the 7-year itch. CAN J EMERG MED 2022; 24:569-573. [PMID: 35819640 PMCID: PMC9273920 DOI: 10.1007/s43678-022-00349-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/15/2022] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Samuel G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
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BELOW CRISTIANO, BRIANTI ISABELACAMPOS, PARREIRA JOSÉGUSTAVO, LUCARELLI-ANTUNES PEDRODESOUZA, SAADE NELSON, GOLIN MURILO, PIVETTA LUCAGIOVANNIANTONIO, VEIGA JOSÉCARLOSESTEVES, ASSEF JOSECESAR. Investigação da presença de lesões traumáticas em segmento cefálico em motociclistas vítimas de acidentes de tráfego: Estudo observacional prospectivo. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: análise crítica da investigação diagnóstica de lesões em segmento cefálico de motociclistas vítimas de acidentes de tráfego. Método: estudo observacional prospectivo incluindo motociclistas adultos vítimas de trauma, sem intoxicação exógena, em um período de 12 meses. A tomografia de crânio (TC) foi indicada de acordo com uma modificação dos “critérios canadenses”. Os pacientes que não foram submetidos a TC de crânio tiveram acompanhamento telefônico por três meses. A presença de lesões foi correlacionada com as varáveis coletadas através dos testes Qui-quadrado, t de Student ou Fisher, considerando p<0,05 como significativo. Resultados: dos 208 inicialmente incluídos, 206 (99,0%) estavam usando capacete. Dezessete estavam com sinais de intoxicação exógena e foram excluídos, restando 191 para análise. Noventa pacientes (47,1%) realizaram TC e 12 (6,3%) apresentaram lesões craniencefálicas, que se associaram significativamente a Escala de Coma de Glasgow (ECG) <15 (52,3% vs. 2,8% - p<0,001) e alterações ao exame físico da região cefálica/neurológico (17,1% vs. zero - p<0,05). Quatro pacientes (2,1%) precisaram tratamento cirúrgico de lesões intracranianas. Nenhum dos pacientes admitidos com ECG 15, em uso de capacete e sem alterações no exame físico apresentou TC alterada. Conclusões: para pacientes admitidos com ECG 15, que utilizavam o capacete no acidente e não apresentavam quaisquer alterações no exame físico, a realização da TC de crânio não trouxe mudanças no atendimento ao paciente. .
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Affiliation(s)
- CRISTIANO BELOW
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil; Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
| | | | - JOSÉ GUSTAVO PARREIRA
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil; Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
| | | | - NELSON SAADE
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil; Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
| | - MURILO GOLIN
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil; Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
| | | | - JOSÉ CARLOS ESTEVES VEIGA
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil; Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
| | - JOSE CESAR ASSEF
- Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil; Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
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Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging - a systematic review of interventions and outcomes. BMC Health Serv Res 2021; 21:983. [PMID: 34537051 PMCID: PMC8449221 DOI: 10.1186/s12913-021-07004-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. METHODS An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. RESULTS The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. CONCLUSIONS Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Lesley J. J. Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, Alberta T2N 4Z6 Canada
| | - Leti van Bodegom-Vos
- Medical Decision making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318 Oslo, Norway
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10
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Masood S, Woolner V, Yoon JH, Chartier LB. Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department. BMJ Open Qual 2020; 9:bmjoq-2019-000811. [PMID: 32019751 PMCID: PMC7011890 DOI: 10.1136/bmjoq-2019-000811] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/06/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022] Open
Abstract
Over 90% of patients with head trauma seen in emergency departments (EDs) are diagnosed with minor head injuries. Over-utilisation of CT scans results in unnecessary exposure to radiation and increases healthcare utilisation. Using recommendations from the Choosing Wisely Canada (CWC) campaign and quality improvement (QI) methodology, we aimed to reduce the CT scan rate for head injuries by 10% over a 6-month period. Baseline CT scan rates were determined through a 27-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and Plan-Do-Study-Act (PDSA) cycles, which included (1) improving provider knowledge about the CWC campaign recommendations; (2) testing, refining and implementing a modified Canadian CT Head Rule checklist; (3) developing CWC-themed head injury–specific patient handouts; and (4) feedback on CT scan group ordering rates to providers. Our primary outcome measure was the number of CT scans performed for patients with head injuries. Process measures included the number of checklists completed and ED length of stay (LOS). Our balancing measure was return ED visits within 72 hours (with or without admission). Baseline CT scan rates prior to our interventions was 46.1%. Our QI initiative resulted in a ‘shift’ in the Statistical Process Control chart of the weekly CT scan rates, associated with the first and second PDSA cycles, resulting in a 13.9% reduction in CT rates during the initial 3 months, and a sustained reduction of 8% at 16 months (p<0.05). Mean ED LOS for all patients with head injuries decreased by 1.5 min (p=0.74). 33% of checklists were completed. 72-hour return visits did not change significantly (p=0.68). Through provider and patient education, and the creation of a user-friendly evidence-based tool, our local QI initiative was successful in achieving long-term reduction in CT rates for patients presenting to EDs with head injuries.
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Affiliation(s)
- Sameer Masood
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada .,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Woolner
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Joo Hyung Yoon
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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