Agreement between routine emergency department care and clinical decision support recommended care in patients evaluated for mild traumatic brain injury

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 CDS-recommended 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. Resumen Concordancia entre la Atencion Rutinaria y la Recomendada por Sistemas de Soporte a la Decision Clinica en los Pacientes Valorados por Traumatismo Craneoencefalico Leve en el Servicio de Urgencias Objetivos El uso de la tomografia computarizada (TC) en el servicio de urgencias (SU) se ha incrementado significativamente en la ultima decada. Se ha sugerido que la adherencia a los sistemas de soporte a la decision clinica (SSDC) puede resultar en una reduccion segura de la solicitud de TC. En este estudio se cuantifico el porcentaje de concordancia entre la atencion rutinaria y recomendada por un SSDC, y la consecuencia anticipada de la adherencia rigurosa al SSDC en el uso de la TC en el traumatismo craneoencefalico (TCE) leve. Metodologia Estudio observacional prospectivo de pacientes con TCE leve que acudieron a un SU urbano y universitario de un hospital terciario. Se incluyeron los pacientes de 18 anos o mas que consultaron dentro de las 24 horas siguientes de presentar un TCE no penetrante desde agosto de 2010 a julio de 2011. Se completaron formularios estructurados de datos por asistentes formados de investigacion. El resultado principal fue la solicitud de una TC craneal recomendada por la aplicacion de los SSDC (el Canadian head CT, el New Orleans rules o el 2008 ACEP neuroimaging). Las diferencias entre los grupos se evaluaron usando la ji-cuadrado para variables categoricas y el test de Kruskal-Wallis para variables cuantitativas. Se calculo el porcentaje de concordancia entre la practica rutinaria y la recomendada por los SSDC. Resultados De los 169 pacientes incluidos, 130 (76,9%) recibieron una TC craneal y 5 de los 130 (3,8%) tuvieron hallazgos intracraneales agudos traumaticos. Para todos los sujetos, la concordancia entre la atencion rutinaria y recomendada por los SSDC fue 77,5%, 65,7%, y 78,1%, para el 2008 ACEP neuroimaging, el Canadian head CT y el New Orleans rules, respectivamente. La adherencia estricta al SSDC 2008 ACEP neuroimaging no resultaria en una diferencia estadisticamente significativa en el uso de la TC craneal (atencion rutinaria 76,9%, recomendada por SSDC 82,8%, p = 0,17); la adherencia estricta al SSDC New Orleans rules resultaria en un incremento del uso de la TC (atencion rutinaria 76,9%, recomendada por SSDC 94,1%, p < 0,01); y la adherencia estricta al SSDC Canadian head CT resultaria en un descenso del uso de la TC (atencion rutinaria 76,9%, recomendada por SSDC 56,8%, p < 0,01). Conclusiones Existe una concordancia del 60% al 80% entre la practica rutinaria y la recomendada por los SSDC en el uso de la TC. De los SSDC examinados, el unico que puede resultar en una reduccion del uso de la TC si se sigue de forma estricta fue el SSDC Canadian head CT. Se necesitan futuros estudios para examinar las razones de esta menos que optima concordancia entre la atencion rutinaria y la recomendada por el SSDC Canadian head CT.