title: Quality Improvement Effort to Reduce Cranial CTs for Children With Minor Blunt Head Trauma.
abstract: OBJECTIVE
  Blunt head trauma is a common injury in children, although it rarely requires surgical intervention. Cranial computed tomography (CT) is the reference standard for the diagnosis of traumatic brain injury but has been associated with increased lifetime malignancy risk. We implemented a multifaceted quality improvement initiative to decrease the use of cranial CT for children with minor head injuries.
  
  
  METHODS
  We designed and implemented a quality improvement effort that included an evidence-based guideline as well as individual feedback for children aged 0 to 21 years who present to the emergency department (ED) for evaluation of minor blunt head trauma. Our primary outcome was cranial CT rate, and our balancing measure was any return to the ED within 72 hours that required hospitalization. We used statistical process control methodology to measure cranial CT rates over time.
  
  
  RESULTS
  We included 6851 ED visits of which 4242 (62%) occurred in the post-guideline implementation period. From a baseline CT rate of 21%, we observed an absolute reduction of 6% in cranial CT rate (95% confidence interval 3% to 9%) after initial guideline implementation and an additional absolute reduction of 6% (95% confidence interval 4% to 8%) after initiation of individual provider feedback. No children discharged from the ED required admission within 72 hours of initial evaluation.
  
  
  CONCLUSIONS
  An ED quality improvement effort that included an evidence-based guideline as well as individual provider feedback was associated with a reduction in cranial CT rates without an increase in missed significant head injuries.
authors.affiliation: Division of Emergency Medicine, Lise.nigrovic@childrens.harvard.edu.
authors.forename: Lise E
authors.initials: LE
authors.lastname: Nigrovic
authors.affiliation: Division of Emergency Medicine.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Stack
authors.affiliation: Division of Emergency Medicine.
authors.forename: Rebekah C
authors.initials: RC
authors.lastname: Mannix
authors.affiliation: Division of Emergency Medicine.
authors.forename: Todd W
authors.initials: TW
authors.lastname: Lyons
authors.affiliation: Clincial Research Center, and.
authors.forename: Mihail
authors.initials: M
authors.lastname: Samnaliev
authors.affiliation: Division of Emergency Medicine.
authors.forename: Richard G
authors.initials: RG
authors.lastname: Bachur
authors.affiliation: Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Proctor
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D019983:Guideline Adherence; D016489:Head Injuries, Closed / Q000000981:diagnostic imaging*; D006760:Hospitalization; D006801:Humans; D007223:Infant; D008297:Male; D011446:Prospective Studies; D058996:Quality Improvement; D012886:Skull / Q000000981:diagnostic imaging* / Q000293:injuries; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D015599:Trauma Severity Indices; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*