Melnick Edward R, Shafer Katherine, Rodulfo Nayeli, Shi Joyce, Hess Erik P, Wears Robert L, Qureshi Rija A, Post Lori A
Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
Department of Emergency Medicine, Yale University, New Haven, CT.
Acad Emerg Med. 2015 Dec;22(12):1474-83. doi: 10.1111/acem.12824. Epub 2015 Nov 14.
Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance.
The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury.
This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus.
Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT.
Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury.
尽管有诸如加拿大头部CT扫描规则（CCHR）等已制定且经过严格验证的临床决策规则，但针对轻度头部损伤的计算机断层扫描（CT）仍在过度使用。遵循这一敏感且特异的规则可使轻度头部损伤患者的CT扫描次数减少35%。但在实际操作中，尽管CCHR表现准确，却未能减少检查次数。
目的是确定在急诊科（ED）就诊的轻度头部损伤患者中，促进或抑制CT合理使用的非临床人为因素。
这是一项分三个阶段的定性研究，每个阶段都有多学科团队制定的访谈指南。研究对象从城市学术急诊科和卫星社区急诊科中因轻度头部损伤接受治疗并出院的患者以及医护人员中招募。对患者（共4组，22名受试者）和医护人员（共3组，22名受试者）进行焦点小组访谈，直至达到主题饱和。焦点小组的研究结果与认知任务分析相结合，包括在急诊科进行直接观察（超过150小时），以及使用关键决策方法对四名资深医师主题专家进行个人半结构化访谈。这些专家因其在安全减少检查次数同时保持患者安全和参与度方面的技能而得到同行认可。焦点小组和访谈进行了录音，由两名独立记录员做笔记。笔记录入ATLAS.ti软件，并使用扎根理论的持续比较法进行分析，这是一个反复编码以确定主题的过程。数据进行了双重编码，并检查差异以达成共识。
分析得出五个核心领域：建立信任、焦虑（患者和医护人员）、与急诊科实践相关的限制、他人的影响以及患者期望。这些领域中的关键主题包括患者参与度、医护人员的信心和经验、识别和管理患者焦虑的能力、时间限制、脑震荡知识差距、医护人员的影响以及患者进行CT检查的期望。
尽管有高质量证据指导轻度头部损伤患者CT的使用，但在实际操作中，多种因素影响着进行CT检查的决策。识别并传播相关方法以及设计有助于临床医生在急诊科环境中建立信任和管理不确定性的系统，可优化轻度头部损伤患者CT的使用。
