临床指南和决策支持与儿童轻度创伤性脑损伤 CT 应用的关联。

Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury.

机构信息

Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.

Children's Hospital Association, Lenexa, KS.

出版信息

J Pediatr. 2021 Aug;235:178-183.e1. doi: 10.1016/j.jpeds.2021.04.026. Epub 2021 Apr 22.

DOI:10.1016/j.jpeds.2021.04.026

PMID:33894265

Abstract

OBJECTIVE

To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT).

STUDY DESIGN

We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits.

RESULTS

There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS.

CONCLUSIONS

Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.

摘要

目的

研究轻度创伤性脑损伤（mTBI）临床指南和临床决策支持（CDS）的存在是否与头部计算机断层扫描（CT）使用减少有关。

研究设计

我们对 2015 年至 2019 年期间儿科医院信息系统中的 45 家儿科急诊部（ED）进行了横断面研究。我们纳入了 mTBI 出院的儿童，并调查了 ED 临床主任，以确定临床指南和 CDS 的存在和实施年份。调整相关混杂因素后，评估了临床指南和 CDS 与 CT 使用的关联。作为次要结果，我们评估了 ED 住院时间和 3 天内 ED 复诊率以及复诊后的入院率。

结果

有 216789 名儿童因 mTBI 出院，其中 20.3%（44114/216789）在 ED 就诊时进行了 CT 检查。调整后的特定医院 CT 使用率范围为 11.8%至 34.7%（中位数 20.5%，IQR 17.3%，24.3%）。在 45 家 ED 中，17 家（37.8%）有临床指南，9 家（20.0%）有 CDS，19 家（42.2%）两者都没有。与既没有临床指南也没有 CDS 的 ED 相比，有 CDS 的 ED（aOR 0.52 [0.47, 0.58]）或临床指南的 ED（aOR 0.83 [0.78, 0.89]）进行 mTBI 头部 CT 的可能性较低。ED 住院时间和复诊率与临床指南或 CDS 的存在无关。