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Clinical Decision Support for Mild Traumatic Brain Injury

Project Final Report (PDF, 256.31 KB) Disclaimer

Giving clinicians the tools to support patient-provider communication could result in fewer CTs ordered, higher physician trust, and higher patient knowledge in cases involving minor head injuries.

Project Details -
Completed

Imaging is the fastest growing healthcare expenditure in the United States, increasing twice as fast as total healthcare costs. Clinical decision support (CDS) tools have been developed to minimize costs and make safe decisions regarding imaging at the bedside. While clinically helpful, health information technology can hinder the clinician-patient relationship. The development of patient-centered CDS tools is needed to promote evidence-based decisions for mild traumatic brain injury patient imaging.

This project developed and validated the Concussion or Brain Bleed application (app), an innovative CDS tool that integrated a patient-centered decision aid and CDS at the bedside for the management of minor head injury in the emergency department (ED). This project aimed to shift paradigms for CDS and the ED patient encounter by bringing CDS to the point-of-care for shared use by the patient and provider. The app was based on the Canadian Computed Tomography (CT) Head Rule (CCTHR), a CDS tool designed and validated to safely reduce imaging in minor head injury.

The specific aims of the project were to:

  • Identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the ED with minor head injury. 
  • Evaluate an CDS app that helps clinicians determine the need for CT use based on the CCTHR in a patient-centered and evidence-based manner. 
  • Describe the use of the Concussion or Brain Bleed app in a high-volume ED. 

Researchers conducted focus groups with patients and semi-structured interviews with providers to inform the iterative design and development of the Concussion or Brain Bleed app. The study team then led a prospective pilot study with 41 ED patients. Patients and clinicians used the app and completed a survey to determine baseline efficacy on patient experience, clinician experience, health care utilization, and patient safety. In patients with low-risk minor head injury who were being considered for CT head imaging in the ED, use of the Concussion or Brain Bleed app resulted in increased patient knowledge and was associated with a low rate of CT use, high trust in the physician, low patient decisional conflict, high clinician Net Promoter Score, and high system usability score without any adverse events in patients. Investigators recommend that future research focus on assessing and optimizing the implementation of the app into routine ED care.

When Costly and Potentially Harmful CT Scans Are Not Necessary

Key Finding and Impact:

Giving clinicians the tools to support patient-provider communication could result in fewer CTs ordered, higher physician trust, and higher patient knowledge in cases involving minor head injuries.

Is that CT scan in the patient’s best interest?

While the increased use of diagnostic imaging tests like CT has outpaced healthcare growth, the use of these tests does not always reflect patient-centered care. Frequently overused in the ED setting, CT scans are often ordered in scenarios where there is no evidence of improved patient outcomes. Additionally, non-essential CT scans can result in increased healthcare costs, exposure to unnecessary radiation, and longer hospital stays.

Aligning best practices for CT scans for patients with minor head injuries.

“About 1 out of every 3 CT scans that are performed in the ER for minor head injury are not clinically indicated.”
- Dr. Edward Melnick

Dr. Edward Melnick and his research team at Yale University sought to identify the non-clinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the ED with minor head injury. They talked to patients and providers to inform the development of the Concussion or Brain Bleed application (integrated patient- and provider-facing app), an innovative CDS tool that integrated a patient-centered decision aid and CDS at the bedside for the management of minor head injury in the ED. The app was based on the Canadian Computed Tomography Head Rule (CCTHR), a clinical decision rule designed and validated to safely reduce imaging in minor head injury.

Sorry, Doctor, did you say I don’t need a CT?

The team’s overall goal was to better prepare clinicians to guide patients with minor head injuries on appropriate CT use and to evaluate the tool through a pilot study. When physicians expressed empathy and had increased knowledge of when CT use was appropriate, patients accepted the recommended treatment, even when not utilizing advanced imaging like CT scan. While development of CDS for minor head injuries increased the likelihood of clinically appropriate CT, implicit in this process is the time spent with the patient to assure they understand and are comfortable with a treatment plan that does not involve CT.