Guidelines for mild TBI could cut CT exams 20%, but docs unprepared

The gap between evidence and practice in the use of head CTs to assess patients with mild traumatic brain injury (TBI) in the emergency department (ED) is wide and might be mitigated by comprehensive strategies to integrate evidence-based medicine into resident education, according to a perspective published online April 30 in Annals of Emergency Medicine.

Approximately 1.7 million patients present to EDs in the U.S. with TBI, and most are evaluated with a head CT. Large cohort studies report a 5 to 9 percent incidence of clinically significant findings among this population, according to Melinda J. Morton, MD, MPH, and Frederick K. Korley, MD, of the department of emergency medicine at Johns Hopkins University School of Medicine in Baltimore. Mild TBIs account for approximately 650,000 head CT exams annually.

The authors noted the rapidly growing use of head CTs in the ED, which increases costs and exposes patients to radiation. “The high prevalence of presentations for mild TBI to EDs, as well as the potential public health implications of unnecessary imaging necessitates increased resident education about clinical decisionmaking for mild TBI,” wrote Morton and Korley.

The authors suggested the New Orleans and Canadian Head CT rules are sensitive and specific in determining which patients have clinically important intracranial lesions. The Canadian Head CT rule, if used consistently, could reduce the number of head CTs 20 percent and result in a 2.5 hour decrease in ED length of stay for patients who do not undergo imaging, according to Morton and Korley.

A 2008 national survey of emergency physicians indicated 30 percent were aware of the rule and 12 percent used the decision rule.

Implementation of clinical guidelines for TBI into practice is important for residents, wrote Morton and Korley. Thus, the authors summarized key barriers to adoption, which include:

• There is a need for, and shortage of, to faculty role models to develop curricula and translate knowledge into practice.
• Resident barriers to evidence-based practice include limits in time, attitude and evidence-based knowledge and skills. Additional barriers included residents’ position, faculty and staff influences and limited ability to change work parameters.
• Emergency medicine program directors have cited lack of trained faculty, lack of time and a need for funding as perceived barriers.
• Evidence-based medicine may be poorly integrated into the clinical curriculum.

The authors noted the utility an evidence-based medicine curriculum, and wrote, “[E]ven a brief four-session course for residents has been shown to yield a statistically significant effect in resident comprehension of key evidence-based medicine concepts.”

They noted disparate awareness of adherence to guidelines and suggested multiple strategies to support and boost compliance: clinical meetings, audit and feedback, pocket summary reminder cards, physician champions, mobile telephone applications, local opinion leaders and computer decision support rules.

Morton and Korley concluded by emphasizing that program directors, faculty and resident physicians all have important, active roles in the process of integrating evidence-based medicine into the ED.