Azari, Sarah

Browne, Marybeth, MD

Dunstan, Michele, MSN

Harrison, Timothy J, DO, MS

Hoover, Travis

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works USF-LVHN SELECT Review, Monitor, Educate: A Quality Improvement Initiative for Sustained Chest Radiation Reduction in Pediatric Trauma Patients Sarah Azari Lehigh Valley Health Network, Sarah.Azari@lvhn.org Travis Hoover Lehigh Valley Health Network, Travis.Hoover@lvhn.org Michele Dunstan MSN Lehigh Valley Health Network, Michele.Dunstan@lvhn.org Timothy J. Harrison DO, MS Lehigh Valley Health Network, timothy_j.harrison@lvhn.org Marybeth Browne MD Lehigh Valley Health Network, Marybeth.Browne@lvhn.org Follow this and additional works at: https://scholarlyworks.lvhn.org/select-program  Part of the Medical Education Commons Published In/Presented At Azari, S., Hoover, T., Dunstan, M., Harrison, T.J., & Browne, M. (2020). Review, monitor, educate: A quality improvement initiative for sustained chest radiation reduction in pediatric trauma patients. Poster presented at Lehigh Valley Health Network, Allentown, PA. This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. © 2018 Lehigh Valley Health NetworkLehigh Valley Health Network, Allentown, Pennsylvania• Chest CTs following a normal chest x-ray largely do not change clinical management in pediatric trauma patients• Judicious use of chest CTs reduces exposure to radiation, incidental findings, and unnecessary costs• Implementation of a guideline can reduce the number of inappropriate CTs• Continued monitoring and education following guideline implementation improves outcomesReview, Monitor, Educate: A Quality Improvement Initiative for Sustained Chest Radiation Reduction in Pediatric Trauma PatientsREFERENCES• Between study periods, there were statistically significant associations with: – Gender (p=0.0470)– Cause of injury (p=0.0007)– Injury severity score (p=0.0001)Figure 1: Retrospective review from Jan 2013 to Jun 2016Figure 2: Prospective review from Jan 2017 to Jun 2019Table 1: Imaging before and after guideline implementation 1/13 to 6/16 1/17 to 6/19Had chest x-ray83.3% (205/246) 100% (188/188)Had chest CT43.9% (108/246) 16.0% (30/188)Had chest CT without prior x-ray 26.7% (41/246) 0% (0/188)Had chest CT with normal x-ray 23.2% (57/246) 8.5% (16/188)• A retrospective chart review of all trauma alert patients < 15 years evaluated at our pediatric trauma center between January 2013 and June 2016 was performed • Charts were reviewed to determine if there were significant findings that could alter clinical care– Pneumothorax >10%– Hemothorax – First rib fracture – Multiple rib fractures – Lung contusion  • Based on the retrospective review, a radiologic reduction guideline was established emphasizing – X-rays prior to CT – No CTs after normal x-rays • A prospective review was performed from January 2017 to June 2019 to assess efficacy of the guideline • Education was provided monthlySarah Azari, Travis Hoover, Michele Dunstan M.S.N., Timothy J. Harrison D.O., M.S., Marybeth Browne M.D., M.S.BackgroundMethodsResults Gathered DiscussionConclusion and Implications1. Scaife ER, Rollins MD. Managing radiation risk in the evaluation of the pediatric trauma patient. Semin PediatrSurg. 2010;19(4):252-6.2. Skinner DL, den Hollander D, Laing GL, Rodseth RN, Muckart DJ. Severe blunt thoracic trauma: differences between adults and children in a level I trauma centre. S Afr Med J. 2015;105(1):47-51.3. Golden J, Isani M, Bowling J, Zagory J, Goodhue CJ, Burke RV, et al. Limiting chest computed tomography in the evaluation of pediatric thoracic trauma. J Trauma Acute Care Surg. 2016;81(2):271-7.4. Macias CG, Sahouria JJ. The appropriate use of CT: quality improvement and clinical decision-making in pediatric emergency medicine. Pediatr Radiol. 2011;41 Suppl 2:498-504.5. Meulepas JM, Ronckers CM, Smets A, Nievelstein RAJ, Gradowska P, Lee C, et al. Radiation Exposure From Pediatric CT Scans and Subsequent Cancer Risk in the Netherlands. J Natl Cancer Inst. 2019;111(3):256-63.6. Westra SJ, Brody AS, Mahani MG, Guillerman RP, Hegde SV, Iyer RS, et al. The incidental pulmonary nodule in a child. Part 1: recommendations from the SPR Thoracic Imaging Committee regarding characterization, significance and follow-up. Pediatr Radiol. 2015;45(5):628-33.7. Coates A, Zwerdling R. Pulmonary Incidentalomas In: Cleveland R, ed. Imaging in Pediatric Pulmonology Boston, MA: Springer; 2012.8. 2018; https://www.acr.org/Advocacy-and-Economics/Radiology-Economics/Medicare-Medicaid/MPFS Problem Statement• There are currently no national pediatric computed tomography (CT) guidelines 1• CT scans confer a considerable amount of radiation exposure to children 1• Due to the flexibility of the pediatric chest wall, thoracic injury due to blunt trauma presents differently in children and adults 2• Golden et al. demonstrated that chest CT scans can be limited to patients who have abnormal plain chest films 3• Literature supports that evidence-based guidelines minimize care variation and most importantly improve outcomes 4• We hypothesized that chest CT scans after a normal chest x-ray would not add clinically relevant information to justify the use of the imaging and that the addition of a radiation reduction guideline would reduce overutilization of chest CT scans Acknowledgements A special thanks to Judith Schultz for her work on maintenance of the trauma registry and biostatistician Jennifer Macfarlan, MPH for her assistance with our statistical analysis. 246Met inclusion criteria 205 (83.3%)Had chest x-ray193 (94.2%)Chest x-ray was not significant57 (29.5%)Had chest CT1 (1.8%)Chest CT was significant56 (98.2%)Chest CT was not significant 136 (70.5%)Did not have chest CT12 (5.9%)Chest x-ray was significant 41 (26.7%)Chest CT without chest x-ray188Met inclusion criteria 188 (100.0%)Had chest x-ray170 (90.4%)Chest x-ray was not significant16 (9.4%)Had chest CT1 (6.3%)Chest CT was significant15 (93.7%)Chest CT was not significant 154 (90.6%)Did not have chest CT18 (9.6%)Chest x-ray was significant 0 (0.0%)Chest CT without chest x-ray• In the two patients with significant chest CTs following normal x-ray, the CT did not result in additional interventions • Guideline implementation and education reduced inappropriate CTs• Guideline implementation required buy in from radiology, pediatric surgery, and trauma surgery • This was part of a larger cultural change in our institution to reduce unnecessary radiation • Drawbacks to unnecessary radiation include:• Possible increase in cancer risk 1, 5• Possibility of finding pulmonary incidentalomas, resulting in workup 6,7• Increased costs: 2018 Medicare reimbursement for a chest CT was $156.28 while a chest x-ray was $19.79 8• Study limitations • Partially retrospective • Differences between study period groups 

Review, Monitor, Educate: A Quality Improvement Initiative for Sustained Chest Radiation Reduction in Pediatric Trauma Patients

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1337&context=select-program

Review, Monitor, Educate: A Quality Improvement Initiative for Sustained Chest Radiation Reduction in Pediatric Trauma Patients

Abstract

Similar works

Full text

Available Versions

Lehigh Valley Health Network: LVHN Scholarly Works