Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt

Measure Specification

Though it is difficult to directly attribute the effects of smaller dosages of radiation, such as that received through computed tomography (CT), the dosage of radiation from CTs has increased in recent years, in part due to the increased speed of image acquisition. Additionally, there is evidence to suggest that the radiation doses from CTs are higher and more variable than generally quoted.

Further, as “radiation doses associated with commonly used CT examinations resemble doses received by individuals in whom an increased risk of cancer was documented,” the use of some CT scans is associated with a “nonnegligible” lifetime attributable risk of cancer. As over 1.3 million individuals are treated and released from the ED for mild traumatic brain injury annually, it is critical that CT scans only be utilized when clinically appropriate.

Through measurement of the share of CT scans that are performed inappropriately, a focus can be brought to quality improvement and increased application of clinical decision tools around this topic.

The following evidence statements are quoted verbatim from the referenced clinical guidelines and other references: A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy.

(Level A recommendation) (American College of Emergency Physicians (ACEP), 2008). A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.

[Dangerous mechanism of injury includes ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs.] (Level B recommendation) (American College of Emergency Physicians (ACEP), 2008) Based on the recommendations, patients age ≥ 65 are always considered high risk according to the Canadian CT head injury rule.

The New Orleans Rule, on the other hand, uses an age cutoff of 60. It categorizes patients aged 60+ as high risk under certain circumstances (LOC or amnesia/disorientation). This leads to a situation where patients age 60-64 are categorized differently because of idiosyncrasies in how the Canadian and New Orleans studies were designed, and the measure appropriately incorporates these rules into its design.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation of this measure, this visit measure is submitted each time a patient is seen by the individual MIPS eligible clinician during the performance period.