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, there is evidence to suggest that the low dose radiation emitted through the use of some CT scans is associated with a small, but cumulative risk of radiation- induced cancer, particularly in children. 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. This measure is an overuse measure - its intention is to capture those instances in which a pediatric patient is characterized as low risk yet still receives a CT.

As such, the measure is scored such that a lower score indicates better quality. The measure is constructed in this manner due to the available evidence; the PECARN clinical policy defines the low-risk population, but does not clearly define the medium and high risk populations. The measure then uses the definable population as its numerator, necessitating an "overuse" construction.

The following evidence statements are quoted verbatim from the referenced clinical guidelines and other references: [ADAPTED] Suggested CT algorithm for children aged 2 years and older with GCS scores of 14-15 after head trauma (PECARN, 2003): If GCS=14 or other signs of altered mental status or signs of basilar skull fracture, then CT recommended.

If no GCS=14 nor other signs of altered mental status nor signs of basilar skull fracture and no history of LOC, nor history of vomiting, nor severe mechanism of injury nor severe headache, then CT not recommended. If no GCS=14 nor other signs of altered mental status nor signs of basilar skull fracture AND If History of LOC, or history of vomiting, or severe mechanism of injury or severe headache, then observation versus CT on the basis of other clinical factors including: - Physician experience - Multiple versus isolated findings - Worsening symptoms or signs after ED observation - Parental preference For a visual decision rule aid that describes the prediction rule, visit https://www.

aliem.com/2017/06/pecarn-pediatric- head-trauma-official-visual-decision-aid/. 1.4.9 For children who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified: • Suspicion of non-accidental injury. • Post-traumatic seizure but no history of epilepsy. • On initial emergency department assessment, GCS less than 14.

• At 2 hours after the injury, GCS less than 15. • Suspected open or depressed skull fracture or tense fontanelle. • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). • Focal neurological deficit. (NICE, 2023) 1.4.10 For children who have sustained a head injury and have more than 1 of the following risk factors (and none of those in recommendation 1.

4.9), perform a CT head scan within 1 hour of the risk factors being identified: • Loss of consciousness lasting more than 5 minutes (witnessed). • Abnormal drowsiness. • Three or more discrete episodes of vomiting. • Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 meters, high-speed injury from a projectile or other object).

• Amnesia (antegrade or retrograde) lasting more than 5 minutes. (NICE, 2023) 1.4.11 Children who have sustained a head injury and have only 1 of the risk factors in recommendation 1.4.10 (and none of those in recommendation 1.4.9) should be observed for a minimum of 4 hours after the head injury. If during observation any of the risk factors below are identified, perform a CT head scan within 1 hour: • GCS less than 15.

• Further vomiting. • A further episode of abnormal drowsiness. (NICE, 2023) REFERENCES Frush, D. e. (2003). Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics, 951-7. Melnick, E. e. (2012). CT Overuse for Mild Traumatic Brain Injury. The Joint Commission Journal on Quality and Patient Safety, 483-489.

NICE. (2023). Head injury: assessment and early management. Manchester: National Institute for Health and Care Excellence (NICE). PECARN. (2003). Identifi cation of children at very low risk of. Lancet, 1160 - 70. COPYRIGHT: ©2025 American College of Emergency Physicians. All Rights Reserved. CPT® contained in the Measure specifications is copyright 2004-2025 American Medical Association.

ICD-10 is copyright 2025 World Health Organization. All Rights Reserved. 2026 Clinical Quality Measure Flow Narrative for Quality ID #416: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years INVERSE MEASURE: LOWER SCORE – BETTER Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator 2. Check Patients aged 2 through 17 years on the date of the encounter. a. If Patients aged 2 through 17 years on the date of the encounter equals No, do not include in Eligible Population/Denominator. Stop processing. b. If Patients aged 2 through 17 years on the date of the encounter equals Yes, proceed to check Diagnosis for minor blunt head trauma as listed in the Denominator*.

3. Check Diagnosis for minor blunt head trauma as listed in the Denominator*: a. If Diagnosis for minor blunt head trauma as listed in the Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing. b. If Diagnosis for minor blunt head trauma as listed in the Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in the Denominator*.

4. Check Patient encounter during the performance period as listed in the Denominator*: a. If Patient encounter during the performance period as listed in the Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing. b. If Patient encounter during the performance period as listed in the Denominator* equals Yes, proceed to check Encounters conducted via telehealth.

5. Check Encounters conducted via telehealth: a. If Encounters conducted via telehealth equals Yes, do not include in Eligible Population/Denominator. Stop processing. b. If Encounters conducted via telehealth equals No, proceed to check Patient presented with a minor blunt head trauma and had a head CT ordered for trauma by an emergency care provider.

6. Check Patient presented with a minor blunt head trauma and had a head CT ordered for trauma by an emergency care provider: a. If Patient presented with a minor blunt head trauma and had a head CT ordered for trauma by an emergency care provider equals No, do not include in Eligible Population/Denominator. Stop processing. b. If Patient presented with a minor blunt head trauma and had a head CT ordered for trauma by an emergency care provider equals Yes, proceed to check Patient has documentation of ventricular shunt, brain tumor, or coagulopathy.

7. Check Patient has documentation of ventricular shunt, brain tumor, or coagulopathy: a. If Patient has documentation of ventricular shunt, brain tumor, or coagulopathy equals Yes, do not include in Eligible Population/Denominator. Stop processing. b. If Patient has documentation of ventricular shunt, brain tumor, or coagulopathy equals No, include in Eligible Population/Denominator.

8. Denominator Population: • Denominator Population is all Eligible Visits in the Denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 80 visits in the Sample Calculation. 9. Start Numerator 10. Check Pediatric patient with minor blunt head trauma not classified as low risk according to the PECARN prediction rules: a.

If Pediatric patient with minor blunt head trauma not classified as low risk according to the PECARN prediction rules equals Yes, include in Data Completeness Met and Performance Not Met**. • Data Completeness Met and Performance Not Met** letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c equals 40 visits in the Sample Calculation.

11. Check Pediatric patient with minor blunt head trauma classified as low risk according to the PECARN prediction rules: a. If Pediatric patient with minor blunt head trauma classified as low risk according to the PECARN prediction rules equals Yes, include in Data Completeness Met and Performance Met**. • Data Completeness Met and Performance Met** letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document.

Letter a1 equals 15 visits in the Sample Calculation. b. If Pediatric patient with minor blunt head trauma classified as low risk according to the PECARN prediction rules equals No, proceed to check Pediatric patient with minor blunt head trauma and PECARN prediction criteria are not assessed. 12. Check Pediatric patient with minor blunt head trauma and PECARN prediction criteria are not assessed: a.

If Pediatric patient with minor blunt head trauma and PECARN prediction criteria are not assessed equals Yes, include in Data Completeness Met and Performance Met**. • Data Completeness Met and Performance Met** letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a2 equals 15 visits in the Sample Calculation.

b. If Pediatric patient with minor blunt head trauma and PECARN prediction criteria are not assessed equals No, proceed to check Pediatric patient with minor blunt head trauma not classified as low risk according to the PECARN prediction rules. 13. Check Pediatric patient with minor blunt head trauma not classified as low risk according to the PECARN prediction rules: a.

If Pediatric patient with minor blunt head trauma not classified as low risk according to the PECARN prediction rules equals Yes, include in Data Completeness Met and Performance Not Met**. • Data Completeness Met and Performance Not Met** letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c equals 40 visits in the Sample Calculation.

b. If Pediatric patient with minor blunt head trauma and PECARN prediction criteria are not assessed equals No, proceed to check Data Completeness Not Met. 14. Check Data Completeness Not Met: • If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 visits have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations: Data Completeness equals Performance Met (a1 plus a2 equals 30 visits) plus Performance Not Met (c equals 40 visits) divided by Eligible Population/Denominator (d equals 80 visits). All equals 70 visits divided by 80 visits. All equals 87.50 percent. Performance Rate** equals Performance Met (a1 plus a2 equals 30 visits) divided by Data Completeness Numerator (70 visits).

All equals 30 visits divided by 70 visits. All equals 42.86 percent. *See the posted measure specification for specific coding and instructions to submit this measure. ** A lower calculated performance rate for this measure indicates better clinical care or control. NOTE: Submission Frequency: Visit The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications.

They should not be used alone or as a substitution for the measure specification.

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. This is an inverse measure which means a lower calculated performance rate for this measure indicates better clinical care or control.

The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.