The Checklist for Head Injury Management Evaluation Study (CHIMES) A cqi initiative to reduce imaging utilization for head injuries

Transcription

1 The Checklist for Head Injury Management Evaluation Study (CHIMES) A cqi initiative to reduce imaging utilization for head injuries Sameer Masood, MD PGY 4 (FRCPC), University of Toronto MPH Candidate, Harvard School of Public Health Faculty Supervisor: Dr. Lucas Chartier MD MPH FRCPC ED QI Director, University Health Network

2 What? : Head Injuries in the ED Very common presentation visits/yr at UHN EDs Over 90% are minor injuries ~10% admission rate at UHN CT imaging across Canadian EDs is variable 50% CT rate at UHN ( )

3 Why? Unnecessary CTs result in 1. Increased costs to healthcare system ($150/CT scan) 2. Longer LOS of patients (6.43 vs 4.72 hr) 102min 3. Increased radiation risk 4. Increased provider time spent (ER/RAD/RN/porter) with reassessments 5. Overcrowding due to delays

4 Choosing Wisely Recommendations for Emergency Physicians aimed at improving the quality of care while reducing unnecessary testing

5 Choosing Wisely

6 How? Methods Ishikawa diagram to do a root cause analysis of reasons for CT overuse - used published data, chart reviews, provider surveys, informal discussions with MDs, RNs Used Ishikawa diagram to develop QI interventions Using administrative data, developed outcome, process and balance measures easy to track

7 Ishikawa/Fishbone diagram Lack of associated cost Medicolegal concerns Work pressures Ease of access Lack of feedback CT overuse CWC awareness CDR misuse Patient preference Local data awareness Patient population

8 Chart Review Total review 200 Missing data 8 Met inclusion/ex 124 Met minor HI defn 27 (21%) Minor HI & CT rule positive 25 (20%) Had CT done 73 (59%)

9 How? To improve awareness and understanding of the CCTHR through QI interventions improved through iterative PDSAs 1. Clinician Survey Survey sent MD/NP/PAs to gauge understanding of current issues regarding over-use of CT heads and understanding of Choosing Wisely recommendation regarding minor head injuries 2. CHIMES check list (Canadian CT head rule) each patient with a triage complaint of HI has a checklist placed in his/her chart to be completed by the RN & MD to aid in decision making 3. Patient Handout Choosing Wisely endorsed handout is given out to patients prior to MD assessment about minor HI and low value of CT heads 4. Weekly reports Weekly CT head rates provided to RNs

10 Patients with mhi that had a CT (%) Results CT head rates for patients with head injuries in two academic EDs 100 Survey Checklist Handout Feedback % 0 Weeks from start of project

11 LOS (Hours) Results ED LOS for discharged patients with head injury Survey Checklist Handout Feedback min 0.0 Weeks from start of project

12 Return Visits (%) Results Return Visits for patients discharged with a head injury Survey Checklist Handout Feedback 4% 4.16% Weeks from start of project

13 Results - Summary Outcome measures 1. 16% relative decrease in CT rate over first 3 months ( ) 10.4% relative decrease in CT rate over first 8 months ( ) 2. LOS decreased by 12 min Balance measure 1. Return visits to the ED increased minimally (4% vs 4.16%). However, not correlated with interventions/unclear signficance Process measure No of checklists added: Reviewed 75 charts 33% (25/75) added, 84% (21/25) of those completed

14 Lessons A local cqi project successfully decreased CT utilization rates for head injuries Short (16%) and Long term (10.4%) success in decreasing CT rates. Decrease in effect over long-term suggests need for continuous reminders to ensure sustainability.

15 Lessons Process related Interventions involved multiple steps + multiple personnel Clerk Triage RN Bedside RN MD/NP/PA Patient Data suggest that initial step of adding checklist is crucial for success Multiple methods of engagement Multiple Interventions targeting various steps Redundancy is key Organizational Strong QI culture and leadership helped in rapid succession of PDSAs and getting approvals