The rising awareness of concussion risks among youngsters in New Jersey — and nationwide — has resulted in a new focus on assessing potential head injuries, identifying possible brain damage, and ensuring proper treatment.
While this is a good thing in many ways, healthcare providers are also concerned about a potential downside associated with one of the most common tools used for diagnosing such damage: CT scans, which use radiation to take a detailed picture of the brain.
While the procedure involves a relatively small amount of radiation, experts said it is still 200 times the strength of a chest X-ray, and they warn that overuse is especially dangerous among children, who can develop cancers as a result.
Fewer CT scans
This concern led nearly four-dozen Garden State hospitals to join forces last fall in an effort to assess CT scan use in emergency departments and identify strategies to reduce unnecessary treatments, particularly among youth. Twelve months later, participants said they had reduced pediatric CT scans by a quarter — sparing nearly 1,000 kids from the radiation involved.
Led by the New Jersey Council of Children’s Hospitals and the New Jersey Hospital Association’s Institute for Quality and Patient Safety, which announced the news on Thursday, the second year of the project will involve sharing the protocols with other hospitals throughout the state, most of which who have signed on to the goals.
The hope is to reduce CT scans by 20 percent at facilities that might now be overusing the technology. (The hospital association in Washington State has also expressed interest in the CT scan toolkit, NJHA said.)
The collaboration is similar to a process NJHA used to improve protocols to reduce hospital-acquired sepsis, a potentially deadly infection, which drove down New Jersey’s sepsis mortality rate by nearly 11 percent in the first year and saved almost 400 lives. In June, the state Department of Health issued regulations to require hospitals to adopt evidence-based protocols to better identify and treat the disease, based in part on this work.
Public information campaign
But when it comes to reducing CT scan use, a public information campaign is also a critical component, NJHA said. The collaboration has developed marketing materials — complete with a #ScanSmart hashtag — designed to educate parents, coaches, and others about the pros and cons of the procedure. Consumer demand is one factor driving the increased use in scans, experts said.
“I’m a mom and I get it — when your child is hurt you want to leave no stone unturned to make sure everything is OK,” said Aline Holmes, a nurse and senior vice president of clinical affairs at NJHA. “But not every head injury requires a CT scan, and in fact the radiation your child is exposed to could be a greater worry in the long run.”
An estimated 60 million CT, or computer tomography, scans are performed each year nationwide, including some 7 million on children. While it is a critical technology for properly diagnosing brain damage, the U.S. Food and Drug Administration, which also advocates for safe use of the procedure, has suggested that one-third to one-half of these may be unnecessary. In addition, the technology is not always calibrated for youngsters to deliver a lower, child-appropriate dose of radiation, experts note.
13,000 pediatric scans
Discharge data from emergency departments in New Jersey’s 71 acute-care hospitals, collected as part of the collaboration, revealed there were about 13,000 scans performed on patients under age 21 last year. (This does not include scans ordered by pediatricians or other providers who are not associated with hospital emergency rooms.)
Roughly half the children who visit Garden State emergency departments with head injuries are given a CT scan, the NJHA found, even though research has determined that the procedure is not necessary to evaluate minor damage. According to the FDA, among children who do get scans, one in three has gone through the process at least three times.
“Diagnostic radiation is very, very useful when used appropriately. But if it’s not used appropriately, it can be dangerous,” said Dr. Ernest Leva, an associate professor and director of the pediatric emergency medicine division at Rutgers Robert Wood Johnson Medical School, who also serves as the physician board chair of the children’s hospitals council.
Once the CT scan data was collected, the collaborative analyzed the varying use rates in emergency departments throughout the state and sought to determine how facilities with lower rates were making their decisions. The group examined these best practices and worked with the Pediatric Emergency Care Applied Research Network to standardize these protocols.
The toolkit that resulted includes an established set of clinical observation criteria designed to help providers appropriately consider the use of CT scans and an algorithm to help them determine when it is indeed medically necessary. NJHA created a laminated pocket card that outlines this process and distributed it to emergency room doctors and nurses statewide; participating hospitals and leaders at the New Jersey chapter of the American Academy of Pediatricians are also working to educate others.
The Hospital Association is now rolling out the public education campaign to help those outside the hospital better understand the benefits and risks of the procedure. The message includes highlighting what the group calls the “COOL approach,” which stands for: Consider using non-radiation testing when appropriate; Only image the indicated area; Only scan once; and use the Lowest amount of radiation possible.
“Working together, informed healthcare consumers can partner with their medical professionals to do the right thing for their kids,” Leva said.