Impact of the Canadian CT head rule supplemented by the original published minimum inclusion criteria to assist emergency department clinicians' assessment of patients presenting post fall from residential aged care: a retrospective audit

Abstract

Background: A large number of CT brain (CTB) scans are ordered in the ED for older patients with a confirmed or possible head strike but no ongoing symptoms of a head injury. This study aimed to evaluate the effect of the Canadian CT head rule supplemented by the original published minimum inclusion criteria to assist clinician assessment of the need for CTB following minimal trauma fall in patients presenting from residential aged care facilities to a major metropolitan emergency department (ED).

Methods: This study was conducted as a pre- and post-intervention retrospective audit. The intervention involved implementation of a decision support tool to help clinicians assess patients presenting to the ED following a fall. The tool integrated the Canadian CT Head Rule (CCHR) in conjunction with a simplified set of inclusion criteria to help clinicians define a minimum threshold for a "minor head injury". Outcome data pertaining to CT brain ordering practices and results were compared over symmetrical 3-month time periods pre- and post-intervention in 2 consecutive years.

Results: The study included 233 patients in the pre-intervention arm and 241 in the post-intervention arm. Baseline demographics and clinical characteristics were similar in both groups. There was a 20% reduction in the total number of CTB scans ordered following tool implementation, with 134 (57.0%) scans in the pre-intervention group and 90 (37.3%) in the post-intervention group (p < 0.01). The diagnostic yield in the pre- and post-intervention groups was 3.7 and 5.6% respectively (p = 0.52). No variation was observed in medical management between groups, and no patients in either group underwent neurosurgical intervention.

Conclusions: Use of the CCHR supplemented by the original published minimum inclusion criteria appeared to safely reduce the number of CTB scans performed in residential aged care facility residents presenting to an ED after a fall, with no associated adverse outcomes. A larger study across multiple centres is required to determine widespread efficacy and safety of this tool.

Keywords: Brain; Canadian CT head rule; Clinical score; Computed tomography; Decision support techniques; Emergency; Falls; Geriatric; Head injury; Intracranial haemorrhage; Residential aged care.