This document discusses quality measures related to appropriate use of head CT for patients with minor blunt head trauma. It provides guidelines for use of head CT in pediatric patients ages 2-17 based on PECARN clinical decision rules. It also provides guidelines for head CT use in adult patients ages 18 and older based on American College of Emergency Physicians guidelines. The document emphasizes the importance of clearly documenting clinical reasoning for ordering or not ordering head CT to satisfy measure requirements and for legal protection. It also provides a cheat sheet summarizing the inclusion criteria for head CT in pediatric versus adult patients with minor head injury.

4. 11 measures
Antibiotic
Stewardship
• #66: Pharyngitis patients
given an abx who had
strep test performed
• #91: Patients with Otitis
Externa given a topical abx
• #93: Patients with Otitis
Externa not given a
systemic abx
• #116: 18-64 y/o with
bronchitis not given abx
within 3 days of encounter
ChoosingWisely:
Head CT Utilization
• #416: 2-17 y/o with
appropriate head CT for
blunt head trauma
(PECARN rules)
• #415: 18+ y/o with
appropriate head CT
ordering for blunt head
trauma
Pregnancy
Measures
• #254: US localization of
pregnancy in pregnant
pts with abd pain
• #255: Rhogam for Rh
negative patients at risk
Miscellaneous
• #54: EKG for non-
traumatic chest pain
• #76: Proper sterile
technique for CVC
placement
• #317: BP Screening and
follow up documented

5. #415 and #416:
Head CT utilization for
minor head injury
adults/pediatrics
Week 2

6. #415 and #416:
Important!
1. Documentation of clinical thinking is optimal for
excellent medical and legal charting.
2. CMS recommends followingthese clinical guidelinesand
may impose penalties in the futurefor not following these
guidelines.
However, providerjudgmentalwaysoverridesdecisionrules
forindividualpatients andthose whodonot clearlyfall
withinthe decisionruleguidelines.

7. #416
ED utilization of Head CT for
minor blunt head trauma
for patients 2-17 years old

8. #416.
Inclusion
Numerator:
• Patient low risk by PECARN decision
rules
Denominator:
• Patients 2-17 years old
• Minor head injury (GCS 15 or no
documentation of mental status)
• Seen <=24 hours after event and
receiving head CT

9. #416.
Inclusion:
following
pecarn rules
• No Altered Mental Status
• No Severe Headache
• No Loss of Consciousness
• No Vomiting
• No Sign of Basilar Skull Fracture
• No Severe Mechanism
• MVC with Ejection
• Death of Another Passenger
• Rollover
• Fall < 5 Feet
• Peds/Cyclist without Helmet Struck by Car
• Head Struck by High Impact Object
• Other Documented Severe Mechanism

10. #416.
Exclusion
Patient reasons:
• Brain Tumor
• Coagulopathy
• Ventricular Shunt
• Other Documented Reason
Alternate reasons:
• Patient seen >24 hours after injury,
patient GCS<15

11. Best Practices
Remember, coders (and not hospital chart extractors) are excellent at following rules but have
limited clinical ability, so it is best to clearly “spell out” your thinking!
Best practice is to state risk and give reason for decision to perform or not perform Head CT:
1. “Patient is low risk for head injury by PECARN rules and head CT deferred after discussion with parents.”
2. “Patient is moderate risk with nausea and emesis and head CT ordered.”
3. “Patient not acting normal per parents, patient not low risk and head CT ordered.”
4. Also acceptable would be “Patient is moderate (or high risk) head injury and head CT ordered.”
Not Acceptable:
1. “Patient with headache and head CT ordered.”
2. No reason given for ordering head CT in Pediatric patient with minor head injury.

12. #415
ED utilization of Head CT for
minor blunt head trauma
for patients >=18 years old

13. #415.
Inclusion
Numerator:
• Patient with proper indication for
Head CT
Denominator:
• Patients 18+ years old
• Seen <=24 hours after event with
Minor Head Injury (GCS 15 or no
documentation of mental status)
• Head CT ordered

14. #415.
Inclusion:
following
ACEP guideline for
head ct with minor
head injury
any of the below:
• >= 65 years old
• Severe Headache
• Vomiting
• Signs of Basilar Skull Fracture
• Focal Neurological Deficit
• Elevated bleeding risk (Coagulopathy,
Low platelets, Anticoagulant such as
Pradaxa, Heparin, Coumadin)
• Serious Mechanism (Pedestrian vs
Car, Ejection, Fall from >3 ft or 5 Stairs,
Other)

15. #415.
Inclusion:
following
acep head
ct guideline
Either loss of consciousness or amnesia
and:
• >= 60 years old
• Any Headache
• Intoxication
• Short term memory deficits
• Any physical evidence of injury above
clavicles
• Seizure

16. #415.
Exclusion
Patient reasons:
• Brain Tumor
• Coagulopathy
• Medication
• Ventricular Shunt
• On Antiplatelet Medication
(essentially all other than aspirin)
• Other Reason
Alternate reasons:
• Patient seen >24 hours after injury,
patient GCS<15

17. Best Practices
Remember, similar for pediatrics, coders (and not hospital chart extractors) are excellent at
following rules but have limited clinical ability. Remember to specifically state you are
following guideline or ACEP guideline!
Best practice is to state risk and give reason for decision to perform or not perform head ct.
1. “Patient has severe headache, and per guideline, head CT ordered.”
2. “Patient is intoxicated with mild confusion after minor head injury and, per guideline, head CT ordered.”
3. “Patient is intoxicated and precludes reliable exam, therefore Head CT ordered.” or “Patient is intoxicated and not oriented to time, and head CT ordered.”
4. “Patient has mild headache only and no other symptoms after minor head injury, per ACEP guideline no head CT ordered.” (This patient would not be
included in the measure as no CT done, but would be acceptable documentation.)
5. “Patient is 65 years old after minor head injury and per guideline head CT ordered.” (While this would satisfy guideline, not all patients would require Head
CT.)
Not Acceptable:
1. “Patient with mild headache after minor head injury and head CT ordered.” (Patient <65).
2. No reason given for ordering head CT in patient with minor head injury.

18. Cheat Sheet
These head injury rules are a little tricky to remember, so we have an attached “Cheat Sheet” to post for easy reference.
(Inclusion: Patients seen < 24 hours after minor head injury with GCS 15.)
Age 2-17
PECARN Rules
CT not recommended if:
• No Altered Mental Status
• No Loss of Consciousness
• No Severe Headache
• No Vomiting
• No Sign of Basilar Skull Fracture
• No Severe Mechanism
Age 18+
ACEP Guidelines Head CT is OK if:
Any of the following:
• Age ≥65 years old
• Severe Headache
• Vomiting
• Signs of Basilar Skull Fracture
• Serious Mechanism
• Neurological Deficit
• Elevated Bleeding Risk
o Medical Condition
o Anticoagulants (such as
Pradaxa, Coumadin,
Heparin, Plavix, Aggrenox
but No Aspirin Exclusion)
OR
Loss of Consciousness or Amnesia AND
• ≥60 years old
• Headache (any)
• Intoxication
• Short Term Memory Deficit
• Physical Evidence Injury above
Clavicles
• Seizure