providers could enter symptom information and receive a risk category and
course of treatment recommendation.
Physician recommendations for blunt
head trauma were incorporated into a
graphic presentation of the risk estimates
and course of treatment guidelines (see
Figure 2). This information was also
embedded into clinical order-sets for
both conditions. Both the educational
website and the clinical order-sets were
considered essential parts of the unnecessary CT reduction strategy.
Engaging patient family stakeholders
was an important piece of this CT reduction strategy. Patient and family sections
of PEMguidelines.org were developed
initially by medical students and then
reviewed and refined by physicians in
the ED. ED medical students researched
existing parent focused information on
each condition and drew from existing
discharge handouts written by the hospital’s patient education department.
These materials were used to create
several informational sections for each
condition including: what is the condition, what does it feel like, CT scans and
radiation, and suggested management
at home. Discharge handouts were also
included in the website and available in
English, Spanish, and Somali. Figures 3
and 4 provide examples of patient and
family focused web content.
The completed website and clinical order-sets were introduced in early
2012. Educational sessions were held for
providers at the two target hospitals to
introduce the intervention and encourage use of both strategies. The website
was also mentioned to families at the
time of discharge from the ED at the two
target hospitals to remind them of this
To begin with, trends in appendicitis
imaging were examined before and after
the launch of the initiative in both the
pediatric and community EDs. Pediatric
Figure 1 • Screen capture of PEMGuidelines.org main page.
Figure 2 • PECARN head trauma guideline from Kupperman et al, 2009.