For most mild head injured patients that seek care at the Emergency Department a head CT is the traditional assessment tool used. While this makes sense as providers want to rule out the likelihood of the most serious diagnosis (intracranial hemorrhage), which in over 90% of patients scanned will be negative. A single head CT delivers the equivalent radiation as 20 chest X-rays, increasing an individual’s lifetime risk of cancer.
The Centers for Medicare and Medicaid Services (CMS) also saw the value in reducing CT scans for minor head injury and made CT reduction one of a small handful of Emergency Medicine Clinical Quality Measures that may be reported as part of the Merit Based Incentive Program (MIPS). CMS' Merit-Based Incentive Payment System (MIPS) includes a quality measure specifically to address the need to reduce low clinical value head CTs. This is the rational for the CMS Clinical Quality Measure (CQM) #415, which states:
“Though it is difficult to directly attribute the effects of smaller dosages of radiation, such as that received through computed tomography (CT), the dosage of radiation from CTs has increased in recent years, in part due to the increased speed of image acquisition. Additionally, there is evidence to suggest that the radiation doses from CTs are higher and more variable than generally quoted. Further, as “radiation doses associated with commonly used CT examinations resemble doses received by individuals in whom an increased risk of cancer was documented,” the use of some CT scans is associated with a “nonnegligible” lifetime attributable risk of cancer. As over 1.3 million individuals are treated and released from the ED for mild traumatic brain injury annually, it is critical that CT scans only be utilized when clinically appropriate.”1
CMS Clinical Quality Measure (CQM) #415 tracks the percentage of ED visits for patients aged 18 years and older who present with minor blunt head trauma who had an indication for a head CT ordered by an Emergency Clinician. Avoiding unnecessary head CTs in minor blunt Trauma has become a core tenant of Emergency Medicine, and CMS has tied reimbursement penalties and incentives to their judicious use through the MIPS program.
While it has been almost 10 years after identifying head CTs in minor head injury as an opportunity to improve the value based care in the ED, it appears that the use of CT in minor head injury continues to rise. Emergency medicine providers recognize the importance and need to reduce CT scans for the mild head injured patient population, but cite “concern for serious diagnosis” or “patient or family expectations” for the reason why they continue to order low value head CTs. In their discussion, the authors state: “some clinicians may have a good understanding of the evidence base, but choose to deviate from guidelines and rely on patient clinical factors or “gestalt,” as decision rules are imperfect.”2
Given that 3.6% of all ED visits present for head injury, there is significant opportunity to improve the value of care for ED patients. Head CTs, that expose patients to ionizing radiation and can increase a patients’ lifetime risk of cancer, should not be performed when clinicians can safely risk stratify a patient without the expense of a potentially harmful test.3
BrainScope is a brain electrical activity based biomarker that is easily used in patients with minor head injury (FDA cleared for patients with GCS 13-15 within 72 hours of injury) and provides a rapid and objective assessment of mild traumatic brain injury (mTBI). BrainScope demonstrated a 99% sensitivity in identifying the likelihood of the smallest detectable level of intracranial blood (>1 mL) in patients with minor head injury.4 Through an objective, AI-derived biomarker, BrainScope aids Emergency Clinicians in assessing the likelihood of a structural brain injury (a “bleed”) and a functional brain index that objectively assesses a patient’s probability of brain function impairment after a minor head injury. These objective measures give both clinicians and their patient’s objective information related to their head trauma without ionizing radiation.
In an example of a 40,000 patient visit per year ED, the amount of total radiation that patients will potentially avoid is equivalent to 3,696 -4,407 chest x-rays. BrainScope is an objective biomarker that helps risk stratify patients with minor head injury. In practice, EDs that use BrainScope see a reduction in CT utilization and a corresponding decrease in radiation exposure for their patients.5
Read Next: Capacity Creation in the Emergency Department
Are you interested in discovering more about BrainScope and its potential impact on your hospital? 
1. Quality ID #415: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older (CMS) https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_415_MIPSCQM.pdf (accessed October 24, 2022).
2. Lin, M. P., Nguyen, T., Probst, M. A., Richardson, L. D., & Schuur, J. D. (2017). Emergency physician knowledge, attitudes, and behavior regarding ACEP's choosing wisely recommendations: a survey study. Academic Emergency Medicine, 24(6), 668-675.
3. Nation’s Emergency Physicians Announce Second List Of Tests And Procedures To Question As Part Of Choosing Wisely® Campaign, Choosing Wisely (2014) https://www.choosingwisely.org/nations-emergency-physicians-announce-second-list-of-tests-and-procedures-to-question-as-part-of-choosing-wisely-campaign/ (accessed 11/15/2022).
4. Hanley, D., Prichep, L. S., Bazarian, J., Huff, J. S., Naunheim, R., Garrett, J., ... & Hack, D. C. (2017). Emergency department triage of traumatic head injury using a brain electrical activity biomarker: a multisite prospective observational validation trial. Academic emergency medicine, 24(5), 617-627.
5. Clay, M.S., (2021) Clinical Utility of an EEG Based Biomarker for the Triage of Head Injured Patients in the ED: INOVA Pilot Study BrainScope White Paper, August 2021
