The effect of observation on cranial computed tomography utilization for children after blunt head trauma
Lise E Nigrovic1, Jeff E Schunk, Adele Foerster
1Division of Emergency Medicine, Children's Hospital Boston, Boston, Boston, MA 02115, USA. lise.nigrovic@childrens.harvard.edu
Insights
Clinical observation of children with minor blunt head trauma reduces computed tomography scans. This strategy is effective in lowering imaging rates without increasing clinically important traumatic brain injuries.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Trauma Care
Background:
- Children with minor blunt head trauma often undergo observation in emergency departments.
- The decision for computed tomography (CT) use in these cases is critical to balance diagnostic accuracy and radiation exposure.
Purpose of the Study:
- To evaluate the impact of clinical observation as a strategy on CT utilization in children with minor blunt head trauma.
- To assess the effect of observation on the rates of clinically important traumatic brain injury (TBI).
Main Methods:
- A subanalysis of a prospective multicenter observational study involving children with minor blunt head trauma.
- Clinicians recorded whether observation preceded the CT decision.
- Clinically important TBI was defined by specific adverse outcomes (death, surgery, prolonged intubation/admission).
- Generalized estimating equation models were used to compare CT rates, controlling for clustering and patient characteristics.
Main Results:
- Observation was noted in 14% of 40,113 children.
- CT use was lower in observed children (31.1%) compared to unobserved (35.0%).
- Rates of clinically important TBI were similar between observed and unobserved groups (0.75% vs 0.87%).
- Adjusted analysis confirmed significantly reduced CT use in the observed group (aOR: 0.53).
Conclusions:
- Clinical observation is associated with reduced computed tomography use in pediatric patients with minor blunt head trauma.
- This strategy appears effective in decreasing unnecessary CT scans while maintaining patient safety regarding significant injuries.
Objective:
Children with minor blunt head trauma often are observed in the emergency department before a decision is made regarding computed tomography use. We studied the impact of this clinical strategy on computed tomography use and outcomes.
Methods:
We performed a subanalysis of a prospective multicenter observational study of children with minor blunt head trauma. Clinicians completed case report forms indicating whether the child was observed before making a decision regarding computed tomography. We defined clinically important traumatic brain injury as an intracranial injury resulting in death, neurosurgical intervention, intubation for longer than 24 hours, or hospital admission for 2 nights or longer. To compare computed tomography rates between children observed and those not observed before a decision was made regarding computed tomography use, we used a generalized estimating equation model to control for hospital clustering and patient characteristics.
Results:
Of 42 412 children enrolled in the study, clinicians noted if the patient was observed before making a decision on computed tomography in 40 113 (95%). Of these, 5433 (14%) children were observed. The computed tomography use rate was lower in those observed than in those not observed (31.1% vs 35.0%; difference: -3.9% [95% confidence interval: -5.3 to -2.6]), but the rate of clinically important traumatic brain injury was similar (0.75% vs 0.87%; difference: -0.1% [95% confidence interval: -0.4 to 0.1]). After adjustment for hospital and patient characteristics, the difference in the computed tomography use rate remained significant (adjusted odds ratio for obtaining a computed tomography in the observed group: 0.53 [95% confidence interval: 0.43-0.66]).
Conclusions:
Clinical observation was associated with reduced computed tomography use among children with minor blunt head trauma and may be an effective strategy to reduce computed tomography use.
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