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Published on: February 5, 2019
Interobserver agreement in the clinical assessment of children with blunt abdominal trauma
Kenneth Yen1, Nathan Kuppermann, Kathleen Lillis
1Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
Insights
Physician agreement on historical and physical exam findings for pediatric blunt abdominal trauma is generally acceptable. This supports developing clinical prediction rules for intra-abdominal injuries in children.
Area of Science:
- Emergency Medicine
- Pediatric Surgery
- Clinical Assessment
Background:
- Blunt abdominal trauma in children requires accurate evaluation in the emergency department (ED).
- Interobserver agreement on clinical findings is crucial for reliable assessment and decision-making.
Purpose of the Study:
- To assess the reliability of historical and physical examination findings recorded by clinicians during the ED evaluation of pediatric blunt abdominal trauma.
- To identify variables with acceptable interobserver agreement for potential use in clinical prediction rules.
Main Methods:
- A prospective, multicenter cohort study involving children under 18 with blunt abdominal trauma.
- Two clinicians independently assessed patients, recording findings before advanced imaging or laboratory results.
- Interobserver agreement was quantified using kappa (κ) statistics, with acceptable agreement defined as a 95% lower confidence limit κ ≥ 0.4.
Main Results:
- Data from 632 patient evaluations were analyzed across 23 variables.
- Acceptable agreement was achieved for 16 (70%) of the variables.
- While most subjective and objective findings showed good agreement, some, like flank tenderness and pelvis instability, had lower reliability.
Conclusions:
- Clinicians demonstrate at least moderate agreement on most historical and physical examination variables in pediatric blunt abdominal trauma.
- These reliably assessed variables are suitable for developing clinical prediction rules to aid in diagnosing intra-abdominal injuries.
Objectives:
The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma.
Methods:
This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement.
Results:
A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation.
Conclusions:
Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.
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