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Nurse and physician agreement in the assessment of minor blunt head trauma
Lise E Nigrovic1, Deborah Schonfeld, Peter S Dayan
1Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA. lise.nigrovic@childrens.harvard.edu
Insights
Registered nurses and physicians showed moderate agreement on Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) rules for older children, but fair agreement for younger children. RN assessments need physician verification, especially in young pediatric patients.
Area of Science:
- Emergency Medicine
- Pediatric Traumatology
- Clinical Prediction Rules
Background:
- The Pediatric Emergency Care Applied Research Network (PECARN) developed clinical prediction rules to identify children with minor blunt head trauma at low risk for clinically important traumatic brain injuries (TBIs).
- Assessing agreement between registered nurses (RNs) and physicians (MDs) in applying these rules is crucial for consistent patient care.
Purpose of the Study:
- To measure the agreement between RN and MD assessments using the PECARN TBI clinical prediction rules.
- To evaluate the reliability of RN assessments in identifying low-risk pediatric patients with minor blunt head trauma.
Main Methods:
- A cross-sectional study was conducted on children under 18 with minor blunt head trauma presenting to an emergency department.
- RNs and MDs independently assessed patients, recording PECARN predictors within 60 minutes of each other.
- Agreement was measured using the κ statistic, focusing on the overall PECARN rule.
Main Results:
- Of 1624 eligible children, 1191 (73%) had complete RN and MD evaluations.
- Overall RN-MD agreement was moderate for children aged 2-18 years (κ = 0.55) and fair for children under 2 years (κ = 0.32).
- Agreement was higher in older children compared to younger children.
Conclusions:
- RN and MD agreement on PECARN TBI prediction rules is moderate in older children and fair in younger children.
- Physician (MD) verification of initial RN assessments is recommended, particularly for pediatric patients under 2 years old.
- This highlights the need for careful application and potential refinement of TBI prediction rules in young children.
Objective:
The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) clinical prediction rules identify children with minor blunt head trauma who are at low risk for clinically important traumatic brain injuries. We measured the agreement between the registered nurse (RN) and physician (MD) assessments.
Methods:
We performed a cross-sectional study of all children <18 years of age with minor blunt head trauma who presented to a single emergency department. RNs and MDs independently assessed each child and recorded age-based PECARN predictors. As symptoms can change over time, we included cases only when both evaluations were completed within 60 minutes. We used the κ statistic to measure RN-MD agreement, with the main analysis focusing on the overall PECARN rule agreement.
Results:
Of the 1624 eligible children, 1191 (73%) had evaluations completed by both RN and ED providers, of which 437 (37%) were in children <2 years of age. The median time between completions of the provider forms was 12 minutes (interquartile range 4-25 minutes). The overall agreement between the RN and MD was higher for the older children (κ 0.55, 95% confidence interval 0.49-0.61 for children 2-18 years versus κ 0.32, 95% confidence interval 0.23-0.41 for children <2 years).
Conclusions:
The overall agreement between RN and MD for the PECARN TBI prediction rules was moderate for older children and fair for younger children. Initial RN assessments should be verified by the MD before clinical application, especially for the youngest children.
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