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Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study
Franz E Babl1, Ed Oakley1, Stuart R Dalziel2
1Emergency Department, Royal Children's Hospital, Melbourne, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Parkville, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Parkville, Victoria, Australia.
Insights
Clinician accuracy in identifying traumatic brain injuries in children is already high. Clinical decision rules like PECARN, CATCH, and CHALICE may not improve detection and could increase CT scans for pediatric head injuries.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Clinical Decision Making
Background:
- Established clinical decision rules (PECARN, CATCH, CHALICE) demonstrate high accuracy for pediatric head injuries.
- The effectiveness of these rules is contingent upon the baseline accuracy of clinicians in a specific healthcare setting.
- Assessing existing clinician accuracy is crucial for determining the added value of decision rules.
Purpose of the Study:
- To evaluate the accuracy of clinician practice in diagnosing clinically important traumatic brain injuries (ciTBI) in children with head injuries.
- To compare clinician diagnostic accuracy against established clinical decision rules (PECARN, CATCH, CHALICE).
Main Methods:
- Secondary analysis of a prospective observational study involving over 20,000 children with head injuries across 10 Australian and New Zealand centers.
- Focused on a cohort of children with mild head injuries (Glasgow Coma Scale 13-15) presenting within 24 hours.
- Assessed physician accuracy in identifying ciTBI using computed tomography (CT) scans in emergency departments (EDs).
Main Results:
- In a cohort of 18,913 children with mild head injuries, clinician identification of ciTBI had a sensitivity of 98.8% and specificity of 92.4%.
- The Pediatric Emergency Care Applied Research Network (PECARN) rule showed 100% sensitivity in children younger than 2 years and 99.2% in older children.
- Canadian Assessment of Tomography for Childhood Head Injury (CATCH) and Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) rules demonstrated sensitivities of 91.9% and 92.5%, respectively.
Conclusions:
- In settings with high existing clinician accuracy and low CT utilization rates, the implementation of PECARN, CATCH, or CHALICE may offer limited additional benefit.
- These clinical decision rules might not significantly enhance the detection of ciTBI and could potentially lead to an increased rate of CT scans.
- The utility of clinical decision rules should be considered in the context of local clinician performance and resource utilization.
Study Objective:
Three clinical decision rules for head injuries in children (Pediatric Emergency Care Applied Research Network [PECARN], Canadian Assessment of Tomography for Childhood Head Injury [CATCH], and Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE]) have been shown to have high performance accuracy. The utility of any of these in a particular setting depends on preexisting clinician accuracy. We therefore assess the accuracy of clinician practice in detecting clinically important traumatic brain injury.
Methods:
This was a planned secondary analysis of a prospective observational study of children younger than 18 years with head injuries at 10 Australian and New Zealand centers. In a cohort of children with mild head injuries (Glasgow Coma Scale score 13 to 15, presenting in <24 hours) we assessed physician accuracy (computed tomography [CT] obtained in emergency departments [EDs]) for the standardized outcome of clinically important traumatic brain injury and compared this with the accuracy of PECARN, CATCH, and CHALICE.
Results:
Of 20,137 children, 18,913 had a mild head injury. Of these patients, 1,579 (8.3%) received a CT scan during the ED visit, 160 (0.8%) had clinically important traumatic brain injury, and 24 (0.1%) underwent neurosurgery. Clinician identification of clinically important traumatic brain injury based on CT performed had a sensitivity of 158 of 160, or 98.8% (95% confidence interval [CI] 95.6% to 99.8%) and a specificity of 17,332 of 18,753, or 92.4% (95% CI 92.0% to 92.8%). Sensitivity of PECARN for children younger than 2 years was 42 of 42 (100.0%; 95% CI 91.6% to 100.0%), and for those 2 years and older, it was 117 of 118 (99.2%; 95% CI 95.4% to 100.0%); for CATCH (high/medium risk), it was 147 of 160 (91.9%; 95% CI 86.5% to 95.6%); and for CHALICE, 148 of 160 (92.5%; 95% CI 87.3% to 96.1%).
Conclusion:
In a setting with high clinician accuracy and a low CT rate, PECARN, CATCH, or CHALICE clinical decision rules have limited potential to increase the accuracy of detecting clinically important traumatic brain injury and may increase the CT rate.
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