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Author Spotlight: Advancing Traumatic Brain Injury Research - A Closed-Head Model for Accurate Replication and Rapid Assessment
Published on: September 22, 2023
Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head
Onyinyechi I Ukwuoma1, Veerajalandhar Allareddy2, Veerasathpurush Allareddy3
1From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH.
Insights
The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules did not reduce overall computed tomography of the head (CT-H) use in children with mild head injuries. However, CT-H use decreased in metropolitan teaching hospitals after the rules were published.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma Research
- Health Services Research
Background:
- Mild closed head injuries are common in children, but most do not require neuroimaging due to low risk of clinically important traumatic brain injury (ciTBI).
- Validated clinical prediction rules by the Pediatric Emergency Care Applied Research Network (PECARN) were published in 2009 to identify children at risk of ciTBI.
Purpose of the Study:
- To evaluate the impact of the PECARN prediction rules on the utilization of computed tomography of the head (CT-H) in children with closed head injuries presenting to emergency departments.
- To determine if the adoption of evidence-based guidelines influenced neuroimaging practices in pediatric head injury management.
Main Methods:
- Analysis of a nationwide emergency department (ED) sample from 2008-2013, including over 4.5 million children with mild closed head injuries.
- Assessment of patient and hospital characteristics, including hospital type (teaching vs. nonteaching) and geographic location (metropolitan vs. nonmetropolitan).
Main Results:
- Overall, there was no significant change in nationwide CT-H utilization rates following the publication of the PECARN rules.
- CT-H utilization decreased significantly in metropolitan teaching hospitals after 2009.
- Conversely, CT-H utilization increased in nonteaching and nonmetropolitan hospitals compared to metropolitan teaching hospitals.
Conclusions:
- The PECARN prediction rules did not lead to a widespread reduction in CT-H use for pediatric mild head injuries.
- Evidence suggests partial adoption of the PECARN tool in metropolitan teaching hospitals, indicated by reduced CT-H utilization.
- Further investigation is needed to understand the barriers to adopting these validated prediction rules in nonteaching and nonmetropolitan hospital settings.
Objectives:
Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN).
Methods:
We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed.
Results:
Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals.
Conclusions:
There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.
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