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Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource
Rasha D Sawaya1, Cynthia Wakil1, Adonis Wazir1
1Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
Insights
The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules reduced computed tomography (CT) use in young children with head trauma. This head injury guideline implementation did not increase missed clinically important traumatic brain injuries (ciTBI).
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Trauma Surgery
Background:
- Managing minor head trauma in children requires careful evaluation for clinically important traumatic brain injury (ciTBI).
- Computed tomography (CT) use for ciTBI identification in pediatric head trauma is a significant clinical challenge.
- The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules were implemented to guide CT decisions.
Purpose of the Study:
- To evaluate the impact of implementing PECARN prediction rules on CT utilization.
- To assess the effect of PECARN rules on clinical outcomes in pediatric head trauma patients.
- To determine if PECARN rule implementation influenced the rate of ciTBI detection.
Main Methods:
- Retrospective cohort study of pediatric head trauma patients in a pediatric emergency department.
- Comparison of CT rates and outcomes between pre-PECARN (December 2012-2013) and post-PECARN (January 2014-2016) implementation periods.
- Stratification of patients by age (<2 and ≥2 years) and ciTBI risk level (low, intermediate, high).
Main Results:
- Overall CT rates showed no significant change (21.6% pre vs. 18.6% post).
- CT rates significantly decreased in children <2 years old (25.2% to 16.5%, p=0.03), particularly in low-risk patients (20.7% to 11.4%, p=0.02).
- No significant change in CT rates for patients ≥2 years old; no increase in missed ciTBI, hospital admissions, or positive CT findings.
Conclusions:
- PECARN rule implementation effectively reduced CT scan rates in younger children (<2 years) with low risk of ciTBI.
- The adoption of PECARN guidelines did not lead to an increase in missed ciTBI diagnoses.
- PECARN rules provide a valuable tool for judicious CT utilization in pediatric head trauma management.
Background:
Managing children with minor head trauma remains challenging for physicians who evaluate for the need for computed tomography (CT) imaging for clinically important traumatic brain injury (ciTBI) identification. The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules were adopted in our pediatric emergency department (PED) in December 2013 to identify children at low risk for ciTBI. This study aimed to evaluate this implementation's impact on CT rates and clinical outcomes.
Methods:
Retrospective cohort study on pediatric patients with head trauma presenting to the PED of the American University of Beirut Medical Center in Lebanon. Participants were divided into pre- (December 2012 to December 2013) and post-PECARN (January 2014 to December 2016) groups. Patients were further divided into < 2 and ≥ 2 years and stratified into groups of low, intermediate and high risk for ciTBI. Bivariate analysis was conducted to determine differences between both groups.
Results:
We included 1362 children of which 425 (31.2%) presented pre- and 937 (68.8%) presented post-PECARN rules implementation with 1090 (80.0%) of low, 214 (15.7%) of intermediate and 58 (4.3%) of high risk for ciTBI. CTs were ordered on 92 (21.6%) pre- versus 174 (18.6%) patients post-PECARN (p = 0.18). Among patients < 2 years, CT rates significantly decreased from 25.2% (34/135) to 16.5% (51/309) post-PECARN (p = 0.03), and dropped in all risk groups but only significantly for low risk patients from 20.7% (24/116) to 11.4% (30/264) (p = 0.02). There was no significant decrease in CT rates in patients ≥2 years (20% pre (58/290) vs 19.6% post (123/628), p = 0.88). There was no increase in bounce back numbers, nor in admission rates or positive CT findings among bounce backs.
Conclusions:
PECARN rules implementation did not significantly change the overall CT scan rate but reduced the CT scan rate in patients aged < 2 years at low risk of ciTBI. The implementation did not increase the number of missed ciTBI.
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