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A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings
Kent P Hymel1, Veronica Armijo-Garcia2, Matthew Musick3
1Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA.
Insights
The Pediatric Brain Injury Research Network (PediBIRN) 4-variable clinical decision rule (CDR) improved abuse evaluations in pediatric intensive care units (PICUs). This led to a reduction in potential cases of missed abusive head trauma, enhancing patient care.
Area of Science:
- Pediatric critical care medicine
- Child abuse and neglect research
- Clinical decision support systems
Background:
- Abusive head trauma (AHT) is a significant concern in pediatric intensive care units (PICUs).
- Accurate and timely evaluation for abuse is crucial to prevent further harm.
- Existing diagnostic tools may not fully capture the complexity of AHT in critically injured children.
Purpose of the Study:
- To assess the impact of the Pediatric Brain Injury Research Network (PediBIRN) 4-variable clinical decision rule (CDR) on abuse evaluations.
- To determine the effect of the PediBIRN-4 CDR on identifying and managing abusive head trauma in PICU settings.
- To evaluate the reduction in missed abusive head trauma cases through the implementation of the PediBIRN-4 CDR.
Main Methods:
- A cluster randomized trial involving 8 pediatric intensive care units (PICUs) in US academic medical centers.
- Physician-directed interventions included training, access to an AHT probability calculator, and information sessions.
- Outcomes measured included thorough abuse evaluations (skeletal survey, retinal exam) and missed AHT cases.
Main Results:
- Intervention PICUs showed a trend towards evaluating more higher-risk patients thoroughly (81% vs. 73%).
- Potential cases of missed abusive head trauma significantly decreased in the intervention group (21% vs. 32%).
- Significant positive changes in thorough evaluations and reduced potential missed AHT cases were observed from baseline to trial.
Conclusions:
- The PediBIRN-4 CDR implementation positively influenced abuse evaluation practices in PICUs.
- The application of the PediBIRN-4 CDR was associated with a reduction in potential cases of missed abusive head trauma.
- The study highlights the effectiveness of clinical decision rules in improving care for critically injured children at risk for abuse.
Objective:
To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings.
Study Design:
This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models.
Results:
Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22).
Conclusions:
PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings.
Trial Registration:
ClinicalTrials.gov: NCT03162354.
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