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Interventions to Reduce Imaging in Children With Minor Traumatic Head Injury: A Systematic Review
Nick Lesyk1, Scott W Kirkland1, Cristina Villa-Roel1
1Department of Emergency Medicine, Faculty of Medicine & Dentistry, College of Health Sciences.
Insights
Implementing multifaceted interventions, including the PECARN rule, significantly reduces head CT scans for children with minor traumatic brain injuries. Complex strategies in high-imaging EDs showed the most substantial decreases in unnecessary imaging.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Clinical Interventions
Background:
- Reducing unnecessary computed tomography (CT) head imaging in children with minor traumatic brain injuries (mTBIs) presenting to emergency departments (EDs) is a key healthcare goal.
- Systematic reviews are crucial for evaluating the effectiveness of interventions aimed at optimizing diagnostic imaging practices.
Purpose of the Study:
- To systematically review and synthesize evidence on interventions designed to decrease head imaging utilization in pediatric patients with mTBIs.
- To identify factors influencing the success of these interventions in real-world clinical settings.
Main Methods:
- A comprehensive search of eight electronic databases and gray literature was conducted to identify relevant comparative studies.
- Two independent reviewers screened studies, assessed quality, and extracted data, employing metaregression to analyze predictors of imaging reduction.
- Studies utilizing before-after designs and multifaceted interventions, particularly those incorporating the Pediatric Emergency Care Applied Research Network (PECARN) rule, were analyzed.
Main Results:
- Twenty-eight studies were included, with most employing before-after designs and multifaceted interventions (median of 3 components).
- The Pediatric Emergency Care Applied Research Network (PECARN) rule was the most frequently implemented intervention (71%).
- Multifaceted interventions incorporating the PECARN rule demonstrated a significant reduction in head CT imaging (relative risk = 0.73), with higher baseline imaging rates and more intervention components associated with greater decreases.
Conclusions:
- Implementing complex interventions, especially those including the PECARN decision rule in high-baseline CT ordering EDs, effectively reduces head imaging in children with mTBIs.
- These strategies, particularly when multifaceted, can decrease CT orders by a median of 27%.
- Further research is needed to elucidate specific factors driving successful implementation and sustained reductions in imaging.
Context:
Reducing unnecessary imaging in emergency departments (EDs) for children with minor traumatic brain injuries (mTBIs) has been encouraged.
Objective:
Our objective was to systematically review the effectiveness of interventions to decrease imaging in this population.
Data Sources:
Eight electronic databases and the gray literature were searched.
Study Selection:
Comparative studies assessing ED interventions to reduce imaging in children with mTBIs were eligible.
Data Extraction:
Two independent reviewers screened studies, completed a quality assessment, and extracted data. The median of relative risks with interquartile range (IQR) are reported. A multivariable metaregression identified predictors of relative change in imaging.
Results:
Twenty-eight studies were included, and most (79%) used before-after designs. The Pediatric Emergency Care Applied Research Network (PECARN) rule was the most common intervention (71%); most studies (75%) used multifaceted interventions (median components: 3; IQR: 1.75 to 4). Before-after studies assessing multi-faceted PECARN interventions reported decreased computed tomography (CT) head imaging (relative risk = 0.73; IQR: 0.60 to 0.89). Higher baseline imagine (P < .001) and additional intervention components (P = .008) were associated with larger imaging decreases.
Limitations:
The limitations of this study include the inconsistent reporting of important outcomes and that the results are based on non-randomized studies.
Conclusions:
Implementing interventions in EDs with high baseline CT ordering using complex interventions was more likely to reduce head imaging in children with mTBIs. Including the PECARN decision rule in the intervention strategy decreased orders by a median of 27%. Further research could provide insight into which specific factors influence successful implementation and sustained effects.
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