Impact of a Triage-Based Blunt Trauma Assessment on PECARN Recommendations and Neuroimaging Use in Pediatric Head
Cheuk Kwok1,2, Jamie Marliere1,3, Shaye Busse1,4
1University of Central Florida College of Medicine, Orlando, FL, USA.
Insights
A best practice advisory for pediatric head injuries showed limited agreement with established guidelines, leading to inconsistent head CT scans. Clinical factors and advisory recommendations influenced provider decisions, indicating a need for improved decision support.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Clinical Decision Support
Background:
- Head injuries are common in children, necessitating accurate diagnostic imaging.
- Pediatric Emergency Care Applied Research Network (PECARN) provides evidence-based guidelines for head injury assessment.
- Best practice advisories (BPAs) are increasingly used to guide clinical decisions in emergency settings.
Purpose of the Study:
- To evaluate the impact of a triage-based blunt trauma assessment (BPA) on PECARN-guided recommendations and head CT utilization in pediatric head injuries.
- To assess agreement between BPA recommendations, PECARN risk categories, and actual head CT use.
- To identify factors associated with deviations from PECARN guidance.
Main Methods:
- Retrospective analysis of pediatric patients (<18 years) with head injuries.
- Comparison of BPA recommendations, PECARN risk stratification, and head CT usage.
- Statistical analysis including Mann-Whitney, Kruskal-Wallis, Fisher exact, and chi-squared tests.
Main Results:
- Agreement between BPA and PECARN was 47%.
- PECARN recommendations aligned with head CT use in 73% of cases, while BPA aligned in 39%.
- Significant rates of head CT use occurred against PECARN recommendations in both younger (<2 years) and older (≥2 years) children (42% and 38%, respectively).
- Overall agreement among BPA, PECARN, and CT use was 35%.
- Symptoms like speech changes, lethargy, altered mood, and gait abnormalities were linked to deviations from PECARN.
Conclusions:
- PECARN guidelines influence head CT decisions, but BPAs and other clinical factors impact provider behavior.
- Opportunities exist to refine decision support tools to reduce unnecessary head CT scans in pediatric head injuries.
- Clinical judgment and presenting symptoms play a significant role in imaging choices, sometimes diverging from established protocols.
Abstract:
This study aimed to evaluate the impact of a triage-based blunt trauma assessment (best practice advisory) on Pediatric Emergency Care Applied Research Network (PECARN)-guided recommendations and actual head computed tomography (CT) use in children <18 years old presenting with head injury. We examined agreement between best practice advisory recommendations, PECARN risk categories, and head CT use, as well as risk factors associated with deviation from PECARN guidance. Group comparisons were analyzed by Mann-Whitney rank-sum test, Kruskal-Wallis test, Fisher exact test, or χ2 test, as indicated. Best practice advisory and PECARN agreement was 47%. The best practice advisory aligned with CT use in 39% of cases, whereas PECARN aligned 73%. In children <2 years, 42% received a head CT despite a PECARN recommendation against it (P < .001). In children ≥2 years, 38% received a head CT against PECARN recommendations (P < .001). Overall agreement among best practice advisory, PECARN, and head CT use was 35%. Symptoms such as speech changes, lethargy, altered mood, and gait abnormalities were associated with deviations from PECARN. Findings suggest that although PECARN guides imaging decisions, numerous clinical factors and best practice advisory recommendations influence provider behavior, highlighting opportunities to improve decision support and reduce unnecessary CT scans.
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