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Evaluation of head injury in a pediatric emergency department: pretrauma and posttrauma system
1Department of Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, 19104, USA.
Insights
Trauma center protocols increased diagnostic tests for children with minor head injuries, leading to higher costs without improving outcomes. This study highlights potential overuse of medical services in trauma care.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Surgery
- Health Services Research
Background:
- Trauma center designation aims to standardize and improve care for injured patients.
- Protocols are implemented to guide evaluation and management of specific injuries.
Purpose of the Study:
- To evaluate the impact of trauma center protocols on diagnostic testing and resource utilization for pediatric head injuries.
- To compare test utilization and length of stay before and after trauma center implementation.
Main Methods:
- Retrospective review of pediatric patients with isolated head injuries admitted to an urban children's hospital.
- Comparison of data from before (1985) and after (1991) implementation of trauma center protocols.
Main Results:
- Increased use of radiologic and laboratory studies for patients with minimal or minor head injuries post-protocol implementation.
- Patients with minimal head injury were significantly more likely to undergo cranial CT scans, cervical spine X-rays, and hepatic enzyme tests in 1991.
- No significant difference in diagnostic evaluation for moderate or severe head injuries was observed.
Conclusions:
- Trauma system protocols for isolated head injuries lead to increased utilization of diagnostic services.
- This increased utilization may escalate healthcare costs without a clear improvement in patient outcomes.
Objective:
To determine if trauma center protocols affect the number of tests and consultations performed and the length of time spent in the emergency department or hospital.
Design:
A retrospective review and comparison of treatment for children with isolated head injury admitted to the emergency department before trauma center designation (group 1, 1985), and 5 years after implementation of trauma center protocols (group 2, 1991).
Setting:
Urban children's hospital, level I trauma center.
Results:
One hundred sixty-five children met the enrollment criteria in 1985 and 162 met the criteria in 1991. Falls were the predominant mechanism of injury (55%) for both years. For patients with moderate injury (Glasgow Coma Scale score, 9-12) or severe injury (Glasgow Coma Scale score, <9), there was no difference in radiographic or laboratory evaluation. For patients with minimal head injury (Glasgow Coma Scale score, 15, no loss of consciousness, amnesia, seizure, focal neurologic findings, or persistent symptoms) and minor head injury (Glasgow Coma Scale score, >12, and loss of consciousness or amnesia), more radiologic and laboratory studies were done in 1991 that showed no clinically significant abnormalities. Patients with minimal head injury in group 2 were 14 times more likely to have cranial computed tomographic scans performed (95% confidence interval [CI], 3.4-67); 11 times more likely to have cervical spine radiographs (95% CI, 2.2-76.6); and 23 times more likely to have hepatic enzymes obtained (95% CI, 3-491). These differences persisted when analyzed by both the age of the patient and mechanism of injury.
Conclusions:
Application of trauma system protocols to isolated head injury patient evaluation results in increased use of laboratory and radiologic services. These practices have the potential to increase the cost of medical care without significantly improving outcome.