ED Observation Decreases CT Use in Head-Injured Children

Abstract

Research Article| May 01 2014 ED Observation Decreases CT Use in Head-Injured Children AAP Grand Rounds (2014) 31 (5): 53. https://doi.org/10.1542/gr.31-5-53 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation ED Observation Decreases CT Use in Head-Injured Children. AAP Grand Rounds May 2014; 31 (5): 53. https://doi.org/10.1542/gr.31-5-53 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: craniocerebral trauma, cranium, decision making, emergency service, hospital, head injury, minor, length of stay, pediatric emergency care applied research network, computed tomography, brain injuries, head injuries, closed Source: Schonfeld D, Fitz BM, Nigrovic LE. Effect of the duration of emergency department observation on computed tomography use in children with minor blunt head trauma. Ann Emerg Med. 2013; 62(6): 597– 603; doi: https://doi.org/10.1016/j.annemergmed.2013.06.020Google Scholar Investigators from Boston Children’s Hospital conducted a prospective study to assess the effect of duration of emergency department (ED) observation on cranial computed tomography (CT) decision-making in children with minor head injury. Children presenting to the ED were included in the study if they were aged ≤18 years, sustained a blunt head injury within 24 hours of presentation, and had a Glasgow Coma Scale (GCS) score of 14 or 15. The treating physician completed a standardized questionnaire for each child based on clinical predictors of brain injury as defined by the Pediatric Emergency Care Applied Research Network (PECARN) prediction rule (see AAP Grand Rounds, January 2010;23[1]:11 ). The physician indicated whether he/she planned to observe the child in the ED prior to obtaining a CT. Symptoms, indication for neuroimaging, ED arrival time, CT order time, and ED disposition were also recorded. Positive CT results were defined as skull fracture or a traumatic brain injury (TBI – intracranial hemorrhage, contusion, cerebral edema, infarction, midline shift, brain herniation, diffuse axonal injury, or pneumocephalus). Clinically important TBI was defined as head injury resulting in death, intubation >24 hours, neurosurgery, or hospitalization for 2 days or longer. The primary outcome was performance of a cranial CT, and ED length of stay was the secondary outcome measure. Multivariable logistic regression was used to investigate the relationship between duration of ED observation time and CT rate. During the study period, data were collected on 1,381 children (86% of eligible); 37% were younger than 2 years. A total of 1,369 children were assigned a PECARN risk stratification group: 53% were low-risk, 36% intermediate-risk, and 11% high-risk. Overall CT rate was 20%, varying from 4% (low-risk) to 26% (intermediate-risk) and 69% (high-risk). About half (49%) of the children were observed prior to CT decision-making. Of those not observed, 34% underwent immediate cranial CT and 66% were discharged. Physicians were more likely to observe older children, those who presented sooner after head injury, and those in the intermediate-risk group. There were more positive CT scans in the nonobserved group, most commonly nondisplaced skull fracture. Eight children had clinically important TBI. All 8 children were classified as high-risk; none were observed prior to CT decision-making. CT usage was reduced by an average of 70% for every hour of ED observation. After adjusting for child and physician factors, this relationship was consistent among high-risk (adjusted odds ratio [aOR] = 0.11; 95% CI, 0.05–0.24), intermediate-risk (aOR = 0.28; 95% CI, 0.21–0.36), and low-risk (aOR = 0.47; 95% CI, 0.31–0.73) groups. As expected, ED length of stay increased for children who were observed. The investigators conclude that ED observation before CT decision-making for children with minor blunt head injury is associated with reduced... You do not currently have access to this content.