Hemoglobin, Hematocrit, and Glucose Levels in Patients Aged 0-2 Years with Head Trauma Assessed in the Emergency Department

Many patients are discharged from the emergency department (ED) with an incomplete understanding of the information needed to safely care for themselves at home. Patients have demonstrated particular difficulty in understanding post-ED care instructions (including medications, home care, and follow-up). The objective of this study was to further characterize these deficits and identify gaps in knowledge that may place the patient at risk for complications or poor outcomes. This was a prospective cohort, phone interview-based study of 159 adult English-speaking patients within 24 to 36 hours of ED discharge. Patient knowledge was assessed for five diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the following five domains: diagnosis, medications, home care, follow-up, and return instructions. Knowledge was determined based on the concordance between direct patient recall and diagnosis-specific discharge instructions combined with chart review. Two authors scored each case independently and discussed discrepancies before providing a final score for each domain (no, minimal, partial, or complete comprehension). Descriptive statistics were used for the analyses. The study population was 50% female with a median age of 41 years (interquartile range [IQR] = 29 to 53 years). Knowledge deficits were demonstrated by the majority of patients in the domain of home care instructions (80%) and return instructions (79%). Less frequent deficits were found for the domains of follow-up (39%), medications (22%), and diagnosis (14%). Minimal or no understanding in at least one domain was demonstrated by greater than two-thirds of patients and was found in 40% of cases for home care and 51% for return instructions. These deficits occurred less frequently for domains of follow-up (18%), diagnosis (3%), and medications (3%). Patients demonstrate the most frequent knowledge deficits for home care and return instructions, raising significant concerns for adherence and outcomes.

Altered mental status (AMS) is a common presentation in the emergency department (ED). A previous study revealed 78% electroencephalogram (EEG) abnormalities, including nonconvulsive seizure (NCS; 5%), in ED patients with AMS. The objective of this study was to assess the impact of EEG on clinical management and outcomes of ED patients with AMS. This was a randomized controlled trial at two urban teaching hospitals. Adult patients (≥18 years old) with AMS were included. Excluded patients had immediately correctable AMS (e.g., hypoglycemia) or were admitted before enrollment. Patients were randomized to routine care (control) or routine care plus EEG (intervention). Research assistants used a scalp electrode set with a miniature, wireless EEG device (microEEG) to record standard 30-minute EEGs at presentation, and results were reported to the ED attending physician by an off-site epileptologist within 30 minutes. Primary outcomes included changes in ED management (differential diagnosis, diagnostic work-up, and treatment plan from enrollment to disposition) as determined by surveying the treating physicians. Secondary outcomes were length of ED and hospital stay, intensive care unit (ICU) requirement, and in-hospital mortality. A total of 149 patients were enrolled (76 control and 73 intervention). Patients in the two groups were comparable at baseline. EEG in the intervention group revealed abnormal findings in 93% (95% confidence interval [CI] = 85% to 97%), including NCS in 5% (95% CI = 2% to 13%). Using microEEG was associated with change in diagnostic work-up in 49% (95% CI = 38% to 60%) of cases and therapeutic plan in 42% (95% CI = 31% to 53%) of cases immediately after the release of EEG results. Changes in probabilities of differential diagnoses and the secondary outcomes were not statistically significant between the groups. An EEG can be obtained in the ED with minimal resources and can affect clinical management of AMS patients.

Introduction: The Calgary Stampede is a two-week mass gathering occurring annually in July. Clinicians have anecdotally noted increases in emergency department (ED) and urgent care (UC) visits, especially for complaints related to substance misuse and violence. Our objectives were: 1) to determine if there is an increase in overall visits to EDs and UCs during the Stampede, and 2) to determine if there are increases in presentations related to trauma, violence, or intoxication. Methods: This observational study used prospectively collected administrative data from five EDs and two UCs in Calgary. For the years 2013 to 2016, daily average data during Stampede dates were compared to the data from the 21 days immediately preceding and following the event. Dates were selected to incorporate a similar proportion of weekends and weekdays in the Stampede and non-Stampede periods. The primary outcome was daily average ED and UC utilization. Secondary outcomes included time of arrival, utilization by demographic groups, complaint category at triage, or International Statistical Classification of Diseases, 10th revision (ICD-10) diagnosis. Results: The study period included 263 380 individual ED and UC visits (34 492 Stampede and 228 888 non-Stampede visits). Daily average ED and UC visits increased by 2.1% (p<0.0001) during the Stampede period. Increases in utilization were identified in specific subgroups: male, ambulance arrival, and nighttime arrival between 2000 and 0400 (all p<0.05). The Stampede period saw a marked increase in CTAS 1 visits (16.2%, p<0.01), triage complaints of lacerations (12.4%, p<0.0001) and blunt trauma (19.4%, p<0.0001), and the ICD-10 diagnosis of substance misuse (23.9%, p=0.01). Visits triaged to the minor treatment areas increased by 9.5% (p<0.0001), again most markedly at night (15.3%, p<0.0001).No differences were detected for triage complaints of altered level of consciousness, sexual assault, head or neck injury, limb injury, or social problems. Conclusion: The Calgary Stampede provokes appreciable changes in overall ED and UC utilization, with marked increases in nighttime visits, visits by men, trauma or substance abuse-related complaints, and minor treatment visits. This data may be useful in manpower planning to ensure optimal patient flow and service delivery during mass gatherings.

Quality assurance and clinical indicators in emergency medicine

In the emergency department (ED) setting, prioritizing triage and patient care may lead to challenges in capturing detailed documentation necessary for specific International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding in medical records. Consequently, the prevalent use of the "unspecified head injury" code poses concerns about the precision of ED-based administrative billing claims data when analyzed for public health surveillance of nonfatal traumatic brain injuries (TBIs). Understanding the perspective of medical coders can illuminate coding processes and opportunities to enhance coding accuracy for TBI and other head injuries in the ED. This evaluation explores medical coders' perspectives and challenges when assigning ICD-10-CM codes to head injuries in the ED. This qualitative evaluation utilized a phenomenological approach, which employed semi-structured interviews to understand medical coders' perspectives, processes, and coding determinations for head injuries in the ED. Interviews were conducted using a HIPAA-compliant video-based platform between July 2022 and January 2023. Seventeen medical coders with ED coding experience were interviewed. Their backgrounds were diverse, though most had more than 15years of experience. Four qualitative themes emerged, which highlighted challenges with lack of detailed documentation, defaulting to unspecified codes, time, and productivity pressure, and additional insights into coders' assumptions and code determination processes. Medical coders expressed challenges assigning ICD-10-CM codes to the highest level of specificity, citing issues including insufficient documentation by ED providers and terminology variations. Workplace time constraints and pressure for expedited claims also led to defaulting to unspecified codes. This evaluation highlights the need for improved documentation consistency and detail in ED records to facilitate accurate ICD-10-CM coding. Alleviating time pressures, improving algorithms, and offering specialized training opportunities to medical coders could be helpful steps to improve coding specificity and data accuracy for head injuries in the ED.

BackgroundHead injuries are the leading cause of trauma in Emergency Departments (EDs). Recent studies have shown epidemiological changes in patients consulting ED for head injuries. The main objective of this study was to describe the profile of head injury patients consulting in the EDs in France and assess i) head injury severity across age groups; ii) the delay between the occurrence of head injury and ED arrival; iii) factors associated with traumatic intracranial hemorrhage (ICH).MethodsThis cross-sectional study collected patient data over a three-day period in March 2023. All adult patients (≥ 18 years old) admitted to the ED with a head injury (defined as a trauma to the head) were included. TBI severity was classified according to patients’ initial Glasgow Coma Scale score in the ED: severe (3–8); moderate (9 -12); mild (13–15); and simple head trauma in the absence of transient or persistent neurological symptoms.ResultsAmong the 71 participating EDs, 26,008 patients visited EDs and a total of 1070 patients (4.1%, IC 95 3.9—4.4) presented a head injury were included in the study, with a median age of 68.5 [37–85] years old. Most of the patients (66.7%) were referred to ED after a call to the Emergency Medical Dispatcher (EMD). The median time from head injury to ED visit was 2 h [1.0 – 5.5]. Ground-level falls were the leading cause of head injury (60.3%). Most of patient presented a simple head trauma (n = 715, 66.8%) followed by mild TBI (n = 337, 31.5%). CT head scans were performed for 636 patients (59.6%), of which 58 were positive. Traumatic ICH prevalence was 5.4% (95% CI: 4.1–6.9) and three patients (0.3%) required an urgent neurosurgical intervention. Neither preinjury anticoagulant (p = 0.97) nor antiplatelet (p = 0.93) use was associated with an increased risk of traumatic ICH.ConclusionsOne head injury patient out of two presenting in the ED is aged over 65 years. Patients referred by EMD were more likely to visit ED promptly. The majority of older patients underwent a head CT scan and preinjury anticoagulant use was not associated with increased risk of traumatic ICH.

Background: Delays in clinical handover can compromise a patient's care. The handover is not the sole responsibility of the ambulance personnel or the emergency departments. Reducing delays requires the working together of the entire organization, as well as designing efficient emergency and ambulance departments. Objectives: The study aims at exploring the quality of clinical handover between the emergency department personnel and the ambulance personnel at Hamad General Hospital. Methods: This is a descriptive study using two kinds of anonymous questionnaire surveys to gauge the current opinion regarding patient handover. One was aimed at physicians, who are the hospital employees, and the second was intended for the ambulance personnel. The employees of the Emergency Department were asked to provide their opinion of the handovers that the ambulance employees provided in a given clinical situation. The clinical situations in question included: cardiac arrest, pediatric emergencies, sepsis, chest pain, head injury, and trauma. Results: A total of 65 ambulance employees and 70 medical employees completed the survey. The findings of the study indicate that there is a formal training procedure for patient handover, and that, in general, the quality of communication of history, the general quality of handover, and the knowledge of vital signs reported were high. The ambulance personnel were satisfied with their quality of handover. However, the medical staff were less positive, particularly for sepsis and pediatric emergencies. The findings also indicate that the ambulance employees perceived a high level of delay regarding patient handover. Conclusions: It was encouraging that both groups had a positive perception about the handover. The areas for improvement identified by the medical employees were sepsis and pediatric emergencies, while the ambulance employees perceived a significant delay in the handover. In conclusion, the study proposes the following recommendations as possible solutions: interdisciplinary training, addressing organizational culture, and flexibility in organizational processes.

The aim of this study was to assess the quality of documentation of head-injured patients seen in three accident and emergency (A&E) departments using a specially designed head injury pro forma. A 4-week prospective study of a single head injury pro forma was followed by a second similar study with an improved version (two head injury pro formas, one for young children and babies, the other for older children and adults). The main outcome measures were the degree of completion of the pro forma and questionnaire responses from receptionists, nurses and doctors. A total of 1260 patients had their details completed on the pro forma in both studies. Compared with standard hand written A&E notes, the degree of completion of clinical details specific to the head injury were high, eg. over 95% for symptoms. The pro forma was generally well received by A&E staff, particularly after recommended improvements were made, and the majority of staff felt it should be introduced permanently into the A&E department. Concern about its use in cases of very minor head injury and multiple injuries were raised. As well as improved documentation, the pro forma facilitates the process of audit and may have an important role to play in information technology and computers in the future.

Managing Migraine

373 Concussions in the Emergency Department: A Retrospective Analysis of Clinical Decision Guidelines Utilization

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.

The 2009 H1N1 pandemic and seasonal influenza outbreaks have, at times, overwhelmed capacity in children's hospitals.1 The COVID-19 pandemic is different. Relatively few children have become severely ill when infected with SARS-CoV-2.2 In four weeks from March to April 2020, the Centers for Disease Control and Prevention found 42% reduction in emergency department (ED) visits nationally compared with the prior year and noted the steepest decrease in visits was among children <15 years.

Early airway management of patients with severe head injury: opportunities missed?

We thank the Journal of Athletic Training (JAT) and Deits et al1 for allowing us to comment on the analysis of national emergency department (ED) surveillance data on hockey injuries appearing in this issue. This commentary focuses on the use in descriptive epidemiology of the injury proportion ratio (IPR). We are prompted to comment on the IPR due to its increasing use in the sports injury-prevention literature, including JAT. Our comments are aimed at examining the IPR and highlighting the usefulness and limitations of the measure in relation to other measures in injury-prevention research, notably the injury rate ratio. Our concern is that, without understanding the assumptions underlying these measures, the IPR can be easily misinterpreted, thereby leading readers to draw false conclusions.Published research2–6 has used IPRs in the context of hospital-based surveillance data as well as a Web-based high school surveillance system.7–16 By design, hospital-based ED injury surveillance systems, such as the National Electronic Injury Surveillance System (NEISS), collect information only on injured individuals. Such surveillance systems provide useful descriptive information about severe injury patterns, such as who was injured, what types of injuries occurred, what was happening at the time of injury, and the type of care provided for that injury. However, NEISS does not collect information about the population among whom these injuries occurred or arose: the population of hockey players, in this case. Additionally, NEISS does not collect information on hockey injuries that do not result in a visit to the ED, an issue we will ignore for the purposes of this commentary.The IPR has been defined as a χ2 ratio to compare the relative proportions of categorical variables.1 In their analysis of NEISS data, Deits et al reported that the proportion of head injuries seen at the ED among females was 2.22 times greater than the proportion of head injuries among males. Because 19.9% of the females' injuries were to the head, we can deduce that the proportion of head injuries to males was approximately 9%. In the context of all injuries seen in an ED, this measure represents the injury-care burden to the health care providers: Of all patients with injuries reporting to the ED, providers will treat twice as many head injuries among females as among males.However, no data are included in the NEISS system about the male-to-female sex ratio in the hockey-playing general population. Therefore, the IPR says nothing about the rate of head injury for a female playing hockey compared with a male playing hockey. In other words, the IPR is not the same as the injury rate ratio.The IPR is analogous to another epidemiologic measure, the proportional mortality ratio (PMR), which is used to study proportionate index causes of disease or death in the absence of a defined cohort or population at risk.17 The PMR is most often used in occupational studies when researchers have access to causes of disease or death but have no way of identifying the population of workers among whom these events occurred (ie, the denominator).17 For example, the PMR compares the observed proportion of cancer deaths of all deaths in a defined group to the expected proportion of cancer deaths in a referent or comparison population. It is a useful surrogate of disease risk and can inform the direction of prospective research studies examining risk factors. The limitations of this measure are well described and include the following: (1) No population-at-risk information (denominator) means that diseases or deaths cannot be attributed to actual exposures or risk factors, and (2) the sum of all proportionate causes must equal 1, so any proportion is dependent on the value of all other proportions.17 In other words, an excess in one cause is offset by a deficit in another cause. These limitations significantly limit the validity and generalizability of the PMR.The PMR has been adapted for nonfatal work-related injury studies and called a proportionate injury ratio. In an analysis of construction injuries reported as workers' compensation cases, Dement et al,18 Lipscomb and Li,19 and Lombardi et al20 compared the observed causes of injury among teen construction workers with those expected from a referent population of adult construction workers.Consider a hypothetical study, identical to the NEISS analysis of Deits et al1, with one exception: It also includes data on the total hockey-playing population in the United States and total time spent playing hockey, presented separately for males and females. Clearly such a rich source of exposure data is not available in the NEISS (or anywhere else in the United States). If it was, Deits et al would have been able to compute incidence rates for ED-attended hockey injuries for males and females and compute the ratio of these 2 sex-specific rates (ie, the true injury rate ratio).Obviously, this would have been the first preference of the researchers. But playing-time data were not available, let alone presented separately for males and females. Therefore, in the absence of any data on the playing population, researchers used the IPR.Note that the IPR does not use the sex distribution of the playing population as its denominator. Instead, it uses the sex distribution of the injured population. Thus, a male-to-female head-injury IPR of 2.22 does not inform the reader about the actual rate of incident head injuries among hockey players but about the relationship between the 2 subgroups of injured participants. In fact, the IPR is something the reader can deduce by looking at the proportions alone (19.9% versus 9%).It is important to note that the reader should not draw conclusions about relative injury rates based on the IPR. It would be incorrect to infer that in this study, females had twice the rate of head injury resulting in ED treatment. Interpreting frequency measures as measures of relative risk or rate ratios results in the reader drawing erroneous conclusions about increased or decreased risk or rate based on the IPR estimate itself.Females are overrepresented in head injuries, but underrepresented in nonhead injuries, relative to males, creating a 2-fold IPR. However, this does not necessarily mean that the true injury rate ratio would also be elevated. Based on USA Hockey registration estimates,21 females accounted for about 13% (59 506/465 975) of registered hockey players in the 2008–2009 season. Thus, if the 2008–2009 season was typical of female participation in the sport over the 17-year time period of the Deits et al1 study (which it probably is not; see below), and if playing time (minutes on the ice) and other types of exposure did not vary by sex, the true rate ratio would be about 1 (ie, approximately the same incidence in females and males). This is because the estimated rate of head injury in females (3942 injuries / [17 years × 59 506 athletes], if we used an athlete-years analysis) would be very similar to the estimated rate of head injury in males (25 318 injuries / [17 years × 465 975 athletes]).A rate ratio of 1 (no difference in the rate) is vastly different from the IPR observed by Diets et al1 of 2.2 (2-fold greater in females), simply because the IPR draws from only one part of the equation—the injured athletes—and does not use data on the playing population at risk (which includes the uninjured).In fact, the Deits et al1 study covers a long time period (1990–2006) and, for much of that time, female participation in hockey was much lower than it is today. This suggests that the true injury rate ratio very probably is elevated above 1. Thus, the authors are correct in calling attention to an excess proportion of head injuries in female hockey players seen in EDs.Conclusions from hospital-based ED surveillance data, as with NEISS, are limited without access to data on the source population (in this instance, the general population of ice hockey players). Focusing only on the injured athletes can provide valuable information regarding severity of injury for those who went to the ED, but, without information about uninjured athletes, injury risk factors cannot be properly identified and evaluated.In past published analyses, ED injury data were presented appropriately as a description of injury patterns without implying increased or decreased risk or rate based on specific characteristics, such as the injury mechanism, age, sex, or race. A dearth of descriptive papers on sports injury has existed for far too long, and this research group is to be congratulated for their impressive work in publishing informative descriptive papers from data sources such as NEISS.In the case of such surveillance studies, it may be appropriate to use ratio measures such as a PMR as long as such measures are interpreted appropriately. However, the use of such measures when information about a population at risk is available is not warranted and can be easily confused as rate ratios or risk ratios. It is important to bear in mind that the IPR is not the same as the rate or risk ratio and should be interpreted with caution.

The purpose of this study was to determine if implementation of a Pediatric Emergency Care Applied Research Network (PECARN)-based Closed Head Injury Assessment Tool could safely decrease computed tomography (CT) use for pediatric head injury evaluation at a nonpediatric community emergency department (ED). A quality improvement project was initiated at a nonpediatric community ED to implement an institution-specific, PECARN-based Pediatric Closed Head Injury Assessment Tool. Baseline head CT use at the participating ED was determined for children with closed head injury through retrospective chart review from March 2014 through November 2015. Head injury patients were identified using International Classification of Disease (ICD)-9 codes for head injury, unspecified (959.01) and concussion with and without loss of consciousness (850-850.9) until October 2015, after which ICD-9 was no longer used. To identify eligible patients after October 2015, lists of all pediatric patients evaluated at the participating ED were reviewed, and patients were included in the analysis if they had a physician-assigned discharge diagnosis of head injury or concussion. Exclusion criteria were age ≥ 18 years, penetrating head trauma, history of brain tumor, ventriculoperitoneal shunt, bleeding disorder, or presentation>24 hours postinjury. Medical history, injury mechanism, symptoms, head CT use, and disposition were recorded. Implementation of the Pediatric Closed Head Injury Assessment Tool was achieved through provider education sessions beginning in December 2015 and ending in August 2016. Head CT use was monitored for 12 months postimplementation, from September 2016 through August 2017. Patients were classified into low, intermediate, or high risk for clinically important traumatic brain injury (ciTBI) by chart review. ED length of stay (LOS), disposition, and ED returns within 72 hours were recorded. Categorical variables were compared using chi-square test or Fisher's exact test, and continuous variables, using Kruskal-Wallis test. A total of 252 children with closed head injury were evaluated preimplementation (March 2014 through November 2015), 132 children were evaluated during implementation (December 2015 through August 2016), and 172 children were evaluated postimplementation (September 2016 through August 2017). Overall CT use decreased from 37.7% (95% confidence interval [CI]= 31.7-43.7) preimplementation to 16.9% (95% CI= 11.3-22.5) postimplementation (p<0.001). Only 1% (95% CI= 0%-2.9%) of low-risk patients received a head CT postimplementation compared to 22.6% (95% CI= 16.1%-29.1%) preimplementation (p<0.001). CT use among patients ≥ 24 months decreased from 42.9% (95% CI= 36.5%-49.6%) to 19.6% (95% CI= 13.1%-26.1%; p<0.001) and remained low and unchanged for patients<24 months. Transfers to a pediatric trauma center and ED returns within 72 hours were unchanged, while median ED LOS improved from 1.5 to 1.3 hours (p=0.03). There were no missed ciTBIs after implementation of the guideline. Implementation of the PECARN-based Pediatric Closed Head Injury Assessment Tool reduced head CT use in a nonpediatric ED. The greatest impact was seen among children aged ≥ 24 months at very low risk for ciTBI.