It's Time to Normalize Observation for Pediatric Minor Head Trauma.

Abstract

The 2009 PECARN minor head injury clinical decision rule (CDR) represented an important advance in pediatric emergency care.1 For over a decade, it has offered clinicians a proven evidence-based tool to thoughtfully guide neuroimaging for pediatric minor head trauma while dramatically reducing missed clinically important traumatic brain injuries. When appropriately applied it simultaneously limits harmful radiation exposures and better utilizes health care resources. Nonetheless, in spite of the PECARN CDR, neuroimaging of children for minor head trauma in the United States (as studied between the years 2007 and 2015) has not changed appreciably and remains at approximately 30%.2 In this month's issue of AEM, Singh et al.3 describe their experience, with pediatric minor head trauma and the use of a planned observation period prior to making a decision to CT them. This study is similar to a PECARN study published in 2011; this current study, however, was conducted by the PREDICT Collaborative, specifically in New Zealand and Australia, where the CT rates for pediatric minor head trauma are significantly lower than those in the United States (approximately 8%–10%).3, 4 Planned observation led to an 80% lower adjusted odds of CT use. These findings parallel those of the 2011 PECARN study where observed patients odds of CT use was reduced by nearly half.4 While there are clearly numerous factors contributing to the wide differences in CT rates between the United States and other nations, what is clear is the value of observation as an adjunct to medical decision making in minor head trauma. Management of patients in both the high- and the intermediate-risk groups in this study benefitted from planned observation. While all risk groups in the United States could benefit from more pointed clinical decision support tools, near-term research should focus on intermediate-risk groups where clinician comfort levels may vary in how they interpret symptoms. Decisions to perform a medical test, for better or for worse, are steeped in heuristics defined by experiences that may or may not be evidence based. If time can dull our impulses to CT children with minor head trauma, then quality initiatives should support the use of observation to modify current heuristic tendencies. By evaluating numerous patients who improve during their planned observation in the ED, clinicians could potentially learn to shift their medical judgments toward less interventional stances on neuroimaging. Over a decade has passed since the publication of the PECARN CDR and yet, in spite of sound evidence, we are not making significant progress in reducing overall numbers of CT scans for minor pediatric head injury. Studies, now from both PREDICT and PECARN, have demonstrated the effectiveness of planned observation as a means to trim CT rates. As far medical expenses go, observation time is relatively cheap relative to the costs of unnecessary imaging and cancer. If building planned observation time into the PECARN CDR potentiates the diffusion of the tool to a broader audience, we can begin to chip away at our country's unnecessarily high CT rate.