Care Applied Research Network Rule Research Articles

Performance of Febrile Infant Algorithms by Duration of Fever.

To analyze the performance of commonly used blood tests in febrile infants ≤90 days of age to identify patients at low risk for invasive bacterial infection (bacterial pathogen in blood or cerebrospinal fluid) by duration of fever. We conducted a secondary analysis of a prospective single-center registry that includes all consecutive infants ≤90 days of age with fever without a source evaluated at 1 pediatric emergency department between 2008 and 2021. We defined 3 groups based on caregiver-reported hours of fever (<2, 2-12, and ≥12) and analyzed the performance of the biomarkers and Pediatric Emergency Care Applied Research Network, American Academy of Pediatrics, and Step-by-Step clinical decision rules. We included 2411 infants; 76 (3.0%) were diagnosed with an invasive bacterial infection. The median duration of fever was 4 (interquartile range, 2-12) hours, with 633 (26.3%) patients with fever of <2 hours. The area under the curve was significantly lower in patients with <2 hours for absolute neutrophil count (0.562 vs 0.609 and 0.728) and C-reactive protein (0.568 vs 0.760 and 0.812), but not for procalcitonin (0.749 vs 0.780 and 0.773). Among well-appearing infants older than 21 days and negative urine dipstick with <2 hours of fever, procalcitonin ≥0.14 ng/mL showed a better sensitivity (100% with specificity 53.8%) than that of the combination of biomarkers of Step-by-Step (50.0% and 82.2%), and of the American Academy of Pediatrics and Pediatric Emergency Care Applied Research Network rules (83.3% and 58.3%), respectively. The performance of blood biomarkers, except for procalcitonin, in febrile young infants is lower in fever of very short duration, decreasing the accuracy of the clinical decision rules.

Risk stratification of intermediate-risk children with minor head injury: a secondary publication translated into Korean

The Pediatric Emergency Care Applied Research Network rule helps emergency physicians identify very low-risk children with minor head injury who can forgo head computed tomography. This rule contributes to reducing lifetime risk of radiation-induced cancers while minimizing missing clinically important traumatic brain injury. However, in intermediate-risk children, decisions on whether to perform computed tomography remain at the emergency physicians' discretion. To reduce this gray zone, this review summarizes evidence for risk stratification of intermediate-risk children with minor head injury.

Computed Tomography Use in Children With Minor Head Trauma Presenting to 21 Community Emergency Departments Within an Integrated Health-Care System.

Decreasing unnecessary cranial computed tomography (CT) use in pediatric head trauma patients remains important for emergency departments (EDs) across the US. Our study evaluated CT use in children with minor blunt head trauma in 21 community EDs within an integrated health-care system. We studied all children younger than 18 years old presenting to 21 community EDs between 2016 through 2018 with acute minor blunt head trauma, defined by an algorithm of ED chief complaints and diagnoses. We excluded patients with traumatic brain injuries diagnosed in the prior year, a CT within 24 hours prior to the ED visit, or an ED Glasgow Coma Scale score of less than 14. Among 39,792 pediatric minor head trauma ED visits, the aggregate CT use proportion across all EDs was 12.9% [95% confidence interval (CI), 12.6-13.3%; facility-level range, 5.4-21.6%]. The 7 facilities that had previously received a clinical decision support system intervention implementing the Pediatric Emergency Care Applied Research Network rules during 2013 through 2014 had an aggregate mean CT ordering rate of 11.2% (95% CI, 10.7-11.7%; facility-level range, 5.4-14.3%) compared to 14.1% (95% CI, 13.6-14.5%; facility-level range, 7.3-21.6%) for the nonintervention facilities. CT use for children with minor blunt head trauma in the community EDs of an integrated health-care system was low and stable across facilities from 2016 through 2018. This may be indicative of the safe stewardship of resources in the system, including the absence of financial or medicolegal incentives to scan very low-risk patients as well the availability of resources for close patient follow-up.

Accuracy of Pediatric Emergency Care Applied Research Network Rules in Predicting Brain Injuries

Background and Objectives: Head trauma is one of the most important causes of emergency department (ED) visits and the leading cause of disability and mortality in children. The aim of this study was to evaluate the Pediatric Emergency Care Applied Research Network (PECARN) rules to predict brain injuries in pediatrics with head trauma. Materials and Methods: This descriptive–analytic study was performed on 250 pediatric patients with head trauma referred to Imam Reza Hospital in Tabriz City from August to September 2020. All patients were evaluated in the ED for the existing of any rules of the PECARN, then the results of the PECARN rules and brain computed tomography (CT) scan findings were compared in these patients. According to the PECARN rules, patients were classified into three categories, namely low, moderate, and high risk. For all three groups, if there is an indication of brain CT scan, it was performed and reported by an emergency medicine specialist. Results: The mean age of the patients was 88 months. In this study, 162 (64.8%), 42 (16.8%), and 46 (18.4%) patients were in the low-risk, moderate-risk, and high-risk groups, respectively. Death was occurred in 18 (12.8%) patients. Results showed a statistically significant association between positive CT findings and some variables, such as behavioral change, vomiting, severe headache, LOC over 5 s, confusion, palpable skull fracture, skull base fracture, and the severe mechanism of injury (P < 0.05). Furthermore, a statistically significant association was found between PECARN rules and CT findings (P < 0.001). Conclusions: According to the results of the present study, PECARN rules have a significant association with brain CT scan findings. Therefore, using these rules is recommended to reduce the number of brain CT scan requests for pediatric patients.

Identification of practically important traumatic brain injury using Pediatric Emergency Care Applied Research Network rule in children younger than 2 years with minor head trauma

Background:Minor head trauma is frequently presented to the pediatric emergency department. Despite the burden this injury poses on public health, evidence-based clinical guidelines on the assessment and management of pediatric minor head trauma remain unestablished, particularly in children below 2 years. We aimed to assess the diagnostic accuracy of a clinical decision rule (Pediatric Emergency Care Applied Research Network rule) and physician discretion in the recognition of practically important traumatic brain injury in children below 2 years of age presenting with minor head trauma to the emergency department.Methods:The medical records of children younger than 2 years presenting with head trauma to the emergency department were reviewed with Glasgow Coma Scale scores of 14–15. Practically important traumatic brain injury is a clinically essential traumatic brain injury including all cranial abnormalities (e.g. skull fracture) detected by computed tomography. All predictor variables of the Pediatric Emergency Care Applied Research Network rule and practically important traumatic brain injury outcomes were validated.Results:We enrolled and analyzed 433 children below 2 years. The most frequently observed mechanisms of injury in decreasing order were as follows: falls &gt; 90 cm, head struck by high-impact objects, slip down, and automobile traffic accident. Of 224 children, positive findings were observed in 35 and 144 had one or more predictors of Pediatric Emergency Care Applied Research Network rule. The sensitivity, specificity, and negative likelihood ratio of the Pediatric Emergency Care Applied Research Network rule for practically important traumatic brain injury were 94.3%, 41.3%, and 0.14, respectively.Conclusion:The Pediatric Emergency Care Applied Research Network rule would assist in clinical decision-making to appropriately detect potential head injuries in children below 2 years, thereby reducing unnecessary performance of computed tomography scan.

Impact of Pediatric Emergency Care Applied Research Network Rules on Admission, Cranial Computed Tomography and Skull X-ray Rates in a Central European Hospital.

Mild head injury is a common cause of pediatric emergency department visits. Cranial computed tomography (CCT) is the diagnostic standard, although it involves inherent radiation risks. Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules were developed to reduce the number of CCT scans. They provide a guideline for CCT use in mild head injuries, based on clinical parameters.Our study aims to evaluate the impact of PECARN rules on hospital admission and CCT rate in children with mild head injury. In this retrospective study, we investigated 729 children with mild head injury presenting in the pediatric emergency department between 2012 and 2016. We compared 2 groups, before and after implementation of PECARN criteria in clinical routine. Of 729 included patients (417 male; 5.6 ± 4.8 years;) 380 were seen prior to implementation of the PECARN rules, compared to 349 patients afterwards. Overall admissions to the ward decreased significantly from 83.9% (n = 319) to 71.3% (n = 249) (P < 0.001), a 31.3% reduction. Calculated from all pediatric admissions, the rate of patients with mild head injury fell from 6.0% to 4.3% (P < 0.001).We recorded a nonsignificant decrease in the CCT rate, from 14.7% to 13.2% (P = 0.555).No readmissions were recorded. Our results show a significant reduction in the rate of hospital admission following implementation of the PECARN rules in our hospital. Already low, the CCT rate did not change after implementation.The PECARN rules appear to be safe because no readmissions were recorded.

Risk Stratification of Intermediate-Risk Children With Minor Head Injury.

The Pediatric Emergency Care Applied Research Network rule helps emergency physicians identify very low-risk children with minor head injury who can forgo head computed tomography. This rule contributes to reduction in lifetime risk of radiation-induced cancers while minimizing missing clinically important traumatic brain injury. However, in intermediate-risk children, decisions on whether to perform computed tomography remain at the emergency physicians' discretion. To reduce this gray zone, this review summarizes evidence for risk stratification of intermediate-risk children with minor head injury.

Accuracy of Pediatric Emergency Care Applied Research Network Rules in Prediction of Clinically Important Head Injuries; A Systematic Review and Meta-Analysis

Objective: the present meta-analysis was designed to determine the value of Pediatric Emergency Care Applied Research Network (PECARN) rule in prediction of clinically important traumatic brain injury (ciTBI).Methods: Extensive search was conducted in the databases of Medline, Embase, Scopus, Web of Sciences, Cinahl up to the end of August 2017. The search records were screened and summarized by two independent reviewers, and eventually the findings were presented as summary of receiver operating characteristics (SROC), sensitivity, specificity and diagnostic odds ratio with 95% confidence interval (95% CI). Results:Data from 10 studies were included in this meta-analysis. Area under the curve (AUC) of SROC for PECARN model in prediction of ciTBI in children younger than 2 years old was 0.85 (95% CI: 0.82-0.88). Sensitivity, specificity and diagnostic odds ratio of this model were also calculated to be 0.98 (95% CI: 0.92-1.0), 0.56 (95% CI: 0.48-0.64) and 82.53 (95% CI: 16.23-419.63), respectively. AUC of SROC for this model in prediction of ciTBI in children aged 2-18 years old was also found to be 0.97 (95% CI: 0.95-0.98) with a sensitivity, specificity and diagnostic odds ratio of 0.98 (95% CI: 0.95-0.99), 0.60 (95% CI: 0.53-0.67) and 80.73 (95% CI: 30.59-213.05). Conclusion:The findings of this study are indicative of a high screening value for PECARN model in prediction of ciTBI and classification of patients. So it is recommended that the decision rule be used in routine practice for children referring with mild traumatic brain injuries.

Implications of Increased Weight Status for the Occurrence of Fall-Induced Intracranial Hemorrhage in Children Aged 4 Years or Younger.

The aim of this study was to investigate the association between increased weight status (IWS), a weight for age/sex at greater than the 95th percentile, and fall-induced intracranial hemorrhage (ICH) in children aged 4 years or younger. In 7072 children aged 4 years or younger with head injury who visited a tertiary care hospital emergency department in Korea from 2013 through 2015, the presence of fall-induced ICH was reviewed. The association between IWS and ICH was investigated by multivariable logistic regression. We retrospectively validated the Pediatric Emergency Care Applied Research Network rule alone and in combination with IWS for predicting ICH. Of 7072 children, 547 (7.7%) underwent computed tomography, of whom 451 (6.4%) were enrolled. Of these, 41 (9.1%; estimated event rate, 0.6%) had ICHs, and 26 (5.8%) had IWS. Increased weight status was more common in the children with ICH (P = 0.023). The association between IWS and ICH remained significant after adjustment (odds ratio, 5.24; 95% confidence interval [CI], 1.49-18.46; P = 0.010). The validation of the rule in combination with IWS showed no significant increases in a sensitivity (92.7% [95% CI, 80.1%-98.5%] to 95.7% [95% CI, 83.5%-99.4%]) and negative predictive value (98.2% [95% CI, 94.7%-99.4%] to 98.8% [95% CI, 95.4%-99.8%]). Increased weight status is associated with fall-induced ICH in children aged 4 years or younger. Information on weight status could be potentially helpful in predicting ICH in young children with fall-induced head injury.

Are Pediatric Emergency Care Applied Research Network Rules (PECARN) Sufficient for Computed Cranial Tomography Decision in Pediatric Patients with Mild Head Trauma?

Objective: In this study we aimed to investigate the ap­plicability of Pediatric Emergency Care Applied Research Network (PECARN) rules for decision to perform computed cranial tomography (CCT) in pediatric patients with minor head trauma (MHT). Methods: 317 pediatric patients who underwent CCT for mild head trauma were evaluated retrospectively. The pa­tients were classified in two groups according to PECARN rules: below 2 years old, above 2 years old and then, these patient groups were classified into two subgroups accord­ing to the compatibility with PECARN rules. The patients re­quiring CCT according to PECARN rules were classified as PECARN compatible (PECARN +), the patients who under­went CCT without the need of CCT according to PECARN were classified as PECARN incompatible (PECARN -). Results: Approximately 20% patients in PECARN (+) group had abnormalities leading to prolonged hospitalization and only 3.8% patients of PECARN (-) group had abnormali­ties. However, none of PECARN (-) group patients required follow-up longer than 48 hours in the hospital. The most common symptoms necessitate CCT in PECARN (+) group were scalp swelling, scalp hematoma and vomiting. In PE­CARN (-) group the most common signs were cuts in the scalp and dermal abrasions. The incidence of fracture in CCT was significantly higher in PECARN (+) group. Conclusion: Because CCT poses serious radiation expo­sure, neurological examination and clinical follow-up should be preferred in the evaluation of children with MHT. In con­clusion, PECARN rules were sufficient for CCT decision in pediatric patients with MHT.

Are Pediatric Emergency Care Applied Research Network Rules (PECARN) Sufficient for Computed Cranial Tomography Decision in Pediatric Patients with Mild Head Trauma?

Objective: In this study we aimed to investigate the applicability of Pediatric Emergency Care Applied Research Network (PECARN) rules for decision to perform computed cranial tomography (CCT) in pediatric patients with minor head trauma (MHT). Methods: 317 pediatric patients who underwent CCT for mild head trauma were evaluated retrospectively. The patients were classified in two groups according to PECARN rules: below 2 years old, above 2 years old and then, these patient groups were classified into two subgroups according to the compatibility with PECARN rules. The patients requiring CCT according to PECARN rules were classified as PECARN compatible (PECARN +), the patients who underwent CCT without the need of CCT according to PECARN were classified as PECARN incompatible (PECARN -). Results: Approximately 20% patients in PECARN (+) group had abnormalities leading to prolonged hospitalization and only 3.8% patients of PECARN (-) group had abnormalities. However, none of PECARN (-) group patients required follow-up longer than 48 hours in the hospital. The most common symptoms necessitate CCT in PECARN (+) group were scalp swelling, scalp hematoma and vomiting. In PECARN (-) group the most common signs were cuts in the scalp and dermal abrasions. The incidence of fracture in CCT was significantly higher in PECARN (+) group. Conclusion: Because CCT poses serious radiation exposure, neurological examination and clinical follow-up should be preferred in the evaluation of children with MHT. In conclusion, PECARN rules were sufficient for CCT decision in pediatric patients with MHT. J Clin Exp Invest 2016; 7 (1): 35-40 Key words: Minor head trauma, pediatric trauma, computed cranial tomography