The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma
Background Management of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECA...
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Veröffentlicht in: | Academic emergency medicine 2020-09, Vol.27 (9), p.832-843 |
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creator | Singh, Sonia Hearps, Stephen J. C. Borland, Meredith L. Dalziel, Stuart R. Neutze, Jocelyn Donath, Susan Cheek, John A. Kochar, Amit Gilhotra, Yuri Phillips, Natalie Williams, Amanda Lyttle, Mark D. Bressan, Silvia Hoch, Jeffrey S. Oakley, Ed Holmes, James F. Kuppermann, Nathan Babl, Franz E. Cloutier, Robert |
description | Background
Management of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma.
Methods
This was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children < 18 years old, presenting within 24 hours of blunt head trauma, with Glasgow Coma Scale scores of 14 to 15. The planned observation cohort was defined by those with planned observation and no immediate plan for cranial CT. The comparison cohort included the rest of the patients who were either not observed or for whom a decision to obtain a cranial CT was made immediately after ED assessment. The outcome clinically important TBI (ciTBI) was defined as death due to head trauma, neurosurgery, intubation for > 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects.
Results
The cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI.
Conclusions
Even in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate‐ and higher‐risk groups for ciTBI. |
doi_str_mv | 10.1111/acem.13942 |
format | Article |
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Management of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma.
Methods
This was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children < 18 years old, presenting within 24 hours of blunt head trauma, with Glasgow Coma Scale scores of 14 to 15. The planned observation cohort was defined by those with planned observation and no immediate plan for cranial CT. The comparison cohort included the rest of the patients who were either not observed or for whom a decision to obtain a cranial CT was made immediately after ED assessment. The outcome clinically important TBI (ciTBI) was defined as death due to head trauma, neurosurgery, intubation for > 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects.
Results
The cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI.
Conclusions
Even in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate‐ and higher‐risk groups for ciTBI.</description><identifier>ISSN: 1069-6563</identifier><identifier>EISSN: 1553-2712</identifier><identifier>DOI: 10.1111/acem.13942</identifier><identifier>PMID: 32064711</identifier><language>eng</language><publisher>United States: Wiley Subscription Services, Inc</publisher><subject>Adolescent ; Australia ; Child ; Craniocerebral Trauma ; Emergency medical care ; Emergency Service, Hospital ; Generalized linear models ; Head injuries ; Head Injuries, Closed - diagnostic imaging ; Humans ; New Zealand ; Patients ; Pediatrics ; Prospective Studies ; Tomography, X-Ray Computed ; Trauma ; Traumatic brain injury</subject><ispartof>Academic emergency medicine, 2020-09, Vol.27 (9), p.832-843</ispartof><rights>2020 by the Society for Academic Emergency Medicine</rights><rights>2020 by the Society for Academic Emergency Medicine.</rights><rights>Copyright © 2020 Society for Academic Emergency Medicine</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3932-c733b0fff6f2ddcb33e379825d13fb2f0ecb4efb18684090fd1bac574b9911233</citedby><cites>FETCH-LOGICAL-c3932-c733b0fff6f2ddcb33e379825d13fb2f0ecb4efb18684090fd1bac574b9911233</cites><orcidid>0000-0002-3615-3821 ; 0000-0002-7854-4943 ; 0000-0003-2430-0262 ; 0000-0002-1107-2187 ; 0000-0002-3712-6200 ; 0000-0002-4880-4281 ; 0000-0002-7616-5712</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1111%2Facem.13942$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1111%2Facem.13942$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>314,780,784,1417,1433,27924,27925,45574,45575,46409,46833</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/32064711$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><contributor>Cloutier, Robert</contributor><creatorcontrib>Singh, Sonia</creatorcontrib><creatorcontrib>Hearps, Stephen J. C.</creatorcontrib><creatorcontrib>Borland, Meredith L.</creatorcontrib><creatorcontrib>Dalziel, Stuart R.</creatorcontrib><creatorcontrib>Neutze, Jocelyn</creatorcontrib><creatorcontrib>Donath, Susan</creatorcontrib><creatorcontrib>Cheek, John A.</creatorcontrib><creatorcontrib>Kochar, Amit</creatorcontrib><creatorcontrib>Gilhotra, Yuri</creatorcontrib><creatorcontrib>Phillips, Natalie</creatorcontrib><creatorcontrib>Williams, Amanda</creatorcontrib><creatorcontrib>Lyttle, Mark D.</creatorcontrib><creatorcontrib>Bressan, Silvia</creatorcontrib><creatorcontrib>Hoch, Jeffrey S.</creatorcontrib><creatorcontrib>Oakley, Ed</creatorcontrib><creatorcontrib>Holmes, James F.</creatorcontrib><creatorcontrib>Kuppermann, Nathan</creatorcontrib><creatorcontrib>Babl, Franz E.</creatorcontrib><creatorcontrib>Cloutier, Robert</creatorcontrib><title>The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma</title><title>Academic emergency medicine</title><addtitle>Acad Emerg Med</addtitle><description>Background
Management of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma.
Methods
This was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children < 18 years old, presenting within 24 hours of blunt head trauma, with Glasgow Coma Scale scores of 14 to 15. The planned observation cohort was defined by those with planned observation and no immediate plan for cranial CT. The comparison cohort included the rest of the patients who were either not observed or for whom a decision to obtain a cranial CT was made immediately after ED assessment. The outcome clinically important TBI (ciTBI) was defined as death due to head trauma, neurosurgery, intubation for > 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects.
Results
The cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI.
Conclusions
Even in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate‐ and higher‐risk groups for ciTBI.</description><subject>Adolescent</subject><subject>Australia</subject><subject>Child</subject><subject>Craniocerebral Trauma</subject><subject>Emergency medical care</subject><subject>Emergency Service, Hospital</subject><subject>Generalized linear models</subject><subject>Head injuries</subject><subject>Head Injuries, Closed - diagnostic imaging</subject><subject>Humans</subject><subject>New Zealand</subject><subject>Patients</subject><subject>Pediatrics</subject><subject>Prospective Studies</subject><subject>Tomography, X-Ray Computed</subject><subject>Trauma</subject><subject>Traumatic brain injury</subject><issn>1069-6563</issn><issn>1553-2712</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kU1r3DAQhkVpaD7aS39AEfRSCk70YUnrYzCbppCQUDbkKCR51FWwra1kN-y_jzab9pBDhoGR4OFhmBehz5Sc0lJnxsFwSnlTs3foiArBK6Yoe1_eRDaVFJIfouOcHwghQjXqAzrkjMhaUXqEwmoNeOk9uAlHj2_NFGCc8I3NkP6WTxxx6TaZMZget3HYzBN0eBWH-DuZzXqLf5kJMg4FWoe-SzDi-zCt8XUYY8KXYAqczDyYj-jAmz7Dp5d5gu4ulqv2srq6-fGzPb-qHG84q5zi3BLvvfSs65zlHLhqFkx0lHvLPAFna_CWLuSiJg3xHbXGCVXbpqGUcX6Cvu29mxT_zJAnPYTsoO_NCHHOmnEhJRFioQr69RX6EOc0lu00q2tGFZV8J_y-p1yKOSfwepPCYNJWU6J3AehdAPo5gAJ_eVHOdoDuP_rv4gWge-Ax9LB9Q6XP2-X1XvoEsvGPaw</recordid><startdate>202009</startdate><enddate>202009</enddate><creator>Singh, Sonia</creator><creator>Hearps, Stephen J. C.</creator><creator>Borland, Meredith L.</creator><creator>Dalziel, Stuart R.</creator><creator>Neutze, Jocelyn</creator><creator>Donath, Susan</creator><creator>Cheek, John A.</creator><creator>Kochar, Amit</creator><creator>Gilhotra, Yuri</creator><creator>Phillips, Natalie</creator><creator>Williams, Amanda</creator><creator>Lyttle, Mark D.</creator><creator>Bressan, Silvia</creator><creator>Hoch, Jeffrey S.</creator><creator>Oakley, Ed</creator><creator>Holmes, James F.</creator><creator>Kuppermann, Nathan</creator><creator>Babl, Franz E.</creator><creator>Cloutier, Robert</creator><general>Wiley Subscription Services, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>K9.</scope><scope>NAPCQ</scope><scope>U9A</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-3615-3821</orcidid><orcidid>https://orcid.org/0000-0002-7854-4943</orcidid><orcidid>https://orcid.org/0000-0003-2430-0262</orcidid><orcidid>https://orcid.org/0000-0002-1107-2187</orcidid><orcidid>https://orcid.org/0000-0002-3712-6200</orcidid><orcidid>https://orcid.org/0000-0002-4880-4281</orcidid><orcidid>https://orcid.org/0000-0002-7616-5712</orcidid></search><sort><creationdate>202009</creationdate><title>The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma</title><author>Singh, Sonia ; Hearps, Stephen J. C. ; Borland, Meredith L. ; Dalziel, Stuart R. ; Neutze, Jocelyn ; Donath, Susan ; Cheek, John A. ; Kochar, Amit ; Gilhotra, Yuri ; Phillips, Natalie ; Williams, Amanda ; Lyttle, Mark D. ; Bressan, Silvia ; Hoch, Jeffrey S. ; Oakley, Ed ; Holmes, James F. ; Kuppermann, Nathan ; Babl, Franz E. ; Cloutier, Robert</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3932-c733b0fff6f2ddcb33e379825d13fb2f0ecb4efb18684090fd1bac574b9911233</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Adolescent</topic><topic>Australia</topic><topic>Child</topic><topic>Craniocerebral Trauma</topic><topic>Emergency medical care</topic><topic>Emergency Service, Hospital</topic><topic>Generalized linear models</topic><topic>Head injuries</topic><topic>Head Injuries, Closed - diagnostic imaging</topic><topic>Humans</topic><topic>New Zealand</topic><topic>Patients</topic><topic>Pediatrics</topic><topic>Prospective Studies</topic><topic>Tomography, X-Ray Computed</topic><topic>Trauma</topic><topic>Traumatic brain injury</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Singh, Sonia</creatorcontrib><creatorcontrib>Hearps, Stephen J. C.</creatorcontrib><creatorcontrib>Borland, Meredith L.</creatorcontrib><creatorcontrib>Dalziel, Stuart R.</creatorcontrib><creatorcontrib>Neutze, Jocelyn</creatorcontrib><creatorcontrib>Donath, Susan</creatorcontrib><creatorcontrib>Cheek, John A.</creatorcontrib><creatorcontrib>Kochar, Amit</creatorcontrib><creatorcontrib>Gilhotra, Yuri</creatorcontrib><creatorcontrib>Phillips, Natalie</creatorcontrib><creatorcontrib>Williams, Amanda</creatorcontrib><creatorcontrib>Lyttle, Mark D.</creatorcontrib><creatorcontrib>Bressan, Silvia</creatorcontrib><creatorcontrib>Hoch, Jeffrey S.</creatorcontrib><creatorcontrib>Oakley, Ed</creatorcontrib><creatorcontrib>Holmes, James F.</creatorcontrib><creatorcontrib>Kuppermann, Nathan</creatorcontrib><creatorcontrib>Babl, Franz E.</creatorcontrib><creatorcontrib>Cloutier, Robert</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Premium</collection><collection>MEDLINE - Academic</collection><jtitle>Academic emergency medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Singh, Sonia</au><au>Hearps, Stephen J. C.</au><au>Borland, Meredith L.</au><au>Dalziel, Stuart R.</au><au>Neutze, Jocelyn</au><au>Donath, Susan</au><au>Cheek, John A.</au><au>Kochar, Amit</au><au>Gilhotra, Yuri</au><au>Phillips, Natalie</au><au>Williams, Amanda</au><au>Lyttle, Mark D.</au><au>Bressan, Silvia</au><au>Hoch, Jeffrey S.</au><au>Oakley, Ed</au><au>Holmes, James F.</au><au>Kuppermann, Nathan</au><au>Babl, Franz E.</au><au>Cloutier, Robert</au><au>Cloutier, Robert</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma</atitle><jtitle>Academic emergency medicine</jtitle><addtitle>Acad Emerg Med</addtitle><date>2020-09</date><risdate>2020</risdate><volume>27</volume><issue>9</issue><spage>832</spage><epage>843</epage><pages>832-843</pages><issn>1069-6563</issn><eissn>1553-2712</eissn><abstract>Background
Management of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma.
Methods
This was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children < 18 years old, presenting within 24 hours of blunt head trauma, with Glasgow Coma Scale scores of 14 to 15. The planned observation cohort was defined by those with planned observation and no immediate plan for cranial CT. The comparison cohort included the rest of the patients who were either not observed or for whom a decision to obtain a cranial CT was made immediately after ED assessment. The outcome clinically important TBI (ciTBI) was defined as death due to head trauma, neurosurgery, intubation for > 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects.
Results
The cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI.
Conclusions
Even in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate‐ and higher‐risk groups for ciTBI.</abstract><cop>United States</cop><pub>Wiley Subscription Services, Inc</pub><pmid>32064711</pmid><doi>10.1111/acem.13942</doi><tpages>12</tpages><orcidid>https://orcid.org/0000-0002-3615-3821</orcidid><orcidid>https://orcid.org/0000-0002-7854-4943</orcidid><orcidid>https://orcid.org/0000-0003-2430-0262</orcidid><orcidid>https://orcid.org/0000-0002-1107-2187</orcidid><orcidid>https://orcid.org/0000-0002-3712-6200</orcidid><orcidid>https://orcid.org/0000-0002-4880-4281</orcidid><orcidid>https://orcid.org/0000-0002-7616-5712</orcidid><oa>free_for_read</oa></addata></record> |
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subjects | Adolescent Australia Child Craniocerebral Trauma Emergency medical care Emergency Service, Hospital Generalized linear models Head injuries Head Injuries, Closed - diagnostic imaging Humans New Zealand Patients Pediatrics Prospective Studies Tomography, X-Ray Computed Trauma Traumatic brain injury |
title | The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma |
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