Objectives: Of the currently published clinical decision rules for the management of minor head injury (MHI) in children, the Pediatric Emergency Care Applied Research Network (PECARN) rule, derived and validated in a large multicenter prospective study cohort, with high methodologic standards, appears to be the best clinical decision rule to accurately identify children at very low risk of clinically important traumatic brain injuries (ciTBI) in the pediatric emergency department (PED). This study describes the implementation of an adapted version of the PECARN rule in a tertiary care academic PED in Italy and evaluates implementation success, in terms of medical staff adherence and satisfaction, as well as its effects on clinical practice. Methods:The adapted PECARN decision rule algorithms for children (one for those younger than 2 years and one for those older than 2 years) were actively implemented in the PED of Padova, Italy, for a 6-month testing period. Adherence and satisfaction of medical staff to the new rule were calculated. Data from 356 visits for MHI during PECARN rule implementation and those of 288 patients attending the PED for MHI in the previous 6 months were compared for changes in computed tomography (CT) scan rate, ciTBI rate (defined as death, neurosurgery, intubation for longer than 24 hours, or hospital admission at least for two nights associated with TBI) and return visits for symptoms or signs potentially related to MHI. The safety and efficacy of the adapted PECARN rule in clinical practice were also calculated.Results: Adherence to the adapted PECARN rule was 93.5%. The percentage of medical staff satisfied with the new rule, in terms of usefulness and ease of use for rapid decision-making, was significantly higher (96% vs. 51%, p < 0.0001) compared to the previous, more complex, internal guideline. CT scan was performed in 30 patients (8.4%, 95% confidence interval [CI] = 6% to 11.8%) in the implementation period versus 21 patients (7.3%, 95% CI = 4.8% to 10.9%) before implementation. A ciTBI occurred in three children (0.8%, 95% CI = 0.3 to 2.5) during the implementation period and in two children (0.7%, 95% CI = 0.2 to 2.5) in the prior 6 months. There were five return visits (1.4%) postimplementation and seven (2.4%) before implementation (p = 0.506). The safety of use of the adapted PECARN rule in clinical practice was 100% (95% CI = 36.8 to 100; three of three patients with ciTBI who received CT scan at first evaluation), while efficacy was 92.3% (95% CI = 89 to 95; 326 of 353 patients without ciTBI who did not receive a CT scan). Conclusions:The adapted PECARN rule was successfully implemented in an Italian tertiary care academic PED, achieving high adherence and satisfaction of medical staff. Its use determined a low CT scan rate that was unchanged compared to previous clinical practice and showed an optimal safety and high efficacy profile. Strict monitoring is mandatory to evaluate the long-lasting benefit in patient care and ⁄ or resource utilization.

Overall bacteremia rate is currently <0.5% in well-appearing children aged 3-36 months with FWS attending the PED in areas with PCV-7 widespread vaccination and is sufficiently low to preclude laboratory testing in favour of close follow-up. Further research is needed to evaluate a more conservative approach in infants 2-3 months of age.

The successful treatment with IVIG described in this report suggests that, where appropriate antibiotic and supportive therapy fails to improve the clinical course of severe MPAM, IVIG treatment is worth considering.

The PECARN intermediate-risk predictors did not play a major role in the decision to perform a CT scan. The only factor significantly associated with the decision to perform a CT scan was when the patient was younger than 3 months of age.

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