A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings

Abstract

Objective To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings.Study design This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models.Results Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%/81% vs 78%/73%, P = .01), and potential cases of missed abusive head trauma (40%/21% vs 29%/32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%/7% vs 11%/13%, P = .22).Conclusions PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings.

Evidence for significant misdiagnosis of abusive head trauma in pediBIRN data

“…However, some data is publicly available from tables in the published articles, Hymel et al, 2022 [ 9 ] (Hymel22 hereafter) and Boos et al, 2022 [ 10 ] (Boos22 hereafter). Further, full data for 420 [ 11 ] of the 973 cases were released with an earlier publication [ 12 ]. These 420 cases come from 8 academic medical centers.…”

Data‐driven evidence shows truthful caregiver histories and significant overdiagnosis of abusive head trauma

“…The data consist of 420 infants made available with a publication 9 of the Pediatric Brain Injury Research Network (PediBIRN) (https://www.pedibirn.com/home.php). PediBIRN is a US collaboration between members of various university‐affiliated medical centers who provide data with the aim of creating a clinical decision rule for evaluating AHT.…”

What Will it Take to Achieve Routine Screening for Abuse?

“…After they derived a clinical decision rule with relatively high sensitivity for abuse, they also distributed badge cards, implemented initial and monthly trainings, individually directed clinicians to assess abuse risk using a dedicated website, and used progress reports and in-person sessions to address any barriers to implementation. 5 Yet despite all that, the authors estimate that 5 abused children in their cohort were still missed for lack of testing.…”

“…The authors in the current study in this volume of The Journal highlight the health promotion needs of justice-involved youth coming to an emergency department (ED). 5 Justiceinvolved youth reported higher rates of substance use, violence, and sexually risky behaviors. These youth also had higher rates of school suspension/expulsions, which had the strongest association with a youth being involved with the justice system.…”

“…In this volume of The Journal, Hymel et al share the result of their Herculean effort to improve abuse evaluations in young children admitted to intensive care units for traumatic brain injuries. 5 Although their intensive approach seems to have improved testing moderately, nearly 1 in 5 infants at high risk still went incompletely evaluated. nonjudgmental approach, perhaps we can decrease the number of cases of missed abuse.…”