Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource emergency department: a retrospective cohort study

Abstract

Background Managing children with minor head trauma remains challenging for physicians who evaluate for the need for computed tomography (CT) imaging for clinically important traumatic brain injury (ciTBI) identification. The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules were adopted in our pediatric emergency department (PED) in December 2013 to identify children at low risk for ciTBI. This study aimed to evaluate this implementation’s impact on CT rates and clinical outcomes. Methods Retrospective cohort study on pediatric patients with head trauma presenting to the PED of the American University of Beirut Medical Center in Lebanon. Participants were divided into pre- (December 2012 to December 2013) and post-PECARN (January 2014 to December 2016) groups. Patients were further divided into < 2 and ≥ 2 years and stratified into groups of low, intermediate and high risk for ciTBI. Bivariate analysis was conducted to determine differences between both groups. Results We included 1362 children of which 425 (31.2%) presented pre- and 937 (68.8%) presented post-PECARN rules implementation with 1090 (80.0%) of low, 214 (15.7%) of intermediate and 58 (4.3%) of high risk for ciTBI. CTs were ordered on 92 (21.6%) pre- versus 174 (18.6%) patients post-PECARN (p = 0.18). Among patients < 2 years, CT rates significantly decreased from 25.2% (34/135) to 16.5% (51/309) post-PECARN (p = 0.03), and dropped in all risk groups but only significantly for low risk patients from 20.7% (24/116) to 11.4% (30/264) (p = 0.02). There was no significant decrease in CT rates in patients ≥2 years (20% pre (58/290) vs 19.6% post (123/628), p = 0.88). There was no increase in bounce back numbers, nor in admission rates or positive CT findings among bounce backs. Conclusions PECARN rules implementation did not significantly change the overall CT scan rate but reduced the CT scan rate in patients aged < 2 years at low risk of ciTBI. The implementation did not increase the number of missed ciTBI.

It's a Hard Knock Life

“…10 Pediatric Head Injury and Trauma Algorithm has a 96.3% sensitivity for detecting clinically important TBI in pediatric populations, and its use reduces excessive CT scan use in younger patients. [10][11][12] Other available guidelines are not as comprehensive and tailor to sports-related injuries or adults. 13,14 Educating patients on the expected recovery timeline reduces unnecessary symptom reporting while promoting awareness of symptoms that warrant further evaluation.…”

“…They provide recommendations for assessing level of consciousness, mechanism of injury, indications for CT scan of the head utilizing GCS and the Pediatric Emergency Care Research Network (PECARN) Head Injury and Trauma Algorithm, and preparing personalized discharge instructions 10 . Pediatric Head Injury and Trauma Algorithm has a 96.3% sensitivity for detecting clinically important TBI in pediatric populations, and its use reduces excessive CT scan use in younger patients 10–12 . Other available guidelines are not as comprehensive and tailor to sports-related injuries or adults 13,14 .…”

Misdiagnosis of Pediatric Concussions in the Emergency Department

“…This was a planned secondary analysis of a retrospective chart review done at the American University of Beirut Medical Center, a Lebanese tertiary care center, that aimed to assess the impact of the implementation of the Pediatric Emergency Care Applied Research Network (PECARN) head trauma rules on the rates of computed tomography (CT) scans in pediatric patients presenting within 24 hours of a minor head trauma to the PED. 14 Ethical approval was obtained from the institutional review board of the American University of Beirut Medical Center under the protocol number BIO-2017-0452.…”

Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France

“…Teleradiology uses interoperable information and technology tools that enable rapid collection of large multicentric data sets, especially when structured requests and reports are made . Since the publication of the PECARN guidelines in 2009, clinical investigations have emphasized their sensitivity, safety, and validity, with a reduction of HCT rate in patients younger than 2 years without increasing the number of missed clinically important TBIs . The guidelines have also been acknowledged for their usefulness and ease of use for rapid decision-making by the medical staff, although their specificity may be lower than the specificity from clinical suspicion .…”

“… 14 Since the publication of the PECARN guidelines in 2009, 4 clinical investigations have emphasized their sensitivity, safety, and validity, 15 , 16 with a reduction of HCT rate in patients younger than 2 years without increasing the number of missed clinically important TBIs. 17 The guidelines have also been acknowledged for their usefulness and ease of use for rapid decision-making by the medical staff, 15 , 18 although their specificity may be lower than the specificity from clinical suspicion. 15 However, data from the radiologic perspective (ie, once HCT has been performed) are lacking.…”