Nurse and Physician Agreement in the Assessment of Minor Blunt Head Trauma

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Effective implementation of Pediatric Emergency Care Applied Research Network head trauma rules depends on their early application. As the registered nurse (RN) is often the first to evaluate children with blunt head trauma, initial RN assessments will be an important component of this strategy. WHAT THIS STUDY ADDS:We demonstrated fair to moderate agreement between RN and physician providers in the application of the Pediatric Emergency Care Applied Research Network head trauma rules. Effective implementation strategies may require physician verification of RN predictor assessments before computed tomography decision-making. abstract OBJECTIVE: The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) clinical prediction rules identify children with minor blunt head trauma who are at low risk for clinically important traumatic brain injuries. We measured the agreement between the registered nurse (RN) and physician (MD) assessments. METHODS:We performed a cross-sectional study of all children ,18 years of age with minor blunt head trauma who presented to a single emergency department. RNs and MDs independently assessed each child and recorded age-based PECARN predictors. As symptoms can change over time, we included cases only when both evaluations were completed within 60 minutes. We used the k statistic to measure RN-MD agreement, with the main analysis focusing on the overall PECARN rule agreement. RESULTS:Of the 1624 eligible children, 1191 (73%) had evaluations completed by both RN and ED providers, of which 437 (37%) were in children ,2 years of age. The median time between completions of the provider forms was 12 minutes (interquartile range 4-25 minutes). The overall agreement between the RN and MD was higher for the older children (k 0.55, 95% confidence interval 0.49-0.61 for children 2-18 years versus k 0.32, 95% confidence interval 0.23-0.41 for children ,2 years). CONCLUSIONS:The overall agreement between RN and MD for the PECARN TBI prediction rules was moderate for older children and fair for younger children. Initial RN assessments should be verified by the MD before clinical application, especially for the youngest children. Pediatrics 2013;132:e689-e694

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