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The effect of patient observation on cranial computed tomography rates in children with minor head trauma

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.

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Authors

Sonia Singh

Stephen J.C. Hearps

Meredith L. Borland

Stuart R. Dalziel

Jocelyn Neutze

Susan Donath

John A. Cheek

Amit Kochar

Yuri Gilhotra

Natalie Phillips

Amanda Williams

Silvia Bressan

Jeffrey S. Hoch

Ed Oakley

James F. Holmes

Nathan Kuppermann

Franz E. Babl



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.

Citation

Singh, S., Hearps, S. J., Borland, M. L., Dalziel, S. R., Neutze, J., Donath, S., …Babl, F. E. (2020). The effect of patient observation on cranial computed tomography rates in children with minor head trauma. Academic Emergency Medicine, 27(9), 832-843. https://doi.org/10.1111/acem.13942

Journal Article Type Article
Acceptance Date Feb 14, 2020
Online Publication Date Mar 26, 2020
Publication Date Sep 1, 2020
Deposit Date Jul 21, 2020
Publicly Available Date Mar 28, 2024
Journal Academic Emergency Medicine
Print ISSN 1069-6563
Electronic ISSN 1553-2712
Publisher Wiley
Peer Reviewed Peer Reviewed
Volume 27
Issue 9
Pages 832-843
DOI https://doi.org/10.1111/acem.13942
Keywords Emergency Medicine; General Medicine
Public URL https://uwe-repository.worktribe.com/output/6137198

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