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4th July 2022
The introduction of an alert system to provide clinical decision support in emergency departments on whether to perform a computed tomography (CT) scan on children with head trauma, has resulted in more appropriate use of such scans. This was the main conclusion of a study by a team from Utah, US.
Traumatic brain injury (TBI) is an important public health problem and data produced by the CDC in the US reveal how there are approximately half a million emergency department visits for TBI every year by children aged 0 to 14 years. An important concern for clinicians is to identify whether a child has a clinically important TBI and a CT scan represents an excellent imaging modality for the identification of an intracranial injury. However, not all children with a head injury require a CT scan and clinical decision rules can help standardise and improve the use of CT for children with minor head injury.
For the present study, the US wanted to explore whether the introduction of an alert system at the point when clinicians were considering the use of a CT scan, could provide enhanced support and therefore make more appropriate use of these scans. The alert system made use of the Pediatric Emergency Care Applied Research Network (PECARN) head trauma clinical decision rules, which provided risk stratification to help reduce diagnostic uncertainty and the need for unnecessary CT scans. Prior to the decision-making for the need to perform a CT scan, clinicians were presented with a pop-up’ alert, which provided a risk assessment. In trying to assess the value of introducing the alert system, the researchers considered guideline adherence, which they considered to be not performing a CT scan when the alert system identified the patient as being at low risk. For the study, all sites provided data on the level of CT scans before and after introduction of the intervention for comparative purposes.
Alert system and change in CT scanning
A total of 12, 670 paediatric minor head trauma encounters were included in the analysis. The proportion of guideline-adherent encounters increased from 94.8% in the control period to 99.4% during the time when the intervention was implemented. Furthermore, the proportion of CT scans performed reduced from 38.6% in the control period to 29.8% after implementation of the intervention.
The authors calculated that the odds of an encounter being guideline-adherent was 1.12 (95% CI 1.03 – 1.22) or approximately 10% higher during the intervention compared to the control time period. Moreover, when using a pre-post comparison, guideline adherence remained significantly higher than the control period (odds ratio = 5.33, 95% CI 3.75 – 7.59).
The authors concluded that the implementation of the alert system led to sustained improvements in adherence to guidelines on the need for a CT scan and a modest reduction in scans among low risk patients.
Knighton AJ et al. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study Ann Emerg Med 2022
23rd May 2022
Head injuries in children, and which resulted in hospitalisation, were more than two-fold higher during the COVID-19 pandemic compared with pre-pandemic levels, although the use of CT head scans was not appreciably different. This was the conclusion of a retrospective study by researchers from John Hopkin’s University, Baltimore, Maryland, USA.
Head injuries in children are a common cause for hospitalisation with a report by the US Centers for Disease Control and Prevention citing that in the US in 2016, 8.3% of boys and 5.6% of girls aged 3 –17 years had ever had a significant head injury in their lifetime. Head injuries are damage to the scalp, skull, or brain caused by trauma and in cases where this affects the brain, it is referred to as a traumatic brain injury. The most common causes of such head injuries are falls although other causes in older children are related to sports injuries or even motor vehicle accidents. Little is known about how the pandemic has impacted upon the incidence of head injuries in during during the pandemic although some work based on neuro-trauma admissions observed that while there was a decline in the number of head injury admissions during the pandemic, the severity of the injuries actually increased. However, no studies have compared the level of presentation during COVID-19 with the years prior to the pandemic.
For the present analysis, the US team retrospectively examined the proportion of emergency department visits for head injury in children and the severity of those injuries between March 2020 to June 2020. These data were then compared with data from between March 2019 – June 2019, i.e., pre-pandemic levels. For the analysis, researchers included anyone aged 0 to 21 and set the primary outcomes of interest as the presence of a medically attended head injury, hospital admission for the injury and the need for CT head scanning.
Head injuries in children and hospitalisations
There were a total of 8616 patients with a mean age of 7.4 years (51.4% male) seen with a head injury at the emergency department during the COVID-19 pandemic. This compared with 19,083 visits in the same period during 2019. Overall, there was a significant increase in the proportion of visits during COVID-19 (6.4% vs 5.5%, p = 0.004), for a head injury in children, giving an odds ratio (OR) of 1.2 (95% CI 1.1 – 1.4), even though the absolute number of visits was lower (1058 vs 553, pre-covid vs covid).
In addition, the proportion of visits requiring hospitalisation was more than two-fold higher (OR = 2.3, 95% CI 1.3 – 4.3), which was more likely in male patients (OR = 1.58). However, the need for a CT head scan was not significantly different (OR = 1.04, 955 CI 0.70 – 1.60). Interestingly, there was a lower level of hospital admissions associated with children aged < 2 years (OR = 0.3, 95% CI 0.2 – 0.6) which suggested that head injuries in this age group were less severe.
The authors concluded by suggesting that the higher level of head injuries in children observed during the pandemic period were potentially due to changes in certain factors including supervision and risk exposure in the home.
Satoskar S et al. Impact of the COVID-19 pandemic on pediatric emergency department utilization for head injuries J Investig Med 2022