Validation of Pediatric Emergency Care Applied Research Network (PECARN) rule in children with minor head trauma.
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ABSTRACT:
SUBMITTER: Cho S
PROVIDER: S-EPMC8765658 | biostudies-literature | 2022
REPOSITORIES: biostudies-literature
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Validation of Pediatric Emergency Care Applied Research Network (PECARN) rule in children with minor head trauma.
Cho Sooje S Hwang Soyun S Jung Jae Yun JY Kwak Young Ho YH Kim Do Kyun DK Lee Jin Hee JH Jung Jin Hee JH Park Joong Wan JW Kwon Hyuksool H Suh Dongbum D
PloS one 20220118 1
The Pediatric Emergency Care Applied Research Network (PECARN) rule is commonly used for predicting the need for computed tomography (CT) scans in children with mild head trauma. The objective of this study was to validate the PECARN rule in Korean children presenting to the pediatric emergency department (PED) with head trauma. This study was a multicenter, retrospective, observational cohort study in two teaching PEDs in Korea between August 2015 and August 2016. In this observational study, 4 ...[more]
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Project description:This study aims to evaluate the efficacy of the PECARN Rule (PR) in reducing radiological investigations in children with mild traumatic head injury in comparison with current clinical practice. A retrospective study was performed in our hospital between July 2015 and June 2020. Data of all children < 18 years of age admitted to the emergency department (ED), within 24 h after a head trauma with GCS ≥ 14, were analyzed. PECARN Rule was retrospectively applied to all patients. In total, 3832 patients were enrolled, 2613 patients ≥ 2 years and 1219 < 2 years. In the group of children ≥ 2 years, 10 presented clinically important traumatic brain injury (ciTBI) and were hospitalized, 7/10 underwent neurosurgery, and 3/10 clinical observation in the pediatric ward for more than 48 h. In children < 2 years, only 3 patients presented ciTBI, 2 underwent neurosurgery and 1 hospitalized. Applying the PR, no patient with ciTBI would have been discharged without an accurate diagnosis and we would have avoided 139 CT scans in patients ≥ 2 years, and 23 in those < 2 years of age (29% less).ConclusionWe demonstrated the safety and validity of the PR in our setting with 100% sensitivity in both age groups in identifying patients with ciTBI and theoretically in reducing performed CT scans by 29%. Therefore, in patients classified in the low-risk category, it is a duty not to expose the child to ionizing radiation.What is known• CT is the gold standard to identify intracranial pathology in children with head injury but CT imaging of head-injured children expose them to higher carcinogenic risk. • PECARN Rules support doctors in identifying children with ciTBI in order to reduce exposure to ionizing radiation.What is new• We demonstrate the safety and validity of the PR with 100% sensitivity in both age groups in identifying patients with ciTBI. • In our setting, the application of PECARN Rule would theoretically have allowed us to reduce the CT scan by 29%.
| S-EPMC9056473 | biostudies-literature
Project description:BackgroundTo date, the Pediatric Emergency Care Applied Research Network (PECARN) rule for identifying children who are at very low risk of clinically-important traumatic brain injuries after minor head trauma has not been validated prospectively in an independent population. Our goal was to evaluate the diagnostic performance of the PECARN clinical decision rule in a French pediatric population in multiple clinical settings.MethodsWe conducted a multicenter, prospective, non-interventional cohort study of patients with minor head trauma who presented to three emergency departments in France. We enrolled patients younger than 16 years of age seeking a consultation within 24 h of head trauma with Glasgow Coma Scale scores of 14-15.ResultsDuring the study period, we included 1499 children of which 421 (28 %) were under 2 years of age, and 955 (64 %) were male. A cranial computed tomography (CT) scan was performed on 76 patients (5.1 %). Of the 1499 included patients, 9 children (0.6 %) had a clinically-important traumatic brain injury, and none were classified as very low risk by the PECARN rule. In our study, the sensitivity of this clinical decision rule was 100 % (95 % CI 66.4 to 100 %), the specificity was 69.9 % (95 % CI 67.5 to 72.2 %) and the negative predictive value was 100 % (95 % CI 99.7 to 100 %).DiscussionOur study confirmed the good predictive performances of the PECARN clinical decision rule for minor head trauma in children. The PECARN rule performed similarly to our study and to its internal validation study.ConclusionsWe conducted an external validation study of the PECARN clinical decision rule for the detection of clinically-important traumatic brain injuries in children with minor head trauma, according to the methodological standards. The PECARN rule successfully identified all patients with clinically-important traumatic brain injuries, with a limited use of CT scans. Conducting a broad validation study with a large cohort is a prerequisite to provide sufficient statistical power before authorizing its implementation and generalization.Trial registrationThis study has been registered in ClinicalTrials.gov with identifier number: NCT02752711 on April 27, 2016.
| S-EPMC4973103 | biostudies-literature
Project description:Study objectiveTo improve the efficiency and appropriateness of computed tomography (CT) use in children with minor head trauma, clinical prediction rules were derived and validated by the Pediatric Emergency Care Applied Research Network (PECARN). The objective of this study was to conduct a cost-effectiveness analysis comparing the PECARN traumatic brain injury prediction rules to usual care for selective CT use.MethodsWe used decision analytic modeling to project the outcomes, costs, and cost-effectiveness of applying the PECARN rules compared with usual care in a hypothetical cohort of 1,000 children with minor blunt head trauma. Clinical management was directed by level of risk as specified by the presence or absence of variables in the PECARN traumatic brain injury prediction rules. Immediate costs of care (diagnostic testing, treatment [not including clinician time], and hospital stay) were derived on single-center data. Quality-adjusted life-year losses related to the sequelae of clinically important traumatic brain injuries and to radiation-induced cancers, number of CT scans, number of radiation-induced cancers, number of missed clinically important traumatic brain injury, and total costs were evaluated.ResultsCompared with the usual care strategy, the PECARN strategy was projected to miss slightly more children with clinically important traumatic brain injuries (0.26 versus 0.02 per 1,000 children) but used fewer cranial CT scans (274 versus 353), resulted in fewer radiation-induced cancers (0.34 versus 0.45), cost less ($904,940 versus $954,420), and had lower net quality-adjusted life-year loss (-4.64 versus -5.79). Because the PECARN strategy was more effective (less quality-adjusted life-year loss) and less costly, it dominated the usual care strategy. Results were robust under sensitivity analyses.ConclusionApplication of the PECARN traumatic brain injury prediction rules for children with minor head trauma would lead to beneficial outcomes and more cost-effective care.
| S-EPMC4275394 | biostudies-literature
Project description:ImportanceComputed tomographic (CT) scanning is the standard for the rapid diagnosis of intracranial injury, but it is costly and exposes patients to ionizing radiation. The Pediatric Emergency Care Applied Research Network (PECARN) rules for identifying children with minor head trauma who are at very low risk of clinically important traumatic brain injury (ciTBI) are widely used to triage CT imaging.ObjectiveTo examine whether optimal classification trees (OCTs), which are novel machine-learning classifiers, improve on PECARN rules' predictive accuracy.Design, setting, and participantsA secondary analysis of prospective, publicly available data on emergency department visits for head trauma used by the PECARN group to develop their tool was conducted to derive OCT-based prediction rules for ciTBI in a development cohort and compare their predictive performance vs the PECARN rules in a validation cohort among children who were younger than 2 years and 2 years or older. Data on 42 412 children with head trauma and without severely altered mental status who were examined between June 1, 2004, and September 30, 2006, were gathered from 25 emergency departments in North America participating in PECARN. Data analysis was conducted from September 15, 2016, to December 18, 2018.Main outcomes and measuresThe outcome was ciTBI, with predictive performance measured by estimating the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for the OCT and the PECARN rules. The OCT and PECARN rules' performance was compared by estimating ratios for each measure.ResultsOf the 42 412 children (15 996 [37.7%] girls) included in the analysis, 10 718 were younger than 2 years (25.3%; mean [SD] age, 11.6 [0.6] months) and 31 694 were 2 years or older (74.7%; age, 9.1 [4.9] years). Compared with PECARN rules, OCTs misclassified 0 vs 1 child with ciTBI in the younger and 10 vs 9 children with ciTBI in the older cohort, and correctly identified more children with very low risk of ciTBI in the younger (7605 vs 5701) and older (20 594 vs 18 134) cohorts. In the validation cohorts, compared with the PECARN rules, the OCTs had statistically significantly better specificity (in the younger cohort: 69.3%; 95% CI, 67.4%-71.2% vs 52.8%; 95% CI, 50.8%-54.9%; in the older cohort: 65.6%; 95% CI, 64.5%-66.8% vs 57.6%; 95% CI, 56.4%-58.8%), positive predictive value (odds ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively), and positive likelihood ratio (risk ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively). There were no statistically significant differences in the sensitivity, negative predictive value, and negative likelihood ratio between the 2 sets of rules.Conclusions and relevanceIf implemented, OCTs may help reduce the number of unnecessary CT scans, without missing more patients with ciTBI than the PECARN rules.
| S-EPMC6515573 | biostudies-literature
Project description:IntroductionHeadache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables.Methods and analysisProspective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model.Ethics and disseminationEthics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.
| S-EPMC10668138 | biostudies-literature
Project description:Study objectiveTo measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs).MethodsProspective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician.ResultsDuring the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified.ConclusionImplementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.
| S-EPMC9509420 | biostudies-literature
Project description:BackgroundElectronic health record (EHR)-based registries allow for robust data to be derived directly from the patient clinical record and can provide important information about processes of care delivery and patient health outcomes.MethodsA data dictionary, and subsequent data model, were developed describing EHR data sources to include all processes of care within the emergency department (ED). ED visit data were deidentified and XML files were created and submitted to a central data coordinating center for inclusion in the registry. Automated data quality control occurred prior to submission through an application created for this project. Data quality reports were created for manual data quality review.ResultsThe Pediatric Emergency Care Applied Research Network (PECARN) Registry, representing four hospital systems and seven EDs, demonstrates that ED data from disparate health systems and EHR vendors can be harmonized for use in a single registry with a common data model. The current PECARN Registry represents data from 2,019,461 pediatric ED visits, 894,503 distinct patients, more than 12.5 million narrative reports, and 12,469,754 laboratory tests and continues to accrue data monthly.ConclusionThe Registry is a robust harmonized clinical registry that includes data from diverse patients, sites, and EHR vendors derived via data extraction, deidentification, and secure submission to a central data coordinating center. The data provided may be used for benchmarking, clinical quality improvement, and comparative effectiveness research.
| S-EPMC5966304 | biostudies-literature
Project description:ImportanceMinor head trauma (HT) is one of the most common causes of hospitalization in children. A diagnostic test could prevent unnecessary hospitalizations and cranial computed tomographic (CCT) scans.ObjectiveTo evaluate the effectiveness of serum S100B values in reducing exposure to CCT scans and in-hospital observation in children with minor HT.Design, setting, and participantsThis multicenter, unblinded, prospective, interventional randomized clinical trial used a stepped-wedge cluster design to compare S100B biomonitoring and control groups at 11 centers in France. Participants included children and adolescents 16 years or younger (hereinafter referred to as children) admitted to the emergency department with minor HT. The enrollment period was November 1, 2016, to October 31, 2021, with a follow-up period of 1 month for each patient. Data were analyzed from March 7 to May 29, 2023, based on the modified intention-to-treat and per protocol populations.InterventionsChildren in the control group had CCT scans or were hospitalized according to current recommendations. In the S100B biomonitoring group, blood sampling took place within 3 hours after minor HT, and management depended on serum S100B protein levels. If the S100B level was within the reference range according to age, the children were discharged from the emergency department. Otherwise, children were treated as in the control group.Main outcomes and measuresProportion of CCT scans performed (absence or presence of CCT scan for each patient) in the 48 hours following minor HT.ResultsA total of 2078 children were included: 926 in the control group and 1152 in the S100B biomonitoring group (1235 [59.4%] boys; median age, 3.2 [IQR, 1.0-8.5] years). Cranial CT scans were performed in 299 children (32.3%) in the control group and 112 (9.7%) in the S100B biomonitoring group. This difference of 23% (95% CI, 19%-26%) was not statistically significant (P = .44) due to an intraclass correlation coefficient of 0.32. A statistically significant 50% reduction in hospitalizations (95% CI, 47%-53%) was observed in the S100B biomonitoring group (479 [41.6%] vs 849 [91.7%]; P < .001).Conclusions and relevanceIn this randomized clinical trial of effectiveness of the serum S100B level in the management of pediatric minor HT, S100B biomonitoring yielded a reduction in the number of CCT scans and in-hospital observation when measured in accordance with the conditions defined by a clinical decision algorithm.Trial registrationClinicalTrials.gov Identifier: NCT02819778.
| S-EPMC10951739 | biostudies-literature
Project description:The aim of this study was to determine the potential impact of the Pediatric Emergency Care Applied Research Network (PECARN) rules on the CT rate in a large paediatric minor traumatic head injury (MTHI) cohort and compare this with current national Dutch guidelines. This was a planned sub-study of a prospective multicentre observational study that enrolled 1006 children younger than 18 years with MTHI. We calculated the number of recommended CT scans and described trauma-related CT scan abnormalities. The PECARN rules recommended a significantly lower percentage of CT scans in all age categories, namely 101/357 (28.3%) versus 164/357 (45.9%) (p < 0.001) in patients under 2 years of age and 148/623 (23.8%) versus 394/623 (63.2%) (p < 0,001) versus in patients 2 years and older.Conclusion: The projected CT rate can significantly be reduced if the PECARN rules are applied. We therefore advocate that the PECARN guidelines are also implemented in The Netherlands. What is Known: • To guide clinicians whether to perform a CT scan in children with a minor traumatic head injury (MTHI) clinical decision rules has been developed. • The overall CT scan rate in adherence with the Dutch MTHI guidelines is 44%. What is New: • The projected CT rate can significantly be reduced in a Dutch cohort of MTHI if the PECARN rules are applied. • The Dutch national guidelines for MTHI can safely be replaced by the PECARN rules.
| S-EPMC7479012 | biostudies-literature
Project description:BackgroundThere is no clear consensus regarding radiologic evaluation of head trauma in young children without traumatic brain injury. We conducted a study to develop and validate a clinical decision rule to identify skull fracture in young children with head trauma and no immediate need for head tomography.MethodsWe performed a prospective cohort study in 3 tertiary care emergency departments in the province of Quebec. Participants were children less than 2 years old who had a head trauma and were not at high risk of clinically important traumatic brain injury (Glasgow Coma Scale score < 15, altered level of consciousness or palpable skull fracture). The primary outcome was skull fracture. For each participant, the treating physician completed a standardized report form after physical examination and before radiologic evaluation. The decision to order skull radiography was at the physician's discretion. The clinical decision rule was derived using recursive partitioning.ResultsA total of 811 patients (49 with skull fracture) were recruited during the derivation phase. The 2 predictors identified through recursive partitioning were parietal or occipital swelling or hematoma and age less than 2 months. The rule had a sensitivity of 94% (95% confidence interval [CI] 83%-99%) and a specificity of 86% (95% CI 84%-89%) in the derivation phase. During the validation phase, 856 participants (44 with skull fracture) were recruited. The rule had a sensitivity of 89% and a specificity of 87% during this phase.InterpretationThe clinical decision rule developed in this study identified about 90% of skull fractures among young children with mild head trauma who had no immediate indication for head tomography. Use of the rule would have reduced the number of radiologic evaluations by about 60%.
| S-EPMC4627875 | biostudies-literature