In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) established after a comprehensive prospective study of clinical guidelines for when to obtain a CT following mild traumatic injury.
CT imaging of head-injured children has risks of radiation-induced malignancy. The aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.
International efforts have been focused on identifying children at low risk of clinically important traumatic brain injury in whom computed tomography (CT) neuroimaging can be avoided. They sought to determine if CT use for pediatric head trauma has decreased among US emergency departments (EDs).
This was a cross-sectional analysis of the National Hospital Ambulatory Care Medical Survey database of nationally representative ED visits from 2007 to 2015. They included children <18 years of age evaluated in the ED for a head injury.
Survey weighting procedures were used to estimate the annual proportion of children who underwent CT neuroimaging and to perform multivariable logistic regression.
There were an estimated 14.3 million pediatric head trauma visits during the 9-year study period. Overall, 32% (95% confidence interval [CI]: 29%–35%) of children underwent CT neuroimaging with no significant annual linear trend (P trend = .50).
Multivariate analysis similarly revealed no difference by year (adjusted odds ratio [aOR]: 1.02; 95% CI: 0.97–1.07) after adjustment for the patient- and ED-level covariates.
CT use was associated with age ≥2 years (aOR: 1.51; 95% CI: 1.13–2.01), white race (aOR: 1.43; 95% CI: 1.10–1.86), highest triage acuity (aOR: 8.24 [95% CI: 4.00–16.95]; P < .001), and presentation to a nonteaching (aOR: 1.47; 95% CI: 1.05–2.06) or nonpediatric (aOR: 1.53; 95% CI: 1.05–2.23) hospital.
CT neuroimaging did not decrease from 2007 to 2015. Findings suggest an important need for quality improvement initiatives to decrease CT use among children with head injuries.
Given the risks of excess radiation due to CT scans in children, the PECARN work was intended to decrease CT scans for low-risk children. So how are we doing at decreasing unnecessary CT scans?
Are we following the PECARN criteria and as a result reducing radiation exposure? Burstein et al. shared annualized results of CT scans obtained from a nationally representative collection of ED from the National Ambulatory Care Survey 2007-2015.
The good news is that in dedicated children’s and teaching hospitals, there was a significant decline in CT scans. The bad news is that nearly all of the potentially unnecessary CT scans were in 90% non-pediatric general hospitals, in which there was no change in the rate of CT scans ordered for mild traumatic brain injury.
Why was there no improvement in these general emergency departments despite the strong evidence-based guidelines from PECARN? We asked hospitalist Dr. Eric Coons and intensivist Dr. Susan Bratton from Utah to weigh in with an accompanying commentary.
They point out the lack of diffusion of innovation and change in pediatric care processes outside of children’s hospitals and call for improvement in how we can be more inclusive of communicating the evidence and in turn the need to reduce unnecessary CT scans for minor head injuries in these general hospitals.