Despite guidelines, use of CT for head trauma in children remains unchanged

1. The Pediatric Emergency Care Applied Research Network (PECARN) published clinical prediction rules in 2009 to identify children with head trauma for whom computed tomography (CT) neuroimaging can be avoided.

2. Rates of CT neuroimaging for pediatric head trauma did not significantly decrease after implementation of PECARN guidelines. Age ≥2, white race, higher acuity, and presentation to a nonteaching or nonpediatric hospital were significantly associated with increased neuroimaging.

Evidence Rating Level: 3 (Average)

Study Rundown: Head trauma in children can result in devastating neurological injuries. CT neuroimaging can aid in identification of injuries warranting neurosurgical intervention, but excess CT use contributes to rising health care costs and unnecessarily exposes children to ionizing radiation. PECARN published rules in 2009 to identify children for whom CT can be avoided without missing injuries needing neurosurgical intervention. In this cross-sectional study, researchers used emergency department (ED) visit data from 300 randomly selected hospitals in the United States to identify trends in CT neuroimaging for children with head trauma. About a third of children evaluated in EDs for head trauma underwent CT neuroimaging during the study period, and there was no significant trend in CT neuroimaging rates over time. There was no significant difference in odds of undergoing CT neuroimaging before and after publication of the PECARN rules. Age ≥2, white race, higher acuity, and presentation to a nonteaching or nonpediatric hospital were associated with increased odds of CT neuroimaging.

These findings are limited by the length of the study period, as more time may be required for the PECARN guidelines to be fully adopted. Furthermore, the data set does not contain information regarding severity of the head injury. Nonetheless, the study is strengthened by its large, nationally representative sample. For physicians, these findings highlight the need for quality improvement initiatives to ensure appropriate CT use. 

Click to read the study, published today in Pediatrics 

Relevant reading: Quality Improvement Effort to Reduce Cranial CTs for Children With Minor Blunt Head Trauma

In-Depth [cross-sectional study]: Researchers used ED visit data from 300 randomly selected hospitals between 2007 to 2015 from the National Hospital Ambulatory Medical Care Survey to identify 3089 encounters representing an estimated 14.3 million pediatric ED visits for head trauma. The study compared trends in CT neuroimaging during the study period, especially before (2007-2009) and after (2010-2015) publication of the PECARN rules.

Overall, 32% (95% CI: 29.0%-34.6%) of children evaluated in EDs for head injuries underwent CT neuroimaging. The odds of children with head injuries undergoing CT neuroimaging before and after the PECARN rules did not significantly differ (aOR: 1.07 after PECARN versus before; 95% CI: 0.84-1.38; P = .59). There was no significant association between year and CT neuroimaging after adjusting for patient age, sex, race, insurance provider, and triage acuity in multivariable analysis (adjusted odds ratio [aOR]: 1.02; 95% CI: 0.97-1.07; P = 0.50). Age ≥2, white race, higher acuity (urgent, emergent, or immediate), and presentation to a nonteaching or nonpediatric hospital were significantly associated with increased neuroimaging.

Image: PD

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