Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries - 26/04/19
, Nathan Kuppermann, MD, MPH c, d, David R. Vinson, MD a, e, Eric Tham, MD f, Jeff M. Hoffman, MD g, Marguerite Swietlik, MSN, RN h, Sara J. Deakyne Davies, MPH h, Evaline A. Alessandrini, MD, MSCE i, Leah Tzimenatos, MD c, Lalit Bajaj, MD, MPH f, Dustin G. Mark, MD a, j, Steve R. Offerman, MD k, Uli K. Chettipally, MD, MPH l, Marilyn D. Paterno, MSBI m, Molly H. Schaeffer, MSc n, Rachel Richards, MStat o, T. Charles Casper, PhD o, Howard S. Goldberg, MD m, n, Robert W. Grundmeier, MD p, Peter S. Dayan, MD, MSc qfor the
Pediatric Emergency Care Applied Research Network (PECARN)
Clinical Research on Emergency Services and Treatment (CREST) Network
andPartners HealthCare
Abstract |
Study objective |
To determine the effect of providing risk estimates of clinically important traumatic brain injuries and management recommendations on emergency department (ED) outcomes for children with isolated intermediate Pediatric Emergency Care Applied Research Network clinically important traumatic brain injury risk factors.
Methods |
This was a secondary analysis of a nonrandomized clinical trial with concurrent controls, conducted at 5 pediatric and 8 general EDs between November 2011 and June 2014, enrolling patients younger than 18 years who had minor blunt head trauma. After a baseline period, intervention sites received electronic clinical decision support providing patient-level clinically important traumatic brain injury risk estimates and management recommendations. The following primary outcomes in patients with one intermediate Pediatric Emergency Care Applied Research Network risk factor were compared before and after clinical decision support: proportion of ED computed tomography (CT) scans, adjusted for age, time trend, and site; and prevalence of clinically important traumatic brain injuries.
Results |
The risk of clinically important traumatic brain injuries was known for 3,859 children with isolated findings (1,711 at intervention sites before clinical decision support, 1,702 at intervention sites after clinical decision support, and 446 at control sites). In this group, pooled CT proportion decreased from 24.2% to 21.6% after clinical decision support (odds ratio 0.86; 95% confidence interval 0.73 to 1.01). Decreases in CT use were noted across intervention EDs, but not in controls. The pooled adjusted odds ratio for CT use after clinical decision support was 0.73 (95% confidence interval 0.60 to 0.88). Among the entire cohort, clinically important traumatic brain injury was diagnosed at the index ED visit for 37 of 37 (100%) patients before clinical decision support and 32 of 33 patients (97.0%) after clinical decision support.
Conclusion |
Providing specific risks of clinically important traumatic brain injury through electronic clinical decision support was associated with a modest and safe decrease in ED CT use for children at nonnegligible risk of clinically important traumatic brain injuries.
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| Please see page 441 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Jocelyn Gravel, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: NK and PSD conceptualized and designed the study, obtained funding, designed the data collection instruments and intervention, and coordinated and supervised data collection at all sites. DWB, NK, DRV, and PSD designed the analytic plan and article structure and drafted the initial article. All authors approved the final version of the article. RR and TCC carried out the data analyses and revised the article. DWB, DRV, ET, JMH, MS, SJDD, EAA, LT, LB, DGM, SRO, UKC, MDP, MHS, RR, TCC, HSG, and RWG reviewed the article. DWB, DRV, ET, JMH, EAA, LT, LB, DGM, SRO, and UKC helped design the study, data collection instruments, and intervention; each coordinated and supervised data collection at his or her site. MS, SJDD, MDP, MHS, HSG, and RWG designed the study, data collection instruments, and clinical decision support. DWB takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was supported by American Recovery and Reinvestment Act–Office of the Secretary grant S02MC19289-01-00. PECARN is supported by the Health Resources and Services Administration, Maternal and Child Health Bureau, Emergency Medical Services for Children Program through the following cooperative agreements: U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC00008, U03MC22684, and U03MC22685. Dr. Goldberg provides consultation to the following companies: Intelligent Medical Objects, Chicago, IL, and Practical Solutions in Medical Informatics, Pt Richmond, CA; and is on the Advisory Committee of Clearsense, Jacksonville, FL. |
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| Trial registration number: NCT01453621 |
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Vol 73 - N° 5
P. 440-451 - mai 2019 Retour au numéro
Article précédent
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