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Implementation of Adapted PECARN Decision Rule for Children With Minor Head Injury in the Pediatric Emergency Department
Academic Emergency Medicine, 06/26/2012
Bressan S et al. – The adapted Pediatric Emergency Care Applied Research Network (PECARN) rule was successfully implemented in an Italian tertiary care academic pediatric emergency department (PED), achieving high adherence and satisfaction of medical staff. Its use determined a low computed tomography (CT) scan rate that was unchanged compared to previous clinical practice and showed an optimal safety and high efficacy profile. Strict monitoring is mandatory to evaluate the long–lasting benefit in patient care and/or resource utilization.
Methods- The adapted PECARN decision rule algorithms for children (one for those younger than 2years and one for those older than 2years) were actively implemented in the PED of Padova, Italy, for a 6–month testing period.
- Adherence and satisfaction of medical staff to the new rule were calculated.
- Data from 356 visits for MHI during PECARN rule implementation and those of 288 patients attending the PED for MHI in the previous 6months were compared for changes in computed tomography (CT) scan rate, ciTBI rate (defined as death, neurosurgery, intubation for longer than 24hours, or hospital admission at least for two nights associated with TBI) and return visits for symptoms or signs potentially related to MHI.
- The safety and efficacy of the adapted PECARN rule in clinical practice were also calculated.
- Adherence to the adapted PECARN rule was 93.5%.
- The percentage of medical staff satisfied with the new rule, in terms of usefulness and ease of use for rapid decision–making, was significantly higher (96% vs. 51%, p<0.0001) compared to the previous, more complex, internal guideline.
- CT scan was performed in 30 patients (8.4%, 95% confidence interval [CI]=6% to 11.8%) in the implementation period versus 21 patients (7.3%, 95% CI=4.8% to 10.9%) before implementation.
- A ciTBI occurred in three children (0.8%, 95% CI=0.3 to 2.5) during the implementation period and in two children (0.7%, 95% CI=0.2 to 2.5) in the prior 6months.
- There were five return visits (1.4%) postimplementation and seven (2.4%) before implementation (p=0.506).
- The safety of use of the adapted PECARN rule in clinical practice was 100% (95% CI=36.8 to 100; three of three patients with ciTBI who received CT scan at first evaluation), while efficacy was 92.3% (95% CI=89 to 95; 326 of 353 patients without ciTBI who did not receive a CT scan).