Kent P Hymel1, Veronica Armijo-Garcia2, Matthew Musick3, Mark Marinello4, Bruce E Herman5, Kerri Weeks6, Suzanne B Haney7, Terra N Frazier8, Christopher L Carroll9, Natalie N Kissoon2, Reena Isaac3, Robin Foster4, Kristine A Campbell5, Kelly S Tieves8, Nina Livingston9, Ashley Bucher1, Maria C Woosley2, Dorinda Escamilla-Padilla2, Nancy Jaimon3, Lucinda Kustka7, Ming Wang10, Vernon M Chinchilli10, Mark S Dias11, Jennie Noll12. 1. Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA. 2. University of Texas Health Sciences Center at San Antonio, San Antonio, TX. 3. Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX. 4. Department of Pediatrics, Children's Hospital of Richmond, Richmond, VA. 5. Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT. 6. Department of Pediatrics, University of Kansas School of Medicine, Wichita, KS. 7. Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE. 8. Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO. 9. Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT. 10. Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA. 11. Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA; Department of Neurosurgery, Penn State College of Medicine, Hershey, PA. 12. Department of Human Development and Family Studies, Penn State University, State College, PA.
Abstract
OBJECTIVE: To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. STUDY DESIGN: This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. RESULTS: Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22). CONCLUSIONS: PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03162354.
OBJECTIVE: To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. STUDY DESIGN: This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. RESULTS: Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22). CONCLUSIONS: PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03162354.
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Authors: Kent P Hymel; Wouter Karst; Mark Marinello; Bruce E Herman; Terra N Frazier; Christopher L Carroll; Veronica Armijo-Garcia; Matthew Musick; Kerri Weeks; Suzanne B Haney; Afshin Pashai; Ming Wang Journal: Child Abuse Negl Date: 2022-01-22