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Ann Emerg Med. 2018 Jun;71(6):703-710. doi: 10.1016/j.annemergmed.2018.01.015. Epub 2018 Feb 14.

Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study.

Author information

1
Emergency Department, Royal Children's Hospital, Melbourne, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Parkville, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Parkville, Victoria, Australia. Electronic address: franz.babl@rch.org.au.
2
Emergency Department, Royal Children's Hospital, Melbourne, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Parkville, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Parkville, Victoria, Australia.
3
Emergency Department, Starship Children's Health, and the Liggins Institute, University of Auckland, Grafton, Auckland, New Zealand.
4
Emergency Department, Princess Margaret Hospital for Children, Subiaco, Perth, Western Australia, Australia; Schools of Paediatrics and Child Health and Primary, Aboriginal and Rural Healthcare, University of Western Australia, Crawley, Australia, Australia.
5
Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, South Brisbane, Queensland, Australia.
6
Emergency Department, Women's & Children's Hospital, North Adelaide, South Australia, Australia.
7
Emergency Department, The Children's Hospital at Westmead, Westmead, Sydney, New South Wales, Australia.
8
Emergency Department, Royal Children's Hospital, Melbourne, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Parkville, Victoria, Australia; Emergency Department, Monash Medical Centre, Melbourne, Clayton, Victoria, Australia.
9
Emergency Department, The Townsville Hospital, Townsville, Douglas, Queensland, Australia.
10
Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand.
11
Murdoch Children's Research Institute, Melbourne, Parkville, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Parkville, Victoria, Australia.
12
Murdoch Children's Research Institute, Melbourne, Parkville, Victoria, Australia.
13
Murdoch Children's Research Institute, Melbourne, Parkville, Victoria, Australia; Department of Women's and Children's Health, University of Padova, Padova, Italy.
14
Murdoch Children's Research Institute, Melbourne, Parkville, Victoria, Australia; Emergency Department, Bristol Royal Hospital for Children, and the Academic Department of Emergency Care, University of the West of England, Bristol, United Kingdom.

Abstract

STUDY OBJECTIVE:

Three clinical decision rules for head injuries in children (Pediatric Emergency Care Applied Research Network [PECARN], Canadian Assessment of Tomography for Childhood Head Injury [CATCH], and Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE]) have been shown to have high performance accuracy. The utility of any of these in a particular setting depends on preexisting clinician accuracy. We therefore assess the accuracy of clinician practice in detecting clinically important traumatic brain injury.

METHODS:

This was a planned secondary analysis of a prospective observational study of children younger than 18 years with head injuries at 10 Australian and New Zealand centers. In a cohort of children with mild head injuries (Glasgow Coma Scale score 13 to 15, presenting in <24 hours) we assessed physician accuracy (computed tomography [CT] obtained in emergency departments [EDs]) for the standardized outcome of clinically important traumatic brain injury and compared this with the accuracy of PECARN, CATCH, and CHALICE.

RESULTS:

Of 20,137 children, 18,913 had a mild head injury. Of these patients, 1,579 (8.3%) received a CT scan during the ED visit, 160 (0.8%) had clinically important traumatic brain injury, and 24 (0.1%) underwent neurosurgery. Clinician identification of clinically important traumatic brain injury based on CT performed had a sensitivity of 158 of 160, or 98.8% (95% confidence interval [CI] 95.6% to 99.8%) and a specificity of 17,332 of 18,753, or 92.4% (95% CI 92.0% to 92.8%). Sensitivity of PECARN for children younger than 2 years was 42 of 42 (100.0%; 95% CI 91.6% to 100.0%), and for those 2 years and older, it was 117 of 118 (99.2%; 95% CI 95.4% to 100.0%); for CATCH (high/medium risk), it was 147 of 160 (91.9%; 95% CI 86.5% to 95.6%); and for CHALICE, 148 of 160 (92.5%; 95% CI 87.3% to 96.1%).

CONCLUSION:

In a setting with high clinician accuracy and a low CT rate, PECARN, CATCH, or CHALICE clinical decision rules have limited potential to increase the accuracy of detecting clinically important traumatic brain injury and may increase the CT rate.

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