In the Middle East, the epidemiology of ciTBI and CT imaging rates of children presenting to the PED with head trauma remain understudied (31, 32). This study evaluating the impact of PECARN rules implementation in the PED of the AUBMC in Lebanon provides a better understanding of the characteristics, clinical management and outcomes of pediatric patients presenting to our institution for minor head trauma. Moreover, this is the first study to evaluate the implementation of the PECARN rules in the region and specifically in a middle-income country, without administrative resources for QI work. The main findings of a significant decrease in CT scanning rates among low risk patients less than two years of age without any adverse effect on patient outcomes, suggest that the PECARN rules reliably identify patients at low risk for ciTBI and that their implementation can safely reduce the burden of CT imaging on children with head trauma, even in settings with limited administrative and educational resources and limited implementation efforts and QI initiatives, in order to translate knowledge, implement guidelines and change practice.
In this study, only 8 (1.9%) patients before and 7 (0.7%) patients after implementation were diagnosed with ciTBI. These low incidence rates imply that the majority of head trauma cases encountered in our PED are minor and do not require any imaging. Our results are similar to those of a large US prospective study conducted by Nigrovic et al. where only 0.9% of 42,412 patients with minor blunt head trauma had a ciTBI (30). They are also comparable to those of a French prospective study by Lorton et al. where only 0.6% of 1499 patients with minor head trauma had a ciTBI (5). These low rates of ciTBI thus illustrate the worldwide and, more specifically, the Lebanese population’s heightened awareness and concern for ciTBI and its consequences. Patients thus tend to seek evaluation in the ED even after a minor head trauma. As such, it is essential for ED physicians to optimize their approach to this common presentation for which only a minority are at risk of a bad outcome, given the potential harm associated with CT imaging of children with head trauma (10, 11).
In our study, the baseline CT scanning rate for all included patients pre-PECARN i.e. before any intervention was of 21.6%. Interestingly, in the literature, the several studies investigating the impact of PECARN rules on CT scanning rates of pediatric patients with head trauma display different baseline rates of head CT scanning. Whereas our clinical setting is characterized by a lower overall baseline CT scan rate (21.6% vs. 35.3% in the PECARN study) when compared to the US (4, 30, 33), our CT scanning rates seem to be higher than those reported in Europe (5.1% to 8.4%) (5, 20). Compared to the large prospective US study validating the PECARN prediction rules, our study included a higher percentage of children younger than 2 years of age and a lower proportion of cases with severe mechanisms of injury or with high-risk predictor findings for ciTBI, such as signs of altered mental status or of basilar skull fractures (4). Moreover, the majority (80.0%) of the patients included in this study were at low risk of a ciTBI and only 4.3% of them had a high risk for ciTBI, compared to 56% and 14% of the patients enrolled in the large prospective US study, respectively (4). Actually, in a previous Lebanese study, Habre observed that severe cases of TBI rarely reached hospitals and are thus underestimated in Lebanon (31). These differences reflect the overall lower severity of trauma cases presenting to our PED and further emphasizes the need for selective CT imaging of Lebanese children with minor head trauma. Moreover, the observed variability in baseline rates in different populations highlights the importance of this study in Lebanon as it provides a real-world understanding of how PECARN rules perform differently in different settings.
In our institution, the implementation of the PECARN rules led to a 3% decrease in CT scanning rates of children with head trauma, down to 18.6%. Despite our study’s decrease in the amount of head CTs performed on patients after PECARN rules implementation, it is quite surprising that no significant increase was seen in the frequency of positive CT findings. Among patients who were scanned, only 8.7% (pre) and 7.5% (post) had positive findings on CT. These rates of abnormal CTs are lower than previously reported rates (23), which shows that a high number of unnecessary CT scans are still being performed in our institution. In the literature, implementation studies conducted in different settings achieved mixed results with regards to changing practice. Some studies report no change between implementation and control groups (20, 26, 27), while others report consistent and substantial decreases in CT imaging rates (23-25). The change in CT scanning rates appears to be influenced by the baseline CT rates (16, 19, 34), the preexisting clinician accuracy (27), the medico-legal climate, the inclination for shared decision making with families (25) and the availability of observation units for conservative watchful waiting on intermediate risk patients (20). As such, in settings such as the US and Canada with high baseline CT rates and variability between CT rates (16, 19), clinical decision rules may contribute to a safe reduction in CT rates (24, 25) but perhaps not in other settings with low CT rates or high clinician accuracy as has been shown in Italy (20) or Australia (29, 34, 35) and in our study.
Nevertheless, although our baseline rates are comparable to those of a recent QI study conducted in the US, the implementation of PECARN guidelines in our PED had less of an impact on CT use when compared to results reported by Nigrovic et al. consisting of a CT scan decrease from 21% to 15% after implementation and down to 9% through individual provider feedback (24). Most published studies showing a positive impact from the implementation of the PECARN rules were conducted in developed countries (5, 20-22), with adequate administrative resources, or conducted specifically as QI projects (23, 30). According to previous studies, a CT rate of less than 15% is achievable for all children with minor blunt head trauma (20, 24, 25). Specifically, Nigrovic et al. significantly decreased CT scanning rates through individual provider feedback (24). They had assembled a team, composed of a nurse educator and research expert, a QI expert, and an administrator, to review the literature on implementation, increase awareness about the PECARN rules and develop strategies to encourage their adoption. A head trauma electronic order set that included a link to the rules and supporting text was also created for support. In our setting, we did not have this support which would improve awareness and adherence to guideline recommendations. In fact, we did not have enough staff (administrative or medical) to implement a true QI project which would include Plan-Do-Study-Act (PDSA) cycles and a multidisciplinary team available to track results and provide feedback. We also did not have Information Technology (IT) support to develop an electronic tool to ease the use of the PECARN rules as previously done (23-25) nor to help generate regular reports that would be used for PDSA cycles and feedback to physicians. Knowing that there is substantial variability in adherence to PECARN rules between physicians worldwide (26); some of the physicians working in the pediatric ED section in our institution may have been reluctant to adhere to the rules as their adoption is usually influenced by local practice and culture (36). In addition, the pediatric patients included in this study were evaluated by physicians with a surgical, emergency, or family medicine, rather than pediatric or pediatric emergency, background which have been reported to have higher CT imaging rates (25). As such, individual provider related factors and limited administrative resources might have weakened the impact of PECARN rules implementation on CT scanning rates in our institution.
Moreover, similar to a nonrandomized multicenter trial (25), the decrease in CT rates in this study was particularly significant among low risk children less than 2 years of age decreasing from 20.7% to 11.4% (p=0.02). Our results are consistent with previous reported findings of an overall higher rate of correctly indicated head CT scans ordered on children less than 2 years of age after implementation of PECARN rules (20, 26). These findings are noteworthy as children younger than 2 years are the most sensitive to radiation (4). Specifically, children younger than 2 years with none of the predictor variables for ciTBI have less than 0.02% risk of ciTBI, implying that CT scans are not indicated for most children in this low-risk groups (4). In our institution, however, before implementation, a substantial proportion (20.7%) of low risk children younger than 2 years were still scanned. Physicians’ certainty in evaluating very young patients is usually lower than for older patients due to the concern of being unable to reliably identify ciTBI. Indeed, the clinical assessment of children less than two years of age is challenging as their neurologic examination is difficult to obtain and interpret; they may be asymptomatic despite having a ciTBI, are at risk for abusive head trauma, and are more prone to skull fractures than older children. Additionally, despite being informed of the clinical inappropriateness and radiation risks of CT imaging, parents often prefer to be reassured with negative results for younger children (37). As this study’s results show, PECARN rules reduced uncertainty and improved accuracy in medical decision-making and thus provide support for ED physicians to predict which children can be safely managed without CT scanning (38).
All things considered, according to this study with a relatively large sample size in a limited resource setting, despite not having a QI team in place and an ability to monitor things closely, the PECARN rules seem to meet the objective of limiting the use of CT, yet this reduction could be greater by implementing more changes provided additional resources and administrative support are available.
Because structural support has been shown to be effective at supporting reliable change (39), it may be beneficial to create a head trauma electronic order set to remind clinicians of the ciTBI predictors in children with minor head trauma. Future interventions may also include individual provider feedback on CT scanning rates (40, 41) and surveys for PED physicians about causes for failing to adhere to guidelines (42). Prospective well-designed studies with detailed impact analysis would further support the use of PECARN rules in daily clinical practice. It would then be ideal to implement these changes at a national level, especially given the prevalence of pediatric head trauma.
This is a retrospective single center study, where missing or inaccurate data especially in this history and physical exam findings may not have been accounted for. Moreover, we had no access to the medical records of 37 patients among those who were screened for inclusion, which amount to 2% of the excluded patients. Although we kept the data collection simple, following the PECARN predictors, the reliance on previously documented data might have led to misclassification of patients. Additionally, bounce backs may have presented to outside facilities and may have been missed. However, given that our hospital is the major referral center in our country, bounce backs to other centers would be minimal. Moreover, no standard QI techniques were used to study the effects of implementation. As such, the decrease being a result of the implementation alone is uncertain, however, no other interventions related to care of minor head trauma were implemented at that time.