Interventions to Reduce Imaging in Children With Minor Traumatic Head Injury: A Systematic Review

Abstract

CONTEXT: Reducing unnecessary imaging in emergency departments (EDs) for children with minor traumatic brain injuries (mTBIs) has been encouraged. OBJECTIVE: Our objective was to systematically review the effectiveness of interventions to decrease imaging in this population. DATA SOURCES: Eight electronic databases and the gray literature were searched. STUDY SELECTION: Comparative studies assessing ED interventions to reduce imaging in children with mTBIs were eligible. DATA EXTRACTION: Two independent reviewers screened studies, completed a quality assessment, and extracted data. The median of relative risks with interquartile range (IQR) are reported. A multivariable metaregression identified predictors of relative change in imaging. RESULTS: Twenty-eight studies were included, and most (79%) used before–after designs. The Pediatric Emergency Care Applied Research Network (PECARN) rule was the most common intervention (71%); most studies (75%) used multifaceted interventions (median components: 3; IQR: 1.75 to 4). Before–after studies assessing multi-faceted PECARN interventions reported decreased computed tomography (CT) head imaging (relative risk = 0.73; IQR: 0.60 to 0.89). Higher baseline imagine (P < .001) and additional intervention components (P = .008) were associated with larger imaging decreases. LIMITATIONS: The limitations of this study include the inconsistent reporting of important outcomes and that the results are based on non-randomized studies. CONCLUSIONS: Implementing interventions in EDs with high baseline CT ordering using complex interventions was more likely to reduce head imaging in children with mTBIs. Including the PECARN decision rule in the intervention strategy decreased orders by a median of 27%. Further research could provide insight into which specific factors influence successful implementation and sustained effects.