Multi‐centre study found that strict adherence to guidelines led to computed tomography scans being overused in children with minor head injuries

Abstract

Aim Our primary aim was to calculate the head computed tomography (CT) scan rate in children with a minor head injury (MHI) when the Dutch National guidelines were followed in clinical practice. The secondary aim was to determine the incidence of CT abnormalities and the guideline predictors associated with traumatic abnormalities. Methods We performed a multi‐centre, prospective observational cross‐sectional study in the emergency departments of six hospitals in The Netherlands between 1 April 2015 and 31 December 2016. Results Data on 1002 patients were studied and 69% of cases complied with the guidelines. The overall CT rate was 44% and the incidence of traumatic abnormal CT findings was 13%. CT scans were performed in 19% of children under two years of age, 48% of children between two and five years and 63% of children aged six years or more. Multivariate regression analysis for all age categories showed that CT abnormalities were predicted by a Glasgow Coma Scale of less than 15, suspicion of a basal skull fracture, vomiting and scalp haematomas or external lesions of the skull. Conclusion Strict adherence to the Dutch national guidelines resulted in CT overuse. New guidelines are needed to safely reduce CT scan indications.

Large Variety of Medical Specialties Involved in Management of Pediatric Minor Traumatic Head Injury in the Netherlands

“…First, in our recent multicenter study, we evaluated guidelines adherence and CT use in pediatric MTHI among 1002 children in the northwest region of the Netherlands. 5 We observed that guideline adherence was significantly higher among pediatricians (71%) and emergency physicians (73%), whereas neurologist adherence was lowest at 52%. Strict adherence to the guidelines, however, resulted in overuse of CT scans.…”

“…4 Also, a recent prospective multicenter study among 1002 children in the northwest region of the Netherlands showed a high CT rate of 44%. 5 This high CT use cannot be explained by increase of patient severity or increase rates of clinically important traumatic brain injuries. 4,6,7 Several factors may contribute to CT scan increase.…”

Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries

“…This was a planned sub-study of a prospective multicentre observational study that enrolled 1006 children younger than 18 years with MTHI who presented to six emergency departments in The Netherlands between 1 April 2015 and 31 December 2016 [ 9 ]. Exclusion criteria were incomplete data to compare guidelines on a case by case comparison.…”

“…The Dutch national guidelines define several major and minor clinical criteria, specified by three age categories, namely under the age of two, between 2 and 5 years and 6 years or more (Supplemental Table 1 ) [ 1 , 8 , 9 ]. For children under the age of two, a CT scan was recommended if they had one or more major criteria.…”

“…External validations were performed in many settings and many countries to compare these rules for projected CT rates, diagnostic accuracy, and a cost-effectiveness analysis [ 5 – 7 ]. In The Netherlands, however, 2010 national guidelines are still used in clinical practice and strict adherence to these guidelines results in an overall high CT scan rate of 44% [ 8 , 9 ]. In order to safely reduce this high number, it is methodologically more appropriate to determine the potential impact of one of these validated clinical decision rules on this CT rate [ 6 ].…”