Article: AENJ-D-14-00025
Date: October 17, 2014
Time: 1:56
Advanced Emergency Nursing Journal Vol. 36, No. 4, pp. 294–298 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
R E S E A R C H
T O
Practice Column Editors: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, and Susan E. Shapiro, PhD, RN, FAAN
Does Emergency Department Observation Impact the Rate of Computed Tomography in Children With Minor Blunt Head Trauma? Kari J. Blackburn, DNP, RN, CPEN Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN
Abstract Review of recent evidence with translation to practice for the advanced practice nurse (APN) role is presented using a case study module for “The Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Blunt Head Trauma.” The study results showed that 49% of the patients were “observed” in the emergency department (ED). Of those “observed” (N = 676) in the ED, the authors found that 20% had a computed tomographic (CT) scan performed. However, “observed” patients did experience a lower rate of CT scan (5%) than “nonobserved” patients. The implications and clinical relevance of these findings for APNs are discussed, highlighting best practice evidence. Key words: blunt head trauma, computed tomography, observation
T
HE PURPOSE OF THE RESEARCH to Practice column is to assist advanced practice nurses (APNs) to translate current research and apply it to their everyday practice. A topic and a related research study are selected for each column. Next, a casebased scenario is presented. The research ar-
ticle is reviewed and critiqued. Finally, the implications for translation into practice are discussed. In this column, the following research article is reviewed: “The Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Blunt Head Trauma” (Schonfeld, Fitz, & Nigrovic, 2013). The implications of these findings for APNs are discussed.
Author Affiliation: Makenna David Pediatric Emergency Center, University of Kentucky Chandler Hospital, Lexington. Disclosure: The authors report no conflicts of interest. Corresponding Author: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, Emergency Services, University of Kentucky Healthcare, 1000 S. Limestone St, A.00.401, Lexington, KY 40536 (pkhoward @uky.edu).
THE CASE A 4-year-old African American boy presented to the emergency department (ED) with an initial complaint of falling from a tree approximately 45 min prior to arrival. His mother
DOI: 10.1097/TME.0000000000000041
294
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00025
October–December 2014
Date: October 17, 2014
r Vol. 36, No. 4
reported that her son was climbing a tree in their yard, appeared to lose his footing, and fell about 4 ft. onto a grassy surface. His mother noticed bruising to his right forehead immediately after the incident and presented to the ED requesting a computed tomographic (CT) scan as soon as possible. When questioned, she responded that the child did not have a loss of consciousness (LOC). The mother also stated that her child got up and was ambulatory before she could get to him. Per the ED protocols, the child and his mother were immediately taken to a treatment area for triage; at the time of triage, the child’s only complaint was that his head was hurting. He denied neck or back pain and stated that he wanted to go home and was hungry. His vital signs were as follows: heart rate, 94/min; blood pressure, 94/62 mmHg, respiratory rate, 18/min, oxygen saturation, 100%, oral temperature, 36.6 ◦ C (97.9 ◦ F), and an actual weight of 18 kg. He rated his head hurting as a pain level of 2 out of 10 using the WongBaker Faces Pain Rating Scale (Wong-Baker Faces Foundation, 1983). His mother stated the child had a past medical history of asthma, seasonal allergies, and ear tubes. Across-theroom assessment revealed ecchymosis to the right frontal area with intact skin. The patient recognized his mother, told the clinician the name of his 2-year-old sister, and knew that tomorrow was a school day, which validated the clinician’s initial impression of a Glasgow Coma Scale (GCS) score of 4–6–5; his pupils were 3 mm bilaterally and were equal, round, and reactive to light. The remainder of his physical examination was unremarkable, and his immunizations were current for age. As the APN in a pediatric ED, the clinician recognized that this child would be considered as at very low risk for clinically significant head trauma, based on the decision rules of the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury risk groups for children with minor head injury (Kupperman et al., 2009; see Table 1). The PECARN very low-risk group recommends observation of a child with a minor closed head injury. As the clinician explained
Time: 1:56
ED Observation vs. CT Scan for Mild Head Trauma
295
this to the mother, she seems concerned, frustrated, and continued to demand the CT scan. As the APN caring for her son, the clinician calmly explained that based on the clinician’s careful examination of the child and the recommended practices for children who have a head injury such as her son’s, a CT scan was not indicated at this time (Schutzman, 2014). The clinician also explained the risks associated with radiation and unnecessary exposure to radiation, especially for children. DESIGN AND METHODS Schonfeld et al. (2013) conducted a prospective cohort study over 20 months from April 2011 to December 2012 to determine whether increased ED observation times reduced the number of CT scans ordered for children with minor blunt head trauma. The study sample included children up to the age of 18 years with a GCS score of 14 or greater who sought ED care within 24 hr of the minor blunt head trauma event. Exclusion criteria included children who received neuroimaging prior to study enrollment, those with minor mechanisms of injury, those with bleeding disorders, or those with known neurological disease such as brain tumors or hydrocephalus. The setting was a pediatric ED in an academic medical center. Informed consent was obtained from physicians because the outcome of this study was dependent on physician care practices. The two types of study participants were attending physicians or fellows in pediatric emergency medicine and general pediatricians; of interest, the one APN participating was classified as a general pediatrician in this study. Informed consent was not obtained from parents because the study was looking at outcomes associated with physician decisions. Providers who participated in the investigation completed a study form for each child who met the inclusion criteria. Risk stratification for this study was performed using the PECARN traumatic brain injury clinical predictors of high-, intermediate-, and very low-risk determination for each child and was noted
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00025
Date: October 17, 2014
Time: 1:56
Advanced Emergency Nursing Journal
296
Table 1. PECARN traumatic brain injury risk groups for children with minor head trauma Predictors less than 2 years of age
Predictors 2 or more years of age
Altered mental status Palpable skull fracture Severe injury mechanism Loss of consciousness of more than 5 s Nonfrontal hematoma Not acting right per parents None
Altered mental status Signs of basilar skull fracture Severe injury mechanism Any loss of consciousness
Risk group High Intermediate
Very low
Vomiting Severe headache None
Note. PECARN = Pediatric Emergency Care Applied Research Network. From “Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Head Trauma,” by D. Schonfeld, B. Fitz, and L. Nigrovic, 2013, Annals of Emergency Medicine, 6(62), pp. 597–603. Copyright 2013 by Elsevier. Adapted with permission.
on the associated study form. A determination was made after initial patient assessment as to “observed,” that is, those children for whom a CT scan was deferred for clinical observation, or “nonobserved,” that is, those children for whom an immediate decision was made by the physician/provider for either imaging or ED discharge. Electronic medical records were reviewed up to 7 days postvisit to evaluate if the children received further care related to their minor blunt head trauma event. Data collected included demographics, time of ED arrival, CT scan decision, ED length of stay, and ED disposition. Primary data analysis was completed using descriptive statistics with 95% confidence intervals (CIs), when indicated, and bivariate analyses to evaluate clinical characteristics with care management patterns. Multivariate logistic regression was done to assess for relationships between ED observation times and the rate of CT scan performance across the risk-stratified groups. It is important to note that the researchers assumed a baseline CT scan rate for head trauma of 25% from historical institutional data. RESULTS AND DISCUSSION Ninety-eight physicians completed study forms on 1,381 of 1,605 eligible patients during the study period (86%). Thirty-seven per-
cent of the patients evaluated were younger than 2 years, and only 12 children in total returned to the ED within 7 days of their initial evaluation for reasons related to the initial ED visit. Forty-nine percent of the patients evaluated by the study physicians were “observed” in the ED. Of those “observed” (n = 676) in the ED, the authors found that 20% ultimately had a CT scan performed. However, “observed” patients did experience a lower rate of CT scan (5%) than “nonobserved” patients (34%; odds ratio [OR] = 0.10; 95% CI = 0.07, 0.14). Increased length of observation was correlated with an associated decrease in CT scans performed (OR = 0.31; 95% CI = 0.25, 0.37); this was consistent across all of the PECARN risk groups. Four patients (1%) in the “observed” group had a clinically significant CT finding, whereas there were 49 patients (7%) in the “nonobserved” group with positive CT results. For this study, Schonfeld et al. defined positive or clinically significant findings as “skull fracture or traumatic brain injury (intracranial hemorrhage or contusion, cerebral edema, traumatic infarction, midline shift or signs of brain herniation, diffuse axonal injury, or pneumocephalus)” (2013, p. 599). The researchers did not report median length of stay by group but rather as overall length of ED visit (3.2 hr), CT scan obtained
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00025
October–December 2014
Date: October 17, 2014
r Vol. 36, No. 4
(5.1 hr), and CT scan not obtained (3.2 hr). The decision to “observe” was a provider decision, and it is relevant to recognize that the investigators were unable to identify the optimal length of time for observation following minor blunt head trauma prior to discharge or initiating a CT scan. LIMITATIONS To evaluate potential outcomes in patients with clinically significant head injury who are “observed” prior to a CT scan, the authors of this study identified the need to perform this investigation with a much larger population of children who meet the inclusion criteria. In this study, the time of observation may not be accurate because the authors chose the time of attending sign up as the time physician observation/monitoring began. The time of injury was estimated by caregiver report; this time could be skewed as well. Sevenday clinical follow-up may not be accurate because these data are limited to follow-up at the study site documented in the electronic medical record. The possibility also exists that some “observed” children may have had positive findings if a CT scan had been obtained. The decision to observe or not to observe was at the physician’s discretion. This single factor may have the greatest impact because clinical presentation and initial assessment may influence obtaining a CT scan and could have skewed the number of patients in each group. KARI’S COMMENTS Head injuries account for approximately 700,000 ED visits yearly, with 40%–50% of those being children (National Institute for Health and Clinical Excellence, 2007). Parents/caregivers may bring their child with a potential head injury to the ED requesting a CT scan. Parental request for a CT scan of head following minor head trauma may artificially impact rates of CT scans performed prior to this study. Klassen et al. (2000), Broder, Fordham, and Warshauer (2007), and Blackwell,
Time: 1:56
ED Observation vs. CT Scan for Mild Head Trauma
297
Gorelick, Holmes, Bandyopadhyay, and Kuppermann (2007) found that the rate of pediatric cranial CT use has increased significantly during the last several decades, although CT use rates have decreased in those with minor blunt head injury (Mannix, Meehan, Baucher, & Mounteaux, 2012). The reduction in CT scan rates for very low-risk head trauma is consistent with the finding of Schonfeld et al. (2013) that observation is a common strategy to evaluate minor head injuries in the ED. It is important for the APN to note the study finding that each hour of observation postinjury reduced the incidence of a CT scan by 70%. Although not stated explicitly in the study, longer lengths of observation do provide a greater opportunity to observe the child’s normal behavior and interaction patterns, which if they remain unremarkable, form the basis for deciding not to perform a CT scan at that time. By sharing these observations with the parents, the APN can help allay parents’ anxiety and gain their cooperation in implementing best practices for their child. This study also provides evidence that obtaining a CT scan increases the overall length of ED visit, and the APN should explain this to the parents/caregivers when providing an update on the plan of care. Application of the PECARN risk decision rules to the child’s clinical presentation will provide rationale for ED observation. Information given to the parents/caregivers should include the potential long-term side effects of exposure to radiation during infancy and childhood including an increased incidence of leukemia and brain cancer (Pearce et al., 2012). CASE STUDY OUTCOME The patient was observed in the pediatric ED for 4 hr. The patient continued to complain about his head hurting, with no change in pain rating, and a weight-based dose of acetaminophen was administered. While being observed, he tolerated oral intake and denied feeling sick. He was able to play video games appropriate for his age and ambulated to the
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00025
Date: October 17, 2014
298
bathroom without difficulty. When reassessed and asked about pain, the patient pointed to 0 out of 10 on the Wong-Baker Faces Pain Rating Scale. The mother felt comfortable with the plan to be discharged home after the 4-hr observation period. The mother verbalized to bring her son back to the ED immediately if patient began vomiting, had an altered LOC, or if she had any other concerns. CONCLUSION The study completed by Schonfeld et al. (2013) provides the APN with current evidence in support of observation before initiating a CT scan and helps identify decision-making tips using the PECARN traumatic brain injury risk injury groups for children with minor head trauma. The incidence of head injuries highlights the need for the APN to remain abreast of current management strategies. This investigation provides support for observation of the child with minor blunt head injury in the ED by the APN. REFERENCES Blackwell, C. D., Gorelick, M., Holmes, J. F., Bandyopadhyay, S., & Kuppermann, N. (2007). Pediatric head trauma: Changes in use of computed tomography in emergency departments in the United States over time. Annals of Emergency Medicine, 49(3), 320– 324. Broder, J., Fordham, L., & Warshauer, D. M. (2007). Increasing utilization of computed tomography in the pediatric emergency department. Emergency Radiology, 14(4), 227–232.
Time: 1:56
Advanced Emergency Nursing Journal
Klassen, T., Reed, M., Stiell, I., Nijssen, C., Tenenbein, M., & Joubert, G., Colbourne, M. (2000). Variation in utilization of computed tomography scanning for the investigation of minor head trauma in children: A Canadian experience. Academy of Emergency Medicine, 7(7), 739–744. Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Atabaki, S. M., & Holubkov, R., Pediatric Emergency Care Applied Research Network (PECARN). (2009). Identification of children at very low risk of clinically—Important brain injuries after head trauma: A prospective cohort study. The Lancet, 374, 1160–1170. Mannix, R., Meehan, W., Baucher, R., & Mounteaux, M. (2012). Computed tomography for minor head injury: Variation and trends in major United States pediatric emergency department. Journal of Pediatrics, 160(1), 136–139. National Institute for Health and Clinical Excellence. (2007). Head injury—Triage, assessment, investigation and early management of head injury in infants, children and adults. NICE Clinical Guideline, No 56. Retrieved from http://www.nice.org.uk/ guidance/cG56 Pearce, M., Salotti, J. A., Little, M., McHugh, K., Lee, K., & Howe, N., Berrington, G. (2012). Radiation exposure from CT scans in childhood and subsequent risk of leukemia and brain tumors: A retrospective cohort study. The Lancet, 380, 489–505. Schonfeld, D., Fitz, B., & Nigrovic, L. (2013). Effect of the duration of emergency department observation on computed tomography use in children with minor head trauma. Annals of Emergency Medicine, 6(62), 597–603. Schutzman, S. (2014). Minor head trauma in infants and children: Management. UpToDate. Retrieved from http://www.uptodate.com/contents/minor-headtrauma-in-infants-and-children-management Wong-Baker Faces Foundation. (1983). Wong-Baker R pain rating scale. Retrieved from http:// Faces www.wongbakerfaces.org/
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Date: October 17, 2014
Time: 1:56
Advanced Emergency Nursing Journal Vol. 36, No. 4, pp. 294–298 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
R E S E A R C H
T O
Practice Column Editors: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, and Susan E. Shapiro, PhD, RN, FAAN
Does Emergency Department Observation Impact the Rate of Computed Tomography in Children With Minor Blunt Head Trauma? Kari J. Blackburn, DNP, RN, CPEN Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN
Abstract Review of recent evidence with translation to practice for the advanced practice nurse (APN) role is presented using a case study module for “The Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Blunt Head Trauma.” The study results showed that 49% of the patients were “observed” in the emergency department (ED). Of those “observed” (N = 676) in the ED, the authors found that 20% had a computed tomographic (CT) scan performed. However, “observed” patients did experience a lower rate of CT scan (5%) than “nonobserved” patients. The implications and clinical relevance of these findings for APNs are discussed, highlighting best practice evidence. Key words: blunt head trauma, computed tomography, observation
T
HE PURPOSE OF THE RESEARCH to Practice column is to assist advanced practice nurses (APNs) to translate current research and apply it to their everyday practice. A topic and a related research study are selected for each column. Next, a casebased scenario is presented. The research ar-
ticle is reviewed and critiqued. Finally, the implications for translation into practice are discussed. In this column, the following research article is reviewed: “The Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Blunt Head Trauma” (Schonfeld, Fitz, & Nigrovic, 2013). The implications of these findings for APNs are discussed.
Author Affiliation: Makenna David Pediatric Emergency Center, University of Kentucky Chandler Hospital, Lexington. Disclosure: The authors report no conflicts of interest. Corresponding Author: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, Emergency Services, University of Kentucky Healthcare, 1000 S. Limestone St, A.00.401, Lexington, KY 40536 (pkhoward @uky.edu).
THE CASE A 4-year-old African American boy presented to the emergency department (ED) with an initial complaint of falling from a tree approximately 45 min prior to arrival. His mother
DOI: 10.1097/TME.0000000000000041
294
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00025
October–December 2014
Date: October 17, 2014
r Vol. 36, No. 4
reported that her son was climbing a tree in their yard, appeared to lose his footing, and fell about 4 ft. onto a grassy surface. His mother noticed bruising to his right forehead immediately after the incident and presented to the ED requesting a computed tomographic (CT) scan as soon as possible. When questioned, she responded that the child did not have a loss of consciousness (LOC). The mother also stated that her child got up and was ambulatory before she could get to him. Per the ED protocols, the child and his mother were immediately taken to a treatment area for triage; at the time of triage, the child’s only complaint was that his head was hurting. He denied neck or back pain and stated that he wanted to go home and was hungry. His vital signs were as follows: heart rate, 94/min; blood pressure, 94/62 mmHg, respiratory rate, 18/min, oxygen saturation, 100%, oral temperature, 36.6 ◦ C (97.9 ◦ F), and an actual weight of 18 kg. He rated his head hurting as a pain level of 2 out of 10 using the WongBaker Faces Pain Rating Scale (Wong-Baker Faces Foundation, 1983). His mother stated the child had a past medical history of asthma, seasonal allergies, and ear tubes. Across-theroom assessment revealed ecchymosis to the right frontal area with intact skin. The patient recognized his mother, told the clinician the name of his 2-year-old sister, and knew that tomorrow was a school day, which validated the clinician’s initial impression of a Glasgow Coma Scale (GCS) score of 4–6–5; his pupils were 3 mm bilaterally and were equal, round, and reactive to light. The remainder of his physical examination was unremarkable, and his immunizations were current for age. As the APN in a pediatric ED, the clinician recognized that this child would be considered as at very low risk for clinically significant head trauma, based on the decision rules of the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury risk groups for children with minor head injury (Kupperman et al., 2009; see Table 1). The PECARN very low-risk group recommends observation of a child with a minor closed head injury. As the clinician explained
Time: 1:56
ED Observation vs. CT Scan for Mild Head Trauma
295
this to the mother, she seems concerned, frustrated, and continued to demand the CT scan. As the APN caring for her son, the clinician calmly explained that based on the clinician’s careful examination of the child and the recommended practices for children who have a head injury such as her son’s, a CT scan was not indicated at this time (Schutzman, 2014). The clinician also explained the risks associated with radiation and unnecessary exposure to radiation, especially for children. DESIGN AND METHODS Schonfeld et al. (2013) conducted a prospective cohort study over 20 months from April 2011 to December 2012 to determine whether increased ED observation times reduced the number of CT scans ordered for children with minor blunt head trauma. The study sample included children up to the age of 18 years with a GCS score of 14 or greater who sought ED care within 24 hr of the minor blunt head trauma event. Exclusion criteria included children who received neuroimaging prior to study enrollment, those with minor mechanisms of injury, those with bleeding disorders, or those with known neurological disease such as brain tumors or hydrocephalus. The setting was a pediatric ED in an academic medical center. Informed consent was obtained from physicians because the outcome of this study was dependent on physician care practices. The two types of study participants were attending physicians or fellows in pediatric emergency medicine and general pediatricians; of interest, the one APN participating was classified as a general pediatrician in this study. Informed consent was not obtained from parents because the study was looking at outcomes associated with physician decisions. Providers who participated in the investigation completed a study form for each child who met the inclusion criteria. Risk stratification for this study was performed using the PECARN traumatic brain injury clinical predictors of high-, intermediate-, and very low-risk determination for each child and was noted
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00025
Date: October 17, 2014
Time: 1:56
Advanced Emergency Nursing Journal
296
Table 1. PECARN traumatic brain injury risk groups for children with minor head trauma Predictors less than 2 years of age
Predictors 2 or more years of age
Altered mental status Palpable skull fracture Severe injury mechanism Loss of consciousness of more than 5 s Nonfrontal hematoma Not acting right per parents None
Altered mental status Signs of basilar skull fracture Severe injury mechanism Any loss of consciousness
Risk group High Intermediate
Very low
Vomiting Severe headache None
Note. PECARN = Pediatric Emergency Care Applied Research Network. From “Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Head Trauma,” by D. Schonfeld, B. Fitz, and L. Nigrovic, 2013, Annals of Emergency Medicine, 6(62), pp. 597–603. Copyright 2013 by Elsevier. Adapted with permission.
on the associated study form. A determination was made after initial patient assessment as to “observed,” that is, those children for whom a CT scan was deferred for clinical observation, or “nonobserved,” that is, those children for whom an immediate decision was made by the physician/provider for either imaging or ED discharge. Electronic medical records were reviewed up to 7 days postvisit to evaluate if the children received further care related to their minor blunt head trauma event. Data collected included demographics, time of ED arrival, CT scan decision, ED length of stay, and ED disposition. Primary data analysis was completed using descriptive statistics with 95% confidence intervals (CIs), when indicated, and bivariate analyses to evaluate clinical characteristics with care management patterns. Multivariate logistic regression was done to assess for relationships between ED observation times and the rate of CT scan performance across the risk-stratified groups. It is important to note that the researchers assumed a baseline CT scan rate for head trauma of 25% from historical institutional data. RESULTS AND DISCUSSION Ninety-eight physicians completed study forms on 1,381 of 1,605 eligible patients during the study period (86%). Thirty-seven per-
cent of the patients evaluated were younger than 2 years, and only 12 children in total returned to the ED within 7 days of their initial evaluation for reasons related to the initial ED visit. Forty-nine percent of the patients evaluated by the study physicians were “observed” in the ED. Of those “observed” (n = 676) in the ED, the authors found that 20% ultimately had a CT scan performed. However, “observed” patients did experience a lower rate of CT scan (5%) than “nonobserved” patients (34%; odds ratio [OR] = 0.10; 95% CI = 0.07, 0.14). Increased length of observation was correlated with an associated decrease in CT scans performed (OR = 0.31; 95% CI = 0.25, 0.37); this was consistent across all of the PECARN risk groups. Four patients (1%) in the “observed” group had a clinically significant CT finding, whereas there were 49 patients (7%) in the “nonobserved” group with positive CT results. For this study, Schonfeld et al. defined positive or clinically significant findings as “skull fracture or traumatic brain injury (intracranial hemorrhage or contusion, cerebral edema, traumatic infarction, midline shift or signs of brain herniation, diffuse axonal injury, or pneumocephalus)” (2013, p. 599). The researchers did not report median length of stay by group but rather as overall length of ED visit (3.2 hr), CT scan obtained
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00025
October–December 2014
Date: October 17, 2014
r Vol. 36, No. 4
(5.1 hr), and CT scan not obtained (3.2 hr). The decision to “observe” was a provider decision, and it is relevant to recognize that the investigators were unable to identify the optimal length of time for observation following minor blunt head trauma prior to discharge or initiating a CT scan. LIMITATIONS To evaluate potential outcomes in patients with clinically significant head injury who are “observed” prior to a CT scan, the authors of this study identified the need to perform this investigation with a much larger population of children who meet the inclusion criteria. In this study, the time of observation may not be accurate because the authors chose the time of attending sign up as the time physician observation/monitoring began. The time of injury was estimated by caregiver report; this time could be skewed as well. Sevenday clinical follow-up may not be accurate because these data are limited to follow-up at the study site documented in the electronic medical record. The possibility also exists that some “observed” children may have had positive findings if a CT scan had been obtained. The decision to observe or not to observe was at the physician’s discretion. This single factor may have the greatest impact because clinical presentation and initial assessment may influence obtaining a CT scan and could have skewed the number of patients in each group. KARI’S COMMENTS Head injuries account for approximately 700,000 ED visits yearly, with 40%–50% of those being children (National Institute for Health and Clinical Excellence, 2007). Parents/caregivers may bring their child with a potential head injury to the ED requesting a CT scan. Parental request for a CT scan of head following minor head trauma may artificially impact rates of CT scans performed prior to this study. Klassen et al. (2000), Broder, Fordham, and Warshauer (2007), and Blackwell,
Time: 1:56
ED Observation vs. CT Scan for Mild Head Trauma
297
Gorelick, Holmes, Bandyopadhyay, and Kuppermann (2007) found that the rate of pediatric cranial CT use has increased significantly during the last several decades, although CT use rates have decreased in those with minor blunt head injury (Mannix, Meehan, Baucher, & Mounteaux, 2012). The reduction in CT scan rates for very low-risk head trauma is consistent with the finding of Schonfeld et al. (2013) that observation is a common strategy to evaluate minor head injuries in the ED. It is important for the APN to note the study finding that each hour of observation postinjury reduced the incidence of a CT scan by 70%. Although not stated explicitly in the study, longer lengths of observation do provide a greater opportunity to observe the child’s normal behavior and interaction patterns, which if they remain unremarkable, form the basis for deciding not to perform a CT scan at that time. By sharing these observations with the parents, the APN can help allay parents’ anxiety and gain their cooperation in implementing best practices for their child. This study also provides evidence that obtaining a CT scan increases the overall length of ED visit, and the APN should explain this to the parents/caregivers when providing an update on the plan of care. Application of the PECARN risk decision rules to the child’s clinical presentation will provide rationale for ED observation. Information given to the parents/caregivers should include the potential long-term side effects of exposure to radiation during infancy and childhood including an increased incidence of leukemia and brain cancer (Pearce et al., 2012). CASE STUDY OUTCOME The patient was observed in the pediatric ED for 4 hr. The patient continued to complain about his head hurting, with no change in pain rating, and a weight-based dose of acetaminophen was administered. While being observed, he tolerated oral intake and denied feeling sick. He was able to play video games appropriate for his age and ambulated to the
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Article: AENJ-D-14-00025
Date: October 17, 2014
298
bathroom without difficulty. When reassessed and asked about pain, the patient pointed to 0 out of 10 on the Wong-Baker Faces Pain Rating Scale. The mother felt comfortable with the plan to be discharged home after the 4-hr observation period. The mother verbalized to bring her son back to the ED immediately if patient began vomiting, had an altered LOC, or if she had any other concerns. CONCLUSION The study completed by Schonfeld et al. (2013) provides the APN with current evidence in support of observation before initiating a CT scan and helps identify decision-making tips using the PECARN traumatic brain injury risk injury groups for children with minor head trauma. The incidence of head injuries highlights the need for the APN to remain abreast of current management strategies. This investigation provides support for observation of the child with minor blunt head injury in the ED by the APN. REFERENCES Blackwell, C. D., Gorelick, M., Holmes, J. F., Bandyopadhyay, S., & Kuppermann, N. (2007). Pediatric head trauma: Changes in use of computed tomography in emergency departments in the United States over time. Annals of Emergency Medicine, 49(3), 320– 324. Broder, J., Fordham, L., & Warshauer, D. M. (2007). Increasing utilization of computed tomography in the pediatric emergency department. Emergency Radiology, 14(4), 227–232.
Time: 1:56
Advanced Emergency Nursing Journal
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