A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings

Overview

Journal J Pediatr

Specialty Pediatrics

Date 2021 Apr 2

PMID 33798512

Citations 5

Authors

Kent P Hymel

Veronica Armijo-Garcia

Matthew Musick

Mark Marinello

Bruce E Herman

Kerri Weeks

Suzanne B Haney

Terra N Frazier

Christopher L Carroll

Natalie N Kissoon

Reena Isaac

Robin Foster

Kristine A Campbell

Kelly S Tieves

Nina Livingston

Ashley Bucher

Maria C Woosley

Dorinda Escamilla-Padilla

Nancy Jaimon

Lucinda Kustka

Ming Wang

Vernon M Chinchilli

Mark S Dias

Jennie Noll

Affiliations

Soon will be listed here.

Abstract

Objective: To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings.

Study Design: This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models.

Results: Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22).

Conclusions: PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings.

Trial Registration: ClinicalTrials.gov: NCT03162354.

Citing Articles

Validation of the PediBIRN-7 clinical prediction rule for pediatric abusive head trauma.

Hymel K, Carroll C, Frazier T, Weeks K, Herman B, Marinello M Child Abuse Negl. 2024; 152:106799.

PMID: 38663048 PMC: 11097240. DOI: 10.1016/j.chiabu.2024.106799.

Skeletal survey yields in low vs. high risk pediatric patients with skull fractures.

Isaac R, Greeley C, Marinello M, Herman B, Frazier T, Carroll C Child Abuse Negl. 2023; 139:106130.

PMID: 36905686 PMC: 10120383. DOI: 10.1016/j.chiabu.2023.106130.

Evidence for significant misdiagnosis of abusive head trauma in pediBIRN data.

Brook C Forensic Sci Int Synerg. 2023; 6:100314.

PMID: 36691664 PMC: 9860097. DOI: 10.1016/j.fsisyn.2023.100314.

An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma.

Hymel K, Boos S, Armijo-Garcia V, Musick M, Weeks K, Haney S Child Abuse Negl. 2022; 129:105666.

PMID: 35567958 PMC: 10724711. DOI: 10.1016/j.chiabu.2022.105666.

Screening for pediatric abusive head trauma: Are three variables enough?.

Hymel K, Karst W, Marinello M, Herman B, Frazier T, Carroll C Child Abuse Negl. 2022; 125:105518.

PMID: 35082111 PMC: 8842560. DOI: 10.1016/j.chiabu.2022.105518.

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