Sarah Dalton

Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study

BACKGROUND Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children. METHODS In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13-15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673. FINDINGS Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7-100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4-100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2-99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2-93·4; 125/141) and CHALICE (92·3%, 89·2-94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules. INTERPRETATION The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules. FUNDING National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.

Triggers for head computed tomography following paediatric head injury: Comparison of physicians' reported practice and clinical decision rules.

To compare head computed tomography (CT) triggers for paediatric head injury as reported by senior paediatric emergency physicians in Australia and New Zealand with triggers in published evidence‐based clinical decision rules (CDRs).

Motivating medicine: Why money is not enough

The public health system in Australia currently faces unprecedented challenges managing an ageing population with a rising burden of illness. Health professionals employed in the area are under constant pressure to do more with less, leading to high levels of employee dissatisfaction. Physician satisfaction is a critical aspect of quality health care, allowing the development of a motivated workforce committed to improving patient outcomes. Herzberg has identified several factors that contribute to employee motivation, including financial remuneration, work–life balance and the recognition and reward of good performance. Some strategies are more effective than others; here we discuss their relative advantages, the role of financial rewards, and propose other interventions to ‘switch on’ motivation.

Diagnosing appendicitis: What works, what does not and where to go from here?

Although acute appendicitis is the most common reason for emergency abdominal surgery in children, diagnosis is far from straightforward. Delays in diagnosis can result in significant complications, whereas over‐diagnosis can result in costly inter‐hospital transfers and unnecessary surgery. This article aims to describe current evidence‐based assessment of children with possible appendicitis presenting to the emergency department. We provide an overview of the literature relating to the various available diagnostic approaches, including the application of history, examination, pathology tests, imaging, and clinical decision rules.

Quality of Health Care for Children in Australia, 2012-2013.

Importance The quality of routine care for children is rarely assessed, and then usually in single settings or for single clinical conditions. Objective To estimate the quality of health care for children in Australia in inpatient and ambulatory health care settings. Design, Setting, and Participants Multistage stratified sample with medical record review to assess adherence with quality indicators extracted from clinical practice guidelines for 17 common, high-burden clinical conditions (noncommunicable [n = 5], mental health [n = 4], acute infection [n = 7], and injury [n = 1]), such as asthma, attention-deficit/hyperactivity disorder, tonsillitis, and head injury. For these 17 conditions, 479 quality indicators were identified, with the number varying by condition, ranging from 9 for eczema to 54 for head injury. Four hundred medical records were targeted for sampling for each of 15 conditions while 267 records were targeted for anxiety and 133 for depression. Within each selected medical record, all visits for the 17 targeted conditions were identified, and separate quality assessments made for each. Care was evaluated for 6689 children 15 years of age and younger who had 15 240 visits to emergency departments, for inpatient admissions, or to pediatricians and general practitioners in selected urban and rural locations in 3 Australian states. These visits generated 160 202 quality indicator assessments. Exposures Quality indicators were identified through a systematic search of local and international guidelines. Individual indicators were extracted from guidelines and assessed using a 2-stage Delphi process. Main Outcomes and Measures Quality of care for each clinical condition and overall. Results Of 6689 children with surveyed medical records, 53.6% were aged 0 to 4 years and 55.5% were male. Adherence to quality of care indicators was estimated at 59.8% (95% CI, 57.5%-62.0%; n = 160 202) across the 17 conditions, ranging from a high of 88.8% (95% CI, 83.0%-93.1%; n = 2638) for autism to a low of 43.5% (95% CI, 36.8%-50.4%; n = 2354) for tonsillitis. The mean adherence by condition category was estimated as 60.5% (95% CI, 57.2%-63.8%; n = 41 265) for noncommunicable conditions (range, 52.8%-75.8%); 82.4% (95% CI, 79.0%-85.5%; n = 14 622) for mental health conditions (range, 71.5%-88.8%); 56.3% (95% CI, 53.2%-59.4%; n = 94 037) for acute infections (range, 43.5%-69.8%); and 78.3% (95% CI, 75.1%-81.2%; n = 10 278) for injury. Conclusions and Relevance Among a sample of children receiving care in Australia in 2012-2013, the overall prevalence of adherence to quality of care indicators for important conditions was not high. For many of these conditions, the quality of care may be inadequate.

Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study

Study objective: Three clinical decision rules for head injuries in children (Pediatric Emergency Care Applied Research Network [PECARN], Canadian Assessment of Tomography for Childhood Head Injury [CATCH], and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE]) have been shown to have high performance accuracy. The utility of any of these in a particular setting depends on preexisting clinician accuracy. We therefore assess the accuracy of clinician practice in detecting clinically important traumatic brain injury. Methods: This was a planned secondary analysis of a prospective observational study of children younger than 18 years with head injuries at 10 Australian and New Zealand centers. In a cohort of children with mild head injuries (Glasgow Coma Scale score 13 to 15, presenting in <24 hours) we assessed physician accuracy (computed tomography [CT] obtained in emergency departments [EDs]) for the standardized outcome of clinically important traumatic brain injury and compared this with the accuracy of PECARN, CATCH, and CHALICE. Results: Of 20,137 children, 18,913 had a mild head injury. Of these patients, 1,579 (8.3%) received a CT scan during the ED visit, 160 (0.8%) had clinically important traumatic brain injury, and 24 (0.1%) underwent neurosurgery. Clinician identification of clinically important traumatic brain injury based on CT performed had a sensitivity of 158 of 160, or 98.8% (95% confidence interval [CI] 95.6% to 99.8%) and a specificity of 17,332 of 18,753, or 92.4% (95% CI 92.0% to 92.8%). Sensitivity of PECARN for children younger than 2 years was 42 of 42 (100.0%; 95% CI 91.6% to 100.0%), and for those 2 years and older, it was 117 of 118 (99.2%; 95% CI 95.4% to 100.0%); for CATCH (high/medium risk), it was 147 of 160 (91.9%; 95% CI 86.5% to 95.6%); and for CHALICE, 148 of 160 (92.5%; 95% CI 87.3% to 96.1%). Conclusion: In a setting with high clinician accuracy and a low CT rate, PECARN, CATCH, or CHALICE clinical decision rules have limited potential to increase the accuracy of detecting clinically important traumatic brain injury and may increase the CT rate.

Computed tomography for head injuries in children: Change in Australian usage rates over time

Paediatric head injury is a common presentation to the ED. North American studies demonstrate increasing use of computed tomography (CT) brain scan (CTB) to investigate head injury. No such data exists for Australian EDs. The aim of this study was to describe CTB use in head injury over time in eight Australian EDs.

CareTrack Kids-part 3. Adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review.

Introduction A high-quality health system should deliver care that is free from harm. Few large-scale studies of adverse events have been undertaken in childrens healthcare internationally, and none in Australia. The aim of this study is to measure the frequency and types of adverse events encountered in Australian paediatric care in a range of healthcare settings. Methods and analysis A form of retrospective medical record review, the Institute of Healthcare Improvements Global Trigger Tool, will be modified to collect data. Records of children aged <16 years managed during 2012 and 2013 will be reviewed. We aim to review 6000–8000 records from a sample of healthcare practices (hospitals, general practices and specialists). Ethics and dissemination Human Research Ethics Committee approvals have been received from the Sydney Childrens Hospital Network, Childrens Health Queensland Hospital and Health Service, and the Womens and Childrens Hospital Network in South Australia. An application is under review with the Royal Australian College of General Practitioners. The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.

Management of children with possible appendicitis: a survey of emergency physicians in Australia and New Zealand.

To describe current practice in managing children with possible acute appendicitis in EDs in Australia and New Zealand as the basis for a clinical practice guideline (CPG).

Transporting children with toxicological emergencies.

Each year, the Newborn and Paediatric Emergency Transport Service (NETS) receives over 3600 calls from health professionals regarding the management and transportation of critically ill children across New South Wales, with toxicological emergencies making up 1.5% of these calls. The aim of the present study is to describe the characteristics of patients transported for toxicological emergencies and their retrieval management.