Protocol Development for an Emergency Department at an Urban Utah Hospital

Pediatric head trauma protocols have been shown to decrease unnecessary imaging for patients being evaluated for a head trauma in the emergency department. The purpose of this project was to assess the current imaging and treatment practices of the providers at an urban medical center and to develop a pediatric head trauma protocol for this facility to be integrated into the health care electronic health record (EHR) of the healthcare facility. Information regarding imaging practices and provider protocol preferences for evaluating head trauma in children were identified through the use of provider surveys to query providers about current practices and guiding protocols for managing head trauma. A retrospective chart review was completed (n=117) to analyze the current medical decision-making practices of providers. A pediatric head trauma protocol was developed and presented to stakeholders for feedback and approval. Finally, a smart phrase incorporating the protocol was developed for integration into the EHR at the project implementation site. The Pediatric Emergency Care Applied Research Network (PECARN) protocol was the protocol most frequently used by providers who were surveyed. However, this was not always documented in the notes of charts reviewed. Concerns regarding the lack of physician discretion and fears of increased liability if there was deviation from the protocol were identified during presentation of the protocol draft. Ease of integration of the protocol in the EHR to guide practice was also debated. The protocol was approved by the providers and submitted to administration to begin the approval and adoption process. Once adopted, further study will be necessary to evaluate whether use of the protocol reduces head imaging among pediatric patients seen at the facility for head trauma.

Running head: PEDIATRIC HEAD TRAUMA PROTOCOL Protocol Development for an Emergency Department at an Urban Utah Hospital Erik S. Hansen The University of Utah College of Nursing 1 PEDIATRIC HEAD TRAUMA PROTOCOL 2 Abstract Pediatric head trauma protocols have been shown to decrease unnecessary imaging for patients being evaluated for a head trauma in the emergency department. The purpose of this project was to assess the current imaging and treatment practices of the providers at an urban medical center and to develop a pediatric head trauma protocol for this facility to be integrated into the health care electronic health record (EHR) of the healthcare facility. Information regarding imaging practices and provider protocol preferences for evaluating head trauma in children were identified through the use of provider surveys to query providers about current practices and guiding protocols for managing head trauma. A retrospective chart review was completed (n=117) to analyze the current medical decision-making practices of providers. A pediatric head trauma protocol was developed and presented to stakeholders for feedback and approval. Finally, a smart phrase incorporating the protocol was developed for integration into the EHR at the project implementation site. The Pediatric Emergency Care Applied Research Network (PECARN) protocol was the protocol most frequently used by providers who were surveyed. However, this was not always documented in the notes of charts reviewed. Concerns regarding the lack of physician discretion and fears of increased liability if there was deviation from the protocol were identified during presentation of the protocol draft. Ease of integration of the protocol in the EHR to guide practice was also debated. The protocol was approved by the providers and submitted to administration to begin the approval and adoption process. Once adopted, further study will be necessary to evaluate whether use of the protocol reduces head imaging among pediatric patients seen at the facility for head trauma. PEDIATRIC HEAD TRAUMA PROTOCOL 3 Protocol Development for an Emergency Department at an Urban Utah Hospital Introduction Problem Description As part of the accreditation process of becoming a level III trauma center, a local urban Utah hospital was tasked with developing a pediatric head trauma protocol before the next scheduled accreditation process in 2020. There is currently no head trauma protocol (HTP) in place at the facility and providers often rely on past experience, both clinical and educational, to evaluate and diagnose pediatric patients who present to the emergency department (ED) with head trauma. Variations in providers' experience may lead to inconsistent management of head trauma and performance of unnecessary procedures such as CT scans, which may increase their time spent in the ED. The implementation of a pediatric HTP will help standardize the care provided to these patients while still allowing physician discretion during the diagnostic process. Currently, no decision tools for pediatric head trauma exist within the EHR. The addition of decision support tools to the existing EHR system will aid providers in locating the HTP and may, by extension, improve the consistency and cost effectiveness of managing patients presenting to the ED with head trauma. The purpose of this project is to develop a pediatric HTP for this hospital in an effort to standardize head trauma management using an evidence-based provider guideline for patients presenting to the ED with traumatic brain injury. In addition, this will satisfy specific accreditation requirements for this institution's level III trauma center. Available Knowledge Traumatic brain injury is the leading cause of death following an injury in children age birth to 17 and accounts for approximately 3,000 deaths, 29,000 hospitalizations and more than 473,000 ED visits each year. Terms such as concussion, minor head trauma or injury, and mild PEDIATRIC HEAD TRAUMA PROTOCOL 4 traumatic brain injury (mTBI) have been used interchangeably and may cause confusion among parents and healthcare providers (Lumba-Brown et al., 2016; Atabaki, 2013). There has been an 37.5% increase in patients presenting to the ED with head trauma since 2007 (Gaw & Zonfrillo, 2016). The Pediatric Emergency Care Applied Research Network (PECARN) TBI have published protocols intended to aid providers in identifying individuals who meet criteria for mild TBI but do not require a head CT scan. In this study, pediatric patients were divided into two groups, those who were under 2 years of age and those who were 2 years and older. Head CT scans performed on patients identified as having mTBI accounted for 25% (< 2 years) and 20% (≥ 2 years) of total CT scans. Researchers found that these could have been avoided if the PECARN protocol had been followed (Kupperman et al., 2009). Since this study, many institutions have adopted the PECARN protocol and have implemented clinical decision support tools within the EHR. These changes have been shown to reduce CT scans among pediatric patients who present to the ED with head trauma by as much as 6% (Dayan et al., 2017). Leading institutions such as the Children's Hospital of Philadelphia (CHOP) have adopted the PECARN protocol and adapted it to include additional information for patients having head injuries more severe than mTBI who warrant more extensive evaluation and treatment (Zonfrillo et al., 2018). Early identification of patients with mTBI can lead to improved decision making by the providers, better patient and family education, and more effective symptom control after discharge from the hospital, all of which lead to an overall better patient outcome (Babcock et al., 2013). Rationale PEDIATRIC HEAD TRAUMA PROTOCOL 5 It was determined that developing a pediatric head trauma protocol could potentially reduce costs and improve patient outcomes. Several pediatric head trauma protocols are in use throughout the United States, such as the PECARN and CHOP protocols. These protocols are researched and evidence-based, therefore, starting from scratch was deemed unnecessary and the aforementioned protocols were used in the development of the protocol for this facility. A theoretical model was chosen that aided in the study and implementation of these protocols. The theoretical framework of this project was adopted from The Iowa Model (Dontje, 2007). The Iowa Model is a four-phase model that involves the first step of identifying a problem-focused trigger. The problem identified in this project was the need for a pediatric head trauma protocol to improve consistency in diagnosis and overall patient outcomes. The next step is to review and critique relevant literature. The Pediatric Emergency Care Applied Research Network algorithm and protocols from the CHOP and other pediatric facilities were compared and assessed for their potential use. The third step is identifying research evidence that supports the change in clinical practice. For this project, research illustrating the benefits of the implementation of pediatric head trauma protocols was identified. The final step of the Iowa Model is the implementation of a change in practice and monitoring the outcomes. The approval process was initiated but not completed due to time constraints of the project implementation timeframe and institutional barriers. Specific Aims The overarching goal of this project was to develop an evidence-based pediatric head trauma protocol for clinicians in the emergency department to promote consistency in pediatric head trauma management, improve clinical outcomes for these patients and reduce unnecessary PEDIATRIC HEAD TRAUMA PROTOCOL 6 imaging. A secondary aim is to fulfill the criteria for accreditation of the emergency department of the institution before the next formal evaluation period. Methods Context This quality improvement project took place at a community hospital located in a suburban area of Salt Lake County in Utah. The patient population is of diverse ethnic, racial and socioeconomic status. This health care facility is designated as a trauma 3 facility and provides care for all age groups who present emergently with medical complaints. The unit has 25 beds with four designated as being trauma-specific. The department employs 15 physicians, 13 physician assistants or nurse practitioners, 32 nurses, and six emergency medical technicians. Many specialties take call for the emergency department, including neurologists, orthopedists, and trauma surgeons. The facility began using Cerner as their primary EHR as of February 2018. Interventions Five objectives were identified to aid in the completion of this project. These objectives included evaluation of the current diagnostic and treatment criteria used by the providers in the ED at this facility, the development of a pediatric head trauma protocol based on current best evidence with input from leading pediatric trauma facilities, conduction of a provider educational offering once a working draft of the head trauma protocol was completed, the development of clinical decision support tools within the EHR aimed to direct provider evaluation and management of pediatric head trauma patients, and the submission of a pediatric head trauma protocol for potential institutional adoption. Two approaches were used to evaluate the current diagnostic and treatment criteria used by providers at this facility. First, a survey was designed that queried providers about their PEDIATRIC HEAD TRAUMA PROTOCOL 7 current practices regarding management of head trauma, their use of evidence-based guidelines, and perceived utility of a pediatric head trauma protocol for the institution (Appendix A). Concurrently, a retrospective chart review was performed of pediatric patients, birth to 17 years of age, who presented to the emergency department between February 2018 and September 2018 with a head injury complaint or were later diagnosed with a head injury. Variables of interest included the type of injury, interventions such as head imaging, and whether the patient was discharged or transferred. In order to identify current best practices to aid in the development of a pediatric head trauma protocol, a comprehensive literature review was completed to help identify standards and protocols currently in use by leading pediatric facilities such as CHOP. Databases used for the review of literature included PubMed and CINAHL using the following search terms: concussion, head injury, head trauma, and pediatric. Various protocols were reviewed and adapted based on the specific needs of the facility (Appendix B). To address the lack of a clinical decision support tool within the Cerner EHR system, custom order sets and smart phrases were created for integration into the EHR in order to improve access, thereby increasing consistency of head trauma management among providers (Appendix C). This also serves as a means to track data necessary for evaluation of the intervention as well as data mining for accreditation of the facility's trauma center. Upon completion of a working draft of the protocol, a luncheon was held with ED providers, trauma surgeons, and administration on February 25, 2019. Feedback from stakeholders was elicited for incorporation into the final draft of the protocol. Once feedback was synthesized, the protocol was submitted to the administration and the providers to begin the approval process. PEDIATRIC HEAD TRAUMA PROTOCOL 8 Several team members were recruited to accomplish the goals of this project. The trauma coordinator for the facility, who was a registered nurse experienced in writing protocols, was consulted regularly throughout the creation of the document. He provided access to resources necessary to obtain key data regarding trauma cases and facilitated meetings with the providers and administrators. The lead informatics nurse for the facility was consulted during the retrospective chart review and he provided assistance in procuring data pertaining to variables of interest. Finally, the acting medical director for ED physicians helped arrange provider meetings, ensured that surveys were completed by his partners, and assisted in gathering feedback concerning the protocol through its various stages of development. Study of the Intervention(s) A chart review was conducted in order to determine knowledge and resources that guide stakeholder medical decision making as well as determine head trauma management and clinical practices of ED providers. Provider surveys were also essential in analyzing variances in their management of head trauma and determine areas of deficiency that could be addressed with the proposed head trauma protocol. Knowing practices before implementation of the protocol helps determine if the changes in post-implementation practices were a result of the intervention versus some competing explanation. The creation of custom order sets and "smart phrases" and embedding these in the institution's EHR will be an essential pathway for tracking use of the new protocol by providers following its implementation. Smart phrases provide a digital framework within which evidencebased care algorithms can be stored and subsequently pulled into medical notes and other EHR documentation. These results will be important in the credentialing process for the ED. There PEDIATRIC HEAD TRAUMA PROTOCOL 9 were no other pediatric head trauma projects, nor any other competing quality improvement projects during this project's implementation period that would skew results. Measures To assure the completeness and accuracy of the data collected from survey results, data were reviewed by two separate individuals to check for any discrepancies or outliers in data entry. During the collection of data from the EHR, two individuals reviewed the search criteria, patient demographics, diagnoses, treatments, and disposition to ensure all data were correctly identified and that each patient met the criteria for inclusion in this project. Analysis Provider survey results were analyzed using descriptive statistics to describe sample characteristics. Survey responses were reported as percentages and frequencies to describe practice behaviors. Data from chart reviews of the variables of interest were analyzed using descriptive statistics and collated into an institutional report for presentation to stakeholders and administration. Data were limited to pediatric patients who presented to the ED from February 2018 to September of 2018. It was understood that characteristics of the head injury data collected during this time frame may not represent the entirety of all head injuries seen in the ED due to known seasonal variations in the type and severity of head injuries that may have occurred during the targeted data collection period. Qualitative data were collected from the open-ended survey questions and the detailed notes that were taken from the provider meeting. A content analysis was performed to identify common categories and sub-categories. These were then organized into common themes and summarized. PEDIATRIC HEAD TRAUMA PROTOCOL 10 Ethical Considerations The University of Utah Institutional Review Board reviewed and determined this study exempt from human subjects review. No conflicts of interest were identified. Results A systematic chart review was completed on charts of patients seen in the emergency department from February 2018 to September 2018. In total, 117 patients having a diagnosis of head trauma were identified and included in the data analysis. The types of head trauma included falls, motor vehicle accidents, all-terrain vehicle accidents, bicycle-involved accidents, assault, laceration or contusion, and gunshot wound (Figure 1). The largest percentage of head injuries was unspecified head trauma. The various head injury types were then categorized based on whether or not they received a head CT (Figure 1). Forty-six (39%) of these patients received a head CT. Only five (4%) of these patients were identified as having head trauma serious enough to require transfer to a pediatric trauma facility for further evaluation and care (Figure 2). It was found that only 15 (13%) of the charts included notations indicating that PECARN had been used in the medical decision-making process of whether or not to perform a CT. There was no indication in the remaining charts that a clinical decision tool or protocol had been used in the medical decision-making process. Prior to the retrospective chart review, provider surveys were completed by 15 of the 32 providers who currently work in the ED at this facility. Data gathered using the survey included identifying providers' use of specific guidelines when evaluating head trauma, factors that influenced or guided providers to order head imaging, providers' estimate of the frequency with which head imaging is ordered, confidence in their current head trauma management skills, PEDIATRIC HEAD TRAUMA PROTOCOL 11 perceived usefulness of implementing a head trauma protocol, their concerns regarding pediatric head trauma management, and barriers to practice (Table 3). Survey results indicated that PECARN was the most frequently used guideline for evaluating pediatric patients who had suffered a head injury (n=12). When providers were asked how frequently they ordered head imaging on pediatric patients who present to the ED with head trauma, 11 providers had underestimated the percentage of head CTs that were ordered. A majority of providers expressed concerns regarding the implementation of a pediatric head trauma protocol. Seven providers were concerned that such a protocol might potentially inhibit provider discretion in management of these patients. Nine providers expressed concerns regarding potential liability if the protocol was not followed. Eight providers indicated their concern regarding potential problems with incorporating the protocol into the EHR. Once the final draft was completed, it was presented in a stakeholder meeting of providers who work in the emergency department. Each provider received a copy of the draft prior to the meeting for review. The draft was then presented to the group with time allotted for comments following the presentation. The providers were also encouraged to share any pertinent comments or concerns on their physical copy of the draft and submit it to the director of the ED by the end of the week. No further comments were offered and no concerns were identified by stakeholders at that time. The final draft of the protocol was then submitted to administration to begin the approval process for institutional adoption of the pediatric head trauma protocol. A smart phrase was developed to integrate the protocol into the providers' notes (Appendix C). Integration into the EHR is currently being managed by the information technology team at the institution. PEDIATRIC HEAD TRAUMA PROTOCOL 12 Discussion Project results demonstrated that, while many providers stated they used evidence-based clinical decision tools such as PECARN, very few documented their use of these guidelines in patients' charts, making it difficult to determine the rationale for the interventions performed. Many providers expressed concerns related to a perceived lack of physician discretion and the potential for liability if the protocol was not followed, which may inhibit the providers' use of the head trauma protocol. In light of a new EHR having been introduced with the new health system ownership, providers expressed concern about potential difficulty in incorporating the guideline into the EHR chart notes. Notwithstanding these concerns, most providers felt that it would be beneficial to have an evidence-based protocol in place for managing pediatric head trauma. Interpretation Provider surveys revealed that the PECARN criteria were already being used by many of the providers in the ED and that these were informally guiding their care of head trauma patients. After individual conversations with the providers, it was made clear that PECARN criteria were essential to underpin a formal head trauma protocol. Due to the consensus of providers, it is expected that they will use the protocol. Informal use of PECARN by providers before official adoption by institutions has also been identified in similar studies analyzing implementation of similar protocols (Dayan, et al., 2017). In light of findings from previous studies of health care systems' adoption of PECARN criteria, it is unclear whether the protocol will reduce frequency of head CTs being ordered by providers at this facility. Dayan et al. (2017) showed varying levels of provider adherence to PECARN-based protocols after its implementation. PEDIATRIC HEAD TRAUMA PROTOCOL 13 Concerns regarding the lack of physician discretion and fears of increased liability were addressed by adding additional notes to the protocol directing providers to individualize their decision-making where appropriate. Protocols are put into place to guide clinical decisionmaking, but not to supplant clinicians' decision-making. It is important to also consider that only about half of stakeholders returned surveys and therefore results may not represent the clinical practices and concerns of all providers working in the ED at this facility. Medical providers, administrators, and other employees impacted by this intervention were receptive to the protocol and eager to help by answering questions, giving advice, and scheduling the necessary times to present findings to stakeholders. The approval process for the head trauma protocol has begun. Its implementation should not unduly burden the facility in terms of time and cost of its implementation. Resources to imbed the protocol into the EHR will require additional cost and resources for the health care system. These exact costs are currently unknown. Limitations There were several limitations to this project. During the development of this project and before its implementation, the hospital was purchased by a large health system corporation, and as a consequence a new EHR system was implemented. Data of interest were difficult to recover during the retrospective chart review using the new system. Patient charts were identified using chief complaint and diagnosis; these qualifiers are somewhat subjective in nature and may have differed among providers. Therefore, trauma patients who lacked a well-defined diagnosis of head trauma may have been missed during the chart review process. Funds to support additional EHR changes were not made available to support integration of the protocol into the EHR during the project implementation timeline, thus precluding PEDIATRIC HEAD TRAUMA PROTOCOL 14 addition of the smart phrases to the EHR before the project's deadline for completion. However, smart phrase content was developed and submitted for institutional approval (Appendix C). The protocol approval process for this facility and organization may take several months for the proposed protocol to be adopted and implemented at the facility. With this limitation in mind, the primary goal was to study the current practices and trends and to also receive provider input throughout the entire process in order to submit a final draft of the protocol for approval that had wide acceptance among stakeholders. The lack of pediatric neurosurgery, neurology, and trauma services at this facility decreases it's generalizability for other facilities who have these resources. Conclusions This project illustrates the need for a pediatric head trauma protocol to guide providers in consistent management of head trauma. Once the protocol is implemented, responsibility for sustainability will fall on the providers to use the tools they are given. The use of the protocol and the associated EHR tools will not incur additional costs and can be shared freely amongst providers and ED staff. This protocol is slated for use at several other facilities in the area once the approval process has been completed at this facility. The protocol may need to be reevaluated at a later date if this hospital, or other local hospitals within the same health care network, expand their medical specialty services to include pediatric services such as neurology, neurosurgery, or trauma. Next steps include integrating the protocol in to the EHR, evaluating use of the protocol by providers, and determining whether the protocol reduces head imaging in the pediatric patients seen at the facility. PEDIATRIC HEAD TRAUMA PROTOCOL 15 References Atabaki, S. M. (2013). Updates in the general approach to pediatric head trauma and concussion. Pediatric Clinics of North America, 60(5), 1107-1122. Retrieved from https://www.sciencedirect.com/science/article/pii/S0031395513000771?via%3Dihub Babcock, L., Byczkowski, T., Wade, S. L., Ho, M., Mookerjee, Sohug., & Bazarian, J. J. (2013). Predicting postconsussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. Journal of the American Medical Association Pediatrics, 167(2), 156-161. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461429/ Dayan, P. S., Ballard, D. W., Tham, E., Hoffman, J. M., Swietlik, M., Deakyne, S. J.,… Kuppermann, N. (2017). Use of traumatic brain injury prediction rules with clinical decision support. Pediatrics, 139(4). Retrieved from http://pediatrics.aappublications.org/content/early/2017/03/22/peds.2016-2709 Dontje, K. J. (2007). Evidence-based practice: Understanding the process. Topics in Advanced Practice Nursing eJournal, 7(4). Retrieved from https://www.medscape.com/viewarticle/567786 Gaw, C. E. & Zonfrillo, M. R. (2016). Emergency department visits for head trauma in the United States. Boston Medical Center Emergency Medicine. 16(5). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717651/pdf/12873_2016_Article_71.pd f Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Atabaki, S. M., Holubkov, R.,… Nadel, F. M., for the Pediatric Emergency Care Applied Research Network (PECARN). (2009). Identification of children at very low risk of clinically-important brain injuries PEDIATRIC HEAD TRAUMA PROTOCOL 16 after head trauma: A prospective cohort study.. Lancet, 374, 1160-1170. Retrieved from https://www.pecarn.org/currentresearch/documents/Kuppermann_2009_The-Lancet.pdf Lumba-Brown, A., Yeates, K. O., Gioia, G., Turner, M., Benzel, E., Suskauer, S.,… Timmons, S. (2016). Report from the pediatric mild traumatic brain injury guideline workgroup: Systematic review and clinical recommendations for healthcare providers on the diagnosis and management of mild traumatic brain injury among children. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/injury/pdfs/bsc/systematicreviewcompilation_august_2016.pdf Zonfrillo, M., Nadel, F., Corwin, D., Mittal, M., Jacobstein, C., & Lavelle, J. (2018). ED pathway for evaluation/treatment of acute head trauma. Children's Hospital of Philadelphia. Retrieved from http://www.chop.edu/clinical-pathway/head-trauma-acuteclinical-pathway PEDIATRIC HEAD TRAUMA PROTOCOL 17 CT Frequency by Injury Type Head injury, unspecified Laceration/Contusion Assault MVA/Bike Fall GSW 0 5 10 15 20 25 GSW Fall MVA/Bike Assault No CT 1 11 1 1 CT 0 3 8 12 30 35 40 45 50 Laceration/Co Head injury, ntusion unspecified 30 26 6 18 Figure 1. CT frequency by injury type Transfers 20% 20% MVC/ATV/Bike - 1 Assault - 2 Head injury, unspecified - 1 20% GSW - 1 40% Figure 2. Transfers by accident type PEDIATRIC HEAD TRAUMA PROTOCOL 18 Table 1 Provider survey results Survey Questions (Multiple choice/select all that apply) Guidelines currently used by providers • PECARN • CHALICE • UpToDate • Personal Experience Indications/signs/symptoms identified for head imaging • Multiple episodes of vomiting • GCS < 14 • Scalp hematoma • Lethargy or irritability • Loss of consciousness • Headache • Parent request • Mechanism of injury n = 15 (%) • • • Removes/decreases provider discretion Liability if protocol is not followed Difficulty incorporating protocol into charting None Barriers that prevent caring for pediatric head trauma patients • Lack of pediatric specialists • Insufficient staff knowledge n = 15 (%) 12 (80) 1 (7) 3 (20) 3 (20) Provider estimated frequency of ordering head imaging • Less than 25% • About 25% • About 50% • 100% 7 (47) 4 (27) 3 (20) 1 (7) 14 (93) Confidence in management of pediatric head trauma • Somewhat confident 3 (20) 15 (100) 5 (33) 13 (87) 10 (67) 3 (20) 5 (33) 11 (73) Concerns of implementing a pediatric head trauma protocol • Survey Questions (Multiple choice/select all that apply 7 (47) • • • Mostly confident Very confident Always confident Perceived usefulness of pediatric head trauma protocol • Not at all useful 3 (20) 6 (40) 3 (20) 1 (7) 9 (60) • Somewhat useful 2 (13) 8 (53) • Mostly useful 4 (27) 2 (13) • • Very useful Extremely useful 5 (33) 2 (13) 8 (53) 4 (27) PEDIATRIC HEAD TRAUMA PROTOCOL • • • No universal protocol Lack of specialty equipment None 5 (33) 2 (13) 4 (27) 19 PEDIATRIC HEAD TRAUMA PROTOCOL 20 Appendix A Pediatric Head Trauma Protocol Provider Survey 1. Which guideline or resources, if any, do you currently use when caring for a pediatric patient who presents to the ED with a head injury? a) b) c) d) e) f) PECARN - Pediatric Emergency Care Applied Research Network CATCH - Canadian Assessment of Tomography for Childhood Head Injury CHALICE - Children's Head Injury Algorithm for the Prediction of Important Clinical Events UpToDate None. I rely on my previous training and experience. Other_______________________________ 2. What indications, signs, or symptoms warrant ordering head imagine such as a CT scan or MRI? (Select all that apply) Multiple episodes of vomiting GCS < 14 Scalp hematoma Lethargy or irritability Loss of consciousness Headache Parent request Mechanism of injury Other_________________________ 3. How frequently do you order imaging on pediatric patients who present to the ED with head injury? a) b) c) d) e) Less than 25% of cases About 25% of cases About 50% of cases About 75% of cases 100% of cases 4. How confident do you feel in your management of pediatric head trauma? a) b) c) d) e) Not at all confident Somewhat Confident Mostly confident Very confident Always confident PEDIATRIC HEAD TRAUMA PROTOCOL 21 5. How useful would you find a head trauma protocol in practice? a) b) c) d) e) Not at all useful Somewhat useful Mostly useful Very useful Extremely useful 6. What concerns do you have concerning the implementation of pediatric head trauma protocol at this facility? (Select all that apply) Removes/decreases provider discretion Liability if protocol is not followed Difficulty incorporating protocol into charting system None Other___________________________ 7. What barriers exist, if any, that prevent you from caring for pediatric head trauma patients at this facility? a) b) c) d) e) f) Lack of pediatric specialists such as pediatric neurology and neurosurgery Insufficient staff knowledge pertaining to pediatric head trauma No universal protocol Lack of specialty equipment None Other________________________ PEDIATRIC HEAD TRAUMA PROTOCOL 22 Appendix B Pediatric Head Trauma Protocol PECARN Criteria Kupperman N, Holmes JF, Dayan PS et al. Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. PEDIATRIC HEAD TRAUMA PROTOCOL 23 Appendix C Smart Phrase Draft - PECARN Under 2 years GCS = 14 - Y/N AMS - Y/N Palpable skull fx - Y/N If yes to any of these, CT recommended If no, continue Occipital, parietal, or temporal hematoma - Y/N Hx of LOC = 5 seconds - Y/N Severe mechanism of injury - Y/N Not acting normally per parent = Y/N If yes to any of these, consider observation vs CT based on clinical factors listed below: Physician experience Multiple vs isolated findings Worsening symptoms or signs Age < 3 Parental preference 2 years and older GCS = 14 - Y/N AMS - Y/N Palpable skull fx - Y/N If yes to any of these, CT recommended If no, continue Hx of LOC = 5 seconds - Y/N Hx of vomiting - Y/N Severe mechanism of injury - Y/N Severe headache - Y/N If yes to any of these, consider observation vs CT based on clinical factors listed below: Physician experience Multiple vs isolated findings Worsening symptoms or signs Parental preference ***If CT is positive for intracranial injury or patient identified as unstable, initiate consult and transfer to pediatric trauma facility***