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Implementation of a CT scan practice guideline for pediatric trauma patients reduces unnecessary scans without impacting outcomes

McGrew, Patrick R., MD; Chestovich, Paul J., MD; Fisher, Jay D., MD; Kuhls, Deborah A., MD; Fraser, Douglas R., MD; Patel, Purvi P., MD; Katona, Chad W., MD; Saquib, Syed, MD; Fildes, John J., MD

Journal of Trauma and Acute Care Surgery: September 2018 - Volume 85 - Issue 3 - p 451–458
doi: 10.1097/TA.0000000000001974
AAST 2017 PODIUM PAPER
Editor's Choice
EAST Journal Club

INTRODUCTION Computed tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the use of CT scan guidelines in the management of pediatric trauma. The study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT use before and after CT-guideline implementation.

METHODS Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis using published criteria from the Pediatric Emergency Care and Research Network. There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age < 15) trauma patients seen in our TC from 2010 to 2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay, readmissions, and mortality. Categorical and continuous variables were analyzed with χ 2 and Wilcoxon rank-sum tests, respectively. p < 0.05 was considered significant.

RESULTS We identified 1,934 patients: 1,106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8%, respectively (p < 0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged.

CONCLUSIONS Implementation of a pediatric CT guideline significantly decreases CT use, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children.

LEVEL OF EVIDENCE Therapeutic study, level IV.

From the Department of Surgery, Division of Acute Care Surgery, University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada.

Submitted: August 31, 2017, Revised: April 24, 2018, Accepted: April 26, 2018, Published online: May 22, 2018.

Address for reprints: Paul J. Chestovich, MD, University of Nevada Las Vegas, Las Vegas, NV; email: paul.chestovich@unlv.edu.

Presented at the 76th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 15, 2017. Baltimore Marriott Waterfront, Baltimore, Maryland.

© 2018 Lippincott Williams & Wilkins, Inc.