Implementation of Adapted PECARN Decision Rule for Children With Minor Head Injury in the Pediatric Emergency Department
Authors: Bressan Silvia , Romanato Sabrina , Mion Teresa , Zanconato Stefania , Da Dalt Liviana 
Published: June 2012

ACADEMIC EMERGENCY MEDICINE 2012; 19:801–807 © 2012 by the Society for Academic Emergency Medicine

Objectives:  Of the currently published clinical decision rules for the management of minor head injury (MHI) in children, the Pediatric Emergency Care Applied Research Network (PECARN) rule, derived and validated in a large multicenter prospective study cohort, with high methodologic standards, appears to be the best clinical decision rule to accurately identify children at very low risk of clinically important traumatic brain injuries (ciTBI) in the pediatric emergency department (PED). This study describes the implementation of an adapted version of the PECARN rule in a tertiary care academic PED in Italy and evaluates implementation success, in terms of medical staff adherence and satisfaction, as well as its effects on clinical practice.

Methods:  The adapted PECARN decision rule algorithms for children (one for those younger than 2 years and one for those older than 2 years) were actively implemented in the PED of Padova, Italy, for a 6‐month testing period. Adherence and satisfaction of medical staff to the new rule were calculated. Data from 356 visits for MHI during PECARN rule implementation and those of 288 patients attending the PED for MHI in the previous 6 months were compared for changes in computed tomography (CT) scan rate, ciTBI rate (defined as death, neurosurgery, intubation for longer than 24 hours, or hospital admission at least for two nights associated with TBI) and return visits for symptoms or signs potentially related to MHI. The safety and efficacy of the adapted PECARN rule in clinical practice were also calculated.

Results:  Adherence to the adapted PECARN rule was 93.5%. The percentage of medical staff satisfied with the new rule, in terms of usefulness and ease of use for rapid decision‐making, was significantly higher (96% vs. 51%, p < 0.0001) compared to the previous, more complex, internal guideline. CT scan was performed in 30 patients (8.4%, 95% confidence interval [CI] = 6% to 11.8%) in the implementation period versus 21 patients (7.3%, 95% CI = 4.8% to 10.9%) before implementation. A ciTBI occurred in three children (0.8%, 95% CI = 0.3 to 2.5) during the implementation period and in two children (0.7%, 95% CI = 0.2 to 2.5) in the prior 6 months. There were five return visits (1.4%) postimplementation and seven (2.4%) before implementation (p = 0.506). The safety of use of the adapted PECARN rule in clinical practice was 100% (95% CI = 36.8 to 100; three of three patients with ciTBI who received CT scan at first evaluation), while efficacy was 92.3% (95% CI = 89 to 95; 326 of 353 patients without ciTBI who did not receive a CT scan).

Conclusions:  The adapted PECARN rule was successfully implemented in an Italian tertiary care academic PED, achieving high adherence and satisfaction of medical staff. Its use determined a low CT scan rate that was unchanged compared to previous clinical practice and showed an optimal safety and high efficacy profile. Strict monitoring is mandatory to evaluate the long‐lasting benefit in patient care and/or resource utilization.