51 - Clinician Characteristics Associated with Computed Tomography Use in Children with Minor Blunt Head Trauma

Poster Number: 51
Publication Number: 51.104

Pradip P. Chaudhari, Children's Hospital Los Angeles, Los Angeles, CA, United States; Irma Ugalde, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, United States; Mohamed Badawy, University of Texas Southwestern Medical School, Dallas, TX, United States; Paul Ishimine, University of California, San Diego School of Medicine, San Diego, CA, United States; Kenneth Yen, University of Texas Southwestern Medical School, Dallas, TX, United States; Kevan A. McCarten-Gibbs, University of California, San Francisco, School of Medicine, Oakland, CA, United States; Donovan Nielsen, University of California, Davis, School of Medicine, Sacramento, CA, United States; Nisa S. Atigapramoj, University of California, San Francisco, School of Medicine, San Francisco, CA, United States; Daniel J. Tancredi, University of California, Davis, School of Medicine, Sacramento, CA, United States; James F. Holmes, University of California, Davis, School of Medicine, sacramento, CA, United States; Nathan Kuppermann, University of California, Davis, School of Medicine, Sacramento, CA, United States

Background:
Evidence-based clinical prediction rules improve care delivery to children in the emergency department (ED), however clinician-level factors may impact rule implementation.

Objective:
We aimed to investigate the association of clinician perceptions, demographic characteristics, and risk tolerance with cranial computed tomography (CT) imaging ordering in children with blunt head trauma at very low risk for clinically important traumatic brain injuries (ciTBI) based on validated PECARN decision rules.

Design/Methods:
We surveyed clinicians caring for children enrolled in a prospective, multicenter cohort study of children aged < 18 years with minor blunt head trauma (GCS ≥14) who were evaluated in 6 EDs from December 2016 to December 2020. The clinician survey consisted of questions on demographics, clinical experience, self-reported risk tolerance based on a validated scale, and perceptions/self-reported use of clinical prediction rules. Children were considered very low risk for ciTBI if they had no PECARN ciTBI risk variables. ciTBI was defined as death, neurosurgery, intubation >24 hours, or hospitalization ≥2 nights due to TBI in association with a positive CT. We performed multivariable logistic regression analyses to identify variables associated with CT ordering in children at very low risk of ciTBI.

Results:
486/601 (81%, 95% CI 77, 84%) ED clinicians completed surveys, and 8,312 children enrolled were very low risk for ciTBI, with a mean age of 5.1 ± 4.8 years. Of the very low risk children, 629 (7.6%, 95% CI 7.0, 8.2%) underwent CT. Mean clinician age was 37.4 ± 8.1 years and mean years of clinician experience were 6.8 ± 7.7 years. 27% (n=130) of surveyed clinicians were Pediatric Emergency Medicine (EM), 25% (n=123) were General EM, and 15% (n=75) were Pediatrics. Clinician characteristics associated with ordering CTs in children very low risk for ciTBI included: caring for < 50% pediatric patients (OR=4.36, 95% CI 2.33, 8.17) and disagreeing with using clinical prediction rules (OR=2.05, 95% CI 1.23, 3.41). Clinicians who were risk tolerant were less likely to order CT (OR=0.65, 95% CI 0.45, 0.95).
Conclusion(s): Clinicians uncommonly ordered CTs in children at very low risk for ciTBI based on the PECARN ciTBI decision rules. Clinicians who provide less frequent care to children and disliked the use of clinical decision rules were associated with more frequent CT ordering. Clinicians who were more risk tolerant, however, were associated with lower CT ordering. This information can be used to target education to certain clinician types to further safely lower CT use in very low risk children.