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The Pediatric Emergency Care Applied Research Network (PECARN) and Trauma Outcomes Research. - PowerPoint PPT Presentation
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The Pediatric Emergency Care Applied Research Network (PECARN)
and Trauma Outcomes Research The PECARN is supported by cooperative agreements U03MC00001, U03MC00003,
U03MC00006, U03MC00007, and U03MC00008 from the Emergency Medical Services for Children Program of the Maternal and Child Health Bureau, Health Resources and Services
Administration, Department of Health and Human Services
Surgical and Trauma Outcomes Research: Current Status and Future Directions
Nathan Kuppermann, MD, MPHDepartments of Emergency Medicine and Pediatrics
UC Davis School of MedicineMarch 15th, 2013
Disclosure
● No financial or other conflicts of interest
What is PECARN?
A collaborative research group of hospital EDs organized into nodes and coordinated by a Steering Committee
The infrastructure supported by funding from HRSA PECARN works with the EMSC/MCHB/HRSA:
• multi-center randomized trials
• observational studies
• other issues related to emergency medical services for children
Highlighted in 2006 IOM reports on the future of EMSC
PECARN Structure
PECARNSteering Committee
Data Coordinating Center (DCC)
Pediatric Emergency Medicine Northeast, West
and South
PEM-NEWS
Hospitals of the Midwest Emergency Research
Node
HOMERUN
Great Lakes Emergency Medical Services for Children Research
Network
GLEMSCRN
Pittsburgh, Rhode Island, Delaware Network
PRIDENET
Washington, Boston, Chicago Applied Research
Node
WBCARN
Pediatric Research in Injuries and Medical
Emergencies
PRIME
PI: Peter Dayan
PI: Rich Ruddy
PI: Rachel Stanley
PI: Bob Hickey
PI: Jim Chamberlain
PI: Nathan Kuppermann
PECARN Subcommittees
Protocol Review and Development
Quality Assurance, Safety and Regulatory
Feasibility and Budget
Grant Writing and
Publication
HRSA/MCHB/EMSC
Federal Project Officer: Tasmeen Weik
PI: Mike Dean
PECARN Sites
● = PRIME Node● = GLEMSCRN Node
= PEM-NEWS Node= WBCARN Node
●●
■= Data Coordinating Center
= HOMERUN Node●
= PRIDENET Node●
●●
●■ ●
●
●●
●
● ●●●
●●
●
●
●
●
Ongoing PECARN Research Development
Patient safety and error reductionPatient safety and error reduction
Quality of PEM careQuality of PEM care
Evaluation of head trauma
C-Spine immobilization
Steroids in acute bronchiolitis
The burden of mental illness and psychiatric emergencies in PED
RCT of fluids for DKA
Magnesium for sickle cell pain
Therapeutic hypothermia in pediatric Therapeutic hypothermia in pediatric cardiopulmonary arrestcardiopulmonary arrest
Diagnostic categorization of illnesses Diagnostic categorization of illnesses and injuries in the PED and injuries in the PED
Management of status epilepticusManagement of status epilepticus
Evaluation of abdominal traumaEvaluation of abdominal trauma
Progesterone for severe TBIProgesterone for severe TBI
Knowledge translation of TBI rulesKnowledge translation of TBI rules
RNA transcription biosignatures to diagnoseRNA transcription biosignatures to diagnose febrile infantsfebrile infants
Childhood Head Trauma: A Neuroimaging Decision Rule
Supported by grant R40MC02461-01-00from EMSC/MCHB/HRSA
The PECARN Head Injury Study
Goal: to derive a clinical decision rule to accurately identify children at near zero risk of clinically important traumatic brain injury after blunt trauma with high accuracy and wide generalizability
Methods● Design:
– Prospective multicenter study over 28 mo. (6/04 – 9/06) in 25 sites in PECARN
● Inclusion Criteria: – Age < 18 years with head trauma evaluated in ED
● Exclusion Criteria:– Ground-level mechanisms and no symptoms or signs of TBI– Penetrating trauma– Injury > 24 hours old– Pre-existing neurological disease impeding assessment– Transfer with neuroimaging already performed
Outcome Definition
Clinically-important TBI (ciTBI)– Death from TBI– Neurosurgical procedure– Intubation for > 24 hours for head injury– Positive CT in association with hospitalization > 2 nights
Variables Considered
Age in years 3-level mechanism severity
High risk MVC - ejection, rollover, death Ped or unhelmeted bicyclist struck by
motorized vehicle Fall > 5 feet (> 3 feet if < 2 yrs) High impact / projectile
Amnesia (if > 2 yrs) LOC (duration) Seizure Acting normal per parent Headache (severity, location) if > 2 yrs Emesis (number, timing)
GCS (14 vs. 15) Other mental status
Agitated Sleepy Slow to respond Repetitive
Palpable skull fx signs Basilar skull fx signs Bulging fontanelle Scalp hematoma (location,
size, quality) Focal neurological deficit Other system injuries Evidence of intoxication
Results57,030 eligible
42,412(78.3%)
11,749 (21.7%)
88 ciTBI
(1.0%)
EnrolledNot enrolled
54,161 GCS 14-15
2,869 GCS <14 or other exclusion
Validation 8,627
Derivation 33,785
288 ciTBI
(0.9%)
Inter-observer agreement0 0.2 0.4 0.6 0.8 1
mechanism of injury
mechanism of injury (low vs. high risk)
dizziness
amnesia for event
any LOCLOC duration*
seizure
acting normal per parent
headache
headache severity*
vomiting
vomiting frequency*
palpable fracture
bulging fontanelle (age<2 only)
basilar fracturehematoma present
hematoma location
hematoma size*
hematoma quality
any sign of trauma above clavicles
focal neurologic deficit
other substantial injury
intoxication
GCS*
GCS 15 vs <15
other signs of altered mental statusagitated
slow to respond
sleepy
repetitive (age>=2 only)
any signs of altered mental status
Kappa
Kuppermann/Holmes, 2009
The PECARN TBI Rules (derived and validated)
Children < 2 years Children 2-18 years
Severe mechanism of injuryHistory of LOC > 5 secGCS = 14 or other signs of altered mental statusNot acting normally per parentPalpable skull fractureOccipital/parietal/temporal scalp hematoma
Severe mechanism of injuryHistory of LOCGCS = 14 or other signs of altered mental statusHistory of vomitingSevere headache in the EDSigns of basilar skull fracture
Children are at very low risk of clinically-important traumatic brain injury (TBI) if they meet all criteria in age-specific rule:
Under 2 years Over 2 years
Recommendations for children younger than 2
The Rule
Recommendations for children younger than 2
Suggestions
Recommendations for children 2 years and older
The Rule
Recommendations for children 2 years and older
Suggestions
PECARN Clinical Prediction Rulefor Abdominal CT in Pediatric Trauma
● Prospective multicenter study 2007 - 2010– < 18 years with blunt abdominal trauma– Clinical data recorded before abd CT (if done)– Follow-up obtained on all patients:
Discharged patient: telephone follow-up Admitted patients: medical record review
● Primary outcome: IAI requiring therapy (IAIAI)– Recursive partitioning analysis– 761 (6.3%) with IAI and 203 (1.7%) with IAIAI
Prediction Rule for IAIAI (n=12,044) 1,963 patients 112 (5.7%) IAIAI
No
GCS < 14826 patients 38 (4.6%) IAIAI
Abdomen tender 2,532 patients 36 (1.4%) IAIAI
Thoracic Trauma
Abdominal pain
↓ Breath Sounds
Emesis
Abdominal Wall Trauma
955 patients 6 (0.6%) IAIAI
305 patients 2 (0.7%) IAIAI
34 patients 1 (2.9%) IAIAI
395 patients 2 (0.5%) IAIAI
No
No
No
No
No
5,034 patients
No
6 (0.1%) IAIAI
Sensitivity = 197/203 (97.0%; 95% CI 93.7, 98.9%)
Specificity = 5028/11841 (42.5%; 95% CI 41.6, 43.4%)
NPV = 5028/5034 (99.9%; 95% CI 99.7, 100%)
LR- = 0.07 (95% CI 0.03, 0.15)
1,234 CT scans (25%)
Holmes/Kuppermann, 2013
How to get clinicians to use the prediction rules?
Knowledge Translation Pipeline
● EBM – continuum here
Glasziou/Haynes, 2005
Translating Research into Practice What works
Clinical decision support more successful when:
● Automatic provision of support in workflow● Recommendations given rather than risks● Support given at the time and location of
decision-making ● Support is computer based
Kawamoto, 2005
Implementation of the PECARN Traumatic Brain Injury Prediction
Rules Using Electronic Health Record-Based Clinical Decision Support:
An Interrupted Time Series Trial
Funded by the American Recovery and Reinvestment Act – Office of the Secretary: Grant #S02MC19289-01-00
Data Completion by Nursing
If Triage RN enters “Yes-less than 24 hours ago” items for risk assessment will be cascade
Blunt Head Trauma Assessment
Courtesy: Peter S. Dayan, MD, PECARN
Clinical Decision Support
• Clinician receives a statement no matter what is entered
• Formatted similarly across statements
1. Recommendation
2. Risk estimate of clinically-important TBI based on PECARN data
3. Details regarding recommendations/risks
4. List of predictors and responses
5. Links to useful information(e.g. the prediction rules)
Decision Support: Patient < 2 years who meets rule
Month of Trial 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Pre-intervention phase Intervention Intervention maintained Main Comparisons: implemented (post-intervention phase) Pre to post int.
Intervention Group Measurement (receives CDS)
Baseline rate of CT use Post-intervention rate of CT use
Control Group Measurement (standard of care) Rate of CT use measured throughout the study period
Methods – design
Interrupted Time Series Trial with Concurrent Controls
1.Glasziou P, Haynes B. The paths from research to improved health outcomes. ACP J Club 2005;142:A8-10.2.Graham ID, Stiell IG, Laupacis A, O’Connor AM, Wells GA. Emergency physicians’ attitudes toward and use of clinical decision rules for radiography. Acad Emerg Med 1998;5:134-40.3.Holmes JF, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P et al and PECARN. Identifying children at very low risk of clinically-important blunt abdominal. Ann Emerg Med 2013 [Epub ahead of print].4.Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005;330:765 [Epub].5.Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R et al and PECARN. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374:1160-70.6.Laupacis A, Sekar N, Stiell IG. Clinical prediction rules: a review and suggested modifications of methodological standards. JAMA 1997;277:488-494.
Selected References
7.Maguire JL, Kulik DM, Laupacis A, Kuppermann N, Uleryk EM, Parkin PC.Clinical prediction rules for children: a systematic review. Pediatrics 2011;128:e666-77. 8.Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med 2003;42:492-506.9.Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33:437-447.10.The Pediatric Emergency Care Applied Research Network. The Pediatric Emergency Care Applied Research Network (PECARN): Rationale, development, and first steps. Acad Emerg Med 2003;10:661-668.
Selected References