Avoiding The CT Scam: Prospective Evaluation Of An Evidence-based Guideline To Reduce CT Use In The Assessment Of Blunt Pediatric Abdominal Trauma
Michaela Gaffley, Leah M Sieren, *Kristen A Zeller, *Lucas P Neff, *Thomas Pranikoff, Tammy Rush, *John K Petty
Wake Forest School of Medicine, Winston Salem, NC
Background (issue): To determine effectiveness of a guideline for abdominopelvic CT (computed tomography) to evaluate blunt abdominal trauma at a Level I pediatric trauma center.
Methods: Pediatric blunt trauma patients (n=999) age 0-15 years who presented from the injury scene were evaluated over a 10 year period. After five years, we implemented an evidence-based guideline in which the decision for CT was standardized based on mental status, abdominal examination, and laboratory results (alanine aminotransferase, aspartate aminotransferase, hemoglobin, urinalysis). Delayed decisions for imaging or intervention were based on changes during the course of observation.
Findings: There were no differences in age, Glasgow Coma Score (GCS), elevated shock index pediatric-adjusted (SIPA) or ISS scores between the patients before or after guideline implementation. Nearly half of the patients (48.3%) underwent CT scan before guideline implementation compared to 36.7% after (p<0.0002).We evaluated the agreement between the indication for a CT and performance of CT before versus after guideline implementation. The pre-guideline period (κ=0.25) versus the post-guideline period (κ=0.40) revealed that there was greater agreement in the latter group (Test for Equal Kappa p<0.006). There was no difference in ISS (p=0.5387) in CT scanned patients and no difference in rate of intervention(p=.0.2310),comparing before and after guideline implementation.Readmission rate was 0.2% and not different between the groups.
Conclusions (implications for practice): Implementation of a clinical guideline for pediatric patients with blunt abdominal trauma decreases the rate of CT utilization while accurately identifying significant injuries.
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