Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury.

OBJECTIVES: Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN). METHODS: We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed. RESULTS: Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals. CONCLUSIONS: There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.

The Impact of an Emergency Department Upgrade to Level I Trauma Status on the Timeliness of Nontrauma Computed Tomography Scans.

BACKGROUND: Resources such as computed tomography (CT) scanners are sometimes shared when separate adult and pediatric emergency departments (EDs) exist in proximity. OBJECTIVES: To assess the impact of American College of Surgeons Level I trauma verification of an adult ED on the timeliness of nontrauma CT scans in a pediatric and adult ED that share a CT scanner. METHODS: ED patient records were retrospectively reviewed to determine the time from order to completion of nontrauma CT scans. We compared the timeliness of CT scan completion between the year leading up to the adult ED being verified as a Level I Trauma Center (2015), and the 2 subsequent years (2016-2017). RESULTS: The median time for nontrauma CT completion in the adult ED prior to Level I verification was 39 min, compared with 50 min and 49 min for the subsequent 2 years (p < 0.001). Similarly, the median time for completion of nontrauma CT scans in the pediatric ED increased from 33 min to 41 min and 39 min (p < 0.001). The proportion of patients who received CT scans within 30 min from order decreased after adult ED trauma upgrade, from 40% in 2015 to 30% and 32% (p < 0.001) in the 2 subsequent years. The pediatric ED showed similar results, with 48% of patients receiving CT scans within 30 min in 2015, compared with 34% in 2016 and 35% in 2017 (p < 0.001). CONCLUSIONS: Level I trauma verification of the adult ED adversely affected the timeliness of nontrauma CT scans in the EDs.

Mortality of Dandy-Walker syndrome in the United States: Analysis by race, gender, and insurance status.

BACKGROUND: Dandy-Walker syndrome (DWS) is a congenital disorder often diagnosed in early childhood. Typically manifesting with signs/symptoms of increased intracranial pressure, DWS is catastrophic unless timely neurosurgical care can be administered via cerebrospinal fluid (CSF) drainage. The rates of mortality, adverse discharge disposition (ADD), and CSF drainage in DWS may not be uniform regardless of race, gender or insurance status; such differences could reflect disparities in access to neurosurgical care. This study examines these issues on a nationwide level. MATERIALS AND METHODS: The Kids' Inpatient Database spanning 1997-2003 was used for analysis. Only patients admitted for DWS (ICD-9-CM = 742.3) were included. Multivariate analysis was adjusted for several variables, including patient age, race, sex, admission type, primary payer, income, and hospital volume. RESULTS: More than 14,000 DWS patients were included. Increasing age predicted reduced mortality (OR = 0.87; P < 0.05), ADD (OR = 0.96; P < 0.05), and decreased likelihood of receiving CSF drainage (OR = 0.86; P < 0.0001). Elective admission type predicted reduced mortality (OR = 0.29; P = 0.0008), ADD (OR = 0.68; P < 0.05), and increased CSF drainage (OR = 2.02; P < 0.0001). African-American race (OR = 1.20; P < 0.05) and private insurance (OR = 1.18; P < 0.05) each predicted increased likelihood of receiving CSF drainage, but were not predictors of mortality or ADD. Gender, income, and hospital volume were not significant predictors of DWS outcome. CONCLUSION: Increasing age and elective admissions each decrease mortality and ADD associated with DWS. African-American race and private insurance status increase access to CSF drainage. These findings contradict previous literature citing African-American race as a risk factor for mortality in DWS, and emphasize the role of private insurance in obtaining access to potentially lifesaving operative care.

The natural history of Dandy-Walker syndrome in the United States: A population-based analysis.

BACKGROUND: Dandy-Walker syndrome (DWS) is a congenital disorder typically manifesting with hydrocephalus. The classic anatomic hallmarks of DWS are hypoplasia of the cerebellar vermis, anterior-posterior enlargement of the posterior fossa, upward displacement of the torcula and transverse sinuses, and cystic dilatation of the fourth ventricle. AIMS: Although optimal treatment of DWS typically requires neurosurgical intervention to prevent intracranial pressure increases incompatible with life, the natural history of this disorder has yet to be evaluated on a nationwide level. SETTINGS AND DESIGN/MATERIALS AND METHODS: The Kids' Inpatient Database covering 1997-2003 was used for analysis. Children younger than age 18 admitted for DWS (ICD-9-CM = 742.3) were analyzed with a matched control group. The primary procedure codes for operative CSF drainage were coded into the analysis. The incidence of DWS was 0.136%; 14,599 DWS patients were included. STATISTICAL ANALYSIS USED: Multiple logistic regression models were used. Odds ratios (OR) were reported with 95% confidence intervals. RESULTS AND CONCLUSIONS: Mortality (OR = 10.02; P < 0.0001) and adverse discharge disposition (OR = 4.59; P < 0.0001) were significantly greater in DWS patients compared with controls. 20.4% of DWS patients received operative cerebrospinal fluid (CSF) drainage, 81-times more than controls (P < 0.0001). CSF drainage reduced mortality by 44% among DWS patients (P < 0.0001). Although DWS is associated with a 10-fold increase in mortality, operative CSF drainage nearly halves the mortality rate. Based on these findings (Class IIB evidence), it is likely that the increased mortality associated with DWS is directly attributable to the nearly 80% of DWS patients who did not receive operative CSF drainage for hydrocephalus. Consequently, increased access to neurosurgical intervention could reduce the mortality rate of DWS towards that of the general population.