A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings

Abstract

Objective: To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings.

Study design: This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models.

Results: Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22).

Conclusions: PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings.

Trial registration: ClinicalTrials.gov: NCT03162354.

Keywords: child abuse; clinical decision rule; screening test.

Figure 1. Patient attrition and the impacts of abusive head trauma screening and evaluation practices at intervention vs. control sites over the course of the CRT.

Of the 631 acutely head-injured patients under 3 years of age hospitalized in a participating PICU over the course of the 32-month CRT, 211 (33%) were excluded from study participation. 183 (44%) of the remaining 420 eligible patients were admitted to an intervention PICU, where clinicians were encouraged to apply the PediBIRN-4 CDR as an abusive head trauma screening tool. The remaining 237 patients (56%) were hospitalized in a control PICU, where providers practiced abusive head trauma screening as usual. The yellow boxes track abusive head trauma screening and evaluation practices—and relevant clinical impacts of those practices—in patients the CDR categorized as higher risk. Green boxes track the equivalent practices and outcomes in the remaining lower risk patients. Red boxes highlight corroborated cases of abusive head trauma and estimates of missed abusive head trauma in higher vs. lower risk patients in each arm of the CRT. Abbreviations: CDR=clinical decision rule, CNS=central nervous system, CRT=cluster randomized trial, PediBIRN=pediatric brain injury research network, PICU=pediatric intensive care unit, MVA=motor vehicle accident