A secondary analysis to inform a clinical decision rule for predicting skull fracture and intracranial injury in children under age two

UNCG Author/Contributor (non-UNCG co-authors, if there are any, appear on document)
Elizabeth L. Stone (Creator)
The University of North Carolina at Greensboro (UNCG )
Web Site: http://library.uncg.edu/
Leslie Davis

Abstract: The purpose of the current study was to identify the variables associated with the risk of closed head injury (CHI) in children under age two with suspected minor head injuries based on age-appropriate, or near age-appropriate, mental status on exam, as defined by a Glascow Coma Score (GCS) of 15 or 14, respectively. The goal was to propose a set of variables that, when considered together, have a high degree of predictive accuracy in identifying CHI in this population. This set of variables could eventually be used to inform a clinical decision rule which may help triage nurses make acuity decisions in a more evidence-based manner. The study was guided by Donabedian’s Structure, Process, Outcome model that allows for the assessment of the various factors that inform and influence the ED triage process. The current study was a secondary data analysis of the public-use dataset from the largest prospective, multi-center pediatric head injury study found in the current literature. As part of the secondary analysis, an existing clinical decision rule by Greenes and Schutzman (2001) (Greenes and Schutzman Risk Scoring System [the Scalp Score]),was examined using a sample of 3,329 children under age two to determine whether it, or the individual variables within it, could be utilized alone, or in conjunction with other variables to accurately predict the risk of underlying CHI in this population.In consideration of the factors related to best practice for clinical decision ruledevelopment, the optimal set of variables for a clinical decision rule to predict CHI inchildren under age two would include the following variables: age in months, acomposite variable representing hematoma presence/size, and location; and severity of injury mechanism. An evidence-based, nurse-driven clinical decision rule designed as a risk scoring system could serve to improve the “structure” of ED triage. Such a resource could influence the “process” of the triage assessment and acuity assignation to be more accurate, ultimately also optimizing the primary “outcome” of triage accuracy for children under age two with CHIs. Such a tool could help overcome inconsistencies in triage acuity decisions due to variation in knowledge, thereby improving triage accuracy and consistency for children under age two who present for evaluation of suspected minor head injuries. The results of this study could also be used to inform more agespecific recommendations for children under age two in triage and educational resources and in national trauma criteria. The findings from this study add to the body of knowledge regarding whatvariables are, and are not, associated with CHI in children under age two with suspected minor head injuries. The key to an accurate triage assessment for children under age two with suspected minor head injuries includes familiarity with the main regions of the skull, being able to assess for the presence and size of any scalp hematoma and having access to accurate information regarding the child’s age and the details of the injury mechanism.

Additional Information

Language: English
Date: 2018
Assessment, Head Injury, Nursing, Pediatric, Risk, Triage
Clinical medicine $x Decision making
Pediatric nursing
Head $x Wounds and injuries
Toddlers $x Wounds and injuries
Triage (Medicine)

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