Pediatrics/brief research report
Pediatric Head Trauma: Changes in Use of Computed Tomography in Emergency Departments in the United States Over Time

Presented at the Society for Pediatric Research, May 2004, San Francisco, CA.
https://doi.org/10.1016/j.annemergmed.2006.09.025Get rights and content

Study objective

Head trauma is common in children. In the absence of evidence-based recommendations, variations exist in the initial emergency department (ED) evaluation and treatment of children with head trauma. We sought to describe the use of computed tomography (CT) over time in the treatment of children with acute closed head trauma in US EDs.

Methods

This was a cross-sectional analysis of data from the National Hospital Ambulatory Care Survey database from 1995 to 2003. We identified patients aged 0 to 18 years, with head trauma by chief complaint or discharge diagnosis. We collected the following data: chief complaint, patient demographics, patient disposition, discharge diagnosis, and use of CT. Frequency and characteristics of the use of CT scan for evaluation of children with head trauma. We used descriptive statistics with appropriate weighting to account for the survey methodology. We determined the frequency and the characteristics of the use of CT scans for evaluation of children with head trauma. We used descriptive statistics with appropriate weighting to account for the survey methodology.

Results

We identified 2,747 patient encounters, representing 10,536,717 pediatric head trauma visits during the 9-year period. The use of CT increased from 12.8% to 22.4% from 1995 to 2003, with a peak of 28.6% in 2000. CT was used more frequently in the older age groups: 13% (<1 year), 11% (1 to 4 years), 20% (5 to 9 years), and 32% (10 to 18 years). CT was also used more frequently in general EDs (22%) than in pediatric-specific EDs (13%). There were no differences in CT use between teaching and nonteaching facilities (21% in each). Overall, 6.4% of children were either admitted to the hospital or transferred, and this rate remained stable over time.

Conclusion

The use of CT has increased substantially in the evaluation of children with head trauma from 1995 to 2003. Further study is needed to identify objective criteria for cranial CT in head-injured children and to evaluate the impact of increased CT use on patient outcomes.

Introduction

Acute closed head trauma is a common event in the pediatric age group. Emergency department (ED) evaluation of children with head trauma can reveal important findings, including traumatic brain injuries and skull fractures. Many previous studies have documented important variations in the evaluation and treatment of these children.1, 2 In part to address these variations, investigators have recently published clinical decision rules to aid in the evaluation of pediatric head trauma.3, 4, 5 However, because of the inconsistency in clinical criteria among them, these rules may not limit practice variation. Furthermore, management strategies may be influenced by other factors such as local standards, the setting in which that evaluation takes place, the specialty/training of the physician treating the patient, and the available resources, including medical staffing and technology.2, 6

The optimal use of neuroimaging for children with minor head trauma has been a subject of controversy in the pediatric literature during the last several decades. Since the introduction of computed tomography (CT) in the 1970s, cranial CT has clearly become the diagnostic reference standard for management strategies for patients with acute head trauma.7 During the past 2 decades, researchers have tried to focus on optimizing the use of CT scanning in patients with acute minor head trauma. Despite such efforts, it is unclear whether in the recent past the use of CT is increasing or decreasing in the evaluation of head-injured children.

The aim of this study is to describe the use of CT over time in the treatment of children with acute closed head trauma in US EDs.

Section snippets

Study Design

The study was a cross-sectional analysis of data obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data sets for 1995 to 2003. The NHAMCS is an annual survey of hospital ED and outpatient department visits, conducted by the National Center for Health Statistics.8 With a multistage sampling scheme, data are collected on approximately 25,000 visits annually to some 600 hospital EDs and outpatient departments in the United States. Because data are publicly available

Characteristics of Study Subjects

We identified 2,747 patient encounters in children aged 0 to 18 years and with a diagnosis of head trauma from 1995 to 2003. According to the NHAMCS sampling strategy, these observations represent 10,536,717 patient encounters for children aged 0 to 18 years for the same interval, or an estimated 1,170,746 annual visits. One thousand seven hundred forty-three (63.6%) of the 2,747 were male patients, and 1,818 (69.0%) were of white/non-Hispanic decent. Four hundred forty-four (12.6%) patients

Limitations

This study has several limitations. It represents a cross-sectional analysis of previously collected data. Only 2,747 patient evaluations were obtained from the NHAMCS database during the 9-year period, from approximately 600 hospitals surveyed annually. However, the multistage sampling techniques are designed to make the sample representative of the entire United States. The data available in the NHAMCS database are also limited with respect to clinical information. As such, the most common

Discussion

The results of this study demonstrate an increased use of CT scans from 1995 to 2003 for the evaluation of children with head trauma. The upward trend in the use of CT scan may be due to a lower threshold for CT use that has developed among physicians during this period. However, the benefits of increased CT use with regard to patient outcomes remain unclear.

Although we did not have data on GCS or other specific markers of severity of head injury, it is likely that the increase in CT use is

References (10)

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    Blackwell et al. and Mannix et al. restricted their samples to pediatric patients presenting with head trauma. Blackwell et al. reported that unadjusted head CT rates at pediatric hospitals from 1995 to 2003 were significantly lower than at non-pediatric hospitals (13% vs. 22%).30 Mannix et al. seems to have strengthened support of those results by reporting that the adjusted odds of head imaging between 2002 and 2006 were significantly higher at non-pediatric hospitals compared to pediatric hospital (adjusted OR (95% CI): 2.4 (1.1–5.3)).21

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Supervising editor: Kathy N. Shaw, MD, MSCE

Author contributions: CDB, MG, and NK conceived the study. CDB and MG performed data collection from the NHAMCS database. MG provided statistical advice on study design. CDB and MG performed the main data analysis. JFH, SB, and NK contributed to data analysis and interpretation. CDB drafted the article, and all authors contributed substantially to its revision. CDB takes responsibility for the paper as a whole.

Funding and support: The authors report this study did not receive any outside funding or support.

Reprints not available from the authors.

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