The Pediatric Emergency Care Applied
Research Network (PECARN)
and Trauma Outcomes Research
The PECARN is supported by cooperative agreements U03MC00001, U03MC00003,
U03MC00006, U03MC00007, and U03MC00008 from the Emergency Medical Services for
Children Program of the Maternal and Child Health Bureau, Health Resources and Services
Administration, Department of Health and Human Services
Surgical and Trauma Outcomes Research:
Status and Future Directions
Current
Nathan Kuppermann, MD, MPH
Departments of Emergency Medicine and Pediatrics
UC Davis School of Medicine
March 15th, 2013
Disclosure
●
No financial or other conflicts of interest
What is PECARN?
 A collaborative
research group of hospital EDs organized
into nodes and coordinated by a Steering Committee
 The
infrastructure supported by funding from HRSA
 PECARN
•
•
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works with the EMSC/MCHB/HRSA:
multi-center randomized trials
observational studies
other issues related to emergency medical services for children
 Highlighted
in 2006 IOM reports on the future of EMSC
PECARN Structure
PECARN
Steering Committee
Data
Coordinating
Center (DCC)
Quality Assurance,
Safety and
Regulatory
Protocol Review
and Development
PI: Mike Dean
HRSA/
MCHB/
EMSC
Grant Writing
and
Publication
Feasibility
and Budget
Federal Project Officer:
Tasmeen Weik
PECARN Subcommittees
Pediatric Emergency
Medicine Northeast, West
and South
Great Lakes Emergency
Medical Services for
Children Research
Network
PEM-NEWS
GLEMSCRN
PI: Peter Dayan
PI: Rachel Stanley
Hospitals of the Midwest
Emergency Research
Node
HOMERUN
PI: Rich Ruddy
Washington, Boston,
Chicago Applied Research
Node
WBCARN
PI: Jim Chamberlain
Pittsburgh, Rhode Island,
Delaware Network
PRIDENET
Pediatric Research in
Injuries and Medical
Emergencies
PRIME
PI: Bob Hickey
PI: Nathan Kuppermann
PECARN Sites
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Data Coordinating Center
PRIDENET Node
PRIME Node
GLEMSCRN Node
PEM-NEWS Node
WBCARN Node
HOMERUN Node
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Ongoing PECARN Research Development
 Patient safety and error reduction
 Quality of PEM care
 Evaluation of head trauma
 Therapeutic hypothermia in pediatric
cardiopulmonary arrest
 Diagnostic categorization of illnesses
and injuries in the PED
 C-Spine immobilization
 Management of status epilepticus
 Steroids in acute bronchiolitis
 Evaluation of abdominal trauma
 The burden of mental illness and
 Progesterone for severe TBI
psychiatric emergencies in PED
 RCT of fluids for DKA
 Magnesium for sickle cell pain
 Knowledge translation of TBI rules
 RNA transcription biosignatures to diagnose
febrile infants
Childhood Head Trauma:
A Neuroimaging Decision Rule
Supported by grant R40MC02461-01-00
from EMSC/MCHB/HRSA
The PECARN Head Injury Study
Goal: to derive a clinical decision rule to accurately
identify children at near zero risk of clinically
important traumatic brain injury after blunt trauma
with high accuracy and wide generalizability
Methods
●
Design:
– Prospective multicenter study over 28 mo. (6/04 – 9/06) in 25
sites in PECARN
●
Inclusion Criteria:
– Age < 18 years with head trauma evaluated in ED
●
Exclusion Criteria:
– Ground-level mechanisms and no symptoms or signs of TBI
– Penetrating trauma
– Injury > 24 hours old
– Pre-existing neurological disease impeding assessment
– Transfer with neuroimaging already performed
Outcome Definition
Clinically-important TBI (ciTBI)
–
–
–
–
Death from TBI
Neurosurgical procedure
Intubation for > 24 hours for head injury
Positive CT in association with hospitalization > 2 nights
Variables Considered
 Age in years
 3-level mechanism severity
 High risk
 MVC - ejection, rollover, death
 Ped or unhelmeted bicyclist struck by
motorized vehicle
 Fall > 5 feet (> 3 feet if < 2 yrs)
 High impact / projectile






 GCS (14 vs. 15)
 Other mental status








Agitated
Sleepy
Slow to respond
Repetitive
Palpable skull fx signs
Basilar skull fx signs
Amnesia (if > 2 yrs)
Bulging fontanelle
LOC (duration)
Scalp hematoma (location,
size, quality)
Seizure
 Focal neurological deficit
Acting normal per parent
Headache (severity, location) if > 2 yrs  Other system injuries
 Evidence of intoxication
Emesis (number, timing)
Results
57,030 eligible
2,869 GCS <14
or other exclusion
54,161 GCS 14-15
Not enrolled
Enrolled
42,412
(78.3%)
11,749
(21.7%)
Derivation
33,785
Validation
8,627
288 ciTBI
88 ciTBI
(0.9%)
(1.0%)
Inter-observer agreement
0
m e c ha nis m o f injury
m e c ha nis m o f injury ( lo w v s . high ris k )
dizzine s s
a m ne s ia f o r e v e nt
a ny LO C
LO C dura t io n*
s e izure
a c t ing no rm a l pe r pa re nt
he a da c he
he a da c he s e v e rit y*
v o m it ing
v o m it ing f re que nc y*
pa lpa ble f ra c t ure
bulging f o nt a ne lle ( a ge <2 o nly)
ba s ila r f ra c t ure
he m a t o m a pre s e nt
he m a t o m a lo c a t io n
he m a t o m a s ize *
he m a t o m a qua lit y
a ny s ign o f t ra um a a bo v e c la v ic le s
f o c a l ne uro lo gic de f ic it
o t he r s ubs t a nt ia l injury
int o xic a t io n
GC S*
G C S 15 v s <15
o t he r s igns o f a lt e re d m e nt a l s t a t us
a git a t e d
s lo w t o re s po nd
s le e py
re pe t it iv e ( a ge >=2 o nly)
a ny s igns o f a lt e re d m e nt a l s t a t us
0.2
Kappa
0.4
0.6
0.8
1
Kuppermann/Holmes, 2009
The PECARN TBI Rules
(derived and validated)
Children are at very low risk of clinically-important traumatic brain injury (TBI) if
they meet all criteria in age-specific rule:
Children < 2 years
Children 2-18 years
Severe mechanism of injury
History of LOC > 5 sec
GCS = 14 or other signs of altered
mental status
Not acting normally per parent
Palpable skull fracture
Occipital/parietal/temporal scalp
hematoma
Severe mechanism of injury
History of LOC
GCS = 14 or other signs of altered
mental status
History of vomiting
Severe headache in the ED
Signs of basilar skull fracture
Under 2 years
Over 2 years
Recommendations for children younger than 2
The Rule
Recommendations for children younger than 2
Suggestions
Recommendations for children 2 years and older
The Rule
Recommendations for children 2 years and older
Suggestions
PECARN Clinical Prediction Rule
for Abdominal CT in Pediatric Trauma
●
Prospective multicenter study 2007 - 2010
– < 18 years with blunt abdominal trauma
– Clinical data recorded before abd CT (if done)
– Follow-up obtained on all patients:


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Discharged patient: telephone follow-up
Admitted patients: medical record review
Primary outcome: IAI requiring therapy (IAIAI)
– Recursive partitioning analysis
– 761 (6.3%) with IAI and 203 (1.7%) with IAIAI
Prediction Rule for IAIAI (n=12,044)
1,963 patients
112 (5.7%) IAIAI
Abdominal Wall
Trauma
No
Sensitivity = 197/203 (97.0%; 95% CI 93.7, 98.9%)
Specificity = 5028/11841 (42.5%; 95% CI 41.6, 43.4%)
826 patients
38 (4.6%) IAIAI
GCS < 14
No
NPV = 5028/5034 (99.9%; 95% CI 99.7, 100%)
LR- = 0.07 (95% CI 0.03, 0.15)
2,532 patients
36 (1.4%) IAIAI
Abdomen tender
No
955 patients
6 (0.6%) IAIAI
Thoracic Trauma
No
305 patients
2 (0.7%) IAIAI
Abdominal pain
No
↓ Breath Sounds
No
34 patients
1 (2.9%) IAIAI
Emesis
No
1,234 CT scans (25%)
5,034 patients
395 patients
2 (0.5%) IAIAI
6 (0.1%) IAIAI
Holmes/Kuppermann, 2013
How to get clinicians to use the prediction rules?
Knowledge Translation Pipeline
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EBM – continuum here
Glasziou/Haynes, 2005
Translating Research into Practice
What works
Clinical decision support more successful when:
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Automatic provision of support in workflow
Recommendations given rather than risks
Support given at the time and location of
decision-making
Support is computer based
Kawamoto, 2005
Implementation of the PECARN Traumatic
Brain Injury Prediction
Rules Using Electronic Health Record-Based
Clinical Decision Support:
An Interrupted Time Series Trial
Funded by the American Recovery and Reinvestment
Act – Office of the Secretary: Grant #S02MC19289-01-00
Data Completion by Nursing
If Triage RN enters “Yes-less than 24 hours ago”
items for risk assessment will be cascade
Blunt Head Trauma Assessment
Courtesy: Peter S. Dayan, MD, PECARN
Clinical Decision Support
• Clinician receives a statement no matter what is entered
• Formatted similarly across statements
1. Recommendation
2. Risk estimate of clinically-important TBI based on
PECARN data
3. Details regarding recommendations/risks
4. List of predictors and responses
5. Links to useful information(e.g. the prediction rules)
Decision Support: Patient < 2 years who meets rule
Methods – design
Interrupted Time Series Trial with
Concurrent Controls
Month of Trial
0 1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Pre-intervention phase
Intervention
implemented
Intervention maintained
(post-intervention phase)
Main Comparisons:
Pre to post int.
Intervention Group Measurement (receives CDS)
Baseline rate of CT use
Post-intervention rate of CT use
Control Group Measurement (standard of care)
Rate of CT use measured throughout the study period
Selected References
1.Glasziou P, Haynes B. The paths from research to improved health outcomes. ACP
J Club 2005;142:A8-10.
2.Graham ID, Stiell IG, Laupacis A, O’Connor AM, Wells GA. Emergency physicians’
attitudes toward and use of clinical decision rules for radiography. Acad Emerg Med
1998;5:134-40.
3.Holmes JF, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P et al and
PECARN. Identifying children at very low risk of clinically-important blunt abdominal.
Ann Emerg Med 2013 [Epub ahead of print].
4.Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using
clinical decision support systems: a systematic review of trials to identify features
critical to success. BMJ 2005;330:765 [Epub].
5.Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R et al
and PECARN. Identification of children at very low risk of clinically-important brain
injuries after head trauma: a prospective cohort study. Lancet 2009;374:1160-70.
6.Laupacis A, Sekar N, Stiell IG. Clinical prediction rules: a review and suggested
modifications of methodological standards. JAMA 1997;277:488-494.
Selected References
7.Maguire JL, Kulik DM, Laupacis A, Kuppermann N, Uleryk EM, Parkin PC.Clinical
prediction rules for children: a systematic review. Pediatrics 2011;128:e666-77.
8.Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at
low risk for brain injuries after blunt head trauma. Ann Emerg Med 2003;42:492-506.
9.Stiell IG, Wells GA. Methodologic standards for the development of clinical decision
rules in emergency medicine. Ann Emerg Med 1999;33:437-447.
10.The Pediatric Emergency Care Applied Research Network. The Pediatric
Emergency Care Applied Research Network (PECARN): Rationale, development,
and first steps. Acad Emerg Med 2003;10:661-668.