P0501 - CT imaging of the head in pediatric mild traumatic brain injury: association with pediatric hospital classification and trauma center designation in Maryland

Background:
The majority of pediatric emergency department (ED) visits in the US occur in community settings with varying provider experience in caring for injured youth. The 2009 PECARN head injury study identified children at low risk for clinically important brain injury for whom computed tomography head imaging (head CT), and its associated radiation exposure can be safely avoided. Despite the wide dissemination of the PECARN decision tool, many children with mild traumatic brain injury (mTBI) continue to receive a head CT when evaluated in the ED.

Objectives:
To determine the association of pediatric hospital classification or hospital trauma designation with receiving a head CT for mTBI, and to determine the temporal trend in head CT use for mTBI in the state of Maryland

Methods:
Children ≤19 years presenting to Maryland EDs 04/2012-09/2017 with mTBI were identified using the Maryland Health Services Cost Review Commission database. Encounters for mTBI and head CT scan were defined using ICD-9/10 codes. Pediatric hospital classifications were defined as free-standing EDs, local, regional, comprehensive, and subspecialty pediatric centers. Trauma designation was defined using Maryland TraumaNet classifications. Patient and injury characteristics were compared using chi-squared testing. Two multivariable Poisson regression models were used to determine the relative risk of receiving a head CT (model 1- pediatric hospital classification, model 2- trauma designation).

Results:
We identified 25,410 youth presenting to the ED for an mTBI-related visit, of which 12,014 (47%) received a head CT. Overall, 88% of encounters occurred at local or regional hospitals and 78% at non-trauma designated centers (Table 1). Compared to pediatric subspecialty centers, presentation to other facilities was associated with a 34-70% increase in relative risk of head CT (Table 2, model 1). Compared to individuals treated at a pediatric trauma center, treatment at centers of other trauma designation was associated with a 47-64% increase in relative risk of head CT (Table 2, model 2). Of the individuals receiving a head CT, 328 (2.7%) had an mTBI-related ED return visit within four weeks and 55 (17%) had a repeat head CT, representing 0.5% of the overall population receiving initial head CT. The state-wide probability of receiving a head CT decreased over time (52.8% in 2012 to 44.8% in 2017, p < 0.001).

Conclusions:
We identified an important group of hospitals, those with lower pediatric hospital classification or adult trauma designation, where there is a higher risk of head CT utilization for pediatric mTBI. This represents an opportunity for advocates of reducing head CT in pediatric mTBI to target educational efforts. There was a modest decrease in annual rates of head CTs in this population over the 5-year period, which is encouraging and may reflect ongoing endeavors to provide evidence-based trauma care throughout Maryland.