PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study

BACKGROUND

The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma.

METHODS

For this prospective validation study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician's discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury).

FINDINGS

7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery.

INTERPRETATION

The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma.

FUNDING

The Eunice Kennedy Shriver National Institute of Child Health and Human Development.

1292. Integrating HIV and Hepatitis C Screening in a High-Risk Emergency Department Population

Background

With the acceleration of the hepatitis C (HCV) epidemic in the United States and the ongoing public health impact of undetected human immunodeficiency virus (HIV) co-infection, there is a critical need for enhanced secondary prevention efforts where patients accessing care are not routinely screened. The purpose of this program was to implement routine opt-out HIV and HCV screenings in a high-volume urban emergency department (ED) through the use of an EMR enhancement to increase a provider’s likelihood of testing eligible patients, and to provide linkage to care for patients identified to have positive tests.

Methods

From November 27, 2018 to March 31, 2019, EMR-based HIV and HCV screening was implemented in a quaternary care ED in Northern California. EMR best practice alerts were developed based on a combination of local and CDC guidelines and populated on registered patients receiving blood laboratories or receiving STI testing. Laboratory HIV/HCV screening utilized a unique two-specimen collection scheme to enable molecular testing without requiring patient return visits. Patients were excluded if they chose to opt out from testing or the provider deemed opt out was not possible. Upon notification of a positive test result through the EMR, a patient navigator was responsible for providing disease education and linking patients to care.

Results

The prevalence of HCV antibody positivity was 9.6% (637/6,627) and 0.97% (55/5,628) for HIV. Of the 255 HCV-RNA positives, 110 were known and 145 newly diagnosed. Of the 90 HIV patients, 31 were known and 8 newly diagnosed. Although current CDC hepatitis C screening guidelines recommend screening all adults born during 1945–1965, we conducted universal screening of adults 18 years or older. Of those screened antibody-positive for HCV 64% fell within the 1945–1965 birth cohort.

Conclusion

Introducing routine opt-out testing using an automated EMR-based screening program is an effective method to identify and screen eligible patients for HIV and HCV in episodic care safety net settings where universal screenings are not routinely implemented. The unexpectedly high rate of HIV seroprevalence suggests the ED environment continues to be an important setting to access populations not receiving routine care despite longstanding CDC recommendations for universal screening.

Disclosures

All authors: No reported disclosures.

433. Implementation of an Emergency Department Syphilis Screening Program

Background

Syphilis incidence across all regions of California increased by 22% compared with 2016 cases; with the largest number of chlamydia, gonorrhea, syphilis, and congenital syphilis cases among all states (CDC 2017). The USPSTF recommends targeted syphilis screening in patients at increased risk. However, in emergency departments (EDs) targeted syphilis screening is not routinely performed even when patients present for concerns of a sexually transmitted infection (STI). The purpose of this program was to implement routine syphilis screening among ED patients being tested for chlamydia and gonorrhea (CT/GC) through the use of an EHR enhancement to maximize the number of new syphilis diagnoses.

Methods

From November 27, 2018 to March 31, 2019, EHR-based syphilis screening was implemented in a quaternary care ED in Northern California serving urban and rural populations. EMR best practice alerts (BPA) were developed and populated on patients receiving STI testing. Syphilis testing employed a reverse sequence algorithm, which is suggested for high prevalence settings and provides rapid turnaround time. Patients were excluded if they opted out from testing. We determined the proportion of all CT/GC tested patients who underwent syphilis screening and the prevalence of syphilis among this group.

Results

During a four-month period, 649 ED patients with suspected STI received a BPA to screen for syphilis. Of those, 425 patients (65.5%) were screened for syphilis, 22 had a reactive IgG/IgM and RPR, while 5 patients had a reactive IgG/IgM and a nonreactive RPR which required a TPPA test to detect their infection. Fourteen of the 22 patients with a reactive RPR had titers of 1:32 or higher. Nine (32%) of those with a positive CT/GC test tested positive for syphilis.

Conclusion

Implementation of a syphilis screening program in patients undergoing testing for other STIs yielded 28 new diagnoses compared with those tested prior to the screening in 2018. Introducing an automated EMR-based syphilis screening program is an effective method to maximize syphilis screening in all ED patients seeking treatment for STIs. The screening data suggest that the majority of patients undergoing STI testing in our ED are not screened for syphilis, yet the prevalence of infection in those screened is substantial.

Disclosures

All authors: No reported disclosures.

Video versus traditional informed consent for neonatal circumcision

AIM

To determine if videotapes about newborn circumcision would be superior to traditional physician 'informed consent' discussion for maternal knowledge, satisfaction and perception of provider bias.

DESIGN/METHODS

A convenience sample of mothers interested in or undecided about circumcision was randomized to watch a video on: (i) circumcision risks/benefits ('Video-Plus' n = 168); or (ii) unrelated material followed by traditional physician risk/benefit discussion ('Standard-MD' n = 136). Questionnaires were administered during hospitalization and subsequent telephone interviews. Statistical differences were analysed by chi-square and Wilcoxon signed rank test.

RESULTS

Most mothers (82%) decided about circumcision prenatally. Fewer mothers perceived bias from the video vs. physicians [1.1% vs. 6.8%, p = 0.04]. Composite knowledge (correct of 10 answers) [ (SD) 6.5 (2.1) vs. 6.4 (2.1), p = 0.78] or satisfaction [5-point Likert scale, 3.98 (1.50) vs. 3.75 (1.58), p = 0.16] did not differ by group, although more highly educated mothers preferred the video [satisfaction 4.08 (1.01) vs. 2.63 (0.99), p = 0.04]. Significant knowledge gaps existed in both groups.

CONCLUSION

In this setting, no difference in maternal knowledge was found between 'Video-Plus' and traditional informed consent although more highly educated mothers preferred the video. Better ways to achieve understanding of risks and benefits for this elective procedure should be sought.