A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings.

OBJECTIVE To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. STUDY DESIGN Cluster randomized trial. Participants were 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive acutely head-injured patients <3 years (n=183 and n=237, intervention vs. control). PICUs were stratified by patient volumes, pair matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster level interventions included initial and booster training, an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. RESULTS Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs. 73%, P=.11) and had fewer potential cases of missed abusive head trauma (21% vs. 32%, P=.05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P=.22). From baseline (in prior studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs. 78%→73%, P=.01), and potential cases of missed abusive head trauma (40%→21% vs. 29%→32%, P=.003), diverged significantly. We did not identify a significant change in the number of estimated cases of missed abusive head trauma (15%→7% vs. 11%→13%, P=.22). CONCLUSION PediBIRN-4 CDR application facilitated changes in evaluations that reduced potential cases of missed abusive head trauma in PICU settings.