Abusive Head Trauma Study (Project 2)

Pediatric Abusive Head Trauma Study

Among all forms of violence directed against infants and young children, Abusive Head Trauma (AHT) is the leading cause of traumatic death and disability, impacting at least 690,000 U.S. children annually. To help confirm or exclude AHT masquerading as accidental head trauma, physicians must decide whether or not to launch a workup for child abuse in their young, acutely head-injured patients.

Research Focus

Improve screening for abusive head trauma in pediatric intensive care settings

• Implementation trial of a validated clinical decision rule in 8 PICU’s hospitals around the country
• Save lives of children who would otherwise return to abusive homes

Who participates?

Eight Pediatric Intensive Care Unit (PICU) sites, located in diverse regions of the U.S. and representative of large and small PICU settings, will be matched into four pairs (intervention + control) based on each site’s projected volume of high-risk patients. Although we need complete data for 416 patients to test our hypotheses, the actual subjects of this trial will be the Providers.

The new AHT screening tool comes in the form of a CDR.

A clinical prediction rule is an evidence- based tool that measures and then combines the specific predictive contributions of multiple clinical findings or test results to estimate or predict the probability of a diagnosis, prognosis, or response to therapy in an individual patient. A clinical prediction rule rises to the level of a clinical decision rule (CDR) if and when physicians use the tool to guide a specific clinical decision. Our screening tool was developed to serve first and foremost as an effective decision rule. Our rule was derived and validated in strict accordance with established guidelines and was developed to function effectively as an AHT screening tool in PICU settings. It includes four highly reliable predictors and makes a recommendation to complete an abuse evaluation on all patients that it categorizes as high risk. Because the CDR’s predictor variables are all readily available, physicians can apply this AHT screening tool when they need it—at or near the time of PICU admission—to inform or guide their early decisions to either launch or forgo child-abuse evaluations in their young, acutely head-injured patients. If applied as recommended, it will categorize all patients who present for PICU admission with any one or more of its four variables as high risk and make a recommendation to evaluate all high-risk patients for abuse.

Why is this research important?

A doctor’s flawed decision to forgo an abuse evaluation in an abused head-injured child puts that child at substantial risk for further abuse and/or death when returned to his or her abusive caregiver(s). Accurate and consistent application of this new, broadly validated CDR could:

1. reduce disparities in current AHT screening and evaluation practices
2. minimize the negative impacts of clinicians’ inexperience, uncertainty, and inherent biases
3. significantly increase AHT detection (87% to 96%)
4. increase the overall diagnostic yield of patients’ completed abuse evaluations (i.e., the percentage of patients whose completed skeletal surveys and/or retinal exams reveal corroborating findings of abuse; 49% to 56%)
5. lower evidence-based estimates of missed AHT among patients not evaluated for abuse (0.19 to 0.07)
6. decrease unnecessary abuse evaluations of patients with accidental head trauma (67% to 60%)
7. lower the cost per correctly identified child with AHT (by 15.1%)
8. dramatically lower overall AHT-associated acute health care costs in PICU settings (by 74.2%).