title: The effect of observation on cranial computed tomography utilization for children after blunt head trauma.
abstract: OBJECTIVE
  Children with minor blunt head trauma often are observed in the emergency department before a decision is made regarding computed tomography use. We studied the impact of this clinical strategy on computed tomography use and outcomes.
  
  
  METHODS
  We performed a subanalysis of a prospective multicenter observational study of children with minor blunt head trauma. Clinicians completed case report forms indicating whether the child was observed before making a decision regarding computed tomography. We defined clinically important traumatic brain injury as an intracranial injury resulting in death, neurosurgical intervention, intubation for longer than 24 hours, or hospital admission for 2 nights or longer. To compare computed tomography rates between children observed and those not observed before a decision was made regarding computed tomography use, we used a generalized estimating equation model to control for hospital clustering and patient characteristics.
  
  
  RESULTS
  Of 42 412 children enrolled in the study, clinicians noted if the patient was observed before making a decision on computed tomography in 40 113 (95%). Of these, 5433 (14%) children were observed. The computed tomography use rate was lower in those observed than in those not observed (31.1% vs 35.0%; difference: -3.9% [95% confidence interval: -5.3 to -2.6]), but the rate of clinically important traumatic brain injury was similar (0.75% vs 0.87%; difference: -0.1% [95% confidence interval: -0.4 to 0.1]). After adjustment for hospital and patient characteristics, the difference in the computed tomography use rate remained significant (adjusted odds ratio for obtaining a computed tomography in the observed group: 0.53 [95% confidence interval: 0.43-0.66]).
  
  
  CONCLUSIONS
  Clinical observation was associated with reduced computed tomography use among children with minor blunt head trauma and may be an effective strategy to reduce computed tomography use.
authors.affiliation: Division of Emergency Medicine, Children's Hospital Boston, Boston, Boston, MA 02115, USA. lise.nigrovic@childrens.harvard.edu
authors.forename: Lise E
authors.initials: LE
authors.lastname: Nigrovic
authors.forename: Jeff E
authors.initials: JE
authors.lastname: Schunk
authors.forename: Adele
authors.initials: A
authors.lastname: Foerster
authors.forename: Arthur
authors.initials: A
authors.lastname: Cooper
authors.forename: Michelle
authors.initials: M
authors.lastname: Miskin
authors.forename: Shireen M
authors.initials: SM
authors.lastname: Atabaki
authors.forename: John
authors.initials: J
authors.lastname: Hoyle
authors.forename: Peter S
authors.initials: PS
authors.lastname: Dayan
authors.forename: James F
authors.initials: JF
authors.lastname: Holmes
authors.forename: Nathan
authors.initials: N
authors.lastname: Kuppermann
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D016489:Head Injuries, Closed / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D011446:Prospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012886:Skull / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014193:Trauma Centers; D015599:Trauma Severity Indices