Head injury in children is a common problem presenting to emergency departments, and cranial computed tomography scanning is the diagnostic standard for these patients. Several decision rules are used to determine whether computed tomography scans should be used; however, the use of computed tomography scans is often influenced by guardians’ preference toward the scans. The objective of this study was to identify changes in guardian preference for minor head injuries after receiving an explanation based on the institutional clinical practice guideline.
A survey was conducted between July 2010 and June 2012. Patients younger than 16 years with a Glasgow Coma Scale score of 15 after a head injury and their guardians were included. Pre- and post-explanation questionnaires were given to guardians to assess their preference for computed tomography scans and factors related to the degree of preference. Treating physicians explained the risks and benefits of cranial computed tomography scanning using the institutional clinical practice guideline. Guardian preference for a computed tomography scan was examined using a 100-mm visual analog scale.
In total, 208 patients and their guardians were included in this survey. Guardian preference for computed tomography scans was significantly reduced after explanation (46.7 vs. 17.4, P<0.01). Pre-explanation preference and the strength of the physician recommendation to get a computed tomography were the most important factors affecting pre- and post-explanation changes in preferences.
Explanation of the risks and benefits of cranial computed tomography scans using the institutional clinical practice guideline may significantly reduce guardian preference for computed tomography scans.
Cranial computed tomography scan is the diagnostic standard for intracranial injury. However, the radiation risk of computed tomography scans is problematic, particularly in children.
When physicians explain the risks and benefits of cranial computed tomography scans using the institutional clinical practice guideline, guardian preference for computed tomography scans can be reduced.
Head injury in children is a common problem presenting to emergency departments (EDs) [
This study was a survey including pre- and post-explanation questionnaires (
Our institutional clinical practice guideline for pediatric minor head injury was developed by an institutional joint committee of EP and pediatric neurologists [
The clinical practice guideline was implemented beginning in July 2010. During 6 months prior to the survey, we educated emergency physicians (EP) about the new guideline and posted it for them to consult at any time. The survey was conducted between July 2010 and June 2012 from 10 am to 10 pm. The study period was limited due to the working time of clinical research nurses. Inclusion criteria were age younger than 16 years, GCS of 15, and treatment in our ED after head injuries. Patients with preexisting neurologic diseases or coagulation diseases, those with non-blunt head injuries or with injuries to other body parts, and those who were transported after head imaging studies at other hospitals were excluded from the survey. When an eligible patient arrived at the ED, the triage nurse gave the guardian the preliminary questionnaire form after describing the study. After the guardian completed the questionnaire, a board-certified EP examined the patient and explained the risks and benefits of CT scans, and symptoms and signs that required a CT scan, based on the clinical practice guideline. After hearing the explanation, the guardian filled out the post-explanation questionnaire. Informed consent of guardians was also obtained. The preliminary questionnaire asked about patient characteristics such as sex, age, presence of siblings, experience, numbers of previous CT scans, injury time, mechanism of injury, and symptoms related to the injury. The symptoms related to the injury included amnesia, loss of consciousness, seizure, irritability, headache, dizziness, vomiting, lethargy, and abnormal behavior. We also collected data about the guardian, including sex, age, relationship to the patient, education level, severity of the injury as perceived, and guardian preference toward a CT scan. It was not possible to assess whether patients younger than 3 years had amnesia, headache, or dizziness. The post-explanation questionnaire asked about previous knowledge about the risk of CT scans, how they learned about the risk, the degree to which the physician recommended CT, and guardian preference toward a CT scan. The severity of the injury as perceived by guardians, the degree to which the physician recommended CT, and guardian preference toward a CT scan were assessed in the pre- and post-explanation questionnaires using a 100-mm visual analog scale. A value of “0” indicated that the guardian did not want the use of CT scans.
Ninety days after discharge, a follow-up telephone call was made to identify symptoms and management in other hospitals due to head injuries [
The primary outcomes were changes in guardian preferences after receiving an explanation according to the new clinical practice guideline. The secondary outcomes were the related factors affecting changes in guardian preferences.
Statistical analysis was performed using the IBM SPSS Statistics ver. 19.0 (Armonk, NY, IBM Corp., USA). In the analysis of the survey study, pre- and post-explanation guardian preference was compared using the paired t-test. Factors affecting these changes were identified using univariate linear regression, and factors with P-values less than 0.1 were included in multivariate linear regression. Correlations between knowledge of the risk of CT scans, experience with previous CT scans, highest education level, and pre-explanation preference were identified using the χ2 test and Student’s t-test. A P-value less than 0.05 was considered statistically significant.
A total of 208 patients were surveyed during the study period. Male patients accounted for 61.5% (128 patients) and the mean age was 3.6 (standard deviation 3.3) years (range, 2 months to 15 years). Twenty patients (9.6%) had undergone CT scans previously. The most common cause of injury was a fall. Headache was the most common symptom, and scalp hematoma was the most common sign. No patients had a focal neurologic deficit, sign of a scalp fracture, or bulging fontanel. Although skull radiographs were performed in 78 patients, no fractures were detected (
Female guardians accounted for 75.0%, and most guardians were parents. About half of the guardians knew about the radiation risk of CT scans, and half had obtained this information from the mass media (
Guardian preference for CT scans was significantly reduced after receiving an explanation (46.7 vs. 17.4; P<0.01; 95% confidence interval, 25.1 to 33.5). Change in preference before and after explanation, as measured using the VAS, was significantly affected by pre-explanation preference and the strength of the physician recommended CT. However, change in preference was not significantly associated with age, presence of siblings, previous experiences with CT scans, mechanism of injury, symptoms, signs, or performance of skull radiography. Variables related to guardians, such as sex, age, relationship to the patient, highest education level, knowledge about radiation risk, source of knowledge about radiation, and severity of the injury as perceived by guardians, were not significantly related to change in preferences (
At 90 days, three patients were not assessed for their symptoms. The remaining patients had recovered from their symptoms and were not being managed in other hospitals. The proportion of children who received CT scans after implementing the practice guideline was significantly reduced compared with that before the practice guideline period (7.3% vs. 13.6%, P<0.01).
This is the first study to explore changes in guardian preferences for CT scans after receiving an explanation by physicians about the risks and benefits of the clinical practice guideline. Guardian preference was significantly reduced after explanation, and this change was associated with pre-explanation preference and the strength of the physicians recommended CT.
Since the introduction of CT scans in the 1970s, their use has increased among both adults and children [
Pre-explanation preference was not associated with knowledge about radiation risk. This suggests that greater pre-explanation preference would result in a greater change in preference, i.e., preference was significantly reduced by explanation.
Physicians have difficulty deciding whether CT scans are required for minor head injuries due to the variability in management [
This study had several limitations. First, this was a survey study that included some, but not all, children with head injuries. Therefore, the results may reveal reduced preference among their guardians. Because we could not access the characteristics of the unenrolled patients, we identified the performance rate of CT scans after the guideline period. We assumed that the clinical practice guideline affected the use of CT scans based on the lower numbers of CT scans performed after guideline period. Second, because the survey was conducted from 10 am to 10 pm, selection bias may have been involved. The limited study time may also have had an effect in that all suspected patients were not included. However, the characteristics of guardians and patients may not have been different during other time periods. Third, as the hospital is located in a metropolitan area, the patients and guardians visiting this hospital represent a reasonably well-educated sample; thus, they may better understand the explanation of physicians. Therefore, the results may not necessarily apply to a less educated population. Fourth, this study was conducted in a single center, so the ability to generalize the results is limited.
In conclusion, explanation of the risks and benefits of cranial CT scans using the clinical practice guideline may significantly reduce guardian preference toward CT.
No potential conflict of interest relevant to this article was reported.
This study was supported by grant number 11-2010-025 from Seoul National University Bundang Hospital research fund.
Baseline characteristics of survey patients
Clinical variable | Patient (n = 208) |
---|---|
Sex | |
Male | 128 (61.5) |
Female | 80 (38.5) |
Age (yr) | 3.6 ± 3.3 |
Presence of sibling | 107 (51.4) |
Previous experience with CT scans | 20 (9.6) |
Previous number of CT scans | 1.2 ± 0.5 |
Mechanism of injury | |
Falling | 99 (47.6) |
Collision | 56 (26.9) |
Slipping down | 53 (25.5) |
Symptoms of patients | |
Amnesia |
5 (4.7) |
Loss of consciousness |
9 (4.3) |
Seizure | 1 (0.5) |
Irritability | 51 (24.5) |
Headache |
82 (77.4) |
Dizziness | 36 (34.0) |
Vomiting | 48 (23.1) |
Lethargy | 45 (21.6) |
Abnormal behavior | 43 (20.7) |
Signs of patients | |
Focal neurologic deficit | 0 (0) |
Scalp hematoma | 63 (30.3) |
Scalp laceration | 3 (1.4) |
Scalp fracture sign | 0 (0) |
Bulging fontanel | 0 (0) |
Performance of skull radiograph | 79 (38.0) |
Values are presented as number (%) or mean±standard deviation.
CT, computed tomography.
These findings were sought in 106 patients.
Baseline characteristics of guardians
Clinical variable | Guardian (n = 208) |
---|---|
Sex | |
Male | 46 (22.1) |
Female | 156 (75.0) |
Age (yr) | 36.8 ± 4.5 |
Relationship with patients | |
Parents | 200 (96.2) |
Teacher | 1 (0.5) |
Highest level of education | |
High school graduate | 11 (5.3) |
In college or graduated | 151 (72.6) |
Graduate school | 40 (19.2) |
Knowledge about radiation risk | 98 (47.1) |
Source of knowledge about radiation | |
The mass media | 50 (24.0) |
Hospitals | 26 (12.5) |
Acquaintances | 16 (7.7) |
Internet | 9 (4.3) |
Other | 6 (2.9) |
Pre-questionnaire preference of guardians | 46.7 ± 32.0 |
Post-questionnaire preference of guardians | 17.4 ± 19.3 |
Strength of physicians recommended CT | 17.6 ± 17.6 |
Severity of injury perceived by guardians | 27.6 ± 17.7 |
Values are presented as number (%) or mean±standard deviation. There were some missing values.
CT, computed tomography.
Factors affecting change in preference between pre- and post-explanation questionnaires
Variable | β (SE) | P-value | 95% CI |
|
---|---|---|---|---|
Lower | Upper | |||
Sex of patients | 2.21 (4.41) | 0.62 | –6.48 | 10.90 |
Age of patients | –0.33 (0.65) | 0.61 | –1.61 | 0.95 |
Presence of sibling | 6.48 (4.35) | 0.14 | –2.10 | 15.06 |
Previous experience with CT scans | –2.54 (7.26) | 0.73 | –16.86 | 11.77 |
Body part of CT scans in previous experiences | 7.85 (9.29) | 0.41 | –11.96 | 27.66 |
Mechanism of injury | –1.97 (2.56) | 0.47 | –6.91 | 3.18 |
Performance of skull radiograph | 3.05 (4.40) | 0.49 | –5.63 | 11.73 |
Sex of guardians | –2.44 (5.14) | 0.64 | –12.57 | 7.70 |
Age of guardians | –0.54 (0.51) | 0.30 | –1.55 | 0.47 |
Relationship with patients | –16.52 (14.82) | 0.27 | –45.75 | 12.72 |
Highest level of education of guardians | –1.19 (4.74) | 0.80 | –10.54 | 8.17 |
Knowledge about radiation risk of guardians | 7.60 (4.34) | 0.08 | –0.95 | 16.15 |
Source of knowledge about radiation | 1.21 (1.99) | 0.55 | –2.74 | 5.15 |
Pre-questionnaire preference of guardians | 0.78 (0.04) | < 0.01 | 0.70 | 0.85 |
Strength of physician recommended CT | –0.25 (0.12) | 0.04 | –0.49 | –0.01 |
Severity of injury as perceived by guardians | 0.20 (0.12) | 0.10 | –0.04 | 0.44 |
SE, standard error; CI, confidence interval; CT, computed tomography.
Factors affecting change in preference between pre- and post-explanation questionnaires, based on multiple linear regression analysis
Variable | β (SE) | P-value | 95% CI |
|
---|---|---|---|---|
Lower | Upper | |||
Knowledge about radiation risk of guardians | 2.40 (2.09) | 0.25 | –1.72 | 6.52 |
Pre-questionnaire preference of guardians | 0.85 (0.03) | < 0.01 | 0.78 | 0.91 |
Strength of physician recommended CT | –0.59 (0.06) | < 0.01 | –0.71 | –0.47 |
SE, standard error; CI, confidence interval; CT, computed tomography.
Preliminary questionnaires
Explanation for patients of minor head injury
Post-explanation questionnaires