Jacobs, Aukelien (2023) Naleving van de richtlijn ‘licht traumatisch hoofd/hersenletsel’ bij kinderen. thesis, Medicine.
Full text available on request.Abstract
Background: The Dutch guideline ‘mild traumatic brain injury’ (mTBI), in Dutch: ‘licht traumatisch hoofd/hersenletsel, indicates in which patients with mTBI a brain computed tomography (CT) or clinical observation is recommended. The guideline recommends a low-threshold to do a CT-scan. However, this increases the risk of radiation malignancies at a young age, while the risk of intracranial hemorrhage is low. Based on this, the local protocol of the pediatricians of Isala hospital (Zwolle) recommends a hospital admission without initial imaging more often. The question is whether this approach is safe and justified for mTBI patients. Objective: Evaluating national and local guideline adherence within children who have mTBI and the safety of a more expectative approach. Methods: Retrospective study of pediatric (0-18 years) mTBI (GCS ≥13) at the emergency department (ED) of Isala from December 2018 to July 2022. Primary outcome were the percentages of hospital admissions and CT-scans; and adherence to national and local guidelines. Secondary outcome were traumatic findings on CT-scan, neurosurgical interventions and financial consequences. Results: Within the period of 3.5 year, 704 patients with mTBI were included and analyzed (387 boys; median age 3.0 (IQR 8)). A CT-scan of the brain was performed in 47 patients (6.7%); 475 patients (67.5%) were admitted to the hospital; and 182 patients (25.9%) were sent home. National guideline adherence was 34.5% (n=243). If the national guideline had been followed, a CT-scan would have been performed in 417 patients (59.2%); 31 patients (4.4%) would have been admitted to the hospital; 181 patients (25.7%) would have had either a CT scan or hospital admission; and 75 patients (10.7%) would have been sent home. Non-adherence to the national guideline existed of choosing for a hospital admission even though a CT-scan was indicated (n=270, 58.6%). Local guideline adherence was 51.4% (n=362). If the local guideline had been followed, a CT-scan would have been performed in 131 patients (18.6%); 238 patients (33.8%) would have been admitted to the hospital; and 335 patients (47.6%) would have been sent home. Non-adherence to the local guideline mostly comprised of overtreatment (n=205, 59.9%). Intracranial hemorrhage was found in 13 patients (1.8%) and 2 patients (0.3%) underwent a neurosurgical intervention. An impression fracture and intracranial contusion were discovered in 1 patient during hospital admission, which would have been diagnosed immediately if the national and local guideline had been followed. Conclusion: The adherence of the pediatricians in Zwolle to the national guideline and local guideline mTBI was poor. Compared to the national guideline, there is a preference for hospital admission even though a CT-scan of the brain was indicated. Compared to the local guideline, there is a preference for hospital admission instead of hospital discharge. This study suggests that a more expectative approach without initial imaging appears to be sufficiently safe and exposes fewer children to the risks of radiation or unnecessary hospital admissions
| Item Type: | Thesis (UNSPECIFIED) |
|---|---|
| Supervisor name: | Bekhof, dr. J. |
| Date Deposited: | 19 Apr 2023 13:07 |
| Last Modified: | 19 Apr 2023 13:07 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/3485 |
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