Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.
Emergency Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.
PLoS One. 2020 Feb 11;15(2):e0228715. doi: 10.1371/journal.pone.0228715. eCollection 2020.
Head injuries in children are a common and potentially devastating presentation. The CareTrack Kids (CTK) study assessed care of Australian children aged 0-15 years, in 2012 and 2013, to evaluate the proportion in line with guideline-based indicators for 17 common conditions. Overall adherence to guideline-based recommended practice occurred 59.8% of care encounters (95% CI: 57.5-62.0), and 78.3% (95% CI: 75.1-81.2) for head injury. This paper presents results for head injury, at indicator level.
A modified version of the RAND-UCLA method of indicator development was used. Indicators, measurable components of a standard or guideline, were developed from international and national guidelines relating to head injury in children and were ratified by clinical experts using a Delphi process. Paediatric nurses extracted data from medical records from general practitioners (GPs), emergency departments (EDs) and inpatient wards in Queensland, New South Wales and South Australia, for children under 15 years receiving care in 2012-13. Our purpose was to estimate the percentage adherent for each indicator.
The medical records of 629 children with head injury were examined. Fifty-one percent of children were under 5 years old, with more males (61%) than females. Thirty-eight indicators were assessed. Avoidance of nasotracheal airways (100%; 95% CI: 99.4-100) or nasogastric tubes (99.7%; 95% CI: 98.5-100) for children with a head injury had the highest adherence. Indicators relating to primary and secondary assessment of head injuries were mostly adhered to. However, adherence to other indicators was poor (e.g., documentation of the past history of children (e.g., presence or absence of seizures) before the injury; 29.9% (95% CI: 24.5-35.7)), and for others was difficult to estimate with confidence due to small sample sizes (e.g., Children with a head injury who were intubated had PaO2 above 80mm Hg; 56.0% (95% CI: 28.6-80.9)). Indicators guiding clinical decision making regarding the need for CT scan had insufficient data to justify reporting.
This study highlights that management of head injury in children mostly follows guidelines, but also flags some specific areas of inconsistency. Individual sites are encouraged to use these results to guide investigation of local practices and inform quality improvement endeavours.
儿童头部损伤是一种常见且潜在具有破坏性的疾病。CareTrack Kids（CTK）研究评估了 2012 年和 2013 年澳大利亚 0-15 岁儿童的护理情况，以评估 17 种常见疾病中符合基于指南的指标的比例。在总共 59.8%（95%CI：57.5-62.0）的护理中，有 78.3%（95%CI：75.1-81.2）符合头部损伤的基于指南的建议实践。本文在指标层面呈现了头部损伤的研究结果。
采用改良版的 RAND-UCLA 指标开发方法。与儿童头部损伤相关的国际和国家指南中的可衡量的标准或指南组成部分被开发为指标，并通过德尔菲法（Delphi process）由临床专家进行了批准。昆士兰州、新南威尔士州和南澳大利亚州的儿科护士从全科医生（GPs）、急诊室（ED）和住院病房的医疗记录中提取了 2012-13 年接受治疗的 15 岁以下患有头部损伤的儿童的数据。我们的目的是估计每个指标的达标比例。
对 629 名患有头部损伤的儿童的医疗记录进行了检查。51%的儿童年龄在 5 岁以下，男性（61%）多于女性（39%）。评估了 38 个指标。对于头部损伤的儿童，采用鼻气管（100%；95%CI：99.4-100）或鼻胃管（99.7%；95%CI：98.5-100）的方法，其达标率最高。头部损伤的初步和二次评估的指标大多得到了遵守。然而，其他指标的遵守情况较差（例如，记录受伤前儿童的既往病史（例如，有无癫痫发作）；29.9%（95%CI：24.5-35.7）），而对于其他指标，由于样本量小，难以有信心地估计（例如，头部损伤后需要插管的儿童的 PaO2 高于 80mmHg；56.0%（95%CI：28.6-80.9））。指导 CT 扫描临床决策的指标的数据不足，无法进行报告。
本研究表明，儿童头部损伤的管理大多遵循指南，但也存在一些不一致的具体领域。鼓励各个地点使用这些结果来指导当地实践的调查，并为质量改进工作提供信息。
