1. Simulation using the PECARN Head
Trauma Rule to Reduce CT Imaging
(Effectiveness of a Simulation Curriculum on Clinical
Execution: a Pilot Study)
Ilana Harwayne-Gidansky MA MD, Son McLaren MD, Jennifer
Garnett MD, Kristen Critelli MD, Kevin Ching MD
New York Presbyterian Hospital - Weill Cornell Medical College
3. Problem
Limiting unnecessary CT scans for children with head trauma
Best practice
• PECARN clinical prediction rule helps identify children with very low
risk for TBI (traumatic brain injury)
• Simple, intuitive, validated rule to decide who needs a head CT
• High negative predictive value
• Assists experienced practitioners and physicians-in-training alike
Actual practice
• Busy pediatric emergency department (PED)
• Faulty memory = imprecise interpretation of PECARN rule
• Reliance on misguided clinical judgment, experience, and intuition
Result
Children subjected to unnecessary radiation from avoidable CT scans
Background
Kupperman, et al. PECARN (Pediatric Emergency Care Applied Research Network), Lancet 2009
4.
5. Hypothesis
Growing evidence: transfer of procedural skills proficiency
acquired thru simulation to clinical practice
Limited evidence: transfer of more global clinical skills acquired
thru simulation to clinical practice
By learning the PECARN rule thru simulation training, we predict
that pediatric interns will demonstrate more rigor and precision
when using this rule on REAL children compared to its use by
non-simulated interns and more senior level residents.
The implication may be fewer unnecessary head CT scans.
6. Objectives
• Develop a pediatric simulation exercise illustrating the use of the
PECARN clinical prediction rule
• Quantitatively improve a pediatric intern’s ability to apply this
clinical prediction rule and measurably prolong knowledge
retention:
• on written and simulation post-tests
• when managing children with head trauma in the PED
• Conduct a proof-of-concept study to document the longitudinal
impact of this simulation exercise on resident education and
patient care
8. Methods
• Structured Clinical Observations (SCO)
• PED: all children with head trauma
• Head CT or NO head CT. Why?
• Self checklist by residents PGY 1-3
• Scored by trained faculty
• Written post-test
• Post-test simulation exercise
All pediatric residents
PGY 1-3 at NYP-Cornell
(60)
September 2013-
present
Structured clinical observations:
use of PECARN rule in all children
who have head trauma
ALL residents (60)
Post-test
simulation
PGY 1 (20)
11. Preliminary Results: Table 1
Intervention (1A)
N (%)
Control (1B)
N (%)
P Value
Average age 26-30 26-20 0.2357
Gender (% F) 70 100 0.0603
Prior work in healthcare 7 (0.7) 8 (0.8) 0.6056
Prior history in caring for
patients with TBI
7 (0.7) 4 (0.4) 0.1775
Prior history in caring for
patients with increased
ICP
9 (0.9) 4 (0.4) 0.0191
Prior participation in
simulated exercises
10 (1.0) 10 (1.0) 1
Prior education in
recognition or
management of TBI or
increased ICP
4 (0.4) 4 (0.4) 1
Pre-test Score 50% 54% 0.4386
SIM score 45% 42% 0.579757834
12. Preliminary Results: Table 2
Intervention (1A) Control (1B) PGY 2/3 P value
Agreement between
attending and
resident to scan
7 (1) 6 (1) 6 (.85) 0.38
Correct use of
PECARN rule by
resident
5 (.71) 4 (0.67) 4 (0.8) 0.59
Plan made to scan 0 (0) 0 (0) 1 (0.16) 0.21
CT actually obtained 12 (0.8) 19 (0.86) 14 (0.87) 0.82
% correct PECARN
criteria identified
0.61 0.50 0.37 0.15
Attending number of
PECARN criteria
(agreement with
resident)
3.43 3.31 3.00 0.84
Resident: Attending
agreement on
PECARN criteria
1.17 1.05 0.86 0.55
13. Challenges
• Development of SCOs that are simple, easy to use, and effective in
a busy ER setting
• Compliance of residents and attendings in completing SCOs
• RedCAP database design that was easy to input data and
accommodate changes in SCOs
14. Conclusion
Our preliminary proof of concept data suggests that pediatric interns
participating in simulation training may demonstrate clinical
performance competencies when using the PECARN clinical prediction
rule that are measurably similar and even more advanced than more
experienced senior level residents – suggesting that a global clinical
skill learned in simulation is being transferred to real patient care.
This study suggests that we may improve the efficiency of information
delivery through simulation, and has promising implications for future
larger studies.
15. References
1. Boulet, J., Murray, D., Kras, J. &
Woodhouse, J. Reliability and validity of a
simulation-based acute care skills assessment
for medical students and residents.
Anesthesiology 1270–1280 (2003). at
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Housestaff Competence in Emergency Airway
Management Using Scenario Based Simulation
Training* : Comparison of Attending vs
Housestaff Trainers. (2006).
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3. Overly, F. L., Sudikoff, S. N. & Shapiro, M.
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doi:10.1111/j.1365-2923.2009.03547.x
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