1. CDR Implementation Trial
Initial Training
CDR Implementation Trial
NOTE: This initial training should take less than 15 minutes to complete.

2. Background

3. Background
Abusive head trauma (AHT) is the leading cause of traumatic death and disability in early childhood, affecting thousands of children annually in the U.S.
Intensive care providers and child abuse consultants elect to launch—or to forgo—child abuse evaluations in their young, acutely head-injured patients based on an individualized assessment of risk.
Without data, these decisions have been subject to variability and bias.

4. Background
Pediatric Brain Injury Research Network (PediBIRN) investigators have derived and validated a PICU-based screening tool for AHT.
This evidence-based AHT screening tool comes in the form of a clinical decision rule (CDR).

5. The CDR for AHT reads as follows…
“To minimize missed cases, every acutely head-injured infant or young child hospitalized for intensive care who presents with any one or more of these four predictor variables should be considered ‘high risk’ and thoroughly evaluated for abuse:
Any clinically-significant respiratory compromise at the scene of injury, during transport, in the emergency department, or prior to hospital admission;
Any bruising involving the child’s ear(s), neck OR torso;
Any subdural hemorrhage(s) or fluid collection(s) that are bilateral OR involve the interhemispheric space; and/or…
Any skull fracture(s) other than an isolated, unilateral, nondiastatic, linear, parietal skull fracture.”

6. Background
The CDR was derived in a multicenter study of 209 acutely head-injured patients less than 3 years of age.
Its AHT screening performance was then validated in a second multicenter study of 291 acutely head-injured children.
Both studies were conducted at 14 sites.
Both studies were strictly observational.

7. Background
Applied accurately and consistently at the time of PICU admission, the CDR would have correctly identified (categorized as ‘high risk’)…
96% of validation study patients who met a priori definitional criteria for AHT,
98% of validation study patients ultimately diagnosed with AHT, and…
99% of derivation or validation patients whose completed skeletal survey and/or retinal exam revealed corroborating findings of abuse.

8. Background
Secondary, theoretical analyses suggest that CDR application as an AHT screening tool in PICU settings could…
Increase AHT detection from 87% to 96%,
Decrease unnecessary abuse evaluations of patients with accidental head trauma from 67% to 60%, and…
Reduce overall, AHT-associated, acute health care costs by 72%.

9. Our CDR implementation trial

10. Our CDR Implementation Trial
The time has come to assess the CDR’s AHT screening performance when it is actively applied in PICU settings.
Your PICU will participate in our ‘CDR Implementation Trial’ as one of four intervention sites.
Four matched sites will serve as controls.
Once begun, active data capture will continue for approximately 36 months, but could be extended to 42 months.

11. Our CDR Implementation Trial
Here’s what your participation in this CDR implementation trial will mean for you:
You will be expected to apply the CDR as an AHT screening tool, and to actively consider its recommendations, whenever an eligible, acutely head-injured patient is admitted to your PICU, and…
We will deploy a variety of active strategies designed specifically to encourage you to follow the CDR’s recommendations.

12. The CDR Implementation Trial
You should consider the CDR to be directive, but not mandatory.
You are free to reject its recommendation to workup all ‘high risk’ patients for abuse.
If you decide to not workup a ‘high risk’ patient for abuse, we will simply ask you to help us document why you did so.

13. The CDR Implementation Trial
The CDR makes no specific recommendation about abuse workups in ‘low risk’ patients—those who present with none of the CDR’s four predictor variables.
In our validation study, 7% of these ‘low risk’ patients met our definitional criteria for AHT, and 4% were ultimately diagnosed with AHT.
Because a few AHT patients will be categorized as ‘low risk’, you are encouraged to workup ‘low risk’ patients for abuse if/when your clinical intuition tells you to do so.
If you decide to workup a ‘low risk’ patient for abuse, we will simply ask you to help us document why you did so.

14. The CDR Implementation Trial
To help you make these decisions, you will be given access to an online or smartphone “AHT Probability Calculator.”
The calculator will ask you whether or not your head- injured patient presented for PICU admission with any one or more of the CDR’s four predictor variables.
Answer those four questions, and the calculator will provide you with an evidence-based, patient-specific, estimate of the probability of AHT (and other useful data).

15. The CDR Implementation Trial
Your patients with acute head trauma resulting from a motor vehicle accident or collision are ineligible. The CDR is not meant to be applied to these patients.
Our prior studies suggest that your PICU will admit less than four eligible patients per month.

16. The CDR Implementation Trial
We know that your time is highly valuable.
Therefore, your Site PI and Research Coordinator will be doing most of the heavy lifting.
They have been directed to interfere with direct patient care as little as possible.
When they do come to talk to you about a specific patient, your active involvement will very likely take <10 minutes.

17. The CDR Implementation Trial
Over the course of the trial, you will be required…
To complete multiple, brief, online surveys, and…
To participate in periodic ‘information sharing sessions’ with your Site PI, where you will review data about CDR acceptance and utilization at your site, and discuss local barriers limiting the CDR’s adoption as an AHT screening tool.