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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 231-236

Knowledge, attitudes, and self-reported practices of pediatric emergency physicians toward the pediatric emergency care applied research network criteria in Al-Qassim region


1 Department of Pediatric, Unaizah College of Medicine, Qassim University, Al-Qassim, Saudi Arabia
2 Department of Medical Intern, Unaizah College of Medicine, Al-Qassim, Saudi Arabia
3 Department of Community and Family Medicine, Unaizah College of Medicine, Qassim University, Al-Qassim, Saudi Arabia

Date of Web Publication4-Oct-2019

Correspondence Address:
Mohammad Abdulaziz Alhasoon
Department of Pediatric, Unaizah College of Medicine, Qassim University, Al-Qassim
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JNSM.JNSM_77_18

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  Abstract 


Objective: The study was conducted to assess the knowledge, attitudes, and self-reported practices of pediatric emergency physicians toward Pediatric Emergency Care Applied Research Network (PECARN) criteria among physicians who are covering the emergency room at Ministry of Health Hospitals in the Al-Qassim Region. Methodology: A cross-sectional study was conducted. A questionnaire that included various sociodemographic variables and items on knowledge, attitude, and self-reported practices was administered. To explore significant differences across different sociodemographic variables, the Mann–Whitney U-test and Kruskal–Wallis test were implemented as appropriate. Results: A total of 117 pediatric emergency physicians were surveyed. The data show a mean knowledge score of 8.17 (standard deviation [SD] 3.14). There were no significance differences in age group, gender, nationality, experience, or doctor category (P > 0.05). However, significant differences were observed in level of education (P = 0.014). The mean score for attitude was 6.81 (SD 2.3). Among sociodemographic variables, only those in educational level (P = 0.004) and experience in years (P = 0.001) were significant. Practice average score was 5.79 (SD 1.8). As in the case of attitude, the data showed significant differences in level of education (P = 0.002), as well as years of experience (P = 0.004). Conclusions: This demonstrates that the application of PECARN in Al-Qassim Province, Saudi Arabia, will minimize the risk of exposure to radiation in the pediatric population with head trauma. Positive knowledge, attitudes, and practices regarding PECARN identified pediatric patients at low risk of clinically significant traumatic brain injuries.

Keywords: Al-Qassim, clinical decision rule, head trauma, pediatric, Pediatric Emergency Care Applied Research Network, traumatic brain injury


How to cite this article:
Alhasoon MA, Altowayan R, Alqufly A, Aloqayli R, Alfeneekh A, Alkharaz G, Aljohani MS. Knowledge, attitudes, and self-reported practices of pediatric emergency physicians toward the pediatric emergency care applied research network criteria in Al-Qassim region. J Nat Sci Med 2019;2:231-6

How to cite this URL:
Alhasoon MA, Altowayan R, Alqufly A, Aloqayli R, Alfeneekh A, Alkharaz G, Aljohani MS. Knowledge, attitudes, and self-reported practices of pediatric emergency physicians toward the pediatric emergency care applied research network criteria in Al-Qassim region. J Nat Sci Med [serial online] 2019 [cited 2019 Dec 13];2:231-6. Available from: http://www.jnsmonline.org/text.asp?2019/2/4/231/260449




  Introduction Top


Worldwide, head injury is one of the leading causes of morbidity and mortality.[1] In Saudi Arabia, the most commonly injured body parts due to car accidents are the head and neck.[2] The prevalence of head injuries associated with falls occurs in the pediatric population, primarily preschool and elementary school age groups under the age of 6 years old.[3] The pediatric population in the emergency department (ED) presents symptoms associated with head injuries. Pediatric emergency physicians generally perform computed tomography (CT) scans to diagnose acute head injury and traumatic brain injury (TBI).[4]

The problem arises when pediatric emergency physicians overuse CT scans, resulting in the exposure of pediatric patients to excessive amounts of radiation. Increased exposure to radiation significantly heightens the risk of brain tumors and leukemia.[5] However, unnecessary CTs can be costly and a waste of time. Accordingly, it is common for pediatric emergency physicians to use evidence-based practices criteria such as the Canadian Assessment of Tomography for Childhood Head injury (CATCH) and the Children's Head injury Algorithm for the prediction of Important Clinical Events (CHALICE) as the clinical decision rule (CDR). However, the Pediatric Emergency Care Applied Research Network (PECARN) outperforms both CATCH and CHALICE rules based on the detection of TBI to demonstrate the appropriate need for CT utilization within the pediatric population.[6],[7],[8] As a CDR, the PECARN criteria allow pediatric emergency physicians to collect information about the presenting symptoms in an effort to accurately identify clinically significant TBI, thereby reducing physicians' overutilization of harmful diagnostic tests.[7]

The study aimed to assess the knowledge, attitudes, and self-reported practices of pediatric emergency physicians toward PECARN criteria among physicians who are covering the emergency room at Ministry of Health (MOH) Hospitals in the Al-Qassim Region.


  Methodology Top


Ethical approval

Ethical approval has been received from the Regional Research Committee at General Directorate of Health Affairs, Al-Qassim Region National Committee of Bio and Med. Ethics Registration No. H-04-Q-001 numbered as 20180519 before commencing this work. Verbal consent secured from each participant and hospital directors' approvals were obtained.

Design and settings

A cross-sectional design was conducted among physicians who were covering pediatric emergency in various MOH Hospitals inclusive of Ar Rass General Hospital, Badayea General Hospital, King Saud Hospital, Maternal and Children's Hospital, and Muznib General Hospital, all of which are located in the Province of Al-Qassim. According to the MOH Statistical Yearbook 2017, the number of MOH hospitals is 19, the number of beds is 2859, and doctors are 2092. In addition, emergency visits were 1,451,672 visits.[9]

Sample size

Although the sample size equation and computations revealed that the study should include a total of 150 participants, convenience sampling led to the inclusion of 117 pediatric emergency physicians.

Data collection method

Data collection was based on a self-administered survey questionnaire. The questionnaire measured demographic information such as age, experience, gender, level of education, and category. Additional survey questions measured pediatric emergency physician knowledge and attitude toward PECARN as well as physician self-reported practices regarding the use of CT for pediatric patients with head trauma. Questions were graded on a Likert scale. The study questionnaire has been validated by reviewing a study by Ballard et al., and three consultants evaluated face and content validity (one pediatric and two community medicine).[10] A pilot study was conducted for ten physicians to test the general understanding, clarity, and reliability of the questionnaire. Cronbach's alpha was 0.72, which indicates acceptable internal consistency reliability.

Main outcome measures

This cross-sectional study aims to quantitatively assess the knowledge levels, attitudes, and self-reported practices regarding PECARN criteria in Al-Qassim Province, Saudi Arabia. Such a tool aims to minimize the unnecessary use of CT scans for pediatric brain injuries.

Statistical analysis

Data were presented using descriptive statistics in the form of frequencies and percentages for categorical data and mean and standard deviation (SD) for continuous data. Overall knowledge, attitudes, and practices (KAP) score was the sum of correct responses to the 26 questions. One point was given for the correct answer and zero for the wrong answer. Components' knowledge scores included general questions on knowledge of PECARN (2 questions), specific questions (9 questions), attitude (8 questions), and practice (7 questions). KAP components' scores were treated as nonparametric data, and components' scores were compared across sociodemographic characteristics using Mann–Whitney and Kruskal–Wallis, as appropriate. The Kolmogorov–Smirnov test was significant, so nonnormal distribution was assumed. All P values were two-tailed. P < 0.05 was considered as statistically significant. Statistical package for the social sciences version 19 (SPSS IBM, New York, US) was used for all statistical analyses.


  Results Top


Sociodemographic characteristics

A total of 117 pediatric emergency physicians were surveyed in this study, as shown in [Table 1]. As [Table 1] shows, the largest age groups were 36–45 (42.7%) and ≤35 (41.9%). Male doctors were almost twice the number of female doctors in the study sample, at 78 (66.7%), while females were 39 (33.3%). The majority of the physicians were non-Saudi 73 (62.4%), which is consistent with the doctors' population in the Al-Qassim region where most of them are non-Saudi nationals. In terms of educational level, nearly half of the physicians were board certified (47.9%). A considerable proportion have a master's degree in related fields (20.5%). Nearly half of the physicians, 41.9%, reported that they are residents, while 35.9% and 22.2% were specialists and consultants, respectively. Nearly 30% of them reported having 6–10 years of experience, followed by 11–15 years (24.8%) and 1–5 years (23.9%).
Table 1: Sociodemographic characteristics of the sample

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Main outcome results

Knowledge

[Table 2] provides data analysis for questions on the knowledge component of the questionnaire. Interestingly, the physicians reported knowledge ranges between all responses, although the majority stated that they had previous knowledge of PECARN and were also aware of the criteria (66.7% and 58.1%, respectively). With regard to the specific question about PECARN knowledge, the data indicated there was a general understanding of the principles and practices associated with PECARN.
Table 2: Knowledge component questions of knowledge, attitudes, and practices on pediatric emergency care applied research network

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Attitude

Attitudes toward the PECARN practices are illustrated in the responses in [Table 3]. The population was generally accepting of the practices while maintaining these opinions for various reasons, ranging from being easy to remember to the high sensitivity and specificity of the tool. Responses to a tricky question (q3) in which the answer was NO were consistent with their answers to other attitude questions. However, it showed the lowest percentage of being answered correctly.
Table 3: Frequency and percentage of correct answers on attitude questions on Pediatric Emergency Care Applied Research Network

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Self-reported practices

The participant responses for PECARN practice are presented in [Table 4]. The questions included different case scenarios and questions about correct practices. The respondents' responses indicated that their practice of PECARN was largely good.
Table 4: Frequency and percentage of physicians' correct practices on Pediatric Emergency Care Applied Research Network

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Association between knowledge, attitudes, and practices scores and sociodemographic variables

As shown in [Table 5], for the total KAP score, the average score was 20.77 (SD 6.63). Exhibited significant differences in educational level and years of experience (P = 0.010 and P= 0.009) are shown in [Table 6].
Table 5: Mean and standard deviation of knowledge, attitude, and practices toward Pediatric Emergency Care Applied Research Network criteria

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Table 6: Kruskal-Wallis test for selected sociodemographics (education level and years of experience)

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Knowledge

The data show a mean knowledge score of 8.17 (SD 3.14). To explore significance differences across different sociodemographic variables, Mann–Whitney and Kruskal–Wallis were implemented as appropriate. There were no significance differences in age group, gender, nationality, experience, and doctor category (P > 0.05). However, significant differences were observed in level of education (P = 0.014).

Attitude

The mean score for attitude was 6.81 (SD 2.3). Among sociodemographic variables, only educational level (P = 0.004) and experience in years (P = 0.001) were statistically significant.

Self-reported practices

Practice average score was 5.79 (SD 1.8). As in the case of attitude, the data showed statistically significant differences in the level of education (P = 0.002) as well as years of experience (P = 0.004). Reported practices were correlated with knowledge's as in [Table 7].
Table 7: Spearman's rank correlation coefficient showed correlation of knowledge's scores and practice of Pediatric Emergency Care Applied Research Network

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  Discussion Top


Nowadays, PECARN plays an important role in clinical decision-making after minor head trauma for the identification of children who are at risk without using a CT scan.[6],[7] This study was aimed to assess knowledge, attitude, and self-reported practices toward PECARN criteria among physicians who are covering the emergency room at MOH Hospitals in the Al-Qassim Region. Based on the results of the self-reported questionnaire, the majority of physicians were residents (41.9%) and their ages were ≤35 years old. As regards their scores of knowledge on PECARN, the study showed 8.17 (SD 3.14). Although there were no significant differences in age group, gender, nationality, experience, and doctor category, significant differences were observed in the level of education (P = 0.014).

As resulted from analyzing the reported practices and attitude data, we found the average score of practices was 5.79 (SD 1.8). The data showed significant differences in the level of education (P = 0.002) as well as years of experience (P = 0.004), while the mean score for attitude was 6.81 (SD 2.3). As in the case of practice, only educational level (P = 0.004) and experience in years (P = 0.001) were statistically significant. Ballard et al. demonstrate that physicians with 15 or more years of experience as well as physicians who knew the specifics regarding PECARN prediction rules tend to order CTs less frequently than less experienced physicians.[10] This suggests that more experienced doctors are more likely to reduce their use of CT scans in pediatric patients with head trauma. These research findings are consistent with our study findings demonstrating that physicians with 10–15 years or more of experience were more aware of and used PECARN clinical prediction rules. Similar findings were found in a study by Ballard et al.[10],[11] A smaller percentage of pediatric emergency physicians was aware of the PECARN-specific prediction rules at 40% (vs. 51% in our study); however, 64.5% used the PECARN rules either some or all of the time in clinical practice, yet only a relatively small portion (36%) of physicians failed to use the rules at all in practice.[10],[11]

Although pediatric emergency physicians had a good degree of knowledge alongside more positive attitudes and practices regarding PECARN, a majority of physicians in Al-Qassim Province, Saudi Arabia, were non-Saudi. These findings are contrary to Atabaki et al.'s findings. In comparison to other countries, physicians in the United States adopt and use published CDRs such as the PECARN criteria at lower rates despite demonstrating similarities in the level of awareness.[12],[13]

In this study, findings demonstrate that more than half of all pediatric emergency physicians possess a general understanding of PECARN principles and practices, although the exact level of knowledge varied between physician responses. A significant proportion of physicians surveyed accepted PECARN practices due to the ease of use of the tools. The high specificity was also key toward acceptance, adherence, and use of the PECARN criteria. Despite the PECARN criteria's ease of use, high sensitivity, and specificity, pediatric emergency physicians noted that if the criteria were time-consuming, they would not apply it within their duties. These findings are in alignment with responses regarding physician attitudes. Relative to PECARN, physicians reported substantially good practices. According to physicians' attitude regard utilization of prediction rules in clinical practice, they agree on the effectiveness of PECARN criteria in avoiding the use of invasive and time-consuming test in ED.[10] As it is easily accessible, pertains to typical complaints within the ED, and easy to remember.[10]

Recommendations

Clinical decision support (CDS) can be readily utilized to implement PECARN prediction rules within the ED. However, it is recommended that in order to increase adherence and use of the tool, CDS should be implemented in the electronic health record (EHR) workflow and based on the interventions that are less interruptive of a physician's physical workflow such as pop-ups within the electronic order entry system. Such recommendations will aid in reducing the prevalence of TBI in pediatric patients by preventing the overutilization of CT scans in pediatric populations in the ED. The recommendation is that CDS serves as an augmentation and improvement to clinical judgment. Future studies should examine how to provide pediatric emergency physicians with varying demographical decision support, and whether the implementation of CDS such as PECARN in the EHR workflow will lead to better practices, so physicians could make the most appropriate decision for pediatric patients with head trauma.


  Conclusions Top


Research findings from this cross-sectional study add to the existing body of research literature regarding the influence that KAP have on the use of PECARN criteria by pediatric emergency physicians. In this cross-sectional research study, adequate levels of KAP of PECARN were found. Regardless of age, gender, nationality, and rank, high scores were evident; however, education level and experience revealed significant differences. This demonstrates that the application of PECARN in Al-Qassim Province, Saudi Arabia, will minimize the risk of exposure to radiation in the pediatric population with head trauma. Positive KAP regarding PECARN identified pediatric patients at low risk of clinically significant TBI. Proper CDS with PECARN enables pediatric emergency physicians to use PECARN's CDRs and apply them correctly.

Limitations

The findings are geographically limited to MOH hospitals in Al-Qassim Province since we had a limited sample size and did not include other centers in other regions due to time limitation. Another limitation is associated with the administration of a self-reporting survey questionnaire. Results from this questionnaire are subjected to recall bias.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gean AD, Fischbein NJ. Head trauma. Neuroimaging Clin N Am 2010;20:527-56.  Back to cited text no. 1
    
2.
Mansuri FA, Al-Zalabani AH, Zalat MM, Qabshawi RI. Road safety and road traffic accidents in Saudi Arabia. A systematic review of existing evidence. Saudi Med J 2015;36:418-24.  Back to cited text no. 2
    
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Alhabdan S, Zamakhshary M, AlNaimi M, Mandora H, Alhamdan M, Al-Bedah K, et al. Epidemiology of traumatic head injury in children and adolescents in a major trauma center in Saudi Arabia: Implications for injury prevention. Ann Saudi Med 2013;33:52-6.  Back to cited text no. 3
    
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Bruce DA. Imaging after head trauma: Why, when and which. Childs Nerv Syst 2000;16:755-9.  Back to cited text no. 4
    
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Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: A retrospective cohort study. Lancet 2012;380:499-505.  Back to cited text no. 5
    
6.
Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr. Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet 2009;374:1160-70.  Back to cited text no. 6
    
7.
Lorton F, Poullaouec C, Legallais E, Simon-Pimmel J, Chêne MA, Leroy H, et al. Validation of the PECARN clinical decision rule for children with minor head trauma: A French multicenter prospective study. Scand J Trauma Resusc Emerg Med 2016;24:98.  Back to cited text no. 7
    
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Babl FE, Bressan S. Physician practice and PECARN rule outperform CATCH and CHALICE rules based on the detection of traumatic brain injury as defined by PECARN. Evid Based Med 2015;20:33-4.  Back to cited text no. 8
    
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Ministry of Health. Statistical Yearbook – Statistical Yearbook; 2019. Avaialble from: https://www.moh.gov.sa/en/Ministry/Statistics/book/Pages/default.aspx. [Last accessed on 2019 Jan 23].  Back to cited text no. 9
    
10.
Ballard DW, Rauchwerger AS, Reed ME, Vinson DR, Mark DG, Offerman SR, et al. Emergency physicians' knowledge and attitudes of clinical decision support in the electronic health record: A survey-based study. Acad Emerg Med 2013;20:352-60.  Back to cited text no. 10
    
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Dayan PS, Ballard DW, Tham E, Hoffman JM, Swietlik M, Deakyne SJ, et al. Use of traumatic brain injury prediction rules with clinical decision support. Pediatrics 2017;139. pii: e20162709.  Back to cited text no. 11
    
12.
Atabaki SM, Jacobs BR, Brown KM, Shahzeidi S, Heard-Garris NJ, Chamberlain MB, et al. Quality improvement in pediatric head trauma with PECARN rules implementation as computerized decision support. Pediatr Qual Saf 2017;2:e019.  Back to cited text no. 12
    
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Brehaut JC, Stiell IG, Visentin L, Graham ID. Clinical decision rules “in the real world”: How a widely disseminated rule is used in everyday practice. Acad Emerg Med 2005;12:948-56.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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