Setting standards for pediatric emergency care everywhere
When Nathan Kuppermann sees a sick or injured child in the emergency room, he has to make a number of decisions instantly: whether to give antibiotics to an infant with a 102° fever, if the dizzy boy hit in the head by a softball needs a CT scan, or how rapidly to give intravenous fluids to a young girl in diabetic coma.
Some decisions are easily made – solid evidence shows that certain treatments are likely to help the patient. But many actions are taken because of tradition, even though support of their effectiveness from good clinical studies is often lacking.
"There’s nothing like caring for really sick children to make you think – is there a better way of doing things?" muses Kuppermann, a professor of emergency medicine and pediatrics and chair of the Department of Emergency Medicine at the UC Davis School of Medicine.
Building a research community
Such musings have led him to become a pioneer in developing research collaborations within the pediatric emergency care community. These multicenter research groups have become essential for conducting clinical research aimed at setting standards of care for managing acutely ill and injured children in emergency rooms nationwide.
"There’s nothing like caring for really sick children to make you think – is there a better way of doing things?"
Clinical research is especially difficult in the pediatric population, according to Kuppermann.
"Children are resilient and usually recover from an injury or acute illness no matter how they are treated," he says. "This is great for children and their parents, but complicated for researchers."
Because most children get well, pediatric studies need to include a much larger number of subjects than is required for adults in order to statistically document treatment effects. Recognizing this need, Kuppermann has worked tirelessly over the past 15 years to set up emergency room research networks to pool clinical study data.
Kuppermann started organizing small collaborations through the American Academy of Pediatrics’s Pediatric Emergency Medicine Collaborative Research Committee on a shoestring budget. After a few years, he had the opportunity to sit down with influential federal funders and policy makers.
"They asked me, ‘What is needed to bring research in pediatric emergency medicine to the next higher level?’" Kuppermann recalls. "I responded, ‘Resources and an infrastructure that will enable us to do large-scale studies.’"
Formation of PECARN
His efforts helped create the Pediatric Emergency Care Applied Research Network (PECARN), the only federally funded pediatric emergency care research network in the U.S. Kuppermann chaired the PECARN Steering Committee from its inception in 2001 until stepping down in late 2008, and remains one of the principal investigators of the network.
"[Federal funders and policy makers] asked me, ‘What is needed to bring research in pediatric emergency medicine to the next higher level?’ I responded, ‘Resources and an infrastructure that will enable us to do
Sponsored by the Health Resources and Services Admin-istration, Maternal and Child Health Bureau and the Emergency Medical Services for Children Program, PECARN is organized into four research nodes, including one led by UC Davis. The 22 hospital emergency departments that constitute PECARN serve more than 900,000 acutely ill and injured children every year. These emergency departments represent academic, community, general and children’s hospitals, providing an enormous and diverse database.
At any given time, the network conducts six to eight major research studies. The network has borne substantial fruit – publication of multiple studies in influential journals that have confirmed or changed treatment practices of acutely ill or injured children.
One important PECARN study published in The New England Journal of Medicine in 2007 addressed whether treatment with corticosteroid medication for a child presenting in the emergency room with bronchiolitis was beneficial. The double-blind, randomized study of 600 children in 20 emergency departments found that corticosteroid therapy did not change the rate of hospital admission, the length of stay for children who were admitted or how patients fared subsequently. Unless a child had pre-existing asthma, the standard practice of exposing children with bronchiolitis to corticosteroids was shown to be unnecessary.
"Large studies that we can carry out with the PECARN collaboration really impact standards of care worldwide," says Kuppermann. "Because of the weight of findings based on such large numbers, doctors can make confident decisions about how they treat patients."
New rules for CT scans
The PECARN study, led by Kuppermann and published in
The Lancet in 2009, developed a prediction rule for determining whether a cranial CT scan is indicated following a head injury by considering multiple clinical signs and symptoms, including the presence of physical signs of a skull fracture, mental status, vomiting and headache.
One of the largest studies conducted in PECARN enrolled more than 42,000 infants and children from all PECARN hospitals. The study, led by Kuppermann and published in The Lancet in 2009, developed a prediction rule for determining whether a cranial CT scan is indicated following a head injury by considering multiple clinical signs and symptoms, including the presence of physical signs of a skull fracture, mental status, vomiting and headache.
Although CT scans are a quick and sure way to determine if a dangerous internal bleed is present, the radiation exposure increases risk of malignancy in the long term.
"Developing prediction rules are especially important for ER doctors who must make decisions quickly based on what they see in front of them," says Kuppermann. "Decision rules give confidence that either further study or treatment is really justified, or alter-natively, that a patient is not likely to be in danger and can be sent home safely without it."
A similar PECARN study to develop a rule for the need for a CT scan for infants and children following an abdominal injury will be submitted for publication shortly.
"PECARN has changed pedia-tric emergency medicine," says Kuppermann. "As a result, doctors can make treatment decisions with confidence, improve outcomes, avoid unnecessary side effects of ineffective therapy, and save valuable resources."