Acute Care Clinical Indicators Associated With Discharge Outcomes in Children With Severe Traumatic Brain Injury*

Vavilala, Monica S.; Kernic, Mary A.; Wang, Jin; Kannan, Nithya; Mink, Richard; Wainwright, Mark S.; Groner, Jonathan I.; Bell, Michael J.; Giza, Christopher C.; Zatzick, Douglas; Ellenbogen, Richard G.; Boyle, Linda Ng; Mitchell, Pamela H.; Rivara, Frederick P.

doi:10.1097/ccm.0000000000000507

Cited by 122 publications

(116 citation statements)

References 25 publications

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“…14 Patients were included in the analysis if they were under 18 years of age at admission, were in the intensive care unit (ICU) for a minimum of 2 calendar days, and were treated for a severe TBI. In line with previous work, 5,15 severe TBI was identified based on: (1) an Abbreviated Injury Scale (AIS) score of ‡ 3 and specific to head trauma (predot code beginning with 1), (2) a Glasgow Coma Scale (GCS) score < 9, and (3) a TBI-specific International Classification of Diseases (ICD-9 code on their discharge abstract (800.0-801.9, 803.0-804.9, 850.0-854.1, 950.1-950.3, 959.01, or 995.55). We restricted our cohort to patients treated in Level I and II hospitals to focus on facilities that provide the majority of care for severe TBI injuries as both direct admissions and transfers from lower level trauma centers.…”

Section: Study Setting and Populationsupporting

confidence: 79%

“…Importantly, guideline adherence was associated with better discharge survival. 5 Facility type (e.g., pediatric vs. adult center, trauma level certification) may also be an important predictor of survival, although studies comparing pediatric trauma outcomes between different types of facilities are limited. Previous investigations suggest that severely injured children (particularly those with head injuries) have improved discharge outcomes and lower mortality when treated at pediatric trauma centers compared with adult trauma centers, 6 and that this may be related to differences in treatment (e.g., approach to operative vs. nonoperative management, frequency of neurosurgical intervention by pediatric specialists).…”

Section: Introductionmentioning

confidence: 99%

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Facility Characteristics and Inhospital Pediatric Mortality after Severe Traumatic Brain Injury

Mills

Rowhani-Rahbar

Vavilala

2015

Journal of Neurotrauma

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More than 500,000 children sustain a traumatic brain injury (TBI) each year. Previous studies have described significant variation in inhospital mortality after pediatric TBI. The aim of this study was to identify facility-level characteristics independently associated with 30-day inhospital mortality after pediatric severe TBI. We hypothesized that, even after accounting for patient-level characteristics associated with mortality, the characteristics of facilities where patients received care would be associated with inhospital mortality. Using data from the National Trauma Data Bank from 2009-2012, we identified a cohort of 6707 pediatric patients hospitalized with severe TBI in 391 facilities and investigated their risk of 30-day inhospital mortality. Pre-specified facility-level characteristics (trauma certification level, teaching status, census region, facility size, nonprofit status, and responsibility for pediatric trauma care) were added to a Poisson regression model that accounted for patient-level characteristics associated with mortality. In multivariable analyses, patients treated in facilities located in the Midwest (risk ratio [RR] = 1.42; 95% confidence interval [CI] 1.12-1.81) and South (RR = 1.39; 95% CI: 1.12-1.72) regions had higher likelihoods of 30-day inhospital mortality compared with patients treated in the Northeast. Other facility-level characteristics were not found to be significant. To our knowledge, this is one of the largest investigations to identify regional variation in inhospital mortality after pediatric severe TBI in a national sample after accounting for individual and other facility-level characteristics. Further investigations to help explain this variation are needed to inform evidence-based decision-making for pediatric severe TBI care across different settings.

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Section: Study Setting and Populationsupporting

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Facility Characteristics and Inhospital Pediatric Mortality after Severe Traumatic Brain Injury

Mills

Rowhani-Rahbar

Vavilala

2015

Journal of Neurotrauma

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“…35,52 There are papers discussing survival in severely head-injured adults. Chamoun et al reported survival in 50.8% of adult TBI patients presenting with a GCS score of 3 and good outcome at 6 months in 13.2%.…”

Section: Discussionmentioning

confidence: 99%

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Fulkerson

White

Rees

et al. 2015

PED

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OBJECT Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. METHODS A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a “normal” outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. RESULTS Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. CONCLUSIONS In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.

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“…This is a significant improvement and demonstrates the possibility of improving short-term outcomes by standardizing PICU care for pediatric patients with severe TBI. 31 including maintenance of CPP greater than 40 mm Hg and early start of nutrition. Our results build upon these findings, further reinforcing the evidence that guideline-based care can improve outcomes in pediatric patients with severe TBI.…”

Section: Discussionmentioning

confidence: 99%

Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge

O'Lynnger¹,

Shannon²,

Le³

et al. 2016

Journal of Neurosurgery: Pediatrics

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OBJECT The goal of critical care in treating traumatic brain injury (TBI) is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow. The authors compared short-term outcomes as defined by discharge disposition and Glasgow Outcome Scale scores in children with TBI before and after the implementation of a protocol that standardized decision-making and interventions among neurosurgeons and pediatric intensivists. METHODS The authors performed a retrospective pre- and postprotocol study of 128 pediatric patients with severe TBI, as defined by Glasgow Coma Scale (GCS) scores < 8, admitted to a tertiary care center pediatric critical care unit between April 1, 2008, and May 31, 2014. The preprotocol group included 99 patients, and the postprotocol group included 29 patients. The primary outcome of interest was discharge disposition before and after protocol implementation, which took place on April 1, 2013. Ordered logistic regression was used to assess outcomes while accounting for injury severity and clinical parameters. Favorable discharge disposition included discharge home. Unfavorable discharge disposition included discharge to an inpatient facility or death. RESULTS Demographics were similar between the treatment periods, as was injury severity as assessed by GCS score (mean 5.43 preprotocol, mean 5.28 postprotocol; p = 0.67). The ordered logistic regression model demonstrated an odds ratio of 4.0 of increasingly favorable outcome in the postprotocol cohort (p = 0.007). Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition and 36 patients (36%) had favorable discharge disposition. After protocol implementation, 9 patients (31%) had unfavorable disposition, while 20 patients (69%) had favorable disposition (p = 0.002). In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.04). CONCLUSIONS Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation of a standardized protocol among caregivers based on best-practice guidelines.

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Acute Care Clinical Indicators Associated With Discharge Outcomes in Children With Severe Traumatic Brain Injury*

Cited by 122 publications

References 25 publications

Facility Characteristics and Inhospital Pediatric Mortality after Severe Traumatic Brain Injury

Facility Characteristics and Inhospital Pediatric Mortality after Severe Traumatic Brain Injury

Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4

Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge

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