Introduction of severe traumatic brain injury care protocol is associated with reduction in mortality for pediatric patients: a case study of Children’s Healthcare of Atlanta’s neurotrauma program

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Evidence shows mixed efficacy of applying guidelines for the treatment of traumatic brain injury (TBI) in children. A multidisciplinary team at a children’s health system standardized intensive care unit–based TBI care using guidelines and best practices. The authors sought to investigate the impact of guideline implementation on outcomes.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A multidisciplinary group developed a TBI care protocol based on published TBI treatment guidelines and consensus, which was implemented in March 2011. The authors retrospectively compared preimplementation outcomes (May 2009 to March 2011) and postimplementation outcomes (April 2011 to March 2014) among patients &lt; 18 years of age admitted with severe TBI (Glasgow Coma Scale score ≤ 8) and potential survivability who underwent intracranial pressure (ICP) monitoring. Measures included mortality, hospital length of stay (LOS), ventilator LOS, critical ICP elevation time (percentage or total time that ICP was &gt; 40 mm Hg), and survivor functionality at discharge (measured by the WeeFIM score). Data were analyzed using Student t-tests.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 71 and 121 patients were included pre- and postimplementation, respectively. Mortality (32% vs 19%; p &lt; 0.001) and length of critical ICP elevation (&gt; 20 mm Hg; 26.3% vs 15%; p = 0.001) decreased after protocol implementation. WeeFIM discharge scores were not statistically different (57.6 vs 58.9; p = 0.9). Hospital LOS (median 19.6 days; p = 0.68) and ventilator LOS (median 10 days; p = 0.24) were unchanged.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>A multidisciplinary effort to develop, disseminate, and implement an evidence-based TBI treatment protocol at a children’s hospital was associated with improved outcomes, including survival and reduced time of ICP elevation. This type of ICP-based protocol can serve as a guide for other institutions looking to reduce practice disparity in the treatment of severe TBI.</jats:p></jats:sec>

Quality Indicators for Children With Traumatic Brain Injury After Transition to an American College of Surgeons Level I Pediatric Trauma Center

“…Our results are similar to a large retrospective study of administrative data showing increased rates of pediatric neurosurgical intervention at high-volume hospitals compared with low-volume hospitals, 36 and another showing significant increases in surgical interventions after implementation of a pediatric neurotrauma protocol. 37 These findings are both consistent with our results, as neurotrauma volumes increased after ACS verification and there was similar protocol implementation within all facets of trauma care at our center. Overall, these improvement practices may lead to better patient outcomes, as hospitals with higher patient volumes and more frequent ICP monitoring demonstrate lower rates of mortality or severe disability in pediatric patients with TBI.…”

“…Although it is possible that these 2 children received surgical intervention at the receiving hospital, it is unlikely that emergent interventions would be delayed. Our results are similar to a large retrospective study of administrative data showing increased rates of pediatric neurosurgical intervention at high-volume hospitals compared with low-volume hospitals, 36 and another showing significant increases in surgical interventions after implementation of a pediatric neurotrauma protocol 37 . These findings are both consistent with our results, as neurotrauma volumes increased after ACS verification and there was similar protocol implementation within all facets of trauma care at our center.…”

Invasive brain tissue oxygen and intracranial pressure (ICP) monitoring versus ICP-only monitoring in pediatric severe traumatic brain injury

“…41 In another single-institution, severe pediatric TBI study, ICP monitoring was not associated with a significant increase in average hospital LOS and duration of mechanical ventilation, but fewer intracranial hypertension episodes were associated with decreased mortality. 42 Similarly, a study of severe TBI in adults found no significant association between ICP monitoring and intensive care unit LOS. 43 In our institution, none of the patients with invasive neuromonitoring developed clinically significant or operative intracranial hemorrhage or infection.…”

Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience

“…Major pediatric TBI guidelines are currently based on ICP measurements, while ICP monitoring has been established as a standard of care for sTBI [ 30 , 37 , 38 ]. Moreover, studies show that the implementation of evidence-based TBI treatment algorithms are associated with improved outcomes, highlighting the importance of future precise ICP-based guidelines in order to reduce practice disparity among TBI patients [ 39 ]. A low percentage (3.4%) of ICP monitoring-related hemorrhagic complications was found in the present study, similar to the published literature [ 34 , 40 ].…”