Pediatric Traumatic Brain Injury: Resource Utilization and Outcomes at Adult versus Pediatric Trauma Centers

Abstract INTRODUCTION Recent research has demonstrated improved outcomes for trauma patients at higher volume institutions. However, the volume-outcome relationship for severe pediatric traumatic brain injury (TBI) patients, specifically, has yet to be demonstrated. METHODS We isolated all severe pediatric TBI admissions (GCS admission score 3-8) to pediatric American College of Surgeons (ACS) level 1 and 2 trauma centers in the 2012 National Trauma Data Bank. Pediatric TBI volume was analyzed on a continuous scale as the primary independent variable. Our outcome variables were mortality, hospital discharge disposition (home, rehab/other care facility, died/hospice), presence of complications (deep vein thrombosis [DVT], cardiac arrest, cerebrovascular accident, acute respiratory distress syndrome [ARDS], urinary tract infection [UTI], pneumonia), length of stay (LOS), and intensive care unit (ICU) days. We utilized multivariate analyses to adjust for the following confounding variables: injury type, age, gender, race, hospital teaching status, region of hospital, ISS, comorbidities (hypertension, bleeding disorder, congenital anomalies, respiratory disease), and GCS at admission. Statistical significance was assessed at P < .05. RESULTS There were 1441 severe pediatric TBI admissions in 69 unique pediatric ACS level 1 or 2 trauma centers in 2012. Following multivariate adjustment, the treatment at hospitals with a higher pediatric TBI volume was associated with a shorter LOS (0.5 d per +10 patients, P = .02) and higher odds of discharge home (odds ratio = 1.08 per +10 patients, P = .01). Moreover, patients at higher volume centers had a lower risk of complications (odds ratio = 0.91 per +10 patients, P = .01), particularly ARDS (odds ratio = 0.64 per +10 patients, P < .001) and pneumonia (odds ratio = 0.89 per +10 patients, P = .047). CONCLUSION Among level 1 and 2 pediatric trauma care facilities, patients treated at higher volume centers had lower complication rates, a more favorable discharge, and a shorter LOS. This suggests a need to investigate differences in approach to care between higher and lower volume hospitals and consider the role of transfer and referral networks in optimizing care.

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Variation in seizure prophylaxis in severe pediatric traumatic brain injury

Journal of Neurosurgery Pediatrics ◽

10.3171/2016.4.peds1698 ◽

2016 ◽

Vol 18 (4) ◽

pp. 499-506 ◽

Cited By ~ 10

Author(s):

Paige J. Ostahowski ◽

Nithya Kannan ◽

Mark S. Wainwright ◽

Qian Qiu ◽

Richard B. Mink ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Scale Score ◽

Injury Severity ◽

Pediatric Trauma ◽

Major Complication ◽

Trauma Centers ◽

Multicenter Cohort Study ◽

Seizure Prophylaxis ◽

Diagnosis Codes

OBJECTIVE Posttraumatic seizure is a major complication following traumatic brain injury (TBI). The aim of this study was to determine the variation in seizure prophylaxis in select pediatric trauma centers. The authors hypothesized that there would be wide variation in seizure prophylaxis selection and use, within and between pediatric trauma centers. METHODS In this retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe TBI (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0–801.9, 803.0–804.9, 850.0–854.1, 959.01, 950.1–950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011. RESULTS Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%). CONCLUSIONS While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes.

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Structure, Process, and Culture Differences of Pediatric Trauma Centers Participating in an International Comparative Effectiveness Study of Children with Severe Traumatic Brain Injury

Neurocritical Care ◽

10.1007/s12028-015-0218-6 ◽

2015 ◽

Vol 24 (3) ◽

pp. 353-360 ◽

Cited By ~ 11

Author(s):

Gitte Y. Larsen ◽

Michelle Schober ◽

Anthony Fabio ◽

Stephen R. Wisniewski ◽

Mary Jo C. Grant ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Severe Traumatic Brain Injury ◽

Comparative Effectiveness ◽

Pediatric Trauma ◽

Effectiveness Study ◽

Trauma Centers ◽

Comparative Effectiveness Study ◽

International Comparative ◽

Culture Differences

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National Variability in Intracranial Pressure Monitoring and Craniotomy for Children With Moderate to Severe Traumatic Brain Injury

Neurosurgery ◽

10.1227/neu.0000000000000097 ◽

2013 ◽

Vol 73 (5) ◽

pp. 746-752 ◽

Cited By ~ 21

Author(s):

William Van Cleve ◽

Mary A. Kernic ◽

Richard G. Ellenbogen ◽

Jin Wang ◽

Douglas F. Zatzick ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Care Delivery ◽

Pediatric Trauma ◽

Intracranial Pressure Monitoring ◽

Trauma Centers ◽

Older Children ◽

Pressure Monitoring ◽

Hospital Variation

Abstract BACKGROUND: Traumatic brain injury (TBI) is a significant cause of mortality and disability in children. Intracranial pressure monitoring (ICPM) and craniotomy/craniectomy (CRANI) may affect outcomes. Sources of variability in the use of these interventions remain incompletely understood. OBJECTIVE: To analyze sources of variability in the use of ICPM and CRANI. METHODS: Retrospective cross-sectional study of patients with moderate/severe pediatric TBI with the use of data submitted to the American College of Surgeons National Trauma Databank. RESULTS: We analyzed data from 7140 children at 156 US hospitals during 7 continuous years. Of the children, 27.4% had ICPM, whereas 11.7% had a CRANI. Infants had lower rates of ICPM and CRANI than older children. A lower rate of ICPM was observed among children hospitalized at combined pediatric/adult trauma centers than among children treated at adult-only trauma centers (relative risk = 0.80; 95% confidence interval 0.66-0.97). For ICPM and CRANI, 18.5% and 11.6%, respectively, of residual model variance was explained by between-hospital variation in care delivery, but almost no correlation was observed between within-hospital tendency toward performing these procedures. CONCLUSION: Infants received less ICPM than older children, and children hospitalized at pediatric trauma centers received less ICPM than children at adult-only trauma centers. In addition, significant between-hospital variability existed in the delivery of ICPM and CRANI to children with moderate-severe TBI.

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Intracranial pressure monitoring among children with severe traumatic brain injury

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.3.peds14507 ◽

2015 ◽

Vol 16 (5) ◽

pp. 523-532 ◽

Cited By ~ 15

Author(s):

Aziz S. Alali ◽

David Gomez ◽

Chethan Sathya ◽

Randall S. Burd ◽

Todd G. Mainprize ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Observational Study ◽

Hospital Mortality ◽

Pediatric Trauma ◽

Trauma Centers ◽

Icp Monitoring ◽

Hospital Level ◽

Severe Tbi

OBJECT Well-designed studies linking intracranial pressure (ICP) monitoring with improved outcomes among children with severe traumatic brain injury (TBI) are lacking. The main objective of this study was to examine the relationship between ICP monitoring in children and in-hospital mortality following severe TBI. METHODS An observational study was conducted using data derived from 153 adult or mixed (adult and pediatric) trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and 29 pediatric trauma centers participating in the pediatric pilot TQIP between 2010 and 2012. Random-intercept multilevel modeling was used to examine the association between ICP monitoring and in-hospital mortality among children with severe TBI ≤16 years of age after adjusting for important confounders. This association was evaluated at the patient level and at the hospital level. In a sensitivity analysis, this association was reexamined in a propensity-matched cohort. RESULTS A total of 1705 children with severe TBI were included in the study cohort. The overall in-hospital mortality was 14.3% of patients (n = 243), whereas the mortality of the 273 patients (16%) who underwent invasive ICP monitoring was 11% (n = 30). After adjusting for patient- and hospital-level characteristics, ICP monitoring was associated with lower in-hospital mortality (adjusted OR 0.50; 95% CI 0.30–0.85; p = 0.01). It is possible that patients who were managed with ICP monitoring were selected because of an anticipated favorable or unfavorable outcome. To further address this potential selection bias, the analysis was repeated with the hospital-specific rate of ICP monitoring use as the exposure. The adjusted OR for death of children treated at high ICP–use hospitals was 0.49 compared with those treated at low ICP-use hospitals (95% CI 0.31–0.78; p = 0.003). Variations in ICP monitoring use accounted for 15.9% of the interhospital variation in mortality among children with severe TBI. Similar results were obtained after analyzing the data using propensity score-matching methods. CONCLUSIONS In this observational study, ICP monitoring use was associated with lower hospital mortality at both the patient and hospital levels. However, the contribution of variable ICP monitoring rates to interhospital variation in pediatric TBI mortality was modest.

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