evaluating variation in process of care metrics for critically injured

Evaluating variation in

process of care metrics for

critically injured pediatric

trauma patients

Pediatric Trauma Society

Scottsdale, AZ | November 6-7, 2015

Katherine T. Flynn-O’Brien, MD, MPH

Mary E. Fallat, MD

Tom B. Rice, MD

Christine M. Gall, RN, MS, DrPH

Frederick P. Rivara, MD, MPH

Pediatric

Trauma

Assessment and

Management DatabaseA Trauma Registry-VPS partnership

Disclosures

I have no disclosures.

Pediatric Trauma

Burden of disease is profound

Healthcare quality

Structure Process Outcome

Pediatric Trauma

Burden of disease is profound

Limited ability to study processes of care in pediatric trauma

Pediatric Trauma

Burden of disease is profound

Limited ability to study processes of care in pediatric trauma

Current available

data systems

NTDB/TQIP

PHIS, NSQIP

HCUP

VPS, UDSMR

Pediatric Trauma

Burden of disease is profound

Limited ability to study processes of care in pediatric trauma

Current available

data systems

Fiscal constraints NTDB/TQIP

PHIS, NSQIP

HCUP

VPS, UDSMR

Objectives

Create a comprehensive pediatric trauma

database to assess quality of care in critically

injured children utilizing minimal new

resources.

Objectives

Create a comprehensive pediatric trauma

database to assess quality of care in critically

injured children utilizing minimal new

resources.

Evaluate key processes of care during

different phases of the care continuum, and

quantify site-specific variation

Methods

Merged 3 databases

Trauma Registry (TR)

Virtual Pediatric Systems

(VPS) data

PTAM-specific RedCap

5 Level I/II PTC

All children discharged

from PICU CY 2013

Care Continuum

• Vitals

• GCS

• Transfer

Pre-hospital

• Vitals

• GCS

• Labs*

ED arrival• Vitals

• Labs

• Vent data

ICU stay

• Nutrition

• Constipation

• VTE ppx

Floor• Disposition

• POPC

• PRISM/PIM

Discharge

C-collar DVT ppxFAST

Methods

Univariate analyses

Chi2 test for independence

Non-parametric equality of medians

Multivariable regression

Age, mechanism, severity of injury

Quantify process of care variation

Patient population

N = 692

67% male

Mean age 7.2y (6.0)

Race/Ethnicity

51% White

21% African American

7% Hispanic

Injury Characteristics

77% Blunt

35% ISS >15

Pre-hospital: C-collar use

nSite

variationChi2

Adj.

Wald*

All patients 648 50-83% < 0.001 < 0.001

Head injury 443 59-84% < 0.001 < 0.001

Head injury &

Field response184 69-81% 0.761 0.163

Head injury & Transferred 259 50-89% < 0.001 0.003

*Adjusted for age, mechanism of injury, severity of injury (ISS)

Pre-hospital: C-collar use

Site Use (%) aOR (95% CI)* p-value

A 78.6 3.4 (1.0-11.4) 0.048

B 75.6 2.0 (0.6-7.1) 0.281

C 69.2 Ref Ref

D 76.9 2.7 (0.7-10.2) 0.146

E 81.3 4.5 (1.3-14.9) 0.015

p = 0.761 p = 0.163

aOR, adjusted odds ratio; CI, confidence interval

*Adjusted for age, mechanism of injury, severity of injury (ISS)

Patients with head injury & FIELD response

Pre-hospital: C-collar use

Site Use (%) aOR (95% CI)* p-value

A 52.6 1.3 (0.5-3.2) 0.626

B 84.5 5.0 (01.8-13.8) 0.002

C 50.0 Ref Ref

D 89.2 8.3 (2.4-28.9) 0.001

E 76.9 2.9 (1.2-7.1) 0.020

p < 0.001 p = 0.003

aOR, adjusted odds ratio; CI, confidence interval

*Adjusted for age, mechanism of injury, severity of injury (ISS)

Patients with head injury & transferred

Pre-hospital: C-collar use

nSite

variationChi2

Adj.

Wald*

All patients 648 50-83% < 0.001 < 0.001

Head injury 443 59-84% < 0.001 < 0.001

Head injury &

Field response184 69-81% 0.761 0.163

Head injury & Transferred 259 50-89% < 0.001 0.003

*Adjusted for age, mechanism of injury, severity of injury (ISS)

Only 4 patients (1.5%) had a collar removed prior to transfer

76 patients (29%) never had a collar placed

Site variation 11-50%

Pre-hospital: C-collar use

Site Median (IQR)

A 32 (23-51)

B 26 (13-32)

C 29 (15-90)

D 27 (17-48)

E 19 (8-39)

P = .009

aOR, adjusted odds ratio; CI, confidence interval

*Adjusted for age, mechanism of injury, severity of injury (ISS)

When does it get removed?

ED phase of care: FAST exam

89%

2% 8%

1%0%

0%

No FAST exam completed

Completed, positive

Completed, negative

Completed, inconclusive

Completed, result UK/NR

UK/NR if FAST completed

N = 69

ED phase of care: FAST exam

69 FAST exams recorded (10%)

Site Use (%)

A 36.8

B 0

C 2.4

D 0

E 1.8

p < 0.001

0-37%

ED phase of care: FAST exam

69 FAST exams recorded (10%)

91% completed at a single institution

1/3 children receive FAST

92% for blunt trauma

93% with ISS<25

Of the 6 FAST exams at other institutions

4 blunt with ISS>25

2 penetrating with ISS<25

Hospital course: DVT ppx

Pharmacologic prophylaxis, <48hrs of arrival

4% Yes, 26% not applicable, 70% None

Site Use (%)

A 3.5

B 3.7

C 11.1

D 0

E 0

p < 0.001

0-11%

Hospital course: DVT ppx

Pharmacologic prophylaxis, <48hrs of arrival

4% Yes, 26% not applicable, 70% None

Site Use (%) aOR(95%CI)

A 3.5 0.5 (0.2-1.7)

B 3.7 0.5 (0.1-1.9)

C 11.1 Ref

D 0 --

E 0 --

aOR, adjusted odds ratio; CI, confidence interval

*Adjusted for age, mechanism of injury, severity of injury (ISS)

Hospital course: DVT ppx

Mechanical prophylaxis, <48hrs of arrival

12% Yes, 29% not applicable, 59% None

Site Use (%)

A 18.7

B 0

C 18.4

D 0

E 12.9

p < 0.001

0-19%

Hospital course: DVT ppx

Mechanical prophylaxis, <48hrs of arrival

12% Yes, 29% not applicable, 59% None

Site Use (%) aOR(95%CI)

A 18.7 2.5 (1.2-5.5)

B 0 --

C 18.4 Ref

D 0 --

E 12.9 1.1 (0.5-2.5)

aOR, adjusted odds ratio; CI, confidence interval

*Adjusted for age, mechanism of injury, severity of injury (ISS)

Take Home

Site-specific variation is significant in all

domains of healthcare provision for the injured

child

C-collar placement

Transfers: aOR 3-8

Field response: aOR 3-5

FAST exam utilization

DVT prophylaxis

Pharmacologic: 0-11%

Mechanical: 0-19%

Limitations

Small sample size

Process-specific adjustments

Limited generalizability

Structure Process Outcome

Conclusions

Combining two existing datasets provides

detailed information that allows for

evaluation of of process of care metrics

for critically injured children across the

care continuum

With minimal additional infrastructure

With no additional FTE

Advice

Discovery consists not in seeking new

landscapes but in seeking with new eyes. –

Marcel Proust

Thank you

Special thanks to all trauma registrars

and VPS coordinators at participating

sites

Thank you

Questions?

flynnobr@uw.edu

Injury characteristics

Mechanism of injury

32% Falls

25% MVC

4% Penetrating

Intent

84% unintentional

14% assaults

Place

31% residential

Maximum Head AIS

15% AIS 4/5

43% AIS 3

Other Maximum AIS

67% abd AIS 3-5

57% thoracic AIS 3-5

Injury Severity Score

13% ISS>25

22% ISS 16-25

TRTR

Pre-hospital & ED

Physiologic data

11% tachycardia*

3% hypotension*

9% GCS <9

EMS transport

42% ambulance

14% air

Physiologic data

29% tachycardia*

5% hypotension*

17% GCS <9

ED disposition

14% OR

Transfer status

TRTR*Age-based

ICU first hr & first 12 hrs

SBP

10%

hypotension*

Base excess

-5.2 (4.2)

Pupil reaction

PF ratio

VPS

Phys/Lab data

BP, HR, RR, temp, pH

PaO2, PaCO2

Hgb, WBC

Plt, PT, PTT, bili

K, Na, Ca, albumin, BUN, Cr

Ventilation data

Infection dataVPS

ICU course & outcomes

Baseline POPC

89% Normal

10% Mild/Mod

1% Severe

Discharge POPC

34% Normal

57% Mild/Mod

4% Severe/Coma

5% Brain DeathVPS

Intensivist (98%)

83% Concurrent care

5% Consulting only

10% Primary service

PELOD

baseline, daily, POD

PRISM3

PIM2VPS

Processes

C-collar use

32% No collar

58% Removed

2% Treated

7% Discharged

with collar

3% UK/NR

RC

FAST exam

10% completed

90% not completed

VPS

Processes

DVT mechanical ppx

57% None

14% Given

29% N/A

Nutrition

95% Enteral

6% ParenteralRC

DVT pharmacologic ppx

67% None

7% Given

26% N/A

Bowel regimen

70% None

30% OrderedVPS

Pre-hospital: C-collar use

Site Use (%) aOR (95% CI)*

A 65.0 1.9 (1.1-3.4)

B 76.2 3.3 (1.7-6.3)

C 50.0 Ref

D 82.7 5.5 (2.6-11.7)

E 69.8 2.7 (1.5-4.7)

p < 0.001 p < 0.001

aOR, adjusted odds ratio; CI, confidence interval

*Adjusted for age, mechanism of injury, severity of injury (ISS)

All patients

Was a c-

collar

placed after

the injury

event?

Pre-hospital: C-collar use

Site Use (%) aOR (95% CI)* p-value

A 63.6 1.5 (0.8-3.0) 0.239

B 81.6 3.4 (1.6-7.3) 0.002

C 59.3 Ref Ref

D 84.1 4.4 (1.8-10.5) 0.001

E 78.8 2.8 (1.4-5.7) 0.001

p < 0.001 p < 0.001

aOR, adjusted odds ratio; CI, confidence interval

*Adjusted for age, mechanism of injury, severity of injury (ISS)

Patients with head injury

Take Home

Site-specific variation

C-collar placement

Transfers*

Field response

FAST exam utilization*

DVT prophylaxis

Pharmacologic

Mechanical*

Enteral

Parenteral

p = 0.037p = 0.730