pediatric trauma assessment and management database variation in the management of tbi vps user...
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PEDIATRIC TRAUMA ASSESSMENT AND MANAGEMENT DATABASEVARIATION IN THE MANAGEMENT OF TBI
VPS User Conference| March 24-26, 2015
Katherine T. Flynn-O’Brien, MDMary E. Fallat, MDTom B. Rice, MDChristine M. Gall, RN, MS, DrPHFrederick P. Rivara, MD
The problem
Leading cause of death and disability
Limited ability to study pediatric TBI Traumatic brain injury (TBI)
PECARN National Trauma Databank/Peds TQIP UDSMR FITBIR – Federal Interagency TBI Research
Objectives
Create a comprehensive pediatric trauma database to assess quality of
care in critically injured children utilizing minimal new resources.
Evaluate outcomes related to imaging practices and ICPM
utilization in children with TBI admitted to the PICU.
Objectives
Create a comprehensive pediatric trauma database to assess quality of
care in critically injured children utilizing minimal new resources.
Evaluate outcomes related to imaging practices and ICPM
utilization in children with TBI admitted to the PICU.
Methods
Merged 3 databases Trauma Registry (TR) Virtual PICU Systems
(VPS) data PTAM-specific RedCap
5 Level I/II PTC All children discharged
from PICU CY 2013
Big Picture
TRVPS
Patient Outcom
es
Discharge status Pre-
hospital data
Initial vitals Initial GCS
Injury patterns
ProceduresBedside
procedures
Lab data
PIM2 PRISMIII PELOD
PCPC POPC
MedicalICU LOS
Patient population
N = 457 Head Injury
66% male Mean age 6.3y
(5.8) Race/Ethnicity
54% White 20% African
American 9% Hispanic
Payer 47% Medicaid/Gov.
Mechanism of injury 36% Falls 25% MVC
Maximum Head AIS 33% AIS 4/5
Injury Severity Score 16% ISS>25 25% ISS 16-25
TR
ED/ICU admission
GCS on arrival 21% 3-8 7% 9-12 55% 13-15
Motor GCS 11% paralyzed 4% no motor
resp
Pupillary response 91% Both
reactive 6% Fixed
Lowest GCS in first 12hrs 20% GCS 3-8 13% GCS 9-12 67% GCS 13-15
VPSTR
Hospital disposition
Baseline PCPC 94% Normal 6% Mild/Mod 1% Moderate 0.2% Severe
Discharge PCPC 66% Normal 25% Mild/Mod 4% Severe 5% Brain Death
Hosp length of stay Mean 6.8 (SD
11.0) Median 3 (IQR
2-7) Hosp
disposition 82% home 11% rehab 7% transferred 5% expired
VPSTR
Imaging and procedures
266%
TR alone: 21 ICPM
PTAM: 34 ICPM 635 index hospital 317 before/after ICU
VPS alone ≤318
PTAM: 847 Head CT
162%
212 outside hospital
vs. TR alone
vs. VPS alone
Imaging practices at index hosp
Head CT Mild/Mod TBI (n= 280) Severe TBI (n = 98)
Range 0-7 0-9
Mean (SD) 1.3 (1.0) 2.2 (2.0)
No scans (%)
0 57 (20) 14 (14)
1 133 (48) 35 (36)
2 62 (22) 16 (16)
3 16 (6) 12 (12)
4 9 (3) 7 (7)
5+ 3 (1) 14 (14)
79 missing ED GCS score
Imaging practices at index hosp
Head CT Mild/Mod TBI (n= 280) Severe TBI (n = 98)
Range 0-7 0-9
Mean (SD) 1.3 (1.0) 2.2 (2.0)
No scans (%)
0 57 (20) 14 (14)
1 133 (48) 35 (36)
2 62 (22) 16 (16)
3 16 (6) 12 (12)
4 9 (3) 7 (7)
5+ 3 (1) 14 (14)33%
10%
79 missing ED GCS score
Imaging practices by site
Site No scan 1 CT scan 2 CT scans 3+ CT scans
A 12 (11) 41 (39) 34 (32) 19 (18)
B 35 (40) 37 (42) 12 (14) 3 (3)
C 14 (17) 36 (44) 16 (20) 15 (19)
D 14 (21) 25 (37) 10 (15) 17 (25)
E 30 (26) 58 (50) 14 (12) 13 (11)
Total 105 (23) 197 (43) 86 (19) 67 (15)
Head CT imaging practices by site, n(%)
High vs. Low Utilization?
Imaging practices by site
Site No scan 1 CT scan 2 CT scans 3+ CT scans
A 12 (11) 41 (39) 34 (32) 19 (18)
B 35 (40) 37 (42) 12 (14) 3 (3)
C 14 (17) 36 (44) 16 (20) 15 (19)
D 14 (21) 25 (37) 10 (15) 17 (25)
E 30 (26) 58 (50) 14 (12) 13 (11)
Total 105 (23) 197 (43) 86 (19) 67 (15)
Head CT imaging practices by site, n(%)
High vs. Low Utilization?
Imaging practices by site
Site No scan 1 CT scan 2 CT scans 3+ CT scans
A 12 (11) 41 (39) 34 (32) 19 (18)
B 35 (40) 37 (42) 12 (14) 3 (3)
C 14 (17) 36 (44) 16 (20) 15 (19)
D 14 (21) 25 (37) 10 (15) 17 (25)
E 30 (26) 58 (50) 14 (12) 13 (11)
Total 105 (23) 197 (43) 86 (19) 67 (15)
Head CT imaging practices by site, n(%)
High vs. Low Utilization?
0
1
2
3
4
5
6
7
8
9
10
ABCDE
Imaging practices by site
Site 3+ CT scans
A 19 (18)
B 3 (3)
C 15 (19)
D 17 (25)
E 13 (11)
Total 67 (15)Covariates: age, mechanism of injury (MVC, fall, struck by, etc.), maximum head AIS, Injury Severity Score (ISS), type of head injury, lowest GCS in first 12 hrs, pupils
P-value .003
Multivariable logistic regression
Repeat CTH imaging practices after transfer
Site Repeat scan
A 38 (76)
B 22 (39)
C 15 (52)
D 18 (62)
E 18 (42)
Total 111(54)
High vs. Low Utilization?
Repeat CTH imaging practices after transfer
Site Repeat scan
A 38 (76)
B 22 (39)
C 15 (52)
D 18 (62)
E 18 (42)
Total 111(54)
High vs. Low Utilization?
aOR: 9.8 (2.9, 33.0)
ICP monitor utilization
http://news.wustl.edu/news/Pages/24689.aspx
ICP monitor utilization
ICPM placement by siteSite ICPM placement
in TBI(n = 34)
ICPM placement in severe TBI
(n = 29)
ICPM placement <6hr in severe TBI
(n = 18)
A 5.7% 22.2% 5.6%
B 1.1% 0% 0%
C 16.1% 52.2% 34.8%
D 7.5% 19.2% 15.4%
E 7.8% 33.3% 20.8%
High (C) vs. Low (A) utilization: OR 3.2 (1.2-8.8)
Functional outcomes
Pediatric Cerebral Performance Category (PCPC)
Alertness ADLs School performance
Modeled after GOSE Preinjury-discharge delta
Functional outcomes
AIS ≤3 AIS 4 AIS 5
-4.00
-3.50
-3.00
-2.50
-2.00
-1.50
-1.00
-0.50
0.00
ABCDE
Preinjury-discharge PCPC by ICPM
adj β coefficient
P-value
No ICPM
Ref Ref
ICPM -.84 (-1.2, -.51) <.001
0.0
-0.5
-1.0
-1.5
β = mean difference in delta PCPC Negative – comparison worse (ICPM) Positive – comparison better (ICPM)
ICPM
Covariates: age, mechanism of injury (MVC, fall, struck by, etc.), maximum head AIS, Injury Severity Score (ISS), type of head injury, lowest GCS in first 12 hrs, pupils
∆-0.9
No ICPM
ICPM
Preinjury-discharge PCPC by ICPM & siteSite adj β
coefficientP-value
A -.26 (-.95, .42)
.442
B -.10 (-.55, .356
.676
C -1.2 (-2.1, -.31)
.009
D -.59 (-1.8, .63)
.333
E -1.6 (-2.3, -.79)
<.001
β = mean difference in delta PCPC Negative – comparison worse (ICPM) Positive – comparison better (ICPM)
ICPMby site
0.0
-0.5
-1.0
-1.5
∆-0.5
No ICPM
ICPM
Covariates: age, mechanism of injury (MVC, fall, struck by, etc.), maximum head AIS, Injury Severity Score (ISS), type of head injury, lowest GCS in first 12 hrs, pupils
Results: Delta PCPC by ICPMxsite
Site P-value
A .021
B .661
C .647
D <.001
E Ref
∆-2.0
-
ICPM x site
Covariates: age, mechanism of injury (MVC, fall, struck by, etc.), maximum head AIS, Injury Severity Score (ISS), type of head injury, lowest GCS in first 12 hrs, pupils β = mean difference in differences Negative – comparison worse Positive – comparison better
∆-1.0
ICPM vs. no
ICPM
ICPM vs. no
ICPM
What does that mean?
Change in functional status associated with ICPM was different depending on the
site of care
Limitations
Small sample size Limited power Restricted analyses
PCPC lacks precision No quality of life/long term outcomes
Limited generalizability
Successful utilization of a novel database to explore processes of care in critically injured pediatric TBI patients Comparing H:L sites
aOR8.59 3+ CTH aOR 9.8 repeat CTH s/p transfer OR 3.2 ICPM use
Site variation in functional outcomes
Take Home
Conclusion
Combining databases is an innovative, feasible, cost-effective way to evaluate
management practices and to explore critical
questions related to pediatric trauma management.
Quick add-on
Recall:Dr. Mikhailov EENJusti O’Flynn NAT
NOW is the time
TR/TQIP Peds QL at 6 or 12 mo Midline shift Pupils on ED arrival
VPS Neurocritical care module
TBI focus
Thank you
Special thanks to all trauma registrars and VPS coordinators at participating
sites