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

NCJ Number
249301
Journal
Critical Care Medicine Volume: 42 Issue: 10 Dated: October 2014 Pages: 2258-2266
Author(s)
Monica S. Vavilala; Mary A. Kernic; Jin Wang; Nithya Kannan; Richard B. Mink; Mark S. Wainwright; Jonathan I. Groner; Michael J. Bell; Christopher C. Giza; Douglas F. Zatzick; Richard G. Ellenbogen; Linda Ng Boyle; Pamela H. Mitchell; Frederick P Rivara
Date Published
October 2014
Length
9 pages
Annotation
Since the relationship between acute care clinical indicators in the first Severe Pediatric Traumatic Brain Injury (TBI) Guidelines and outcomes have not been examined, the study reported in this article developed a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes.
Abstract
The study found that acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge scores on the Glasgow outcome scale (GOS). Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe TBI. The study design was a retrospective multi-center cohort study that involved five regional pediatric trauma centers affiliated with academic medical centers. The patients were children under 17 years old with severe TBI (admission Glasgow coma scale (GCS) 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 severity score = 3) who received tracheal intubation for at least 48 hours in the intensive care unit (ICU) between 2007 -2011. Total percent adherence to the clinical indicators across all treatment locations (pre-hospital [PH], emergency department [ED], operating room [OR], and intensive care unit [ICU]) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow outcome scale (GOS) score. Total adherence rate across all locations and all centers ranged from 68-78 percent. Clinical indicators of adherence were associated with survival (aHR 0.94; 95 percent CI 0.91, 0.96). Three indicators were associated with survival: absence of PH hypoxia (aHR 0.20; 95 percent CI 0.08, 0.46), early ICU start of nutrition (aHR 0.06; 95 percent CI 0.01, 0.26), and ICU PaCO2 >30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (aHR 0.22; 95 percent CI 0.06, 0.8). Clinical indicators of adherence were associated with favorable GOS among survivors, (aHR 0.99; 95percent CI 0.98, 0.99). Three indicators were associated with favorable discharge GOS: all OR CPP >40 mm Hg (aRR 0.64; 95 percent CI 0.55, 0.75), all ICU CPP > 40mm Hg (aRR 0.74; 95 percent CI 0.63, 0.87), and no surgery (any type; aRR 0.72; 95 percent CI 0.53, 0.97). (Publisher abstract modified)