pediatric trauma assessment and management database variation in the management of tbi vps user...

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

Thank you

Questions?

flynnobr@uw.edu