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PEDIATRIC TRAUMA ASSESSMENT AND MANAGEMENT DATABASE VARIATION IN THE MANAGEMENT OF TBI VPS User Conference| March 24-26, 2015 Katherine T. Flynn-O’Brien,

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Presentation on theme: "PEDIATRIC TRAUMA ASSESSMENT AND MANAGEMENT DATABASE VARIATION IN THE MANAGEMENT OF TBI VPS User Conference| March 24-26, 2015 Katherine T. Flynn-O’Brien,"— Presentation transcript:

1 PEDIATRIC TRAUMA ASSESSMENT AND MANAGEMENT DATABASE VARIATION IN THE MANAGEMENT OF TBI VPS User Conference| March 24-26, 2015 Katherine T. Flynn-O’Brien, MD Mary E. Fallat, MD Tom B. Rice, MD Christine M. Gall, RN, MS, DrPH Frederick P. Rivara, MD

2 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

3 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.

4 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.

5 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

6 Big Picture TRVPS Patient Outcomes Discharge status Pre-hospital data Initial vitals Initial GCS Injury patterns Procedures Bedside procedures Lab data PIM2 PRISMIII PELOD PCPC POPC Medical ICU LOS

7 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 TR

8 ED/ICU admission  GCS on arrival  21% 3-8  7% 9-12  55%  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 VPSTR

9 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

10 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

11 Imaging practices at index hosp Head CTMild/Mod TBI (n= 280)Severe TBI (n = 98) Range Mean (SD)1.3 (1.0)2.2 (2.0) N o scans (%) 057 (20)14 (14) 1133 (48)35 (36) 262 (22)16 (16) 316 (6)12 (12) 49 (3)7 (7) 5+3 (1)14 (14) 79 missing ED GCS score

12 Imaging practices at index hosp Head CTMild/Mod TBI (n= 280)Severe TBI (n = 98) Range Mean (SD)1.3 (1.0)2.2 (2.0) N o scans (%) 057 (20)14 (14) 1133 (48)35 (36) 262 (22)16 (16) 316 (6)12 (12) 49 (3)7 (7) 5+3 (1)14 (14) 33% 10% 79 missing ED GCS score

13 Imaging practices by site SiteNo scan1 CT scan2 CT scans3+ CT scans A12 (11)41 (39)34 (32)19 (18) B35 (40)37 (42)12 (14)3 (3) C14 (17)36 (44)16 (20)15 (19) D14 (21)25 (37)10 (15)17 (25) E30 (26)58 (50)14 (12)13 (11) Total105 (23)197 (43)86 (19)67 (15)  Head CT imaging practices by site, n(%)  High vs. Low Utilization?

14 Imaging practices by site SiteNo scan1 CT scan2 CT scans3+ CT scans A12 (11)41 (39)34 (32)19 (18) B35 (40)37 (42)12 (14)3 (3) C14 (17)36 (44)16 (20)15 (19) D14 (21)25 (37)10 (15)17 (25) E30 (26)58 (50)14 (12)13 (11) Total105 (23)197 (43)86 (19)67 (15)  Head CT imaging practices by site, n(%)  High vs. Low Utilization?

15 Imaging practices by site SiteNo scan1 CT scan2 CT scans3+ CT scans A12 (11)41 (39)34 (32)19 (18) B35 (40)37 (42)12 (14)3 (3) C14 (17)36 (44)16 (20)15 (19) D14 (21)25 (37)10 (15)17 (25) E30 (26)58 (50)14 (12)13 (11) Total105 (23)197 (43)86 (19)67 (15)  Head CT imaging practices by site, n(%)  High vs. Low Utilization?

16 Imaging practices by site Site3+ CT scans A19 (18) B3 (3) C15 (19) D17 (25) E13 (11) Total67 (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

17 Repeat CTH imaging practices after transfer SiteRepeat scan A38 (76) B22 (39) C15 (52) D18 (62) E18 (42) Total111(54)  High vs. Low Utilization?

18 Repeat CTH imaging practices after transfer SiteRepeat scan A38 (76) B22 (39) C15 (52) D18 (62) E18 (42) Total111(54)  High vs. Low Utilization? aOR: 9.8 (2.9, 33.0)

19 ICP monitor utilization

20 ICP monitor utilization  ICPM placement by site SiteICPM placement in TBI (n = 34) ICPM placement in severe TBI (n = 29) ICPM placement <6hr in severe TBI (n = 18) A5.7%22.2%5.6% B1.1%0% C16.1%52.2%34.8% D7.5%19.2%15.4% E7.8%33.3%20.8% High (C) vs. Low (A) utilization: OR 3.2 ( )

21 Functional outcomes  Pediatric Cerebral Performance Category (PCPC)  Alertness  ADLs  School performance  Modeled after GOSE  Preinjury-discharge  delta

22 Functional outcomes

23 Preinjury-discharge PCPC by ICPM adj β coefficient P-value No ICPMRef ICPM-.84 (-1.2, -.51)<  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

24 Preinjury-discharge PCPC by ICPM & site Site adj β coefficient P-value A-.26 (-.95,.42).442 B-.10 (-.55, 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) ICPM by site ∆ -0.5 No 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

25 Results: Delta PCPC by ICPMxsite SiteP-value A.021 B.661 C.647 D<.001 ERef ∆ 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

26 What does that mean? Change in functional status associated with ICPM was different depending on the site of care

27 Limitations  Small sample size  Limited power  Restricted analyses  PCPC lacks precision  No quality of life/long term outcomes  Limited generalizability

28  Successful utilization of a novel database to explore processes of care in critically injured pediatric TBI patients  Comparing H:L sites  aOR CTH  aOR 9.8 repeat CTH s/p transfer  OR 3.2 ICPM use  Site variation in functional outcomes Take Home

29 Conclusion Combining databases is an innovative, feasible, cost-effective way to evaluate management practices and to explore critical questions related to pediatric trauma management.

30 Quick add-on Recall: Dr. Mikhailov  EEN Justi O’Flynn  NAT

31 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

32 Thank you Special thanks to all trauma registrars and VPS coordinators at participating sites

33 Thank you Questions?


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