title: Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury.
abstract: OBJECTIVE
  The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop 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.
  
  
  METHODS
  Retrospective multicenter cohort study.
  
  
  METHODS
  Five regional pediatric trauma centers affiliated with academic medical centers.
  
  
  METHODS
  Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, 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 ICU between 2007 and 2011 were examined.
  
  
  METHODS
  None.
  
  
  RESULTS
  Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91-0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08-0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01-0.26), and ICU PaCO2 more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06-0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98-0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58-0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63-0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53- 0.86).
  
  
  CONCLUSIONS
  Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury.
authors.affiliation: 1Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA. 2Department of Pediatrics, University of Washington, Seattle, WA. 3Departments of Neurological Surgery and Global Health Medicine, University of Washington, Seattle, WA. 4Department of Epidemiology, University of Washington, Seattle, WA. 5Department of Pediatrics, Harbor-UCLA and Los Angeles BioMedical Research Institute, Torrance, CA. 6Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL. 7Department of Surgery, The Ohio State University College of Medicine, Columbus, OH. 8Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA. 9Department of Neurosurgery and Division of Pediatric Neurology, Mattel Children's Hospital, UCLA, Los Angeles, CA. 10Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA. 11Department of Industrial and Systems Engineering, University of Washington, Seattle, WA. 12School of Nursing, University of Washington, Seattle, WA.
authors.forename: Monica S
authors.initials: MS
authors.lastname: Vavilala
authors.forename: Mary A
authors.initials: MA
authors.lastname: Kernic
authors.forename: Jin
authors.initials: J
authors.lastname: Wang
authors.forename: Nithya
authors.initials: N
authors.lastname: Kannan
authors.forename: Richard B
authors.initials: RB
authors.lastname: Mink
authors.forename: Mark S
authors.initials: MS
authors.lastname: Wainwright
authors.forename: Jonathan I
authors.initials: JI
authors.lastname: Groner
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bell
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Giza
authors.forename: Douglas F
authors.initials: DF
authors.lastname: Zatzick
authors.forename: Richard G
authors.initials: RG
authors.lastname: Ellenbogen
authors.forename: Linda Ng
authors.initials: LN
authors.lastname: Boyle
authors.forename: Pamela H
authors.initials: PH
authors.lastname: Mitchell
authors.forename: Frederick P
authors.initials: FP
authors.lastname: Rivara
mesh_terms: D000293:Adolescent; D001930:Brain Injuries / Q000401:mortality / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D005260:Female; D015600:Glasgow Coma Scale; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric / Q000592:standards / Q000706:statistics & numerical data; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010351:Patient Discharge / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012306:Risk; D016019:Survival Analysis; D016896:Treatment Outcome
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