title: Medical necessity of routine admission of children with mild traumatic brain injury to the intensive care unit.
abstract: OBJECTIVE Approximately 475,000 children are treated for traumatic brain injury (TBI) in the US each year; most are classified as mild TBI (Glasgow Coma Scale [GCS] Score 13-15). Patients with positive findings on head CT, defined as either intracranial hemorrhage or skull fracture, regardless of severity, are often transferred to tertiary care centers for intensive care unit (ICU) monitoring. This practice creates a significant burden on the health care system. The purpose of this investigation was to derive a clinical decision rule (CDR) to determine which children can safely avoid ICU care. METHODS The authors retrospectively reviewed patients with mild TBI who were ≤ 16 years old and who presented to a Level 1 trauma center between 2008 and 2013. Data were abstracted from institutional TBI and trauma registries. Independent covariates included age, GCS score, pupillary response, CT characteristics, and Injury Severity Score. A composite outcome measure, ICU-level care, was defined as cardiopulmonary instability, transfusion, intubation, placement of intracranial pressure monitor or other invasive monitoring, and/or need for surgical intervention. Stepwise logistic regression defined significant predictors for model inclusion with p < 0.10. The authors derived the CDR with binary recursive partitioning (using a misclassification cost of 20:1). RESULTS A total of 284 patients with mild TBI were included in the analysis; 40 (14.1%) had ICU-level care. The CDR consisted of 5 final predictor variables: midline shift > 5 mm, intraventricular hemorrhage, nonisolated head injury, postresuscitation GCS score of < 15, and cisterns absent. The CDR correctly identified 37 of 40 patients requiring ICU-level care (sensitivity 92.5%; 95% CI 78.5-98.0) and 154 of 244 patients who did not require an ICU-level intervention (specificity 63.1%; 95% CI 56.7-69.1). This results in a negative predictive value of 98.1% (95% CI 94.1-99.5). CONCLUSIONS The authors derived a clinical tool that defines a subset of pediatric patients with mild TBI at low risk for ICU-level care. Although prospective evaluation is needed, the potential for improved resource allocation is significant.
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Jared D
authors.initials: JD
authors.lastname: Ament
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Krista N
authors.initials: KN
authors.lastname: Greenan
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Patrick
authors.initials: P
authors.lastname: Tertulien
authors.affiliation: Trauma Surgery, and.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Galante
authors.affiliation: Emergency Medicine, University of California Davis Medical Center, Sacramento, California.
authors.forename: Daniel K
authors.initials: DK
authors.lastname: Nishijima
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Marike
authors.initials: M
authors.lastname: Zwienenberg
mesh_terms: D000367:Age Factors; D001921:Brain / Q000000981:diagnostic imaging; D001924:Brain Concussion / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D000066491:Clinical Decision-Making / Q000379:methods*; D005260:Female; D006801:Humans; D007223:Infant; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: CDR = clinical decision rule; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage; ICP = intracranial pressure; ICU = intensive care unit; ICU monitoring; IQR = interquartile range; ISS = Injury Severity Score; IVH = intraventricular hemorrhage; LOS = length of hospital stay; MLS = midline shift; MVC = motor vehicle crash; NPV = negative predictive value; PECARN = Pediatric Emergency Care Applied Research Network; TBI = traumatic brain injury; clinical decision rule; resource allocation; trauma; traumatic brain injury; triage