Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge

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OBJECT

The goal of critical care in treating traumatic brain injury (TBI) is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow. The authors compared short-term outcomes as defined by discharge disposition and Glasgow Outcome Scale scores in children with TBI before and after the implementation of a protocol that standardized decision-making and interventions among neurosurgeons and pediatric intensivists.

METHODS

The authors performed a retrospective pre- and postprotocol study of 128 pediatric patients with severe TBI, as defined by Glasgow Coma Scale (GCS) scores < 8, admitted to a tertiary care center pediatric critical care unit between April 1, 2008, and May 31, 2014. The preprotocol group included 99 patients, and the postprotocol group included 29 patients. The primary outcome of interest was discharge disposition before and after protocol implementation, which took place on April 1, 2013. Ordered logistic regression was used to assess outcomes while accounting for injury severity and clinical parameters. Favorable discharge disposition included discharge home. Unfavorable discharge disposition included discharge to an inpatient facility or death.

RESULTS

Demographics were similar between the treatment periods, as was injury severity as assessed by GCS score (mean 5.43 preprotocol, mean 5.28 postprotocol; p = 0.67). The ordered logistic regression model demonstrated an odds ratio of 4.0 of increasingly favorable outcome in the postprotocol cohort (p = 0.007). Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition and 36 patients (36%) had favorable discharge disposition. After protocol implementation, 9 patients (31%) had unfavorable disposition, while 20 patients (69%) had favorable disposition (p = 0.002). In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.04).

CONCLUSIONS

Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation of a standardized protocol among caregivers based on best-practice guidelines.

ABBREVIATIONSCPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; OR = odds ratio; PICU = pediatric intensive care unit; TBI = traumatic brain injury.

OBJECT

The goal of critical care in treating traumatic brain injury (TBI) is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow. The authors compared short-term outcomes as defined by discharge disposition and Glasgow Outcome Scale scores in children with TBI before and after the implementation of a protocol that standardized decision-making and interventions among neurosurgeons and pediatric intensivists.

METHODS

The authors performed a retrospective pre- and postprotocol study of 128 pediatric patients with severe TBI, as defined by Glasgow Coma Scale (GCS) scores < 8, admitted to a tertiary care center pediatric critical care unit between April 1, 2008, and May 31, 2014. The preprotocol group included 99 patients, and the postprotocol group included 29 patients. The primary outcome of interest was discharge disposition before and after protocol implementation, which took place on April 1, 2013. Ordered logistic regression was used to assess outcomes while accounting for injury severity and clinical parameters. Favorable discharge disposition included discharge home. Unfavorable discharge disposition included discharge to an inpatient facility or death.

RESULTS

Demographics were similar between the treatment periods, as was injury severity as assessed by GCS score (mean 5.43 preprotocol, mean 5.28 postprotocol; p = 0.67). The ordered logistic regression model demonstrated an odds ratio of 4.0 of increasingly favorable outcome in the postprotocol cohort (p = 0.007). Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition and 36 patients (36%) had favorable discharge disposition. After protocol implementation, 9 patients (31%) had unfavorable disposition, while 20 patients (69%) had favorable disposition (p = 0.002). In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.04).

CONCLUSIONS

Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation of a standardized protocol among caregivers based on best-practice guidelines.

Traumatic brain injury (TBI) is a heterogeneous condition characterized by marked variability in etiology and treatment.4,5,10,26 There have been numerous studies on the treatment of TBI in the adult population,4,6, 8,9,11,15,16,24,25,29 but less research has been performed on treating TBI in pediatric patients.2,5,7,18,21,23 These patients’ still-maturing CNS responds differently to injury and the current treatments available, making it imperative to determine the best course of action to improve outcomes in this population.5,16,18,22

The 2003 Brain Trauma Foundation guidelines,5 which were most recently updated in 2012,14 summarized practice standards for treatment of severe TBI in children. The overarching goal of critical care in treating TBI is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow.5 Despite these evidence-based guidelines, there is considerable variability in how different physicians and institutions treat severe TBI, and the strength of the evidence is low.10

A study by Pineda et al. in 2013 showed significant benefit to the implementation of a neurocritical care program with standardized treatment of severe TBI using a protocol based on the 2003 guidelines.5,21 The authors analyzed discharge disposition in pediatric patients with severe TBI at St. Louis Children’s Hospital before and after implementation of a pediatric neurocritical care program. The protocol was designed to facilitate communication among specialists and to define a plan for monitoring and treatment of children with severe TBI. The protocol was instituted in 2005, and Pineda et al.’s retrospective cohort study looked at short-term outcomes in patients from 1999 to 2012, comparing preprotocol and postprotocol periods. The authors found that, after protocol implementation, patients had a 67% favorable disposition, defined as home with or without therapy, compared with 48% before protocol implementation. An ordinal regression model indicated that outcomes improved across the spectrum of discharge disposition status and Glasgow Coma Scale (GCS) scores after protocol implementation. Notably, a controlled trial by Chesnut et al. from 2012 demonstrated no significant survival benefit when intracranial pressure (ICP)-focused critical care management was used in adolescent and adult patients compared with imaging and clinical examination-based management alone.6,17,20,27 Given these conflicting results, further research into critical care protocols in TBI is necessary.

We conducted a study to evaluate short-term outcomes in children with TBI after the implementation of a protocol that standardized decision-making and intervention among neurosurgeons and intensivists (Fig. 1). Our study had 2 a priori aims: 1) compare pre- and postprotocol discharge disposition, and 2) determine how Glasgow Outcome Scale (GOS) scores differed between the pre- and poststandardization cohorts.

FIG. 1.
FIG. 1.

Traumatic brain injury protocol. CVP = central venous pressure; EEG = electroencephalogram; ETCO2 = end-tidal CO2; EVD = external ventricular drain; Hct = hematocrit; HOB = head of bed; MAP = mean arterial pressure; Na = sodium; NMB = neuromuscular blockade; NS = normal saline; NSGY = neurosurgery; pCO2 = partial pressure of CO2; TP = transpyloric.

Methods

For this retrospective cohort study, we used data from the prospectively maintained Vanderbilt University Medical Center pediatric trauma registry. We included patients less than 18 years of age presenting with TBI with a GCS score of less than 8 between April 1, 2008, and May 31, 2014. All patient electronic medical records with radiographic evidence of TBI were reviewed for this study, and the GCS score used for determination of enrollment was based on the examination by the neurosurgery team after resuscitation. This process helped to limit those patients classified as having an artificially low GCS score upon initial emergency department assessment secondary to sedating medications. Variables not maintained prospectively were extracted from the electronic medical record, including ICP monitoring and hyperosmolar therapy. Patients were followed for the length of their hospitalization. Those who died in the emergency department were excluded from the study. The Vanderbilt institutional review board approved the study protocol.

Chart review was used to extract parameters, including age, sex, race, GCS score after resuscitation, need for surgery, injury type and mechanism, discharge disposition, GOS score at discharge, pediatric intensive care unit (PICU) length of stay, total length of stay, use of hyperosmolar therapy, use of barbiturates, and ICP monitoring. Due to the complexity of each patient’s clinical narrative and associated multiplicity of variables generated, protocol adherence was challenging to assess. However, use of 3% hypertonic saline instead of mannitol was identified as a surrogate measure of adherence given the 2012 guidelines’ focus on 3% NaCl as treatment for elevated ICP and its consistent availability in the medical record. Any usage of mannitol was considered a protocol deviation. Strict usage of solely 3% NaCl for elevated ICP was considered consistent with protocol requirements. Due to the real-time and rapid nature of patient care, we found that compliance for cerebral perfusion pressure (CPP) was challenging to adequately categorize during patients’ hospitalization, and it was not clear whether these data were an accurate representation of the actual clinic course. Therefore, this parameter was not used as a surrogate measure of adherence.

Protocol Implementation

The TBI protocol was implemented on April 1, 2013. Prior to 2013, no specific multidisciplinary protocols were used at the institution in the management of pediatric brain injury. Variation in the overall management paradigm for patients with severe TBI was common. The evidence-based protocol was developed by a multidisciplinary group composed of local experts from pediatric services, including neurosurgery, critical care medicine, trauma surgery, and emergency medicine. Source material that was reviewed included the 2003 Brain Trauma Foundation guidelines5 and the 2012 update14 and institutional protocols from St. Louis Children’s Hospital and Children’s of Alabama. The standardized clinical protocol was devised to guide medical therapy in a stepwise fashion, with an emphasis on maintaining CPP and ICP within strict parameters to reduce secondary brain injury by optimizing cerebral blood flow. The tiered approach to therapy focuses first on optimization of oxygen delivery and cerebral perfusion, secondly on CSF diversion, thirdly on maintenance of adequate sedation/analgesia, and finally on maximization of hyperosmolar therapy prior to progression to second-tier therapies, as defined by the 2012 Brain Trauma Foundation guidelines.14 Each intervention step is followed by immediate reevaluation to determine efficacy and need for further escalation. When developing the protocol, it was determined that simplifying the algorithm to a single hyperosmolar therapy would decrease variation in care. The protocol used hypertonic saline, so this was used as a surrogate adherence measure. In addition, the 2012 Brain Trauma Foundation guidelines note Level II and III evidence for the use of hypertonic saline. There were no studies about the use of mannitol that met inclusion criteria.

Outcomes of Interest

The primary outcome was discharge disposition, categorized as discharge home, discharge to rehabilitation, or death. A single patient was transferred to another acute care facility per the family’s request. This patient was considered to have a “rehabilitation” discharge disposition to maintain the model with only 3 discharge categories. Our secondary outcome was GOS score at discharge.1 We did not use the extended scale, because we did not believe that the retrospective nature of this analysis was sensitive enough to adequately reproduce the scale in a meaningful way.

Statistical Analysis

No trends in outcomes were detected in the 5 years of the preprotocol cohort; as such, this group was analyzed as a whole versus the postprotocol cohort. Study outcomes measured before and after TBI protocol implementation were compared. Mean age, GCS score, and length of stay between cohorts were compared using the Wilcoxon rank-sum test. Need for surgery, the various injury types and mechanisms, ICP monitor placement, barbiturate use, and hyperosmolar use were compared using the chi-square test and Fisher’s exact test where appropriate. Discharge disposition and GOS scores were compared using the Kruskal-Wallis test. Individual groups within discharge disposition were compared using the Wilcoxon rank-sum test.

To compare study outcomes before and after TBI protocol implementation while accounting for potential confounders, we used multivariate ordered logistic regression. Variables were determined a priori based on clinical significance and perceived importance. These variables were pre- and postprotocol status, GCS score after resuscitation, age, ICP monitor placement, and PICU length of stay. The number of parameters was limited to 5 to prevent overfitting the model. In the model, odds ratios (ORs) greater than 1 were associated with increasingly favorable discharge disposition. Ordered logistic regression was also used to predict discharge disposition based on GCS score after resuscitation across the spectrum of TBI severity and to create a plot comparing trends. Statistical significance was set a priori at p < 0.05, and the analysis was conducted using Stata statistical software (version 13, StataCorp).

Results

A total of 128 patients (preprotocol n = 99, postprotocol n = 29) were included in the study. Table 1 shows demographics, injury severity, injury mechanism, length of stay, and ICP treatment parameters. Baseline demographics were not significantly different in the pre- and postprotocol groups. Injury severity as assessed by initial GCS was similar, with a mean of 5.43 in the preprotocol cohort versus 5.28 in the postprotocol group (p = 0.671). Rates of patients requiring a neurosurgical operation were not significantly different (20% preprotocol vs 32% postprotocol; p = 0.648). A significant difference existed in the number of patients presenting with subdural hemorrhage as the predominant radiographic finding (33% preprotocol vs 61% postprotocol; p = 0.009). The injury mechanism was similar, except there was significantly more abusive head trauma in the postprotocol group (48% vs 20%, p = 0.003) and a trend toward fewer motor vehicle collisions (35% vs 17%, p = 0.064). Length of stay was not significantly different between the pre- and postprotocol cohorts. Mean PICU length of stay and overall length of stay did not differ between cohorts (p = 0.986 and p = 0.871, respectively). Before protocol implementation, ICP monitors were placed in 46% of patients compared with 28% of patients after protocol implementation (p = 0.07). Use of barbiturates was similar before and after protocol implementation (16% vs 21%; p = 0.68).

TABLE 1.

Patient characteristics: pre- and postprotocol comparison*

VariablePreprotocolPostprotocolP Value
No. of patients9929
Demographics
 Mean age in yrs (SD)6.54 (5.41)5.89 (6.03)0.239
 Sex, male52 (53)16 (55)0.802
 Race, white78 (79)25 (86)0.375
Severity of injury
 Mean GCS score (SD)5.43 (1.73)5.28 (1.85)0.671
 Neurosurgical operation20 (20)7 (32)0.648
 Subdural hemorrhage33 (33)17 (61)0.009
 Epidural hemorrhage6 (6)3 (11)0.412
Injury mechanism
 MVC35 (35)5 (17)0.064
 Pedestrian7 (7)1 ( 3)0.682
 Fall14 (14)4 (14)0.999
 Abusive head trauma20 (20)14 (48)0.003
 Other23 (23)5 (17)0.493
Length of stay in days
 Mean PICU stay (SD)7.0 (6.5)6.1 (4.9)0.986
 Mean hospital stay (SD)12.3 (14.6)10.6 (9.5)0.871
ICP Treatment
 ICP monitor placement46 (46)8 (28)0.070
 Hyperosmolar (only 3% NaCl)22 (22)12 (41)0.040
 Mannitol w/wo 3% NaCl48 (48)4 (14)0.001
 Barbiturates16 (16)6 (21)0.680

MVC = motor vehicle collision.

Data are shown as number and percentage (%) unless otherwise indicated.

Protocol Adherence

Protocol adherence was difficult to assess based on existing electronic medical records, but use of 3% hypertonic saline over mannitol was used as a surrogate measure. The protocol calls for preferential use of 3% hypertonic saline for treatment of elevated ICP. After protocol implementation, hypertonic saline was given to a greater percentage of patients (22% vs 41%, p = 0.04) and mannitol was administered to a smaller percentage (48% vs. 14%, p = 0.001).

Short-Term Outcomes

Table 2 shows pre- and postprotocol outcomes. In unadjusted bivariate analysis, discharge disposition improved significantly after protocol implementation. Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition (classified as death or inpatient facility placement) and 36 patients (36%) had favorable discharge disposition (classified as discharge home). After protocol implementation, 9 patients (31%) had unfavorable disposition while 20 patients (69%) had favorable disposition (p = 0.002). The number of deaths was significantly decreased, as were overall unfavorable outcomes. In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.041). GOS scores were generally improved after the protocol was initiated, but this difference was not statistically significant (p = 0.124).

TABLE 2.

Pre- and postprotocol outcomes*

VariablePreprotocolPostprotocolp Value
Discharge Disposition
 Death31 (31)6 (21)0.041
 Rehabilitation32 (32)3 (10)
 Home36 (36)20 (69)0.017
 Unfavorable (death/rehab)63 (64)9 (31)
 Favorable (home)36 (36)20 (69)0.002
GOS (score)
 1 (death)31 (31)6 (21)
 2 (vegetative)3 (3)0 (0)
 3 (severe disability)10 (10)3 (10)
 4 (moderate disability)19 (19)5 (17)
 5 (good recovery)36 (36)15 (52)0.124§
 Unfavorable (1–3)44 (44)9 (31)
 Favorable (4–5)55 (56)20 (69)0.197

All data shown as number (%) unless otherwise indicated.

Difference between death and home.

Difference among home, rehab, and death.

Difference among all GOS scores.

Regression Models

A proportional odds ordered logistic regression model of discharge disposition revealed that an improvement in outcomes was associated with being in the postprotocol implementation group and increasing GCS score (Table 3). Treatment in the postprotocol implementation group was associated with an OR of 4.046 (p = 0.007) of increasingly favorable outcomes. GCS score was associated with an OR of 1.844 (p < 0.001). ICP monitor placement itself was associated with worsening categorical outcome, with an OR of 0.206 (p < 0.001). Increasing PICU length of stay was associated with increasingly favorable outcomes, but the OR close to 1 reveals this association to be clinically immaterial. Age was not associated with outcome in the model. Given that GOS scores were not statistically significantly improved in the postprotocol group, an ordered logistic regression model did not reveal a significant positive relationship with postprotocol status.

TABLE 3.

Ordered logistic regression

VariableOR95% CIp Value
Group (pre- vs postprotocol)4.0461.476–11.0870.007
GCS score1.8441.469–2.315< 0.001
Age (yrs)1.0420.974–1.1140.232
ICP monitor placement0.2060.084–0.501< 0.001
PICU length of stay (days)1.0801.001–1.1580.032

CI = confidence interval.

Predicted outcomes improved across the range of GCS scores based on an ordered logistic regression model. Figure 2 demonstrates a dramatic shift in the probability of discharge home in the postprotocol group, as well as a marked decline in the probability of death postprotocol. This remained consistent across the spectrum of GCS scores studied.

FIG. 2.
FIG. 2.

Predictive model of discharge disposition probability before and after protocol implementation.

Discussion

Treatment in the postprotocol implementation group was associated with favorable discharge disposition and decreased mortality. Our ordered logistic regression model demonstrated improved discharge disposition in the postprotocol group with increasing GCS score, as one would expect with decreasing injury severity. In the model, the OR for postprotocol status can be interpreted as follows: in the postprotocol group, patients are 4 times as likely to be discharged home versus the combined disposition of rehabilitation or death, and patients are 4 times as likely to be discharged home or to rehabilitation versus suffer death during hospitalization. Prior to protocol implementation, the mortality rate for severe TBI was 31%, and the rate of discharge home was 36%. This mortality rate is consistent with that in large cohorts in the pediatric traumatic literature.3,12,30,32 After protocol implementation, the mortality rate dropped to 21%, and the rate of discharge home increased dramatically to 69%. This is a significant improvement and demonstrates the possibility of improving short-term outcomes by standardizing PICU care for pediatric patients with severe TBI.

Our results corroborate the findings of Pineda et al. and other groups that instituted standardized ICU care based on guidelines.11,20,21,29 Cuschieri et al. showed in 2012 that disease-focused implementation of standard operating procedures improves outcomes.9 Additionally, a 2014 study by Vavilala et al. demonstrated improvement in mortality and discharge GOS score with increasing adherence to clinical indicators derived from the 2012 Brain Trauma Foundation guidelines,31 including maintenance of CPP greater than 40 mm Hg and early start of nutrition. Our results build upon these findings, further reinforcing the evidence that guideline-based care can improve outcomes in pediatric patients with severe TBI.

Our primary outcome of interest was discharge disposition, which was significantly improved in the postprotocol cohort. With regard to discharge status, the neurosurgery, critical care, and trauma surgery teams worked with the physical therapists and case management teams to determine the optimal environment for discharge. There was no intentional influence by providers to have patients discharged home versus to rehabilitation. In addition, because cohorts were roughly similar, we anticipate that unmeasured factors such as family preference and availability of outpatient therapy services would look similar between cohorts, as well. One major benefit of using a 5-year preprotocol for comparison was that there was no generalized trend toward discharge disposition status noted prior to protocol implementation. There was a trend toward improvement in the secondary outcome GOS scores, but with 5 distinct categories and low overall sample size, this improvement did not reach the level of statistical significance. Discharge disposition is a better measure of overall well-being at discharge compared with GOS, which more narrowly represents neurological recovery. However, we chose to additionally analyze the GOS score because of its widespread use and focus on neurological outcome.18 We were unable to use the extended scale due to the retrospective nature of the analysis, which could not capture the finer variation in disability required of this scale.

The pre- and postprotocol cohorts were similar except the postprotocol group had a higher rate of abusive head trauma as well as a higher rate of subdural hemorrhage as the predominant radiographic finding. Studies have shown that mortality and outcomes are worse in children exposed to abusive head trauma,33 which could potentially lead to an underestimation of the overall improvement in outcomes seen in our postprotocol cohort. The finding that the rate of subdural hemorrhage in the postprotocol cohort was increased is significant given the association between subdural hemorrhage and more severe underlying intracranial injury. One would expect outcomes to be worse in the more severely injured group. However, the postprotocol cohort had improved outcomes, so we may conclude that our results are an underestimate of the true impact of the protocol on outcomes.

Our ordered logistic regression model demonstrated improved outcomes in the postprotocol group and increasing GCS score, as one would expect with decreasing injury severity. Interestingly, ICP monitor placement was a negative predictive factor despite the protocol’s focus on ICP management. We postulated this might be due to bias in initial GCS score reporting, as some patients may initially demonstrate a lower GCS score secondary to sedation. When reevaluated prior to ICP monitor placement, some patients’ examinations may improve, resulting in no ICP monitor placement. Those patients who did receive monitors were those with the worst examinations and hence the greatest injury severity. This would decrease expected outcomes in those who ended up receiving an ICP monitor. There still remains controversy within the literature regarding the effectiveness of ICP-based treatment of TBI on outcomes. Although the protocol indicated patients with GCS scores less than 8 should receive an ICP monitor, this intervention was not strictly enforced at the time of the initial examination, as evidenced by an ICP monitor rate of 28% postprotocol. The protocol includes the overall management strategy, in which placement of an ICP monitor was only a part, albeit an important one. We hypothesize that the protocol, in particular neurosurgical presence and the use of short-acting sedation, enabled a second examination in which the patients may have been found to be improving and not in need of monitor placement.

While our study demonstrates that standardizing care among neurosurgeons and intensivists can improve short-term outcomes, it does not allow us to draw any conclusions on the particular effectiveness of ICP-focused care. Our study was not intended to measure adherence to the protocol, although we noted significantly increased use of hypertonic saline and decreased use of mannitol per guideline recommendations for the treatment of elevated ICP. Interestingly, there was a trend toward fewer ICP monitor placements in the postprotocol cohort. While it could be concluded that the overall proportion of patients receiving ICP monitors being lower in the postprotocol group signals a lack of adherence, the overall goal of this study was not to evaluate the utility of ICP monitors, but rather a focused attention on the evaluation and management of these complex patients across multiple services, with a standardized approach to assessment and decision-making. A patient receiving an ICP monitor and elevated care in the past for a poor GCS score on the first assessment may now be more likely to be placed on the appropriate sedating medication for rapid neurological assessment and receive serial examinations over the earliest portions of their hospital course, which may show improvement beyond the need for ICP monitoring. It may be that the attention to a protocol (i.e., the Hawthorne effect) may be at play here, but the overall goal of improved care is achieved. Whether the effect is sustained in this cohort in follow-up assessments or in future patients is a source of ongoing study and remains to be seen. Our intent was to determine how a multidisciplinary approach with commitment from various groups to care for these challenging patients impacted care. As evidenced by our results, we believe this did improve outcomes. Those who did not require a monitor were still treated under the protocol with goals to maintain adequate mean arterial pressure, nor-monatremia, adequate hematocrit, sufficient sedation and analgesia, appropriate oxygenation, and glucose control. In addition, the initial neurosurgical examination was used to guide treatment of patients rather than presenting examinations in the emergency department, which can often be clouded by patient sedation.

Additionally, our study did not show significant differences in length of stay despite the improvement in outcomes. ICP monitoring-focused care may be associated with longer PICU stays and overall increased length of stay,6,13 but this did not hold true based on the results in this study. Although costs were not measured in this study, length of stay has been validated as a surrogate measure for cost.19 The results of this study could thus imply that outcomes were improved without increasing costs, a significant benefit in a cost-conscious environment.11,28 However, it is premature to draw conclusions in this regard, because complexity and intensity of therapy may be increased with protocol-based care, as demonstrated in a study by Palmer et al.20 This could ultimately increase overall costs despite similar lengths of stay. However, improving outcomes in pediatric patients would be justified even if costs were increased.

There were some limitations to the study, including the retrospective portion of the design, small sample size, and single-center involvement. However, our study attempted to account for these limitations by analyzing outcomes over several years to increase sample size and ensuring our ordered logistic regression model was not overfit with excessive parameters. Ultimately, we were able to demonstrate that short-term outcomes in pediatric patients with severe TBI were improved after a standardized protocol was implemented among caregivers. Further studies are needed that include multiple pediatric critical care centers and assess long-term outcomes.

Conclusions

Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation among caregivers of a standardized protocol based on best-practice guidelines. This improvement occurred despite a higher rate of abusive head trauma in the postprotocol group. Those patients ultimately undergoing ICP monitor placement had worse outcomes as a subgroup. Length of stay was not increased in the postprotocol cohort.

Acknowledgments

The initial protocol that was modified was based in part on that designed and implemented by José Pineda, MD, and David Limbrick, MD, PhD, at Washington University in St. Louis, and James Johnston, MD, at the University of Alabama-Birmingham. We are grateful for their feedback and willingness to collaborate. In addition, the physicians and caregivers in the Vanderbilt Division of Pediatric Critical Care and the Department of Neurosurgery are to be acknowledged for their willingness to standardize care for these complex children. The project described was supported by CTSA award no. UL1TR000445 from the National Center for Advancing Translational Sciences, as well as the Vanderbilt Surgical Outcomes Center for Kids (SOCKs). Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health.

Author Contributions

Conception and design: O’Lynnger, Shannon, Lamb, Wellons. Acquisition of data: O’Lynnger, Greeno. Analysis and interpretation of data: all authors. Drafting the article: O’Lynnger, Shannon, Le, Wellons. Critically revising the article: O’Lynnger, Shannon, Le, Wellons. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: O’Lynnger. Statistical analysis: O’Lynnger, Shannon. Administrative/technical/material support: Greeno. Study supervision: Chung, Lamb, Wellons.

Supplemental Information

Previous Presentation

Portions of this work were presented in poster form at the AANS/CNS Section on Pediatric Neurosurgery, Amelia Island, Florida, December 3, 2014.

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    • Export Citation
  • 21

    Pineda JALeonard JRMazotas IGNoetzel MLimbrick DDKeller MS: Effect of implementation of a paediatric neurocritical care programme on outcomes after severe traumatic brain injury: a retrospective cohort study. Lancet Neurol 12:45522013

    • Search Google Scholar
    • Export Citation
  • 22

    Potoka DASchall LCGardner MJStafford PWPeitzman ABFord HR: Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 49:2372452000

    • Search Google Scholar
    • Export Citation
  • 23

    Salorio CFSlomine BSGuerguerian AMChristensen JRWhite JRNatale JE: Intensive care unit variables and outcome after pediatric traumatic brain injury: a retrospective study of survivors. Pediatr Crit Care Med 9:47532008

    • Search Google Scholar
    • Export Citation
  • 24

    Saul TGDucker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:4985031982

    • Search Google Scholar
    • Export Citation
  • 25

    Saul TGDucker TB: Intracranial pressure monitoring in patients with severe head injury. Am Surg 48:4774801982

  • 26

    Scaife ERStatler KD: Traumatic brain injury: preferred methods and targets for resuscitation. Curr Opin Pediatr 22:3393452010

  • 27

    Shafl SDiaz-Arrastia RMadden CGentilello L: Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. J Trauma 64:3353402008

    • Search Google Scholar
    • Export Citation
  • 28

    Shi JXiang HWheeler KSmith GAStallones LGroner J: Costs, mortality likelihood and outcomes of hospitalized US children with traumatic brain injuries. Brain Inj 23:6026112009

    • Search Google Scholar
    • Export Citation
  • 29

    Stein SCGeorgoff PMeghan SMirza KLEl Falaky OM: Relationship of aggressive monitoring and treatment to improved outcomes in severe traumatic brain injury. J Neurosurg 112:110511122010

    • Search Google Scholar
    • Export Citation
  • 30

    Tude Melo JRDi Rocco FBlanot SOliveira-Filho JRoujeau TSainte-Rose C: Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery 67:154215472010

    • Search Google Scholar
    • Export Citation
  • 31

    Vavilala MSKernic MAWang JKannan NMink RBWainwright MS: Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med 42:225822662014

    • Search Google Scholar
    • Export Citation
  • 32

    White JRFarukhi ZBull CChristensen JGordon TPaidas C: Predictors of outcome in severely head-injured children. Crit Care Med 29:5345402001

    • Search Google Scholar
    • Export Citation
  • 33

    Xiang JShi JWheeler KKYeates KOTaylor HGSmith GA: Paediatric patients with abusive head trauma treated in US Emergency Departments, 2006–2009. Brain Inj 27:155515612013

    • Search Google Scholar
    • Export Citation

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Article Information

Correspondence Thomas M. O’Lynnger, Pediatric Neurosurgery, Vanderbilt University Medical Center, 9222 Doctors’ Office Tower, 2200 Children’s Way, Nashville, TN 37232-9557. email: thomas.olynnger@vanderbilt.edu.

INCLUDE WHEN CITING Published online October 9, 2015; DOI: 10.3171/2015.5.PEDS1544.

Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Traumatic brain injury protocol. CVP = central venous pressure; EEG = electroencephalogram; ETCO2 = end-tidal CO2; EVD = external ventricular drain; Hct = hematocrit; HOB = head of bed; MAP = mean arterial pressure; Na = sodium; NMB = neuromuscular blockade; NS = normal saline; NSGY = neurosurgery; pCO2 = partial pressure of CO2; TP = transpyloric.

  • View in gallery

    Predictive model of discharge disposition probability before and after protocol implementation.

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    Pineda JALeonard JRMazotas IGNoetzel MLimbrick DDKeller MS: Effect of implementation of a paediatric neurocritical care programme on outcomes after severe traumatic brain injury: a retrospective cohort study. Lancet Neurol 12:45522013

    • Search Google Scholar
    • Export Citation
  • 22

    Potoka DASchall LCGardner MJStafford PWPeitzman ABFord HR: Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 49:2372452000

    • Search Google Scholar
    • Export Citation
  • 23

    Salorio CFSlomine BSGuerguerian AMChristensen JRWhite JRNatale JE: Intensive care unit variables and outcome after pediatric traumatic brain injury: a retrospective study of survivors. Pediatr Crit Care Med 9:47532008

    • Search Google Scholar
    • Export Citation
  • 24

    Saul TGDucker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:4985031982

    • Search Google Scholar
    • Export Citation
  • 25

    Saul TGDucker TB: Intracranial pressure monitoring in patients with severe head injury. Am Surg 48:4774801982

  • 26

    Scaife ERStatler KD: Traumatic brain injury: preferred methods and targets for resuscitation. Curr Opin Pediatr 22:3393452010

  • 27

    Shafl SDiaz-Arrastia RMadden CGentilello L: Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. J Trauma 64:3353402008

    • Search Google Scholar
    • Export Citation
  • 28

    Shi JXiang HWheeler KSmith GAStallones LGroner J: Costs, mortality likelihood and outcomes of hospitalized US children with traumatic brain injuries. Brain Inj 23:6026112009

    • Search Google Scholar
    • Export Citation
  • 29

    Stein SCGeorgoff PMeghan SMirza KLEl Falaky OM: Relationship of aggressive monitoring and treatment to improved outcomes in severe traumatic brain injury. J Neurosurg 112:110511122010

    • Search Google Scholar
    • Export Citation
  • 30

    Tude Melo JRDi Rocco FBlanot SOliveira-Filho JRoujeau TSainte-Rose C: Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery 67:154215472010

    • Search Google Scholar
    • Export Citation
  • 31

    Vavilala MSKernic MAWang JKannan NMink RBWainwright MS: Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med 42:225822662014

    • Search Google Scholar
    • Export Citation
  • 32

    White JRFarukhi ZBull CChristensen JGordon TPaidas C: Predictors of outcome in severely head-injured children. Crit Care Med 29:5345402001

    • Search Google Scholar
    • Export Citation
  • 33

    Xiang JShi JWheeler KKYeates KOTaylor HGSmith GA: Paediatric patients with abusive head trauma treated in US Emergency Departments, 2006–2009. Brain Inj 27:155515612013

    • Search Google Scholar
    • Export Citation

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