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Roberts BK, Campbell BT, Jensen AR, Escobar MA, Williams RF, Nathens A, Burd RS, Streck CJ, Falcone R, Letton RW, Maxson RT, Miller M, Hsu BS, Albert GW, Renaud E, Garcia N, Holmes J, Hoeft C, Sathya C. A Modified Delphi Study to Build Consensus on Pediatric-specific Trauma Quality Indicators. J Pediatr Surg 2025; 60:162363. [PMID: 40354976 DOI: 10.1016/j.jpedsurg.2025.162363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2025] [Revised: 04/18/2025] [Accepted: 05/05/2025] [Indexed: 05/14/2025]
Abstract
BACKGROUND Quality improvement efforts across pediatric trauma centers have expanded recently in large part because of the American College of Surgeons Pediatric Trauma Quality Improvement Program. However, consensus on quality indicators (QI) specific to pediatric trauma that measure "quality of care" in this population is lacking. This study aims to identify pediatric-specific trauma QI. STUDY DESIGN An expert panel of pediatric trauma leaders was convened. The panel met virtually to define and refine potential QI using a modified Delphi method, prioritizing indicators to include representing important QI for pediatric trauma. A comprehensive list of defined QI was created to improve the quality of pediatric trauma care. RESULTS 14 experts were included in the panel. After 3 rounds of anonymous voting and meetings, 52 QI were chosen, including 25 outcome, 21 process, and 6 structure variables and spanning 6 domains of quality as defined by the Agency for Healthcare Research and Quality. Indicators comprised 22 unchanged from pTQIP, 10 adapted from currently reported in pTQIP, and 20 new. Indicators encompassed unique treatment pathways for pediatric patients, timeliness of care, screening and prevention of future injuries, and long-term outcomes. CONCLUSION A modified Delphi method was used to develop a novel list of pediatric trauma QI to inform quality improvement and benchmarking efforts for pediatric trauma care. Analysis of outcomes is required to understand the accuracy and usefulness of these newly proposed and existing indicators. This study serves as a starting point for the incorporation of new QI within national quality improvement initiatives. STUDY TYPE AND LEVEL OF EVIDENCE Survey type study, level 4 evidence.
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Affiliation(s)
- Bailey K Roberts
- Department of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA.
| | - Brendan T Campbell
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Aaron R Jensen
- Division of Pediatric Surgery, Department of Surgery, University of California School of Medicine, and UCSF Benioff Children's Hospitals, Oakland, CA, USA
| | - Mauricio A Escobar
- Department of Pediatric Surgery and Pediatric Trauma, Mary Bridge Children's, Tacoma, WA, USA
| | - Regan F Williams
- Department of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Avery Nathens
- Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children's National Hospital, Washington, DC, USA
| | - Christian J Streck
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Richard Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert W Letton
- Division of Pediatric Surgery, Nemours Children's Healthcare, Jacksonville, FL, USA
| | - R Todd Maxson
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Mark Miller
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Benson S Hsu
- Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Gregory W Albert
- Division of Neurosurgery, Arkansas Children's Hospital and Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Elizabeth Renaud
- Division of Pediatric Surgery, Hasbro Children's Hospital, Alpert Medical School at Brown University, Providence, RI, USA
| | - Nilda Garcia
- Department of Surgery, Dell Children's Medical Center, Austin, TX, USA
| | - Julia Holmes
- Department of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA
| | | | - Chethan Sathya
- Department of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA
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Moore L, Yanchar NL, Tardif PA, Weiss M, Beaulieu E, Stang A, Gagnon I, Gabbe B, Stelfox T, Pike I, Macpherson A, Berthelot S, Klassen T, Beno S, Carsen S, Labrosse M, Zemek R, Priestap F, Burstein B, Remick KE, Yeates KO, Merritt N, Kuppermann N, Loellgen R, Davis N, Lecky F, Teague W, Holland A, Malo C, Beaudin M, Archambault P, Freire G. Evidence-Informed Quality Indicators for Pediatric Trauma Care. JAMA Pediatr 2025:2831741. [PMID: 40163207 PMCID: PMC11959479 DOI: 10.1001/jamapediatrics.2025.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Accepted: 12/14/2024] [Indexed: 04/02/2025]
Abstract
Importance Despite the unique physiological characteristics and health care needs of pediatric trauma patients, there is a lack of quality indicators (QIs) based on pediatric-specific evidence to support quality improvement in this population. Objective To develop a consensus-based set of QIs for acute pediatric trauma care that considers evidence on effectiveness, safety, cost-effectiveness, equity, and caregiver perspectives and is applicable in pediatric and nonpediatric trauma centers. Design, Setting, and Participants A modified Research and Development (RAND)/University of California Los Angeles (UCLA) expert consensus study was conducted consisting of an online survey and a virtual workshop, led by an independent moderator. Panelists represented key areas of pediatric trauma patient management, diverse care settings (from level I pediatric trauma centers to level III referring centers), 5 high-resource countries, and caregivers. Data were analyzed from May to August 2024. Exposure Likert-scale ratings of 41 QIs. Main Outcomes and Measures Panelists rated 41 QIs on a 7-point Likert scale according to 4 criteria: importance, supporting evidence, actionability, and measurability. QIs with a global score of 24 of 28 or greater and an importance score of 6 of 7 or greater were considered accepted by consensus. Results A total of 65 experts were invited, of whom 59 accepted (91%; 25 over 50 years of age [44.7%]; 34 female [60.7%]), 56 (95%) completed the first round, and 54 (92%) completed both rounds. Twenty-three QIs were selected covering key areas of acute pediatric trauma management (eg, transfer to a pediatric trauma center for neurotrauma or major multisystem trauma, documentation of vital signs, early rehabilitation, nutritional support), the most common types of injuries (eg, hypertonic saline in severe traumatic brain injury, stabilization of femoral shaft fractures, nonoperative management of solid organ injuries), value in care (eg, imaging in children at low risk on a clinical decision rule), patient-centered care (eg, designated support person, caregiver presence), and equity (eg, mental health screening). Conclusions These results may be used by trauma quality improvement programs in high-resource countries to select context-specific quality indicators to improve the effectiveness, safety, cost-effectiveness, equity, and patient-centered nature of pediatric trauma care.
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Affiliation(s)
- Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec—Université Laval (Hôpital de l’Enfant-Jésus), Québec, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | | | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, Québec, Canada
| | - Matthew Weiss
- Department of Pediatrics, Centre Mère-Enfant Soleil du CHU de Québec, Université Laval, Québec, Québec, Canada
| | - Emilie Beaulieu
- Département de Pédiatrie, Faculté de Médecine, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Antonia Stang
- Department of Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Isabelle Gagnon
- Montreal Children’s Hospital, Division of Pediatric Emergency Medicine, McGill University Health Centre, Montréal, Quebec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thomas Stelfox
- Department of Critical Care Medicine, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Ian Pike
- Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
- BC Children’s Hospital Research Institute, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Alison Macpherson
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec—Université Laval (Hôpital de l’Enfant-Jésus), Québec, Québec, Canada
| | - Terry Klassen
- George & Fay Yee Centre for Health Care Innovation, Children’s Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Suzanne Beno
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mélanie Labrosse
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Roger Zemek
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Fran Priestap
- Trauma Program, London Health Sciences Centre,, London, Ontario, Canada
| | - Brett Burstein
- Montreal Children’s Hospital, Division of Pediatric Emergency Medicine, McGill University Health Centre, Montréal, Quebec, Canada
- Department of Biostatistics, Epidemiology and Occupational Health, McGill University, Montréal, Quebec, Canada
| | - Katherine E. Remick
- Department of Pediatrics, Dell Medical School at the University of Texas at Austin, Austin
| | - Keith Owen Yeates
- Department of Psychology, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Neil Merritt
- Department of Surgery, Western University, London, Ontario, Canada
| | - Nathan Kuppermann
- The Departments of Pediatrics and Emergency Medicine, George Washington School of Medicine and Health Sciences, Children’s National Hospital, Washington, DC
| | - Ruth Loellgen
- Department of Pediatric Emergency Medicine, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Naomi Davis
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
- Trauma Audit and Research Network, United Kingdom
| | - Warwick Teague
- Department of Paediatric Surgery, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Andrew Holland
- The Burns Unit, The Children’s Hospital at Westmead Burns Research Institute, Westmead, New South Wales, Australia
| | - Christian Malo
- Département de Médicine Familiale et de Médicine d’Urgence, Faculté de Médecine, Université Laval, Québec City, Québec, Canada
| | - Marianne Beaudin
- Department of Paediatric Surgery, Sainte-Justine Hospital, Université de Montréal, Montréal, Québec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, Québec, Canada
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Stephens CQ, Fallat ME. Setting an agenda for a national pediatric trauma system: Operationalization of the Pediatric Trauma State Assessment Score. J Trauma Acute Care Surg 2024; 96:838-850. [PMID: 37962143 DOI: 10.1097/ta.0000000000004208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
ABSTRACT Pediatric trauma system development is essential to public health infrastructure and pediatric health systems. Currently, trauma systems are managed at the state level, with significant variation in consideration of pediatric needs. A recently developed Pediatric Trauma System Assessment Score (PTSAS) demonstrated that states with lower PTSAS have increased pediatric mortality from trauma. Critical gaps are identified within six PTSAS domains: Legislation and Funding, Access to Care, Injury Prevention and Recognition, Disaster, Quality Improvement and Trauma Registry, and Pediatric Readiness. For each gap, a recommendation is provided regarding the necessary steps to address these challenges. Existing national organizations, including governmental, professional, and advocacy, highlight the potential partnerships that could be fostered to support efforts to address existing gaps. The organizations created under the US administration are described to highlight the ongoing efforts to support the development of pediatric emergency health systems.It is no longer sufficient to describe the disparities in pediatric trauma outcomes without taking action to ensure that the health system is equipped to manage injured children. By capitalizing on organizations that intersect with trauma and emergency systems to address known gaps, we can reduce the impact of injury on all children across the United States.
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Affiliation(s)
- Caroline Q Stephens
- From the Department of Surgery (C.Q.S.), University of California-San Francisco, San Francisco, CA; and Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine (M.E.F.), Louisville, KY
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Buck Sainz-Rozas P, Casal Angulo C, García Molina P. Quality assessment in initial paediatric trauma care: Systematic review from prehospital care to the paediatric intensive care unit. Nurs Crit Care 2023; 28:1143-1153. [PMID: 37621180 DOI: 10.1111/nicc.12970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 06/21/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Trauma is the most common cause of death and disability in the paediatric population. There are a huge number of variables involved in the care they receive from health care professionals. AIM The aim of this study was to review the available evidence of initial paediatric trauma care throughout the health care process with a view to create quality indicators (QIs). STUDY DESIGN A systematic review was performed from Cochrane Library, Medline, Scopus and SciELO between 2010 and 2020. Studies and guidelines that examined quality or suggested QI were included. Indicators were classified by health care setting, Donabedian's model, risk of bias and the quality of the publication with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment. RESULTS The initial search included 686 articles, which were reduced to 22, with 15 primary and 7 secondary research articles. The snowball sampling technique was used to add a further seven guidelines and two articles. From these, 534 possible indicators were extracted, summarizing them into 39 and grouping the prehospital care indicators as structure (N = 5), process (N = 12) and outcome (N = 3) indicators and the hospital care indicators as structure (N = 4), process (N = 10) and outcome (N = 6) indicators. Most of the QIs have been extracted from US studies. They are multidisciplinary and in some cases are based on an adaptation of the QIs of adult trauma care. CONCLUSIONS There was a clear gap and large variability between the indicators, as well as low-quality evidence. Future studies will validate indicators using the Delphi method. RELEVANCE TO CLINICAL PRACTICE Design a QI framework that may be used by the health system throughout the process. Indicators framework will get nurses, to assess the quality of health care, detect deficient areas and implement improvement measures.
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Affiliation(s)
- Pablo Buck Sainz-Rozas
- Facultad de Enfermería y Podología, Universidad de Valencia, Valencia, Spain
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carmen Casal Angulo
- Facultad de Enfermería y Podología, Universidad de Valencia, Valencia, Spain
- Servicio de Emergencias Sanitarias (SES) de Valencia, Valencia, Spain
| | - Pablo García Molina
- Facultad de Enfermería y Podología, Universidad de Valencia, Valencia, Spain
- Hospital Clínico Universitario de Valencia, Valencia, Spain
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Evans LL, Jensen AR, Meert KL, VanBuren JM, Richards R, Alvey JS, Carcillo JA, McQuillen PS, Mourani PM, Nance ML, Holubkov R, Pollack MM, Burd RS. All body region injuries are not equal: Differences in pediatric discharge functional status based on Abbreviated Injury Scale (AIS) body regions and severity scores. J Pediatr Surg 2022; 57:739-746. [PMID: 35090715 DOI: 10.1016/j.jpedsurg.2021.09.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Functional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity. METHODS Children with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores. RESULTS The study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS< 9) compared to those with a higher GCS score (43% versus 9%; p < 0.01). Patients with AIS 3 extremity and severe head injuries had a higher proportion of abnormal FSS at discharge than AIS 3 abdomen or non-severe head injuries. CONCLUSIONS AIS severity does not account for variability in discharge functional impairment within or between body regions. Benchmarking based on functional status assessment requires clinical factors in addition to AIS severity for appropriate risk adjustment. LEVEL OF EVIDENCE 1 (Prognostic and Epidemiological).
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Affiliation(s)
- Lauren L Evans
- Department of Surgery, Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, 4th Floor OPC2, Oakland CA 94609, United States
| | - Aaron R Jensen
- Department of Surgery, Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, 4th Floor OPC2, Oakland CA 94609, United States.
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI 48201, United States
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
| | - Peter M Mourani
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Michael L Nance
- Division of Pediatric Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington DC 20010, United States
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC 20010, United States
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Burd RS, Jensen AR, VanBuren JM, Richards R, Holubkov R, Pollack MM, Berg RA, Carcillo JA, Carpenter TC, Dean JM, Gaines B, Hall MW, McQuillen PS, Meert KL, Mourani PM, Nance ML, Yates AR. Factors Associated With Functional Impairment After Pediatric Injury. JAMA Surg 2021; 156:e212058. [PMID: 34076684 DOI: 10.1001/jamasurg.2021.2058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown. Objective To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers. Design, Setting, and Participants This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020. Exposure At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5). Main Outcomes and Measures New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites. Results This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge. Conclusions and Relevance In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.
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Affiliation(s)
- Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC
| | - Aaron R Jensen
- University of California San Francisco Benioff Children's Hospital Oakland, Oakland
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Robert A Berg
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Barbara Gaines
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit.,Central Michigan University, Mt Pleasant
| | - Peter M Mourani
- Arkansas Children's Research Institute, Arkansas Children's Hospital, Little Rock
| | - Michael L Nance
- Division of Pediatric Trauma, Department of Surgery, College of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
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Scantling D, Hatchimonji J, Williamson J, Pascual J, Kaplan L. Adjacent Adult and Pediatric Trauma Centers: Which Way to Turn With the Injured Adolescent? Am Surg 2021:31348211033539. [PMID: 34318711 DOI: 10.1177/00031348211033539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Dane Scantling
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA, USA
| | - Justin Hatchimonji
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA, USA
| | - John Williamson
- Department of Surgery, Cooper Medical School, Camden, NJ, USA
| | - Jose Pascual
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA, USA
| | - Lewis Kaplan
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, PA, USA
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Change in functional status among children treated in the intensive care unit after injury. J Trauma Acute Care Surg 2020; 86:810-816. [PMID: 30444861 DOI: 10.1097/ta.0000000000002120] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Because pediatric trauma-related mortality continues to decline, metrics assessing morbidity are needed to evaluate the impact of treatment after injury. Based on its value for assessing children with traumatic brain injuries and other critical illnesses, Functional Status Scale (FSS), a tool that measures function in six domains (communication, feeding, mental, motor, sensory, and respiratory), was evaluated as an outcome measure for the overall population of injured children. METHODS Children with at least one injury (Abbreviated Injury Scale [AIS] severity ≥1) surviving to discharge between December 2011 and April 2013 were identified in a previous study of intensive care unit admissions. Morbidity was defined as additional morbidity in any domain (domain FSS change ≥2 or 'new domain morbidity') and additional overall morbidity (total FSS change ≥3) between preinjury status and discharge. Associations between injury profiles and the development of morbidity were analyzed. RESULTS We identified 553 injured children, with a mean of 2.0 ± 1.9 injuries. New domain and overall morbidity were observed in 17.0% and 11.0% of patients, respectively. New domain morbidity was associated with an increasing number of body regions with an injury with AIS ≥ 2 (p < 0.001), with severe (AIS ≥ 4) head (p = 0.04) and spine (p = 0.01) injuries and with at moderately severe (AIS ≥ 2) lower extremity injuries (p = 0.01). New domain morbidity was more common among patients with severe spine and lower extremity injuries (55.6% and 48.7%, respectively), with greatest impact in the motor domain (55.6% and 43.6%, respectively). New domain morbidity was associated with increasing injury severity score, number of moderately severe injuries and number of body regions with more than a moderately severe injury (p < 0.001 for all). CONCLUSIONS Higher morbidity measured by the FSS is associated with increasing injury severity. These findings support the use of the FSS as a metric for assessing outcome after pediatric injury. LEVEL OF EVIDENCE Prognostic/Epidemiologic, level III.
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Curtis K, Kennedy B, Holland AJ, Mitchell RJ, Tall G, Smith H, Soundappan SS, Loudfoot A, Burns B, Dinh M. Determining the priorities for change in paediatric trauma care delivery in NSW, Australia. Australas Emerg Care 2020; 23:97-104. [DOI: 10.1016/j.auec.2019.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/27/2019] [Accepted: 09/30/2019] [Indexed: 11/16/2022]
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Curtis K, Kennedy B, Holland AJA, Tall G, Smith H, Soundappan SSV, Burns B, Mitchell RJ, Wilson K, Loudfoot A, Dinh M, Lyons T, Gillen T, Dickinson S. Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical, system and human factors peer-review tool. Injury 2019; 50:1089-1096. [PMID: 30683570 DOI: 10.1016/j.injury.2019.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/10/2019] [Accepted: 01/15/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is known variability in the quality of care delivered to injured children. Identifying where care improvement can be made is critical. This study aimed to review paediatric trauma cases across the most populous Australian State to identify factors contributing to clinical incidents. METHODS Medical records from three New South Wales Paediatric Trauma Centres were reviewed for children <16 years requiring intensive care; with an injury severity score of ≥9, or who died following injury between July 2015 and September 2016. Records were peer-reviewed by nurse surveyors who identified cases that might not meet the expected standard of care or where the child died following the injury. A multidisciplinary panel conducted the peer-review using a major trauma peer-review tool. Records were reviewed independently, then discussed to establish consensus. RESULTS A total 535 records were reviewed and 41 cases were peer-reviewed. The median (IQR) age was 7 (2-12) years, the median ISS was 25 (IQR 16-30). The peer-review identified a combination of clinical (85%), systems (51%) and communication (12%) problems that contributed to difficulties in care delivery. In 85% of records, staff actions were identified to contribute to events; with medical task failure the most frequently identified cause (89%). CONCLUSION The peer-review of paediatric trauma cases assisted in the identification of contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change. The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria (definitions), performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury.
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, NSW, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia; The George Institute for Global Health, Sydney, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Belinda Kennedy
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, NSW, Australia.
| | - Andrew J A Holland
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; The Children's Hospital at Westmead, Sydney, NSW, Australia
| | | | | | - Soundappan S V Soundappan
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Brian Burns
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; NSW Ambulance, Sydney, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | | | | | - Michael Dinh
- NSW Institute of Trauma and Injury Management (ITIM), Australia; Sydney Local Health District, NSW, Australia
| | - Timothy Lyons
- Department of Forensic Medicine Newcastle, NSW, Australia
| | - Tona Gillen
- Lady Cilento Children's Hospital, Brisbane, Australia
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Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types. Injury 2019; 50:142-148. [PMID: 30270009 DOI: 10.1016/j.injury.2018.09.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 09/01/2018] [Accepted: 09/18/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trauma is a common indication for computed tomography (CT) in children. However, children are particularly vulnerable to CT radiation and its associated cancer risk. Identifying differences in CT usage across trauma centers and among specific populations of injured children is needed to identify where quality improvement initiatives could be implemented in order to reduce excess radiation exposure to children. We evaluated computed tomography (CT) rates among injured children treated at pediatric (PTC), mixed (MTC), or adult trauma centers (ATC) and estimated the resulting differential in potential cancer risk. METHODS We identified children age ≤18 years with blunt injury AIS ≥2 treated from 2010 to 2013 at 130 U.S trauma centers participating in the Trauma Quality Improvement Program. CT rates were compared across center types using Chi-square analysis. Stratified analyses in children with varying injury severity, mechanism, and age were performed. We estimated the impact of differential rates of CT scans on cancer risk using published attributable risks. RESULTS Among 59,010 children identified, CT rates were higher among injured children treated at ATC and MTC versus PTC. Findings were consistent after stratified analyses and were most striking in children with chest and abdomen/pelvis CT, adolescent age, low injury severity and fall injury mechanism. We estimated that for every 100,000 injured children, imaging practices in ATC and MTC would lead to an additional 17 and 16 lifetime cancers, respectively, when compared to PTC. CONCLUSION CT use among injured children is higher at ATC and MTC compared to PTC. Children with low injury severity, fall injury mechanism, and adolescent age are most vulnerable to differential imaging practices across centers. Quality improvement initiatives aimed at reducing heterogeneity in CT usage across trauma centers are required to mitigate pediatric radiation exposure and cancer risk.
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Anantha RV, Zamiara P, Merritt NH. Surgical intervention in pediatric trauma at a level 1 trauma hospital: a retrospective cohort study and report of cost data. Can J Surg 2018; 61:9817. [PMID: 29582744 DOI: 10.1503/cjs.009817] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Given that the management of severely injured children requires coordinated care provided by multiple pediatric surgical subspecialties, we sought to describe the frequency and associated costs of surgical intervention among pediatric trauma patients admitted to a level 1 trauma centre in southwestern Ontario. METHODS All pediatric (age < 18 yr) trauma patients treated at the Children's Hospital - London Health Sciences Centre (CH-LHSC) between 2002 and 2013 were included in this study. We compared patients undergoing surgical intervention with a nonsurgical group with respect to demographic characteristics and outcomes. Hospital-associated costs were calculated only for the surgical group. RESULTS Of 784 injured children, 258 (33%) required surgery, 40% of whom underwent orthopedic interventions. These patients were older and more severely injured, and they had longer lengths of stay than their nonsurgical counterparts. There was no difference in mortality between the groups. Seventy-four surgical patients required intervention within 4 hours of admission; 45% of them required neurosurgical intervention. The median cost of hospitalization was $27 571 for the surgical group. CONCLUSION One-third of pediatric trauma patients required surgical intervention, of whom one-third required intervention within 4 hours of arrival. Despite the associated costs, the surgical treatment of children was associated with comparable mortality to nonsurgical treatment of less severely injured patients. This study represents the most recent update to the per patient cost for surgically treated pediatric trauma patients in Ontario, Canada, and helps to highlight the multispecialty care needed for the management of injured children.
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Affiliation(s)
- Ram Venkatesh Anantha
- From the Department of Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC (Anantha); the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Zamiara); the Trauma Program, London Health Sciences Centre and Children's Hospital, London, Ont. (Merritt); the Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Merritt); and the Division of Pediatric Surgery, Schulich School of Medicine and Dentistry, London, Ont. (Merritt)
| | - Paul Zamiara
- From the Department of Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC (Anantha); the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Zamiara); the Trauma Program, London Health Sciences Centre and Children's Hospital, London, Ont. (Merritt); the Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Merritt); and the Division of Pediatric Surgery, Schulich School of Medicine and Dentistry, London, Ont. (Merritt)
| | - Neil H Merritt
- From the Department of Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC (Anantha); the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Zamiara); the Trauma Program, London Health Sciences Centre and Children's Hospital, London, Ont. (Merritt); the Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont. (Merritt); and the Division of Pediatric Surgery, Schulich School of Medicine and Dentistry, London, Ont. (Merritt)
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Kaufman EJ, Richmond TS, Wiebe DJ, Jacoby SF, Holena DN. Patient Experiences of Trauma Resuscitation. JAMA Surg 2017; 152:843-850. [PMID: 28564706 DOI: 10.1001/jamasurg.2017.1088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patient satisfaction is an increasingly common feature of quality measurement, and patient-centered care is a key aspect of high-quality clinical care. Incorporating patient preferences in an acute context, such as trauma resuscitation, presents distinct challenges; however, to our knowledge, patients' experiences of trauma resuscitation have not been explored. Objectives To describe patient experiences of trauma resuscitation and to identify opportunities to improve patient experience without compromising speed or thoroughness. Design, Setting, and Participants This qualitative, descriptive study was conducted at an urban, academic, level I trauma center. Semistructured interviews and video observations were conducted from May to December 2015. Interview participants were adult English-speaking patients who had experienced trauma resuscitation and were clinically stable with no alteration in consciousness. We recruited interview participants and conducted video observations until thematic saturation was reached, resulting in 30 interviews and 20 observations. Video observation patients did not overlap with interview participants. The purposive sample included equal numbers of violently and nonviolently injured patients. Data were analyzed for thematic content from June 2015 to April 2016. Main Outcomes and Measures The main outcomes reported are themes of patient experience. Results Of 30 interview participants, 25 were men (83.3%), and 21 were black (70.0%). Of 20 video observation patients, 16 were men (80.0%), and 17 were black (85.0%). Salient aspects of patient experience of trauma resuscitation included emotional responses, physical experience, nonclinical concerns, treatment and procedures, trauma team members' interactions, communication, and comfort. Participants drew satisfaction from trauma team members' demeanor, expertise, and efficiency and valued clear clinical communication, as well as words of reassurance. Dissatisfaction stemmed from the perceived absence of these attributes and from participants' emotional or physical discomfort. Observation data added insight into the components of care that may have contributed to participants' responses and those aspects of care that were not salient to participants. Conclusions and Relevance Although the urgency of trauma care limits explicit discussion and consideration of patient priorities, we found that patient concerns corresponded well with trauma team goals. Patients perceived trauma team members as competent, efficient, and caring. Focusing on patient communication could further improve patient-centeredness in this setting.
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Affiliation(s)
- Elinore J Kaufman
- Department of Surgery, NewYork-Presbyterian Weill Cornell Medical Center, New York
| | | | - Douglas J Wiebe
- Epidemiology in Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sara F Jacoby
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel N Holena
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Curtis K, Mitchell R, McCarthy A, Wilson K, Van C, Kennedy B, Tall G, Holland A, Foster K, Dickinson S, Stelfox HT. Development of the major trauma case review tool. Scand J Trauma Resusc Emerg Med 2017; 25:20. [PMID: 28241880 PMCID: PMC5330157 DOI: 10.1186/s13049-017-0353-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/24/2017] [Indexed: 11/25/2022] Open
Abstract
Background As many as half of all patients with major traumatic injuries do not receive the recommended care, with variance in preventable mortality reported across the globe. This variance highlights the need for a comprehensive process for monitoring and reviewing patient care, central to which is a consistent peer-review process that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure. Methods Development of the trauma case review tool was multi-faceted, beginning with a review of the trauma audit tool literature. Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement was assessed for both the pilot and finalised versions of the tool. Results The final trauma case review tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), positive aspects of care and the outcome of panel discussion. After refinement, the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters. Discussion This research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care. Conclusions This tool can be used to identify opportunities for improvement in trauma care and guide quality assurance activities. Validation is required in the adult population. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0353-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kate Curtis
- Sydney Nursing School, The University of Sydney, 88 Mallet Street, Camperdown, NSW, Australia.,St George Clinical School, Faculty of Medicine, University of New South Wales, Gray St, Kogarah, NSW, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Amy McCarthy
- Sydney Nursing School, The University of Sydney, 88 Mallet Street, Camperdown, NSW, Australia
| | - Kellie Wilson
- NSW Institute of Trauma and Injury Management, Level 4, Sage Building, 67 Albert Avenue, Chatswood, NSW, Australia
| | - Connie Van
- Sydney Nursing School, The University of Sydney, 88 Mallet Street, Camperdown, NSW, Australia.
| | - Belinda Kennedy
- Sydney Nursing School, The University of Sydney, 88 Mallet Street, Camperdown, NSW, Australia
| | - Gary Tall
- NSW Ambulance, Level 2, Sydney Ambulance Centre, Garden St Eveleigh, NSW, 2015, Australia
| | - Andrew Holland
- Sydney Medical School, The University of Sydney and The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Kim Foster
- Sydney Nursing School, The University of Sydney, 88 Mallet Street, Camperdown, NSW, Australia.,NorthWestern Mental Health & School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Level 1 North, City Campus, The Royal Melbourne Hospital Grattan Street, Parkville, VIC, 3050, Australia
| | | | - Henry T Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
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Concordance of performance metrics among U.S. trauma centers caring for injured children. J Trauma Acute Care Surg 2015; 79:138-46. [PMID: 26091327 DOI: 10.1097/ta.0000000000000678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several indicators of quality pediatric trauma care have been proposed including low in-hospital mortality, nonoperative management of blunt splenic injury, use of intracranial pressure monitors after severe traumatic brain injury, and craniotomy for children with severe subdural or epidural hematomas. It is not known if center-level performance is consistent in each of these metrics. We evaluated whether center performance in one area of quality predicted similar performance in other areas of quality. METHODS We reviewed patients 18 years or younger who were hospitalized with an injury Abbreviated Injury Scale (AIS) score of 2 or greater from 2010 to 2011 at trauma centers (n = 150) participating in the Trauma Quality Improvement Program. Random-intercept multilevel modeling was used to generate center-specific adjusted odds ratios for each quality indicator. We evaluated correlations between center-specific adjusted odds ratios of each quality indicator and mortality using Pearson correlation coefficients. Weighted κ statistics were used to test multiple pairwise agreements between indicators and the overall agreement across all four indicators. RESULTS Among 84,880 children identified for analysis, 3,603 had blunt splenic injury, 3,503 had severe traumatic brain injury, and 1,286 had an epidural or subdural hematoma. A negative correlation between center-specific odds of mortality and craniotomy was present (Pearson correlation coefficient, -0.18; p = 0.03). There were no significant correlations between other indicators. Although κ statistics showed slight agreement for the pairwise comparison of odds of mortality and craniotomy (0.17, 0.02-0.32), there was no agreement for all other pairwise comparisons or the overall comparison of all four indicators (-0.01, -0.07 to 0.06). CONCLUSION Our findings demonstrate a lack of concordance in center-level performance across the four pediatric trauma quality indicators we evaluated. These findings should be considered by pediatric trauma quality improvement initiatives to allow for comprehensive measurement of hospital quality as opposed to benchmarking using a single indicator.
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