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Pediatric splenic injury: pathway to play?
R R Gandhi1, M S Keller, C W Schwab
1The Children's Hospital of Philadelphia, PA 19104-4399, USA.
Insights
A new clinical pathway safely reduced hospital stays for pediatric blunt splenic injury (BSI) patients to four days. This standardized care allows for a shorter hospital stay and a defined period of reduced activity post-discharge.
Area of Science:
- Pediatric Trauma Surgery
- Emergency Medicine
- Clinical Pathway Development
Background:
- Nonoperative management of blunt splenic injury (BSI) is standard for pediatric patients.
- Current practice lacks consensus on optimal hospital stay duration and post-discharge activity restrictions.
- Standardization of care may improve outcomes and resource utilization.
Purpose of the Study:
- To evaluate the efficacy of a standardized clinical pathway for managing pediatric blunt splenic injury.
- To assess the impact of the pathway on hospital length of stay and patient outcomes.
- To determine appropriate post-discharge activity guidelines.
Main Methods:
- A clinical pathway was implemented for pediatric patients with BSI.
- Data from patients managed under the pathway were compared to a historical control group.
- Key outcome measures included length of stay, intensive care unit (ICU) stay, transfusions, and follow-up for complications.
Main Results:
- The pathway group showed a significant reduction in general care unit stay (2.9 vs. 5.3 days) and total hospitalization (3.9 vs. 6.7 days).
- No significant differences were observed in age, injury severity, or transfusion requirements between groups.
- Estimated hospital charges were reduced in the pathway group.
- Follow-up revealed no missed injuries or complications at 3 weeks and 3 months.
Conclusions:
- A 4-day hospital stay is safe for hemodynamically stable children with isolated blunt splenic injuries.
- A 3-week period of quiet activities at home followed by 3 months of light activity is recommended post-discharge.
- This standardized pathway effectively reduces hospitalization duration and associated costs without compromising patient safety.
Background:
Nonoperative management of blunt splenic injury (BSI) remains a "gold standard" in pediatric trauma care. Controversy exists regarding the minimal hospital stay necessary for the care of these patients and the appropriate duration of reduced activity required after discharge.
Methods:
A clinical pathway was developed in an attempt to standardize the hospital and outpatient management of children with BSI cared for at the Children's Hospital of Philadelphia. From July 1, 1996 to September 30, 1997, all children with BSI were treated using this pathway (pathway group). To better evaluate outcome, data were compared with an historical control of consecutive children treated at our institution during the previous 2 years (control group).
Results:
Twenty-eight children in the control group and 21 children in the pathway group comprise the study population. Average age, injury mechanism, grade of splenic injury, injury severity score, length of intensive care unit stay, and number of transfusions were not significantly different between the two groups (P<.05). As expected, there was a significant decrease in the length of stay on the general care units (5.3+/-1.2 v 2.9+/-0.9 days, control v pathway, P<.05), which, in turn, resulted in a significant decrease in the total length of hospitalization (6.7+/-1.4 v 3.9+/-1.2 days, P<.05) and estimated hospital charges. During follow-up, no complications or missed injuries were identified at a standard 3-week and the 3-month office visit.
Conclusion:
Hemodynamically stable children with isolated blunt splenic injuries may be treated safely with a 4-day hospital stay followed by 3 weeks of quiet activities at home and 3 months of light activity before return to full, unrestricted activity.