Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital
Joshua B Gaither1, Daniel W Spaite1, Bentley J Bobrow2
1Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.
Insights
Implementing out-of-hospital pediatric traumatic brain injury guidelines improved survival for severe pediatric traumatic brain injury cases. Overall survival did not significantly change, but severity-based analysis shows guideline benefits.
Area of Science:
- Emergency Medicine
- Pediatric Traumatology
- Neurotrauma
Background:
- Pediatric traumatic brain injury (TBI) requires specialized prehospital care.
- Existing guidelines aim to improve outcomes for pediatric TBI patients.
- Evaluating guideline implementation is crucial for optimizing prehospital care.
Purpose of the Study:
- To assess the impact of out-of-hospital pediatric traumatic brain injury guidelines on patient outcomes.
- To determine if guideline implementation affects survival rates in children with major TBI.
- To analyze outcomes across different severity subgroups of pediatric TBI.
Main Methods:
- Secondary analysis of the Excellence in Prehospital Injury Care study.
- Included children (<18 years) with major TBI transported to Level I trauma centers.
- Compared preimplementation (n=2,041) and postimplementation (n=760) cohorts using logistic regression.
Main Results:
- Overall survival to discharge and admission did not significantly improve postimplementation.
- Survival to discharge significantly improved in the severe TBI subgroup (OR=8.42).
- No significant survival improvement was noted in moderate or critical TBI subgroups.
Conclusions:
- Out-of-hospital pediatric TBI guidelines did not improve overall survival across all severities.
- Guideline implementation showed a significant benefit for severe pediatric TBI cases.
- Findings suggest a potential severity-based benefit, supporting widespread guideline adoption.
Study Objective:
We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury.
Methods:
The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders.
Results:
There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+).
Conclusion:
Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
