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Association between trauma center type and mortality for injured children with severe traumatic brain injury
Armaan K Malhotra1, Bhavin Patel, Christopher J Hoeft
1From the Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada (A.K.M., H.S., C.W.S., R.J., J.R.W., C.D.W.); Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada (A.K.M., H.S., C.W.S., R.J., J.R.W., C.D.W.); Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (A.K.M., H.S., R.J., A.V.K., J.R.W., C.D.W., A.B.N.); American College of Surgeons, Chicago, Illinois, United States (B.P., C.J.H., A.B.N.); Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada (A.V.K.); Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (A.B.N.).
Insights
Children with severe traumatic brain injuries had higher mortality rates at adult trauma centers compared to pediatric centers. This highlights a need for standardized care to improve outcomes for pediatric TBI patients.
Area of Science:
- Trauma Surgery
- Pediatric Critical Care
- Neurotrauma
Background:
- Conflicting evidence exists on trauma center type and pediatric traumatic brain injury (TBI) mortality.
- Understanding these differences can drive quality improvement initiatives for standardized care.
Purpose of the Study:
- To investigate the association between trauma center type (adult, pediatric, mixed) and in-hospital mortality in children with severe TBI.
- To identify factors influencing mortality in pediatric TBI patients.
Main Methods:
- Analysis of 2017-2020 Trauma Quality Improvement Program data for children with severe TBI.
- Utilized random intercept multilevel logistic regression to assess trauma center type and mortality.
- Performed secondary analyses on trauma center volume, age, and TBI heterogeneity.
Main Results:
- 10,105 pediatric patients across 512 trauma centers were analyzed.
- Higher crude mortality observed in adult (36.2%) and mixed (28.9%) centers compared to pediatric (25.2%) centers.
- Adjusted analysis revealed increased odds of mortality (OR 1.67) at adult trauma centers versus pediatric centers.
Conclusions:
- Mortality for pediatric TBI patients is higher in adult trauma centers compared to mixed and pediatric centers.
- Findings suggest a need for quality improvement initiatives to standardize care for pediatric TBI.
- Potential for unmeasured confounding warrants further investigation.
Background:
There is conflicting evidence regarding the relationship between trauma center type and mortality for children with traumatic brain injuries. Identification of mortality differences following brain injury across differing trauma center types may result in actionable quality improvement initiatives to standardize care for these children.
Methods:
We used Trauma Quality Improvement Program data from 2017 to 2020 to identify children with severe traumatic brain injury (TBI) managed at levels I and II state or American College of Surgeon-verified trauma centers. We used a random intercept multilevel logistic regression model to assess the relationship between exposure (trauma center type either adult, pediatric, or mixed) and outcome (in-hospital mortality). Several secondary analyses were performed to assess the influence of trauma center volume, age strata, and TBI heterogeneity.
Results:
There were 10,105 patients identified across 512 trauma centers. Crude mortality was 25.2%, 36.2%, and 28.9% for pediatric, adult, and mixed trauma centers, respectively. After adjustment for confounders, odds of mortality were higher for children managed at adult trauma centers (odds ratio, 1.67; 95% confidence interval, 1.30-2.13) compared with pediatric trauma centers. There were several patient demographic and injury factors associated with greater odds of death; these included male sex, self-pay insurance status, interfacility transfer, non-fall related inury, age-adjusted hypotension, lack of pupil reactivity and midline shift >5 mm. Adjustment for trauma volume and subgroup analysis using a homogenous TBI subgroup did not change the demonstrated associations.
Conclusion:
Our results suggest that mortality was higher at adult trauma centers compared with mixed and pediatric trauma centers for children with traumatic brain injuries. Importantly, there exists the potential for unmeasured confounding. We aim for these findings to direct continuing quality improvement initiatives to improve outcomes for brain injured children.
Level Of Evidence:
Prognostic and Epidemiological; Level III.
