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Results of the Pediatric Guideline Adherence and Outcomes (PEGASUS) Program Versus Usual Care Pragmatic Randomized
Monica S Vavilala1,2,3, Silvia Lujan4, Julia Velonjara1,2
1Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA.
Insights
A facilitated program did not improve adherence to severe traumatic brain injury (TBI) guidelines for all pediatric patients. However, the intervention successfully increased TBI guideline adherence in children with isolated severe TBI.
Area of Science:
- Pediatric critical care medicine
- Neuroscience
- Evidence-based practice implementation
Background:
- High-quality evidence-based practices for severe traumatic brain injury (TBI) in pediatric intensive care units (PICUs) are lacking.
- Improving adherence to TBI guidelines is crucial for optimal patient outcomes.
Purpose of the Study:
- To evaluate the effectiveness of a facilitated, multilevel program (PEGASUS) in improving adherence to TBI guidelines in children with severe TBI.
- To assess the impact of the intervention on adherence rates, stratified by the presence of extracranial injury.
Main Methods:
- A pragmatic, multicenter, cluster randomized controlled trial involving 16 South American hospitals.
- The study included pediatric patients (under 18 years) with severe TBI admitted to the ICU.
- Intervention sites received the PEGASUS program (checklists, case reviews), while control sites provided usual care.
Main Results:
- No significant overall difference in the first 3-day cumulative TBI guideline adherence rate between the intervention and control groups (0.1% difference).
- Intervention sites demonstrated significantly higher TBI guideline adherence rates in patients with isolated severe TBI compared to control sites (7.9% increase; p = 0.01).
- Control patients had a lower incidence of extracranial injury than intervention patients (70.7% vs. 82.9%; p = 0.005).
Conclusions:
- The PEGASUS intervention was not superior to usual care in improving overall TBI guideline adherence for all pediatric severe TBI patients.
- The facilitated program effectively enhanced TBI guideline adherence specifically in children with isolated severe TBI.
- Findings suggest targeted implementation strategies may be necessary for broader guideline adherence improvements in pediatric TBI care.
Objectives:
High-quality approaches to increase evidence-based severe traumatic brain injury (TBI) practice is lacking. We examined whether a facilitated, multilevel program improves TBI guideline adherence in children with severe TBI, including extracranial injury patients. The primary outcome was first 3-day cumulative ICU TBI guideline adherence rate for all and stratified by extracranial injury.
Design:
This was an open-label, pragmatic, multicenter, phase 3, superiority, parallel cluster randomized controlled trial. Unadjusted and adjusted percent differences were based on intention-to-treat.
Setting:
Sixteen South American hospitals (14 Argentina, one Chile, and one Paraguay) regularly treating pediatric patients with severe TBI participated.
Patients:
Patient inclusion criteria were younger than 18 years, severe TBI (Glasgow Coma Scale [GCS] score ≤ 8 or, if intubated, motor GCS ≤ 5), and ICU admission.
Interventions:
Sites provided usual care ( n = 8) or the Pediatric Guideline Adherence and Outcomes (PEGASUS) intervention ( n = 8) to participating patients. The PEGASUS intervention included checklists, case reviews, and other components designed to improve adherence to Brain Trauma Foundation pediatric guidelines.
Measurements And Main Results:
Three hundred eighty-nine patients were enrolled (208 control and 181 intervention). Control patients had less extracranial injury than intervention patients (70.7% vs. 82.9%; p = 0.005). TBI guideline adherence rates were 83.7% for control and 84.4% for intervention arms. There was no overall difference in adjusted first 3-day cumulative guideline adherence rate between arms (0.1% [-3.3% to 3.5%]). Intervention sites achieved higher guideline adherence rates than control sites in patients with isolated severe TBI (7.9% [1.9-13.8%]; p = 0.01).
Conclusions:
Implementing an evidence-based TBI program was not superior to usual care in increasing first 3-day cumulative ICU TBI guideline adherence rates in all children with severe TBI. However, implementation increased adherence rates in children with isolated severe TBI.
