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Published on: March 26, 2019
First 3-Day Severe Pediatric Traumatic Brain Injury Guideline Adherence Rates in South American Intensive Care Units
Macarena M Racciatti1, Julia Velonjara2,3, Charles Mock3,4
1Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA.
Insights
Early adherence to Brain Trauma Foundation (BTF) guidelines for severe pediatric traumatic brain injury (TBI) in the intensive care unit (ICU) was high (81.3%). However, nonadherence to specific recommendations highlights areas for improved pediatric TBI care.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Evidence-based guideline implementation
Background:
- Severe traumatic brain injury (TBI) is a significant cause of mortality in children.
- Brain Trauma Foundation (BTF) guidelines provide evidence-based recommendations for managing severe TBI in the intensive care unit (ICU).
- Understanding early adherence to these guidelines is crucial for optimizing patient outcomes.
Purpose of the Study:
- To evaluate early adherence to BTF guidelines in pediatric severe TBI patients within the first 72 hours of ICU admission.
- To identify patient and clinical care characteristics associated with guideline adherence.
- To pinpoint specific recommendations and categories with lower adherence for targeted improvement.
Main Methods:
- Prospective data collection from Argentina, Paraguay, and Chile (September 2019 - July 2020).
- Inclusion of pediatric patients (≤18 years) with severe TBI based on CT evidence and Glasgow Coma Scale (GCS) scores.
- Analysis of cumulative ICU guideline adherence (15 recommendations, 3 categories) over the first 3 days using multivariate logistic regression.
Main Results:
- Overall 3-day guideline adherence was 81.3%.
- Adherence to the 'threshold' category was higher than 'monitoring' or 'treatment' categories (p < 0.001).
- Lower adherence to the 'threshold' category was observed in younger children (1-4 years). Nonadherence to 1-3 recommendations was common (81% of patients).
Conclusions:
- Early adherence to BTF guidelines in severe pediatric TBI is generally high but shows variability.
- Specific patient characteristics (age) and guideline categories impact adherence levels.
- Targeting nonadherent recommendations is essential for enhancing pediatric TBI management strategies.
Abstract:
Severe traumatic brain injury (TBI) is a leading cause of pediatric mortality. Evidence-based Brain Trauma Foundation (BTF) guidelines promote best practices for severe TBI in the intensive care unit (ICU). We examined guideline, patient, and clinical care characteristics associated with early ICU guideline adherence. We used prospectively collected data from September 2019 to July 2020 from Argentina, Paraguay, and Chile. Patients ≤18 years with computed tomography evidence of TBI and Glasgow Coma Scale (GCS) score ≤ 8 or GCS motor score ≤ 5 at admission or at deterioration after admission were included. Cumulative ICU guideline adherence achieved during the first 3 days after TBI was analyzed by guideline recommendation (n = 15), recommendation category (n = 3), and patient and clinical care characteristics. Intergroup differences were compared using multivariate logistic regression with site-cluster adjustment. Among 116 patients, children were 1-4 years (38; 32.7%), male (74; 63.8%), and had extracranial injuries (77; 66.4%). Overall cumulative 3-day ICU guideline adherence rate was 81.3% (standard deviation: 13.0). Among the three guideline categories, adherence to the threshold category was higher than monitoring or treatment categories (p < 0.001). Adherence to the threshold category was lower in patients 1-4 years than 10-14 years (p = 0.02). Adherence to the monitoring category was lowest in minor/moderate Abbreviated Injury Scale and Injury Severity Score groups (p = 0.012 and 0.03, respectively). Ninety-five (81%) patients had nonadherence (0% adherence) to 1-3 recommendations across applicable BTF guideline recommendations. Overall, daily adherence rate was highest on ICU day 3 (p < 0.01). Early overall ICU guideline adherence rate was high but varied by recommendation, recommendation category, and patient characteristics. Nonadherence to a few recommendations was common, highlighting key targets for improvement and strategies to optimize guideline adherence in severe pediatric TBI.
