Report Cards as a Sustainability Tool for Guideline Adherence in Pediatric Traumatic Brain Injury

Severe traumatic brain injury (TBI) is a major cause of pediatric morbidity and mortality; yet, adherence to national guidelines remains variable.

We conducted a single-center quality improvement initiative in our 48-bed pediatric intensive care unit at a level 1 trauma center. Interventions included adding a TBI order set to the electronic health record and a structured "report card" audit-and-feedback system to monitor compliance with specified metrics in the first 72 hours of admission. The primary outcome measure was the number of severe TBI encounters with 50% or greater adherence to institutional guidelines. Process measures included the use of the order set and timeliness of report card dissemination. Key clinical metrics were also tracked. Analyses involved run charts, descriptive statistics, and nonparametric tests.

Of 72 children with severe TBI admitted, 60 were eligible for full guideline adherence assessment. Order set adoption increased from 13% to 92% following the implementation of the report cards and remained above 89% annually thereafter. Guideline adherence increased from 21% to 38.9% postreport cards and stabilized between 42.9% and 59.8% thereafter. Adherence was highest for temperature management, seizure prophylaxis, and cerebral perfusion pressure, whereas sodium and carbon dioxide targets remained challenging. Mortality did not differ by adherence. Higher adherence correlated with longer pediatric intensive care unit, hospital, and rehabilitation stays.

Decision support tools and audit and feedback improved adherence to severe pediatric TBI guidelines. Future multicenter studies should assess how adherence affects functional recovery.