Pediatric solid organ injury operative interventions and outcomes at Harborview Medical Center, before and after introduction of a solid organ injury pathway for pediatrics

Implementation of an evidence-based accelerated pathway: can hospital length of stay for children with blunt solid organ injury be safely decreased?

BACKGROUND

Recent work has demonstrated that an accelerated pathway for pediatric patients with blunt solid organ injuries is safe; however, this is not well-studied in a dual trauma center. We hypothesized that implementation of an accelerated pathway would decrease length of stay (LOS) and hospitalization cost without increased mortality.

METHODS

Retrospective review of patients < 15 years presenting to a dual level 1 trauma center between 2015 and 2020 with traumatic blunt liver and splenic injuries. Patients presenting pre- and post-protocol implementation were compared. The primary outcome was total hospital LOS. Secondary outcomes were number of lab draws, intensive care unit (ICU) LOS, cost of hospitalization, readmissions within 30 days, and mortality.

RESULTS

103 patients were evaluated, 67 pre-protocol and 63 post-protocol. LOS was significantly shorter post-protocol (2 days vs. 4 days, p < 0.001). The ICU LOS was unchanged. There was a decrease in direct hospitalization cost per patient from $6,246 pre-protocol to $4,294 post-protocol (p = 0.001). There was one readmission post-protocol and none pre-protocol. There were no deaths.

CONCLUSION

Implementation of an accelerated pathway for management of blunt solid organ injury at a dual trauma center was associated with decreased LOS and decreased costs with no increased morbidity or mortality.

Isolated high-grade splenic injury among pediatric patients in Japan: Nationwide descriptive study

BACKGROUND

Limited information exists regarding the clinical characteristics, management practice, and outcomes of pediatric patients with isolated splenic injury in Japan. This study aimed to evaluate the characteristics, management, and outcomes, such as survival and splenic salvage rate of pediatric patients with isolated splenic injury in Japan.

METHOD

This study was a multicenter retrospective cohort study using patient data from the Japan Trauma Data Bank (JTDB) collected between 2004 and 2018. Pediatric patients with isolated high-grade splenic injury whose abbreviated injury scale≥3 were classified according to management groups: nonoperative management (NOM); NOM with splenic artery embolization (SAE); and operative management (OM). The primary outcome was in-hospital survival and the secondary outcomes were splenic salvage rate, hospital length of stay (LOS), rate of discharging to home, and complications.

RESULTS

There were 230 pediatric patients with isolated high-grade splenic injury during the study period. Of these, 156 (68%) were managed by NOM, 62 (27%) were managed by NOM with SAE, and 12 (5.2%) were managed by OM. No pediatric patient with isolated high-grade splenic injury died between 2004 and 2018 in Japan, and the splenic salvage rate was 97%.

CONCLUSION

We identified a high survival rate and splenic salvage rate among pediatric patients with isolated high-grade splenic injury in Japan. SAE was often used, in contrast with previous reports.

LEVELS OF EVIDENCE

Level IV.

Severe liver trauma among pediatric patients in the Japan Trauma Registry

Background

Limited information exists regarding the clinical characteristics, management practices, and outcomes of pediatric patients with liver injury in Japan. The aim of this study is to evaluate the characteristics, management, and outcome of pediatric patients with liver injury in Japan.

Methods

We conducted a multicenter, retrospective cohort study using data from the Japan Trauma Data Bank between 2004 and 2018. Pediatric patients with liver injury were classified into the following management groups: nonoperative management (NOM); NOM with angioembolization (AE); operative management (OM). The primary outcome was in-hospital survival, and the secondary outcomes were dispositions, hospital length of stay (LOS), and rate of discharge to home.

Results

There were 308 pediatric patients with severe liver injury (organ injury scale grades ≥Ⅲ) during the study period; 135 patients had isolated liver injury and 173 patients had non-isolated liver injury. The rates of NOM, NOM with AE, and OM among all patients were 65%, 23%, and 12%, respectively. AE was highly used both in patients with isolated liver injury (27%) and non-isolated liver injury (22%). In-hospital survival of patients with isolated liver injury and those with non-isolated liver injury were 99% and 88%, respectively. Regarding secondary outcomes among patients with isolated liver injury, 82% were admitted to the intensive care unit. LOS was 11 (8–14) days and 82% were discharged to home.

Conclusions

Our retrospective observational study showed that management of pediatric patients with severe liver injury in Japan was characterized by high utilization of AE. The in-hospital survival rate in Japan was comparable with that of other developed countries.

Risk factors associated with splenectomy following a blunt splenic injury in pediatric patients

PURPOSE

The purpose of the study was to identify the factors associated with splenectomy in pediatric trauma patients.

METHOD

Pediatric Trauma quality improvement program (P-TQIP) database calendar year 2014-2016 was accessed for the study. All patients, age ≤ 18 years old, who sustained splenic injury due to blunt mechanism, were included in the study. The primary outcome of the study was to identify the risk factors associated with splenectomy. Univariate followed by multivariate analyses were performed. A p value of < 0.05 was considered an indication of statistical significance.

RESULTS

Of 1297 trauma victims, who fulfilled the inclusion criteria, 57 (4.4%) patients underwent total splenectomy. In Univariate analysis, there were significant differences found, in many variables, between the groups who underwent splenectomy versus those who did not have splenectomy. A multivariate logistic regression analysis showed use of blood transfusion within 4 h and severity of splenic injury were the two variables associated with splenectomy. The area under the curve (AUC) value was 0.892 and the 95% confidence intervals were [0.859, 0.923].

CONCLUSION

Blood transfusion within 4 h of patient's arrival to the hospital and high-grade splenic injury were main factors for splenectomy in the pediatric population.

Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review

PURPOSE

The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.

METHODS

A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.

RESULTS

LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.

CONCLUSION

Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.

TYPE OF STUDY

Systematic Review.

LEVELS OF EVIDENCE

Levels 2-4.

Assessing outpatient follow-up care compliance, complications, and sequelae in children hospitalized for isolated traumatic abdominal injuries

BACKGROUND

Currently there is limited knowledge on compliance with follow-up care in pediatric patients after abdominal trauma. The Indiana Network for Patient Care (INPC) is a large regional health information exchange with both structured clinical data (e.g., diagnosis codes) and unstructured data (e.g., provider notes). The objective of this study is to determine if regional health information exchanges can be used to evaluate whether patients receive all follow-up care recommended by providers.

METHODS

We identified 61 patients treated at a Pediatric Level I Trauma Center who were admitted for isolated abdominal injuries. We analyzed medical records for two years following initial hospital discharge for injury using the INPC. The encounters were classified by the type of encounter: outpatient, emergency department, unplanned readmission, surgery, imaging studies, and inpatient admission; then further categorized into injury- and non-injury-related care, based on provider notes. We determined compliance with follow-up care instructions given at discharge and subsequent outpatient visits, as well as the prevalence of complications and sequelae.

RESULTS

After reviewing patient records, we found that 78.7% of patients received all recommended follow-up care, 6.6% received partial follow-up care, and 11.5% did not receive follow-up care. We found that 4.9% of patients developed complications after abdominal trauma and 9.8% developed sequelae in the two years following their initial hospitalization.

CONCLUSIONS

Our findings suggest that health information exchanges such as the INPC are useful in evaluation of follow-up care compliance and prevalence of complications/sequelae after abdominal trauma in pediatric patients.

LEVEL OF EVIDENCE

Level IV.

Review of pediatric abdominal trauma: operative and non-operative treatment in combined adult and pediatric trauma center

Aim

More than 90% of pediatric solid organ abdominal injuries are treated non‐operatively. It remains difficult to decide who should graduate to surgical management, more so if adult physicians must make these decisions on pediatric patients. The purpose of this study was to examine outcomes of all pediatric abdominal trauma cases in a single center, focusing on the decision‐making algorithm for operative or non‐operative treatment by pediatric and adult physicians.

Methods

We undertook a retrospective review of a pediatric trauma database from April 2006 to March 2016. Groups were divided into operative and non‐operative, single or multi‐organ injury, and adult or pediatric physician. Operative treatments included laparotomy or interventional radiology procedures. Primary outcome was survival within 30 days.

Results

There were 53 abdominal trauma cases; among them, 48 (90.6%) survived and 5 (9.4%) died within 30 days. The probability of survival for mortalities was less than 11%. Forty‐two cases were treated non‐operatively and 11 operatively. Injury Severity Score was higher in operative group (17 [9, 41]/9 [4, 16.3]). Adult physicians saw 33 patients including seven operative, whereas pediatric physicians saw 20 including four operative cases. There was no statistical difference for the management decision between adult and pediatric physicians.

Conclusion

Our decisions for intervention were within acceptable rates. Adult physicians did not tend to operate more, but there were cases that did not fit the criteria of the algorithm. Further investigation is needed to look at which factors should be focused on to determine whether or not operative treatments are indicated.

Transfer and nontransfer patients in isolated low-grade blunt pediatric solid organ injury: Implications for regionalized trauma systems

BACKGROUND

Regionalization of trauma care is a national priority and hospitalization for blunt abdominal trauma, which may include transfer, is common among children. The objective of this study was to determine whether there were differences in mortality, treatment, or length of stay between patients treated at or transferred to a higher level trauma center and those not transferred and admitted to a lower level trauma center.

METHODS

Cohort from Washington state trauma registry from 2000 to 2014 of patients 16 years or younger with isolated Grade I-III spleen, liver, or kidney injury.

RESULTS

Among 54,034 patients 16 years or younger, the trauma registry captured 1177 (2.2%) patients with isolated low grade solid organ injuries; 226 (19.2%) presented to a higher level trauma center, 600 (51.0%) presented to a lower level trauma center and stayed there for care, and 351 (29.8%) were transferred to a higher level trauma center. Forty (3.4%) patients underwent an abdominal operation. Among the 950 patients evaluated initially at a lower level trauma center, the risk of surgery did not differ significantly between those who were not transferred compared to those who were (relative risk, 2.19; 95% confidence interval, 0.80-6.01). The risk of total splenectomy was no different for patients who stayed at a lower level trauma center compared with those who were transferred to a higher level trauma center (RR, 0.84; 95% CI, 0.33-2.16). Nontransferred patients had a 0.63 (95% confidence interval, 0.45-0.88) times lower risk of staying in the hospital for an additional day compared with patients who were transferred to a higher level trauma center. One patient died.

CONCLUSION

Few pediatric patients with isolated low grade blunt solid organ injury require intervention and thus may not need to be transferred; trauma systems should revise their transfer policies. Prevention of unnecessary transfers is an opportunity for cost savings in pediatric trauma.

LEVEL OF EVIDENCE

Therapeutic/Care management, level III.

Long-term sustainability of Washington State's quality improvement initiative for the management of pediatric spleen injuries

BACKGROUND

Initial results of Washington State's quality improvement initiative addressing the management of blunt traumatic pediatric spleen injuries were published in 2008. In this update, we evaluated whether these effects were sustained over time.

METHODS

Data from the Washington Trauma Registry for years 1999-2001 (pre-intervention), 2003-2005 (post-intervention), and 2012-2014 (follow-up) were used in a retrospective cohort study. Children between ages 0 to 14 years who were hospitalized with a traumatic blunt spleen injury were included. Multivariable logistic regression was used to account for patient, injury, and hospital characteristics.

RESULTS

Overall, splenectomies continued to be less common with 8.3% of pediatric patients receiving splenectomies in the follow-up period compared with 14.3% and 7.2% in the preintervention and post-intervention periods (p = 0.034). After adjustment, splenectomies remained less likely to be performed in both post-intervention (OR = 0.37; 95% CI = 0.16-0.90) and follow-up periods (OR = 0.29; 95% CI = 0.12-0.70) compared to pre-intervention. Children were much more likely to be cared for at pediatric trauma hospitals in the follow-up period (OR = 5.13; 95% CI = 2.79-9.43) after adjustment.

CONCLUSIONS

Evaluation of this statewide quality improvement initiative showed that positive changes in management practices persist. This evidence suggests that statewide quality improvement initiatives can be sustainable with minimal ongoing effort.

LEVEL OF EVIDENCE

Level III.

Operative Versus Nonoperative Management of Blunt Pancreatic Trauma in Children: A Systematic Review

The aim of this study was to compare operative versus nonoperative management of blunt pancreatic trauma in children. A systematic literature search was performed. Studies including children with blunt pancreatic injuries classified according to the American Association for the Surgery of Trauma classification were included. The primary outcome was pseudocyst formation. After screening 526 studies, 23 studies with 928 patients were included. Sufficient data were available for 674 patients (73%). Of 309 patients with grade I or II injuries, 258 (83%) were initially managed nonoperatively with a 96% success rate. Of 365 patients with grade III, IV, or V injuries, nonoperative management was initially chosen for 167 patients (46%) with an 89% success rate. Pseudocysts occurred in 18% of patients managed nonoperatively versus 4% of patients managed operatively (P < 0.01), of whom 65% were treated nonoperatively. Hospitalization was 20.5 days after nonoperative versus 15.1 days after operative management (nonparametric t test, P = 0.41). Blunt pancreatic trauma in children can be managed nonoperatively in the majority of patients with grade I or II injuries and in about half of the patients with grade III to V injuries. Although pseudocysts are more common after nonoperative management, two thirds can be managed nonoperatively.

Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Delphi process with multiple iterative rounds using a nominal group technique.

OBJECTIVE

The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols.

METHODS

An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

RESULTS

Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge.

CONCLUSION

We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

LEVEL OF EVIDENCE

5.

Nonoperative Management of Blunt Solid Organ Injury in Pediatric Surgery

In the last decade, higher rates of nonoperative management of liver, spleen, and kidney injuries have been achieved. An algorithmic approach may improve success on a national level. Factors for success include management strategy based on physiologic status of the child, early attempt at resuscitation using blood products, and appropriate use of adjuncts. Shorter hospitalizations are appropriate for children who have not bled significantly, and discharge instructions facilitate the safety of early discharge. Although routine imaging is not required for liver or spleen injury, symptoms should prompt reevaluation. Reimaging of renal injuries remains in common use.

Pediatric blunt abdominal trauma: current management

PURPOSE OF REVIEW

Nonoperative management of pediatric blunt abdominal injury has changed significantly in the last few years.

RECENT FINDINGS

Improved resource utilization in the diagnosis of pediatric abdominal injury has been described. Hemodynamic status, rather than grade of injury, now guides care. Stable patients spend less time in the hospital, return to school upon discharge, and are allowed lower hemoglobin levels prior to transfusion. ICUs are reserved for those with recent or ongoing bleeding, previously unstable patients, or children with concomitant injuries necessitating ICU. Risk factors for failure and evidence for adjuncts to nonoperative management are emerging. Operative management of certain pancreatic injuries may have more favorable outcomes than nonoperative management.

SUMMARY

Sufficient evidence has become available to radically change the management of pediatric abdominal injury, which is being incorporated into new evidence-based management algorithms.

Management of Abdominal Solid Organ Injury After Blunt Trauma

Injury to the solid abdominal organs-liver, spleen, kidney, and pancreas-is one of the most common injury patterns in pediatric blunt trauma. Pediatric trauma centers are becoming increasingly successful in managing these injuries without operative intervention. Well-validated guidelines have been established for liver and spleen injury management, and operative intervention is reserved for patients who show evidence of active bleeding after resuscitation. No such guidelines yet exist for the management of traumatic injury of the kidney or pancreas. Exploratory laparotomy remains the treatment of choice in patients suffering hemodynamic collapse, but interventional radiologic or endoscopic procedures are increasingly used to manage all but the most devastating solid organ injuries. [Pediatr Ann. 2016;45(7):e241-e246.].

Variation in intensive care unit utilization and mortality after blunt splenic injury

BACKGROUND

Although trauma patients are frequently cared for in the intensive care unit (ICU), admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients treated for blunt splenic injuries from 2011-2014 at 30 level I and II Pennsylvania trauma centers. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman's rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement between high and low-ICU-utilization centers.

RESULTS

Of 2587 patients with blunt splenic injuries, 63.9% (1654) were admitted to the ICU. Median injury severity score was 17 overall, 13 for non-ICU patients and 17 for ICU patients (P < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9%-87.3%. Risk-adjusted mortality rates ranged from 1.2%-9.6%. There was no correlation between observed-to-expected ratios for ICU utilization and mortality (Spearman's rho = -0.2595, P = 0.2103). Proportionately fewer ICU patients received critical care procedures at high-utilization centers than at low-utilization centers.

CONCLUSIONS

Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality.