process of care metrics for critically injured pediatric trauma - PowerPoint PPT Presentation

Evaluating variation in process of care metrics for critically injured pediatric trauma patients Katherine T. Flynn- O’Brien, MD, MPH Mary E. Fallat, MD Tom B. Rice, MD Christine M. Gall, RN, MS, DrPH Frederick P. Rivara, MD, MPH Pediatric Trauma Society Scottsdale, AZ | November 6-7, 2015

Pediatric Trauma Assessment and Management Database A Trauma Registry-VPS partnership

Disclosures  I have no disclosures.

Pediatric Trauma  Burden of disease is profound  Healthcare quality Structure Process Outcome

Pediatric Trauma  Burden of disease is profound  Limited ability to study processes of care in pediatric trauma

Pediatric Trauma  Burden of disease is profound  Limited ability to study processes of care in pediatric trauma PHIS, NSQIP  Current available HCUP data systems VPS, UDSMR NTDB/TQIP

Pediatric Trauma  Burden of disease is profound  Limited ability to study processes of care in pediatric trauma PHIS, NSQIP  Current available HCUP data systems VPS, UDSMR NTDB/TQIP  Fiscal constraints

Objectives Create a comprehensive pediatric trauma database to assess quality of care in critically injured children utilizing minimal new resources.

Objectives Create a comprehensive pediatric trauma database to assess quality of care in critically injured children utilizing minimal new resources. Evaluate key processes of care during different phases of the care continuum, and quantify site-specific variation

Methods  Merged 3 databases  Trauma Registry (TR)  Virtual Pediatric Systems (VPS) data  PTAM-specific RedCap  5 Level I/II PTC  All children discharged from PICU CY 2013

Care Continuum Floor ED arrival • Disposition • Vitals • Vitals • GCS • Vitals • Labs • Nutrition • POPC • GCS • Constipation • Transfer • Vent data • PRISM/PIM • Labs* • VTE ppx Pre- ICU stay Discharge hospital DVT ppx FAST C-collar

Methods  Univariate analyses  Chi2 test for independence  Non-parametric equality of medians  Multivariable regression  Age, mechanism, severity of injury  Quantify process of care variation

Patient population  N = 692  67% male  Mean age 7.2y (6.0)  Race/Ethnicity  51% White  21% African American  7% Hispanic  Injury Characteristics  77% Blunt  35% ISS >15

Pre-hospital: C-collar use Site Adj. n Chi2 variation Wald* All patients 648 50-83% < 0.001 < 0.001 Head injury 443 59-84% < 0.001 < 0.001 Head injury & 184 69-81% 0.761 0.163 Field response Head injury & Transferred 259 50-89% < 0.001 0.003 *Adjusted for age, mechanism of injury, severity of injury (ISS)

Pre-hospital: C-collar use Patients with head injury & FIELD response Site Use (%) aOR (95% CI)* p-value A 78.6 3.4 (1.0-11.4) 0.048 B 75.6 2.0 (0.6-7.1) 0.281 C 69.2 Ref Ref D 76.9 2.7 (0.7-10.2) 0.146 E 81.3 4.5 (1.3-14.9) 0.015 p = 0.761 p = 0.163 aOR, adjusted odds ratio; CI, confidence interval *Adjusted for age, mechanism of injury, severity of injury (ISS)

Pre-hospital: C-collar use Patients with head injury & transferred Site Use (%) aOR (95% CI)* p-value A 52.6 1.3 (0.5-3.2) 0.626 B 84.5 5.0 (01.8-13.8) 0.002 C 50.0 Ref Ref D 89.2 8.3 (2.4-28.9) 0.001 E 76.9 2.9 (1.2-7.1) 0.020 p < 0.001 p = 0.003 aOR, adjusted odds ratio; CI, confidence interval *Adjusted for age, mechanism of injury, severity of injury (ISS)

Pre-hospital: C-collar use Site Adj. n Chi2 variation Wald* All patients 648 50-83% < 0.001 < 0.001 Head injury 443 59-84% < 0.001 < 0.001 Head injury & 184 69-81% 0.761 0.163 Field response Head injury & Transferred 259 50-89% < 0.001 0.003  Only 4 patients (1.5%) had a collar removed prior to transfer  76 patients (29%) never had a collar placed  Site variation 11-50% *Adjusted for age, mechanism of injury, severity of injury (ISS)

Pre-hospital: C-collar use When does it get removed? Site Median (IQR) A 32 (23-51) B 26 (13-32) C 29 (15-90) D 27 (17-48) E 19 (8-39) P = .009 aOR, adjusted odds ratio; CI, confidence interval *Adjusted for age, mechanism of injury, severity of injury (ISS)

ED phase of care: FAST exam 1% 0% 0% No FAST exam completed 2% 8% Completed, positive N = 69 Completed, negative Completed, inconclusive Completed, result UK/NR 89% UK/NR if FAST completed

ED phase of care: FAST exam  69 FAST exams recorded (10%) Site Use (%) A 36.8 B 0 0-37% C 2.4 D 0 E 1.8 p < 0.001

ED phase of care: FAST exam  69 FAST exams recorded (10%)  91% completed at a single institution  1/3 children receive FAST  92% for blunt trauma  93% with ISS<25  Of the 6 FAST exams at other institutions  4 blunt with ISS>25  2 penetrating with ISS<25

Hospital course: DVT ppx  Pharmacologic prophylaxis, <48hrs of arrival  4% Yes, 26% not applicable, 70% None Site Use (%) A 3.5 B 3.7 C 11.1 0-11% D 0 E 0 p < 0.001

Hospital course: DVT ppx  Pharmacologic prophylaxis, <48hrs of arrival  4% Yes, 26% not applicable, 70% None Site Use (%) aOR(95%CI) A 3.5 0.5 (0.2-1.7) B 3.7 0.5 (0.1-1.9) C 11.1 Ref D 0 -- E 0 -- aOR, adjusted odds ratio; CI, confidence interval *Adjusted for age, mechanism of injury, severity of injury (ISS)

Hospital course: DVT ppx  Mechanical prophylaxis, <48hrs of arrival  12% Yes, 29% not applicable, 59% None Site Use (%) A 18.7 B 0 0-19% C 18.4 D 0 E 12.9 p < 0.001

Hospital course: DVT ppx  Mechanical prophylaxis, <48hrs of arrival  12% Yes, 29% not applicable, 59% None Site Use (%) aOR(95%CI) A 18.7 2.5 (1.2-5.5) B 0 -- C 18.4 Ref D 0 -- E 12.9 1.1 (0.5-2.5) aOR, adjusted odds ratio; CI, confidence interval *Adjusted for age, mechanism of injury, severity of injury (ISS)

Take Home  Site-specific variation is significant in all domains of healthcare provision for the injured child  C-collar placement  Transfers: aOR 3-8  Field response: aOR 3-5  FAST exam utilization  DVT prophylaxis  Pharmacologic: 0-11%  Mechanical: 0-19%

Limitations  Small sample size  Process-specific adjustments  Limited generalizability Structure Process Outcome

Conclusions Combining two existing datasets provides detailed information that allows for evaluation of of process of care metrics for critically injured children across the care continuum With minimal additional infrastructure With no additional FTE

Advice  Discovery consists not in seeking new landscapes but in seeking with new eyes. – Marcel Proust

Thank you Special thanks to all trauma registrars and VPS coordinators at participating sites

Thank you Questions? flynnobr@uw.edu

Injury characteristics  Mechanism of injury  Maximum Head AIS  32% Falls  15% AIS 4/5  25% MVC  43% AIS 3  4% Penetrating  Other Maximum AIS  Intent  67% abd AIS 3-5  57% thoracic AIS 3-5  84% unintentional  Injury Severity Score  14% assaults  Place  13% ISS>25  22% ISS 16-25  31% residential TR TR

Pre-hospital & ED  Physiologic data  Physiologic data  11% tachycardia*  29% tachycardia*  3% hypotension*  5% hypotension*  9% GCS <9  17% GCS <9  EMS transport  ED disposition  42% ambulance  14% OR  14% air  Transfer status TR TR *Age-based

ICU first hr & first 12 hrs  SBP  Phys/Lab data  10%  BP , HR, RR, temp, pH hypotension*  P a O2, P a CO2  Hgb, WBC  Base excess  Plt, PT, PTT, bili  -5.2 (4.2)  K, Na, Ca, albumin,  Pupil reaction BUN, Cr  PF ratio  Ventilation data  Infection data VPS VPS

ICU course & outcomes  Baseline POPC  Intensivist (98%)  89% Normal  83% Concurrent care  10% Mild/Mod  5% Consulting only  1% Severe  10% Primary service  Discharge POPC  PELOD  34% Normal  baseline, daily, POD  57% Mild/Mod  PRISM3  4% Severe/Coma  PIM2  5% Brain Death VPS VPS

Processes  FAST exam  C-collar use  10% completed  32% No collar  90% not completed  58% Removed  2% Treated  7% Discharged with collar  3% UK/NR RC VPS

Processes  DVT pharmacologic  DVT mechanical ppx ppx  67% None  57% None  7% Given  14% Given  26% N/A  29% N/A  Bowel regimen  Nutrition  70% None  95% Enteral  30% Ordered  6% Parenteral RC VPS

Pre-hospital: C-collar use All patients Site Use (%) aOR (95% CI)* Was a c- A 65.0 1.9 (1.1-3.4) collar B 76.2 3.3 (1.7-6.3) placed after C 50.0 Ref the injury D 82.7 5.5 (2.6-11.7) event ? E 69.8 2.7 (1.5-4.7) p < 0.001 p < 0.001 aOR, adjusted odds ratio; CI, confidence interval *Adjusted for age, mechanism of injury, severity of injury (ISS)

Pre-hospital: C-collar use Patients with head injury Site Use (%) aOR (95% CI)* p-value A 63.6 1.5 (0.8-3.0) 0.239 B 81.6 3.4 (1.6-7.3) 0.002 C 59.3 Ref Ref D 84.1 4.4 (1.8-10.5) 0.001 E 78.8 2.8 (1.4-5.7) 0.001 p < 0.001 p < 0.001 aOR, adjusted odds ratio; CI, confidence interval *Adjusted for age, mechanism of injury, severity of injury (ISS)