evaluating variation in process of care metrics for critically injured
TRANSCRIPT
Evaluating variation in
process of care metrics for
critically injured pediatric
trauma patients
Pediatric Trauma Society
Scottsdale, AZ | November 6-7, 2015
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
Assessment and
Management DatabaseA 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
Current available
data systems
NTDB/TQIP
PHIS, NSQIP
HCUP
VPS, UDSMR
Pediatric Trauma
Burden of disease is profound
Limited ability to study processes of care in pediatric trauma
Current available
data systems
Fiscal constraints NTDB/TQIP
PHIS, NSQIP
HCUP
VPS, UDSMR
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
• Vitals
• GCS
• Transfer
Pre-hospital
• Vitals
• GCS
• Labs*
ED arrival• Vitals
• Labs
• Vent data
ICU stay
• Nutrition
• Constipation
• VTE ppx
Floor• Disposition
• POPC
• PRISM/PIM
Discharge
C-collar DVT ppxFAST
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
nSite
variationChi2
Adj.
Wald*
All patients 648 50-83% < 0.001 < 0.001
Head injury 443 59-84% < 0.001 < 0.001
Head injury &
Field response184 69-81% 0.761 0.163
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
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)
Patients with head injury & FIELD response
Pre-hospital: C-collar use
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)
Patients with head injury & transferred
Pre-hospital: C-collar use
nSite
variationChi2
Adj.
Wald*
All patients 648 50-83% < 0.001 < 0.001
Head injury 443 59-84% < 0.001 < 0.001
Head injury &
Field response184 69-81% 0.761 0.163
Head injury & Transferred 259 50-89% < 0.001 0.003
*Adjusted for age, mechanism of injury, severity of injury (ISS)
Only 4 patients (1.5%) had a collar removed prior to transfer
76 patients (29%) never had a collar placed
Site variation 11-50%
Pre-hospital: C-collar use
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)
When does it get removed?
ED phase of care: FAST exam
89%
2% 8%
1%0%
0%
No FAST exam completed
Completed, positive
Completed, negative
Completed, inconclusive
Completed, result UK/NR
UK/NR if FAST completed
N = 69
ED phase of care: FAST exam
69 FAST exams recorded (10%)
Site Use (%)
A 36.8
B 0
C 2.4
D 0
E 1.8
p < 0.001
0-37%
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
D 0
E 0
p < 0.001
0-11%
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
C 18.4
D 0
E 12.9
p < 0.001
0-19%
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
Injury characteristics
Mechanism of injury
32% Falls
25% MVC
4% Penetrating
Intent
84% unintentional
14% assaults
Place
31% residential
Maximum Head AIS
15% AIS 4/5
43% AIS 3
Other Maximum AIS
67% abd AIS 3-5
57% thoracic AIS 3-5
Injury Severity Score
13% ISS>25
22% ISS 16-25
TRTR
Pre-hospital & ED
Physiologic data
11% tachycardia*
3% hypotension*
9% GCS <9
EMS transport
42% ambulance
14% air
Physiologic data
29% tachycardia*
5% hypotension*
17% GCS <9
ED disposition
14% OR
Transfer status
TRTR*Age-based
ICU first hr & first 12 hrs
SBP
10%
hypotension*
Base excess
-5.2 (4.2)
Pupil reaction
PF ratio
VPS
Phys/Lab data
BP, HR, RR, temp, pH
PaO2, PaCO2
Hgb, WBC
Plt, PT, PTT, bili
K, Na, Ca, albumin, BUN, Cr
Ventilation data
Infection dataVPS
ICU course & outcomes
Baseline POPC
89% Normal
10% Mild/Mod
1% Severe
Discharge POPC
34% Normal
57% Mild/Mod
4% Severe/Coma
5% Brain DeathVPS
Intensivist (98%)
83% Concurrent care
5% Consulting only
10% Primary service
PELOD
baseline, daily, POD
PRISM3
PIM2VPS
Processes
C-collar use
32% No collar
58% Removed
2% Treated
7% Discharged
with collar
3% UK/NR
RC
FAST exam
10% completed
90% not completed
VPS
Processes
DVT mechanical ppx
57% None
14% Given
29% N/A
Nutrition
95% Enteral
6% ParenteralRC
DVT pharmacologic ppx
67% None
7% Given
26% N/A
Bowel regimen
70% None
30% OrderedVPS
Pre-hospital: C-collar use
Site Use (%) aOR (95% CI)*
A 65.0 1.9 (1.1-3.4)
B 76.2 3.3 (1.7-6.3)
C 50.0 Ref
D 82.7 5.5 (2.6-11.7)
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)
All patients
Was a c-
collar
placed after
the injury
event?
Pre-hospital: C-collar use
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)
Patients with head injury
Take Home
Site-specific variation
C-collar placement
Transfers*
Field response
FAST exam utilization*
DVT prophylaxis
Pharmacologic
Mechanical*
Enteral
Parenteral
p = 0.037p = 0.730