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

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Evaluating variation in process of care metrics for critically injured pediatric trauma patients Katherine T. Flynn- OBrien, MD, MPH Mary E. Fallat, MD Tom B. Rice, MD Christine M. Gall, RN, MS, DrPH Frederick P. Rivara, MD, MPH Pediatric

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SLIDE 1

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

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SLIDE 2

Pediatric Trauma Assessment and Management Database

A Trauma Registry-VPS partnership

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SLIDE 3

Disclosures

  • I have no disclosures.
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SLIDE 4

Pediatric Trauma

  • Burden of disease is profound
  • Healthcare quality

Structure Process Outcome

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SLIDE 5

Pediatric Trauma

  • Burden of disease is profound
  • Limited ability to study processes of

care in pediatric trauma

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SLIDE 6

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

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SLIDE 7

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

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SLIDE 8

Objectives

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

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SLIDE 9

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

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SLIDE 10

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

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SLIDE 11

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 ppx FAST

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SLIDE 12

Methods

  • Univariate analyses
  • Chi2 test for independence
  • Non-parametric equality of medians
  • Multivariable regression
  • Age, mechanism, severity of injury
  • Quantify process of care variation
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SLIDE 13

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
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SLIDE 14

Pre-hospital: C-collar use

n Site variation Chi2 Adj. Wald* All patients 648 50-83% < 0.001 < 0.001 Head injury 443 59-84% < 0.001 < 0.001 Head injury & Field response 184 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)

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SLIDE 15

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

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SLIDE 16

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

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SLIDE 17

Pre-hospital: C-collar use

n Site variation Chi2 Adj. Wald* All patients 648 50-83% < 0.001 < 0.001 Head injury 443 59-84% < 0.001 < 0.001 Head injury & Field response 184 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%
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SLIDE 18

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?

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SLIDE 19

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

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SLIDE 20

ED phase of care: FAST exam

  • 69 FAST exams recorded (10%)

Site Use (%) A 36.8 B C 2.4 D E 1.8

p < 0.001

0-37%

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SLIDE 21

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
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SLIDE 22

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 E

p < 0.001

0-11%

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SLIDE 23

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

  • E
  • aOR, adjusted odds ratio; CI, confidence interval

*Adjusted for age, mechanism of injury, severity of injury (ISS)

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SLIDE 24

Hospital course: DVT ppx

  • Mechanical prophylaxis, <48hrs of arrival
  • 12% Yes, 29% not applicable, 59% None

Site Use (%) A 18.7 B C 18.4 D E 12.9

p < 0.001

0-19%

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SLIDE 25

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

  • C

18.4 Ref D

  • 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)

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SLIDE 26

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%
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SLIDE 27

Limitations

  • Small sample size
  • Process-specific adjustments
  • Limited generalizability

Structure Process Outcome

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SLIDE 28

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

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SLIDE 29

Advice

  • Discovery consists not in seeking new

landscapes but in seeking with new eyes. – Marcel Proust

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SLIDE 30

Thank you

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

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SLIDE 31

Thank you

Questions? flynnobr@uw.edu

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SLIDE 32

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

TR TR

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SLIDE 33

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

TR TR

*Age-based

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SLIDE 34

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 data

VPS

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SLIDE 35

ICU course & outcomes

  • Baseline POPC
  • 89% Normal
  • 10% Mild/Mod
  • 1% Severe
  • Discharge POPC
  • 34% Normal
  • 57% Mild/Mod
  • 4% Severe/Coma
  • 5% Brain Death

VPS

  • Intensivist (98%)
  • 83% Concurrent care
  • 5% Consulting only
  • 10% Primary service
  • PELOD
  • baseline, daily, POD
  • PRISM3
  • PIM2

VPS

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SLIDE 36

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

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SLIDE 37

Processes

  • DVT mechanical

ppx

  • 57% None
  • 14% Given
  • 29% N/A
  • Nutrition
  • 95% Enteral
  • 6% Parenteral

RC

  • DVT pharmacologic

ppx

  • 67% None
  • 7% Given
  • 26% N/A
  • Bowel regimen
  • 70% None
  • 30% Ordered

VPS

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SLIDE 38

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?

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SLIDE 39

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

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SLIDE 40

Take Home

  • Site-specific variation
  • C-collar placement
  • Transfers*
  • Field response
  • FAST exam utilization*
  • DVT prophylaxis
  • Pharmacologic
  • Mechanical*
  • Enteral
  • Parenteral

p = 0.037 p = 0.730