UPDATE: Long-term Sustainability of Washington States Quality Improvement Initiative in Improving the Management of Pediatric Splenic Injuries
Benjamin J Booth1, Stephen M Bowman1, Sam R Sharar2, *Mauricio A Escobar, Jr.3
1Office of Community Health Systems, Washington State Department of Health, Olympia, WA;2Department of Anesthesiology & Pain Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA;3Mary Bridge Children's Hospital & Health Network, Tacoma, WA
Background: Initial results of Washington State’s quality improvement (QI) initiative addressing the management of pediatric spleen injuries were published in 2008, comparing three-year pre-intervention and post-intervention periods. Splenectomies decreased and patients were more likely to be seen at hospitals with pediatric trauma designation in the post-intervention period. In this update, we evaluated whether these effects were sustained over time to determine if further initiatives were necessary.
Methods: Data from the Washington State 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 and hospital characteristics.
Results: Overall, splenectomies continued to be less common with 8.3% of pediatric patients in the registry receiving splenectomies in the follow-up period compared with 14.3% and 7.2% in the pre-intervention and post-intervention periods (p=0.034). After adjusting for patient, injury, and hospital characteristics, splenectomies remained less likely to occur in the post-intervention (OR=0.39; 95% CI=0.16-0.91) and follow-up periods (OR=0.33; 95% CI=0.12-0.88) compared to pre-intervention. Children were much more likely to be cared for at pediatric trauma hospitals in the follow-up period (OR=4.84; 95% CI=2.50-9.40) after adjustment.
Conclusions: Evaluation of this statewide QI initiative showed that positive changes in management practices persist. General trauma hospitals are now less likely to definitively manage blunt splenic trauma in children, with a corresponding increase in care at pediatric trauma hospitals. This evidence suggests that statewide QI initiatives can be sustainable with minimal ongoing effort.
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