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Is implementation of Guidelines for Management of Severe Traumatic Brain Injury Associated with Improved Outcomes? Experience at a Children's Tertiary Referral Center
Krishanthan Vigneswaran, MD1, Andrew Reisner, MD1,2, John Bleacher, MD4, Michael Sawvel, DO1, Anil K. Roy, MD1, Atul Vats, MD1, Blaire H. Holbrook, CPN4, Jennifer Wheelus, CPN4, Karen Johnson, RN4, Tracie Walton, RN4, Karen Hill, RN4, Greg Pereira, RN4, Kim E. Ono, PhD3,4 Charlotte Yarrow, RN4, Laura S. Blackwell, PhD3, Beverly Rogers, MD2,4, Megan Hamling, MPH4, Chia-Yi Kuan, MD, PhD2,4, Joshua J. Chern, MD, PhD1, Antonius DeGrauw, MD4. 1Department of Neurosurgery, Children's Healthcare of Atlanta, Atlanta, GA, USA, 2Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA, 3Department of Neuropsychology, Children's Healthcare of Atlanta, Atlanta, GA, USA, 4Children's Healthcare of Atlanta, Atlanta, GA, USA.

Background: Treatment guidelines for pediatric traumatic brain injury (pTBI) have limited documented efficacy. A multidisciplinary team at a children's healthcare system standardized pTBI care based on treatment guidelines. We hypothesize that severe pTBI guidelines implementation will be associated with improved outcomes. Design. Interrupted time series analysis: 2 years prior to and 3 years after guideline implementation. Subjects. Patients aged <18 years admitted with severe TBI (Glasgow Coma Score ≤8) with intracranial pressure (ICP) monitoring.

Methods: Published guidelines for pTBI management1 were selected and discussed/modified at quarterly multidisciplinary meetings (neurosurgery, rehabilitation, critical care, trauma surgery, nursing services) based on evidence and consensus. A guideline-based treatment algorithm was implemented in March 2011. Outcomes measures pre-implementation (May 2009 Mar 2011) were compared to post-implementation (April 2011 Mar 2014). Measures included mortality; ICU length of stay (LOS); ventilator LOS; time of critical ICP elevation (% or total monitoring time that ICP was >40 mmHg); and survivor functionality measured by WeeFIM scores on admission and discharge from rehabilitation. Data were analyzed using student t test.

Results: Seventy-one and 121 patients were identified pre- and post-implementation, respectively. Mortality rate (32% vs. 19%; p<0.001) and length of critical ICP elevation (15% vs. 7%; p<0.001) decreased. WeeFIM discharge scores were not statistically different (68.5 vs. 56.5; p=0.76). ICU LOS (median 10 days both, p=0.31) and ventilator LOS (median 8 days both; p =0.44) were unchanged.

Conclusions: A multidisciplinary effort to develop, disseminate, implement, and monitor pTBI guidelines at a children's hospital was associated with improved outcomes.

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