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The Reliability of Chart-based Assessment of Functional Impairment after Pediatric Injury Using the Functional Status Scale
Caroline Melhado1, Emily Kao2, Jacqueline Hogan-Schlientz3, Debbie Crane3, Caroline Q. Stephens1, Lauren Evans4, *Randall S. Burd5, *Aaron Jensen1
1University of California San Francisco, San Francisco, CA; 2University of California San Francisco East Bay, Oakland, CA; 3Benioff Children's Hospital Oakland, Oakland, CA;4Cedars-Sinai Medical Center, Los Angeles, CA; 5Children's National Hospital, Washington, DC

Background: Functional impairment has been proposed as an alternative outcome for quality improvement in pediatric trauma. The functional status scale (FSS) has been used in studies of injured children, but has only been validated with resource-intensive in-person assessment. Implementation with retrospective chart-based FSS assessment would offer a simplified and scalable alternative. The purpose of this study was to evaluate inter-rater reliability of retrospective FSS assessment and to identify factors associated with unreliable assessment.Methods: A retrospective cohort of children admitted with serious (AIS ≥3) injuries between July 2020 and June 2021 was analyzed. Charts were reviewed by two physicians and two nurse registrars to obtain measures of six FSS domains at discharge. Functional impairment was categorized by total FSS scores as good (6-7), mild impairment (8-9), moderate impairment (10-15), severe impairment (16-21), or very severe impairment (>21). Inter-rater reliability was assessed using intra-class correlation (ICC). Predictors of rater disagreement were evaluated using multivariable logistic regression.Results: The cohort included 238 children with median age of 6.3 years and ISS of 10. The median time per chart to assess FSS was 2.5 minutes. Sixty (25%) patients had functional impairment at discharge (20% mild, 3% moderate, 1.5% severe, and 0.5% very severe). Inter-rater reliability was excellent for total FSS score (ICC 0.96 [95% CI 0.94-0.96]), and good for FSS domain subscales (ICC > 0.83). Rater disagreement of functional status classification occurred in 17% of cases overall. Severe injury (ISS>15) was independently associated with more frequent rater disagreement (30%, n=24/80, adjusted OR 3.1 [95% CI 1.4-6.8]), but inter-rater reliability remained very good in this subgroup (ICC 0.88 [95% CI 0.83-0.91]).Conclusion: Chart-based FSS assessment is feasible and reliable, but may require more stringent review for patients with serious injury. Validation of chart-based assessment compared to gold-standard in-person assessment is needed before wide-spread implementation.


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