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Transcript of PEDIATRIC TRAUMA ASSESSMENT AND MANAGEMENT DATABASE A TRAUMA REGISTRY-VPS PARTNERSHIP VPS User...
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PEDIATRIC TRAUMA ASSESSMENT AND MANAGEMENT DATABASEA TRAUMA REGISTRY-VPS PARTNERSHIP
VPS User Conference| March 24-26, 2015
Katherine T. Flynn-O’Brien, MDMary E. Fallat, MDTom B. Rice, MDChristine M. Gall, RN, MS, DrPHFrederick P. Rivara, MD
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Outline
Motivation What we did How we did it What we discovered
I. More data (and better data)II. Risk-adjustment modeling III. Processes of care
Brainstorming
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Motivation
Limited ability to study pediatric trauma NTDB / Pediatric TQIP Virtual Pediatric ICU Systems (VPS)
UDSMR, HCUP, PHIS, MarketScan
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Objective
Create a comprehensive pediatric trauma database to assess quality of
care in critically injured children utilizing minimal new resources.
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Methods
Merged 3 databases Trauma Registry
(TR) Virtual PICU Systems
(VPS) data PTAM-specific
RedCap 5 Level I/II PTC All children
discharged from PICU CY 2013
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Process
PTAM
Trauma
Registry
(local export)
VPS(central export)
Additional
data eleme
nts(data entry)
95.5% match
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Additional variables
C-spine clearance
Hgb prior to transfusion
FAST
Alcohol screening & counseling
(TQIP variables)
All CT scans
ICPM placement
Mech. VTE proph.
Lab upon arrival
Initiation of feeds
Bowel regimen
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Breadth & depth
I. More data | Better data
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Care continuum
Pre-hospital
ED PICU Floor Discharge
You are here.
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Care continuum
• Vitals• GCS• Transfer
Pre-hospital
• Vitals• GCS• Labs*
ED arrival
• Disposition• LOS
Discharge
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Care continuum
Variable Pre-hospital
ED PICU Floor
GCS X X X (X)
Pulse X X XX
Blood Pressure
X X XX
Hemoglobin XX XX
Base Deficit X X
AST X X
ALT X X
Hypoxemia X X
PT/PTT X X
CT scans X X X X
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Care continuum
Variable Pre-hospital
ED PICU Floor
GCS X X X (X)
Pulse X X XX
Blood Pressure
X X XX
Hemoglobin XX XX
Base Deficit X X
AST X X
ALT X X
Hypoxemia X X
PT/PTT X X
CT scans X X X X
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Care continuum
Variable Pre-hospital
ED PICU Floor
GCS X X X (X)
Pulse X X XX
Blood Pressure
X X XX
Hemoglobin XX XX
Base Deficit X X
AST X X
ALT X X
Hypoxemia X X
PT/PTT X X
CT scans X X X X
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Care Continuum
What is the child’s cognitive/physiologic status immediately after injury?
What resuscitation is, or is not, occurring prior to ICU arrival?
How may this information change management in the ICU?
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More data
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Better data
Complications Cardiac arrest CLABSI Unplanned
return to the ICU
Pneumonia Re-intubation
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Better data
Complications Cardiac arrest CLABSI Unplanned
return to the ICU
Pneumonia Re-intubation
4 37
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Better data
Complications Cardiac arrest CLABSI Unplanned
return to the ICU
Pneumonia Re-intubation
1 2
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Better data
Complications Cardiac arrest CLABSI Unplanned
return to the ICU
Pneumonia Re-intubation
3 14
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Better data
Complications Cardiac arrest CLABSI Unplanned
return to the ICU
Pneumonia Re-intubation
5 5
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Better data
Complications Cardiac arrest CLABSI Unplanned
return to the ICU
Pneumonia Re-intubation
0 20
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Better data
Comorbidities Hx of CVA Prematurity Respiratory
distress
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Better data
Comorbidities Hx of CVA Prematurity Respiratory
distress1 1
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Better data
Comorbidities Hx of CVA Prematurity Respiratory
distress6 18
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Better data
Comorbidities Hx of CVA Prematurity Respiratory
distress4 14
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II. Risk adjustment modeling
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Mortality
Model building Model diagnostics Multiple
imputation
PIM2 PRISM3 PELOD
Trauma Registry VPS
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Mortality
Model AUC R2 value AIC
TR-only 0.9360 0.5286 127.57VPS-only 0.9917 0.6723 95.84
TR-VPS 0.9776 0.6843 91.69TR-only covariates: age, mechanism of injury, transfer status, ED systolic blood pressure, ED pulse, ED GCS motor score, max head AIS, max extremity AIS, congenital comorbiditiesVPS-only: PIM2TR-VPS: TR model + VPS-PIM2 model
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Mortality
P = .0165
0.0
00
.25
0.5
00
.75
1.0
0S
ens
itivi
ty
0.00 0.25 0.50 0.75 1.001-Specificity
TRTR+VPS
VPS
ROC by Data Source
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Mortality
0.0
00
.25
0.5
00
.75
1.0
0S
ensi
tivity
0.00 0.25 0.50 0.75 1.001-Specificity
TRTR+VPS
VPS
ROC by Data Source
P = .0165
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Mortality
VPS Can we appropriately risk adjust
without controlling for mechanism of injury? Injury severity?
Trauma Registry Can we do better? Can we improve
model fit? Improve accuracy? Efficiency?
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PCPCPOPCPELODLength of hospital stayDischarge to home (vs. rehab)
Non-mortality outcomes
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Hospital disposition
What factors are most strongly associated with (poor) functional
status?
What are predictors of discharge home?
What are predictors of discharge to a rehab facility?
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III. Processes of Care
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VTE prophylaxis0
200
400
600
mechvte_hrs dvt_hrs
Site A
Site B
Site C
Site D
Site E
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More…
Nutrition management Parenteral Enteral
Daily bowel regimen C-spine clearance Alcohol and drug screening Alcohol counseling
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Limitations
Non-mortality outcomes lack precision
No quality of life measures Limited generalizability
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Scope
75+VPS institutions w/ trauma ~40% ACS trauma centers ~60% state trauma centers
50+ centers can immediately merge data
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Hurdles
Pediatric Trauma Assessment and
Management Database
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Conclusion
Combining databases is an innovative, feasible, cost-effective
way to evaluate management practices and to explore critical
questions related to pediatric trauma management.
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Thank you
Special thanks to all trauma registrars and VPS coordinators at participating
sites
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Challenges…
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…are worth it
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Thank you
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Questions?
TRVPS
Patient Outcom
es
Discharge status Pre-
hospital data
Initial vitals GCS
Injury patterns
ProceduresBedside
procedures
Lab data
PIM2 PRISMIII PELOD
PCPC POPC
Predicted
LOS
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Patient population
67 % male Mean age 7.2y
(6.0) Race/Ethnicity
51% White 21% African
American 7% Hispanic
Payer 35% Private 48% Medicaid/Gov.
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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 max AIS 67% abd AIS 3-5 57% thoracic AIS 3-
5 Injury Severity
Score 13% ISS>25 22% ISS 16-25
TRTR
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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 statusTRTR *Age-based
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ICU first hr & first 12 hrs
SBP 10%
hypotension* Base excess
-5.2 (4.2) Pupil reaction PF ratio
VPS
Physiologic/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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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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Hospital disposition
ICU Length of stay Mean 2.8 (SD
5.0) Median 1.1 (.6-
2.6) ICU disposition
69% floor, SDU 0.7% rehab 1.3% transferred
Hosp length of stay Mean 7.3 (SD
10.9) Median 4 (IQR 2-8)
Hosp disposition 82% home 11% rehab 2% transferred
VPSTR