Variation in therapy and outcome for pediatric head trauma patients.

OBJECTIVE: This study was undertaken to examine variation in therapies and outcome for pediatric head trauma patients by patient characteristics and by pediatric intensive care unit. Specifically, the study was designed to examine severity of illness on admission to the pediatric intensive care unit, the therapies used during the pediatric intensive care unit stay, and patient outcomes. DATA SOURCES AND
SETTING: Consecutive admissions from three pediatric intensive care units were recorded prospectively (n = 5,749). For this study, all patients with an admitting diagnosis of head trauma were included (n = 477). Data collection occurred during an 18-month period beginning in June 1996. All of the pediatric intensive care units were located in children's hospitals, had residency and fellowship training programs, and were headed by a pediatric intensivist.
METHODS: Admission severity was measured as the worst recorded physiological derangement during the period <or=6 hrs before pediatric intensive care unit admission. Therapies and resource use were based on the Therapeutic Intervention Scoring System with adaptations for pediatrics. The use of intracranial pressure monitoring was recorded on admission to the unit (within 1 hr) and at any time during the pediatric intensive care unit stay. Outcomes were measured at the time of pediatric intensive care unit discharge by the Pediatric Overall Performance Category scale. Risk factors for mortality were examined by using bivariate analyses with significant predictors as candidate variables in a logistic regression to predict expected mortality. Intracranial pressure monitoring and other therapies were added to the mortality prediction model to test for protective effects. Finally, race and insurance status were added to the model to test for differences in the quality of care.
RESULTS: The overall mortality rate for the entire sample was 7.8%. Mortality rates for children <or=1 yr old were significantly higher than for children >1 yr old (16.1% vs. 6.1%; p = .002). Comparisons by insurance status indicated that observed mortality rates were highest for self-paying patients. However, patient characteristics were not associated with use of therapies or standardized mortality rates after adjustment for patient severity. There was significant variation in the use of paralytic agents, seizure medications, induced hypothermia, and intracranial pressure monitoring on admission across the three pediatric intensive care units. In multivariate models, only the use of seizure medications was associated significantly with reduced mortality risk (odds ratio = 0.17; 95% confidence interval = 0.04-0.70; p = .014).
CONCLUSIONS: Therapies and outcomes vary across pediatric intensive care units that care for children with head injuries. Increased use of seizure medications may be warranted based on data from this observational study. Large randomized controlled trials of seizure prophylaxis in children with head injury have not been conducted and are needed to confirm the findings presented here.