Higher Volume Predicts Improved Outcomes for Severe Pediatric Traumatic Brain Injury Patients at Level 1 and 2 Trauma Centers

Abstract

Abstract INTRODUCTION Recent research has demonstrated improved outcomes for trauma patients at higher volume institutions. However, the volume-outcome relationship for severe pediatric traumatic brain injury (TBI) patients, specifically, has yet to be demonstrated. METHODS We isolated all severe pediatric TBI admissions (GCS admission score 3-8) to pediatric American College of Surgeons (ACS) level 1 and 2 trauma centers in the 2012 National Trauma Data Bank. Pediatric TBI volume was analyzed on a continuous scale as the primary independent variable. Our outcome variables were mortality, hospital discharge disposition (home, rehab/other care facility, died/hospice), presence of complications (deep vein thrombosis [DVT], cardiac arrest, cerebrovascular accident, acute respiratory distress syndrome [ARDS], urinary tract infection [UTI], pneumonia), length of stay (LOS), and intensive care unit (ICU) days. We utilized multivariate analyses to adjust for the following confounding variables: injury type, age, gender, race, hospital teaching status, region of hospital, ISS, comorbidities (hypertension, bleeding disorder, congenital anomalies, respiratory disease), and GCS at admission. Statistical significance was assessed at P < .05. RESULTS There were 1441 severe pediatric TBI admissions in 69 unique pediatric ACS level 1 or 2 trauma centers in 2012. Following multivariate adjustment, the treatment at hospitals with a higher pediatric TBI volume was associated with a shorter LOS (0.5 d per +10 patients, P = .02) and higher odds of discharge home (odds ratio = 1.08 per +10 patients, P = .01). Moreover, patients at higher volume centers had a lower risk of complications (odds ratio = 0.91 per +10 patients, P = .01), particularly ARDS (odds ratio = 0.64 per +10 patients, P < .001) and pneumonia (odds ratio = 0.89 per +10 patients, P = .047). CONCLUSION Among level 1 and 2 pediatric trauma care facilities, patients treated at higher volume centers had lower complication rates, a more favorable discharge, and a shorter LOS. This suggests a need to investigate differences in approach to care between higher and lower volume hospitals and consider the role of transfer and referral networks in optimizing care.