Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids)

Abstract

Study objective: We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury.

Methods: The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders.

Results: There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+).

Conclusion: Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.

Trial registration: ClinicalTrials.gov NCT01339702.

Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1:

Prehospital TBI Treatment Algorithm for Children

Figure 2:

Enrollment Tree EMS = Emergency Medical Services TBI = Traumatic Brain Injury EPIC = Excellence In Prehospital Injury Care study P1 = Study Phase 1 (Pre-Implementation Phase) P2 = Study Phase 2 (Training Run-In Phase; For each EMS agency, time period from initiation to completion of training) P3 = Study Phase 3 (Post-Implementation Phase)

Figure 3:

Primary Analysis—Adjusted Survival --Post-intervention adjusted odds of survival to hospital discharge or admission for the “moderate” (Regional Severity Score-Head of 1 or 2; Injury Severity Score of 1–14), “severe” (Regional Severity Score-Head of 3 or 4; Injury Severity Score-ISS of 16–24), and “critical” (Regional Severity Score-Head of 5 or 6; Injury Severity Score of 25–75) injury cohorts --N/A – Not Applicable due to numbers being too small for adjusted analysis --aOR = Adjusted Odds Ratio --95% CI = 95% confidence intervals --Analyses without an asterisk (*): Logistic regression was used when there were at least 200 subjects with the event (e.g., survived to discharge) and 200 without (e.g., did not survive to discharge) --Analyses with an asterisk (*): In comparisons that did not meet the criteria of at least 200 subjects with the event and 200 without, Firth’s penalized-likelihood logistic regression was used --Number of events/number of subjects in each subgroup: • All Subjects 0 to 17 Years: survival to hospital discharge 2,510/2,801; survival to hospital admission 2,701/2,801 • Head Injury Severity 1–2: survival to hospital discharge 304/305; survival to hospital admission 305/305 • Head Injury Severity 3–4: survival to hospital discharge 1,981/2,001; survival to hospital admission 1,992/2,001 • Head Injury Severity 5–6: survival to hospital discharge 204/463; survival to hospital admission 379/463 ISS 1 to 14: survival to hospital discharge 1,248/1,253; survival to hospital admission Survival to hospital admission 1,252/1,253 • ISS 16 to 24: survival to hospital discharge 816/826; survival to hospital admission 822/826 • ISS 25+: survival to hospital discharge 442/718; survival to hospital admission 623/718

Figure 4:

Discharge to Home All Subjects 0 to 17 Years: discharge to home 2,104/2,507 Head Injury Severity 1–2: discharge to home 279/302 Head Injury Severity 3–4: discharge to home 1,724/1,980 Head Injury Severity 5–6: discharge to home 85/204 ISS 1 to 14: discharge to home 1,189/1,246 ISS 16 to 24: discharge to home 693/815 ISS 25+: discharge to home 220/442

Figure 5:

Survival Among Patients with Positive Pressure Ventilation (PPV) --Post-intervention adjusted odds of survival to hospital discharge or admission for the “Severe” (Regional Severity Score-Head of 3 or 4; Injury Severity Score-ISS of 16–24), and “Critical” (Regional Severity Score-Head of 5 or 6; Injury Severity Score of 25–75) injury cohorts --aOR = Adjusted Odds Ratio --95% CI = 95% confidence intervals --ETI = Endotracheal Intubation --Analyses without an asterisk (*): Logistic regression was used when there were at least 200 subjects with the event (e.g., survived to discharge) and 200 without (e.g., did not survive to discharge) --Analyses with an asterisk (*): In comparisons that did not meet the criteria of at least 200 subjects with the event and 200 without, Firth’s penalized-likelihood logistic regression was used --Number of events/number of subjects in each subgroup: • PPV Head Injury Severity 3–4: survival to hospital discharge 259/278; survival to hospital admission 269/278 • PPV Head Injury Severity 5–6: survival to hospital discharge 114/363; survival to hospital admission 280/363 • PPV ISS 16 to 24: survival to hospital discharge 122/131; survival to hospital admission 127/131 • PPV ISS 25+: survival to hospital discharge 203/469; survival to hospital admission 375/469 • ETI Head Injury Severity 3–4: survival to hospital discharge 200/217; survival to hospital admission 209/217 • ETI Head Injury Severity 5–6: survival to hospital discharge 88/298; survival to hospital admission 224/298 • ETI ISS 16 to 24: survival to hospital discharge 91/99; survival to hospital admission 95/99 • ETI ISS 25+: survival to hospital discharge 156/382; SHA 298/382