- Email: [email protected]
The effect of delay in rehabilitation on outcome of severe traumatic brain injury
Journal of Pediatric Surgery (2009) 44, 368–372
www.elsevier.com/locate/jpedsurg
The effect of delay in rehabilitation on outcome of severe traumatic brain injury Joseph J. Tepas III a,⁎, Cynthia L. Leaphart a , Pam Pieper a , Cynthia L. Beaulieu b , Louise R. Spierre b , James D. Tuten c , Brian G. Celso d a
University of Florida College of Medicine/Surgery, Jacksonville, FL 32209, USA Brooks Rehabilitation Hospital, Jacksonville, FL 32216, USA c Version2Network, St. Augustine, FL 32084, USA d Department of Psychiatry, University of Florida College of Medicine, Jacksonville, FL 32209, USA b
Received 3 October 2008; accepted 23 October 2008
Key words: Rehabilitation; Outcomes; FIM (functional independence measure); Pediatric trauma
Abstract Background: Expeditious care within minutes of severe injury improves outcome and is the driving force for development of trauma care systems. Transition from hospital care to rehabilitation is an important step in recovery after trauma-related injury. We hypothesize that delay in the transition from acute care to rehabilitation adversely affects outcome and diminishes recovery after traumatic brain injury (TBI). Methods: After institutional review board approval, the trauma registry of our regional level I pediatric trauma center was queried for all children with severe blunt TBI (initial Glasgow Coma Scale score ≤8) that required inpatient rehabilitation. Records were stratified as severe TBI (Glasgow Coma Scale [GCS] scores 3, 4, 5) and moderate TBI (GSC scores 6, 7, 8). Intensity of acute care was defined by need for mechanical ventilation and length of intensive care unit stay. Outcome was defined by functional independence measurement (FIM) scores at time of transfer to inpatient rehabilitation. Linear regression was used to compare time in days between discharge from intensive care and admission to inpatient rehabilitation (delay) to rehabilitation efficiency (RE), defined as the ratio of FIM score improvement to length of stay for inpatient rehabilitation. Functional improvement was determined by analysis of FIM score improvement (ΔFIM) between initiation and completion of inpatient rehabilitation. Results: Between January 2000 and December 2006, 60 children (38 males, mean age, 11.2 years; 22 females, mean age, 10.6 years) with blunt TBI and an initial GCS score of 8 or lower required resuscitation, comprehensive critical care, and inpatient rehabilitation. Mean length of stay in the intensive care unit was 11.1 ± 7.4 days. Fifty-two children required an average of 9.4 ± 6.8 ventilator days. Delay ranged between 0 and 24 days (mean, 4.1 days) and was significantly correlated with RE and ΔFIM (correlation coefficient = −0.346, P = .0068). For children with the highest potential for salvage (GCS scores 6, 7, 8), RE correlation increased to −0.457 (P = .011), whereas those with most severe injury (GCS scores 3, 4, 5) demonstrated a weaker correlation that was not significant. For
Presented at the 55th Annual Congress of the British Association of Paediatric Surgeons, Salamanca, Spain, July 2-5, 2008. ⁎ Corresponding author. Division of Pediatric Surgery, University of Florida College of Medicine/Jacksonville, Jacksonville, FL 32209 USA. Tel.: +1 904 244 3915; fax: +1 904 244 3870. E-mail address: [email protected] (J.J. Tepas). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.10.089
Effect of delay in rehabilitation
369
children with most severe injury (GCS scores 3,4,5), the correlation of ΔFIM was significant (−0.38; P = .035); however, RE was not. Conclusions: These data demonstrate the price of delay of comprehensive rehabilitation, especially for the most vulnerable TBI children with best potential for salvage. The “golden hour,” which has become the mantra for continued refinement of systems of emergency and trauma care, must progress without interruption to the “golden day,” during which comprehensive critical care seamlessly transitions to timely and aggressive rehabilitation to effect the greatest functional recovery. © 2009 Elsevier Inc. All rights reserved.
Emergency medical services exist to provide trained personnel and appropriate resources to patients in need, regardless of circumstances. The heart of trauma systems is a similar commitment of surgical personnel and resources constantly ready to intervene and interrupt the injured patient's spiral toward death or disability. The latter has been framed in the concept of “preventable mortality” and has been the mantra for trauma system development around the world. That trauma systems do save lives is no longer in question [1-3]. That special preparation and training to address the unique needs of injured children yields additional salvage has likewise been documented [4,5]. The investment of expense and commitment to save lives and rescue quality of life is only partially returned, however, if the process of care is not a seamless continuum dedicated to timely and complete progression from emergency resuscitation to comprehensive care. This seemingly self-evident fact implies that barriers to this progression of care interrupt the process of recovery and potentially limit extent of salvage. An injured child whose life has been saved by the miracles of modern emergency and trauma care may be doomed to a life of avoidable impairment if access to timely and comprehensive rehabilitation is unavailable or delayed [6,7]. Instead of nurturing a functioning future citizen, this limitation of care begets a needy recipient of ongoing social support. By extending outcome assessment beyond crude mortality and by including objective metrics of timely and effective rehabilitation, the entire continuum of care for the injured child can be framed in clinically relevant terms that reflect the quality of the child's life as well as adequacy of system performance. Our hypothesis in this review of our experience with pediatric survivors of severe traumatic brain injury (TBI) was that delay in progression from acute intensive care to comprehensive rehabilitation was associated with diminished extent of functional recovery. Delay in this continuum at the point of transition from intensive care to rehabilitation adversely affects outcome and diminishes completeness of recovery.
1. Methods After approval of the University of Florida, Jacksonville's Institutional Review Board, the trauma registry of our regional level I pediatric trauma center was queried for all
children with severe blunt TBI (initial Glasgow Coma Scale [GCS] score ≤8). Survivors who required inpatient rehabilitation comprised the study population. Intensity of acute care was defined by need for mechanical ventilation and length of ICU stay. Delay (DLY) was defined as the period in days between release from intensive care and initiation of comprehensive inpatient rehabilitation. Outcome was defined by functional independence measurement (FIM) score at time of transfer to inpatient rehabilitation. The FIM and WeeFIM are standardized systems that measure and document functional performance in children and adolescents with either acquired or congenital disabilities. It is a reliable outcomes measurement instrument that can be applied uniformly across inpatient, outpatient, and community-based settings [8,9]. As such, it is a benchmarked outcomes management system that provides a method of evaluating individual patients, population-based assessment of patients, and overall medical rehabilitation programs. In the last application, many rehabilitation programs have adopted change in FIM (ΔFIM) as an objective metric for patient progress. Analyzing the ratio of ΔFIM and length of inpatient rehabilitation (rehabilitation efficiency [RE]) is used to assess patient and/or program performance. Linear regression was used to compare DLY to ΔFIM and RE individually, accepting P b .05 as a statistically significant correlation. Because GCS is an ordinal scale that reflects combinations of eye, verbal, and motor function, the study cohort was then stratified and reanalyzed as catastrophic (GCS scores 3, 4, 5) and severe (GCS scores 6, 7, 8).
2. Results Between January 2000 and December 2006, 60 children (38 males, mean age, 11.2 years; and 22 females, mean age, 10.6 years) with blunt TBI and an initial GCS score of 8 or lower required resuscitation, comprehensive critical care, and inpatient rehabilitation. Fig. 1 is a histogram of age by sex. Mechanisms of injury are listed in Table 1, and were all blunt trauma, including one child with a blast injury from a gunshot wound. Mean length of stay in the ICU was 11.1 ± 7.4 days. Fifty-two children required an average of 9.4 ± 6.8 days of mechanical ventilation. Table 2 demonstrates injury severity in terms of resource consumption and injury severity score stratified by initial GCS score.
370
J.J. Tepas III et al. Table 2 Mean resource consumption and severity by sex and GCS GCS Male
Female
No. LOSICU Vent ISS days
Fig. 1
Age distribution of study cohort stratified by sex.
For the entire study group, delay ranged between 0 and 24 days (mean, 4.1 days) and was significantly correlated with both RE and ΔFIM (correlation coefficient = −0.346, P = .0068 both). For children with the highest potential for salvage (GCS scores 6, 7, 8), there was an even stronger correlation between DLY and RE (correlation coefficient = −0. 457, P = .011). However, the correlation between DLY and ΔFIM weakened (correlation coefficient = −0.232, P = −.217). As depicted on Table 3, children with catastrophic injury (GCS scores 3, 4, 5) demonstrated a weak correlation between DLY and RE that was not significant; however, the relationship between DLY and ΔFIM, for example, degree of recovery, was highly significant (correlation coefficient = −0.38, P = .035). Although mean FIM of catastrophically injured children at transfer to rehabilitation was not significantly lower than those with severe injury (30.1 vs 36.2, respectively; P = .21), median FIM of the catastrophically injured was considerably lower (18.5) than for the severe group (28). Because the FIM is a nonlinear scale, this difference reflects that the deficit in functional impairment, or, stated differently, the degree of loss to be overcome, was greater in the children with catastrophic TBI.
3. Discussion In this study, we have demonstrated a relationship between the timeliness of initiation of rehabilitation and Table 1
3 10 4 6 5 3 6 9 7 5 8 5 Total 38
11.4 13.8 20.0 9.1 5.6 5.2 10.3
8.2 8.2 18.0 8.2 3.8 3.2 7.7
No. LOSICU Vent ISS days
28.6 7 28.7 2 25.0 2 27.6 4 25.2 3 23.2 4 26.9 22
15.4 16.5 6.0 12.8 12.0 8.0 12.4
12.3 3.0 4.5 11.0 9.7 5.3 8.9
28.9 25.5 37.5 37.3 27.3 28.5 30.6
Illustrates the severity of injury of the study cohort be listing resource consumption and ISS, stratified by presenting GCS. LOSICU indicates length of stay in the ICU; ISS, injury severity score.
outcome after traumatic brain injury. We have shown that delays in comprehensive rehabilitation, especially for children with severe TBI, diminish outcome and efficiency of rehabilitative care. When patients are stratified by their initial GCS, an additional dimension emerges, implying that those with less severe injuries and the greatest potential for recovery are most efficiently rehabilitated if delays to rehabilitation are minimized. Experience in our regional trauma system demonstrates that most pediatric trauma fatalities die within seconds at the scene, or shortly after arrival at the trauma center. Most of these fatalities are failures of prevention rather than preventable errors in the process of care. What has also been consistently demonstrated is that the incidence of severe morbidity, especially from TBI, is at least equal in volume to the number of fatalities. When considered in concert with the proportion of children with moderate TBI, focus on better system performance in providing timely and effective rehabilitation is clearly a meaningful and relevant metric of outcome. Multiple measures have been developed to measure impairment and track progress toward recovery [10-12], all of which are flawed to some degree. However, by measuring objective change over time and relating it to a point on the continuum of care where delay is common and potentially avoidable, an opportunity for process measurement and performance improvement becomes glaringly
Mechanisms of injury
Mechanism
No.
Table 3
Motor vehicle crash Pedestrian ATV crash Motorcycle crash Bicycle crash Struck Beaten Blast from gun shot wound Machine related
24 17 6 6 2 2 1 1 1
GCS
ΔFIM
RE
3 4 5 6 7 8
−0.38, P = .035
−0.249, P = .183
−0.232, P = .217
−0.457, P = .01
All mechanisms were characterized as blunt injury.
Correlation between delay and outcomes
Correlation coefficients for the subcohort analysis, stratified by TBI severity. ΔFIM = inpatient rehabilitation admission to discharge FIM score changes.
Effect of delay in rehabilitation apparent. The “golden hour,” which has become the mantra for continued refinement of systems of emergency and trauma care, must progress without interruption to a definable interval, during which comprehensive critical care seamlessly transitions to timely and aggressive rehabilitation. The role of comprehensive rehabilitation in transforming a life saved into livelihood salvaged is well documented and accepted [7,13]. Factors that impact the efficacy of this critical next step have not been as well defined or validated. These data clearly demonstrate a relationship does exist between outcome and timeliness of initiation of this increasingly important component of care. The implication is that there is a definable window of opportunity to optimize recovery from traumatic brain injury, especially for young children with very plastic, developing brains [14]. The stimulus for this investigation was frustration in getting legislative support for enhancement of regulations that would guarantee every injured child at least 4 weeks of aggressive rehabilitation. This would begin as soon as the physicians managing the acute phase of injury determined, in concert with rehabilitation consultants, that the child was stable enough to tolerate initiation of this phase of recovery. The primary premise is that denial or delay of this opportunity undermines recovery and unnecessarily diverts salvageable children to lives of misery with avoidable impairment. It is a classic case of pay now for rehabilitation or pay later for long-term societal support. This premise is further validated by the inverse relationship between delay to rehabilitation and both outcome and efficiency of rehabilitative care. By stratifying patients according to presenting GCS score, an additional dimension of cost efficiency emerges, demonstrating that the less severe injuries, which, by definition, should have the greatest potential for recovery, are most efficiently rehabilitated if delay to this care is minimized. This finding, in concert with the inverse correlation between degree of recovery and time of delay for children with severe TBI, clearly demonstrates that, like the “golden hour,” there is a second “golden interval” that must be addressed if the true return on investment in trauma systems is to be realized. We propose that the ideal starting benchmark for this transition from critical care to rehabilitation be set at 24 hours, thereby defining a “golden day.” A limitation of this investigation is that it is a retrospective, uncontrolled study conducted in a trauma system where access to outstanding rehabilitation is readily available. The study design arbitrarily defined delay as the interval between completion of critical care and initiation of inpatient rehabilitation. The events that actually transpired during this interval cannot be accurately defined in this retrospective analysis. Some trauma centers without access to rehabilitation may routinely wait much longer for transfer of recovering children into rehabilitation. Thus, the definition of a 24-hour “golden day” is an arbitrary benchmark intended to define a period of avoidable delay in the
371 continuum of care that may directly impact efficiency and completeness of recovery. Our experience indicates that the relationship between delay to rehabilitation and outcome is statistically significant. This has stimulated initiation of a prospective multiinstitutional investigation designed to define currently unmeasured causes for delay and catalog reasons for these causes. Our experience, and that of many of our colleagues, suggests that common causes for delay to rehabilitation fall into 2 basic categories related to (1) bed availability and (2) financial support. The former reflects the fact that there are not enough rehabilitation facilities qualified to treat children. These facilities are consistently full and, thus, bed availability is a chronic problem even for communities fortunate enough to have these facilities. Trauma centers that are remote from pediatric rehabilitation centers must also deal with the challenge of long-distance transport of these fragile patients once a bed is actually identified. In addition to validation of the effect of delay on outcome, the other major aim of the planned prospective multiinstitutional study is better definition of the appropriate capacity and distribution of pediatric rehabilitation beds throughout our region. The latter problem of financial support is unfortunately becoming more common and severe. Many health insurance plans have eliminated or significantly curtailed rehabilitation benefits. Government sponsored programs are becoming the default provider and often require extensive layers of administrative approval. These include assessment of family financial records, which some parents are loathe to reveal, as well as application of irrelevant, adult based utilization criteria. By cataloging the incidence and effect of each of these factors, strategies for elimination or improved control can be defined, tested and optimized. Once these contributory factors are better defined, the true metric of the “golden day” will be determined, and strategies for eliminating common causes for delay will drive the evolution of trauma systems to the next level of performance. Knowing that this will enhance cost efficiency of care is important for health policy planning. Realizing that this will salvage more children from the misery of decades of avoidable impairment and optimize their chances for restoration of a higher quality of life is a mandate to which everyone responsible for the care of children must commit.
References [1] Mullins RJ, Veum-Stone J, Helfand M, et al. Outcome of hospitalized injured patients after institution of a trauma system in an urban area. JAMA 1994;271(24):1919-24. [2] Durham R, Pracht E, Orban B, et al. Evaluation of a mature trauma system. Ann Surg 2006;243(6):775-83 [discussion 783-785]. [3] Mullins RJ, Mann NC, Hedges JR, et al. Preferential benefit of implementation of a statewide trauma system in one of two adjacent states. J Trauma 1998;44(4):609-16 [discussion 617]. [4] Pracht EE, Tepas III JJ, Langland-Orban B, et al. Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatr Surg 2008;43(1):212-21.
372 [5] Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000;49(2): 237-45. [6] Slomine BS, McCarthy ML, Ding R, et al. Health care utilization and needs after pediatric traumatic brain injury. Pediatrics 2006;117(4): 663-74. [7] Ylvisaker M, Adelson PD, Braga LW, et al. Rehabilitation and ongoing support after pediatric TBI: twenty years of progress. J Head Trauma Rehabil 2005;20(1):95-109. [8] Msall ME, DiGaudio K, Duffy LC, et al. WeeFIM: normative sample of an instrument for tracking functional independence in children. Clin Pediatr 1994;33(7):431-8. [9] Msall ME, DiGaudio K, Rogers BT, et al. The Functional Independence Measure for Children (WeeFIM): conceptual basis and pilot use in children with developmental disabilities. Clin Pediatr 1994;33(7):421-30.
J.J. Tepas III et al. [10] Gabbe BJ, Simpson PM, Sutherland AM, et al. Functional measures at discharge: are they useful predictors of longer term outcomes for trauma registries? Ann Surg 2008;247(5): 854-9. [11] Gabbe BJ, Sutherland AM, Wolfe R, et al. Can the modified functional independence measure be reliably obtained from the patient medial record by different raters? J Trauma 2007;63(6): 1374-9. [12] Willis CD, Gabbe BJ, Butt W, et al. Assessing outcomes in paediatric trauma populations. Injury 2006;37(12):1185-96. [13] Srivastava R, Downey EC, Feola P, et al. Quality of life of children with neurological impairment who receive a fundoplication for gastroesophageal reflux disease. J Hosp Med 2007;2(3): 165-73. [14] Kochanek PM. Pediatric traumatic brain injury: quo vadis? Dev Neurosci 2006;28(4-5):244-55.
www.elsevier.com/locate/jpedsurg
The effect of delay in rehabilitation on outcome of severe traumatic brain injury Joseph J. Tepas III a,⁎, Cynthia L. Leaphart a , Pam Pieper a , Cynthia L. Beaulieu b , Louise R. Spierre b , James D. Tuten c , Brian G. Celso d a
University of Florida College of Medicine/Surgery, Jacksonville, FL 32209, USA Brooks Rehabilitation Hospital, Jacksonville, FL 32216, USA c Version2Network, St. Augustine, FL 32084, USA d Department of Psychiatry, University of Florida College of Medicine, Jacksonville, FL 32209, USA b
Received 3 October 2008; accepted 23 October 2008
Key words: Rehabilitation; Outcomes; FIM (functional independence measure); Pediatric trauma
Abstract Background: Expeditious care within minutes of severe injury improves outcome and is the driving force for development of trauma care systems. Transition from hospital care to rehabilitation is an important step in recovery after trauma-related injury. We hypothesize that delay in the transition from acute care to rehabilitation adversely affects outcome and diminishes recovery after traumatic brain injury (TBI). Methods: After institutional review board approval, the trauma registry of our regional level I pediatric trauma center was queried for all children with severe blunt TBI (initial Glasgow Coma Scale score ≤8) that required inpatient rehabilitation. Records were stratified as severe TBI (Glasgow Coma Scale [GCS] scores 3, 4, 5) and moderate TBI (GSC scores 6, 7, 8). Intensity of acute care was defined by need for mechanical ventilation and length of intensive care unit stay. Outcome was defined by functional independence measurement (FIM) scores at time of transfer to inpatient rehabilitation. Linear regression was used to compare time in days between discharge from intensive care and admission to inpatient rehabilitation (delay) to rehabilitation efficiency (RE), defined as the ratio of FIM score improvement to length of stay for inpatient rehabilitation. Functional improvement was determined by analysis of FIM score improvement (ΔFIM) between initiation and completion of inpatient rehabilitation. Results: Between January 2000 and December 2006, 60 children (38 males, mean age, 11.2 years; 22 females, mean age, 10.6 years) with blunt TBI and an initial GCS score of 8 or lower required resuscitation, comprehensive critical care, and inpatient rehabilitation. Mean length of stay in the intensive care unit was 11.1 ± 7.4 days. Fifty-two children required an average of 9.4 ± 6.8 ventilator days. Delay ranged between 0 and 24 days (mean, 4.1 days) and was significantly correlated with RE and ΔFIM (correlation coefficient = −0.346, P = .0068). For children with the highest potential for salvage (GCS scores 6, 7, 8), RE correlation increased to −0.457 (P = .011), whereas those with most severe injury (GCS scores 3, 4, 5) demonstrated a weaker correlation that was not significant. For
Presented at the 55th Annual Congress of the British Association of Paediatric Surgeons, Salamanca, Spain, July 2-5, 2008. ⁎ Corresponding author. Division of Pediatric Surgery, University of Florida College of Medicine/Jacksonville, Jacksonville, FL 32209 USA. Tel.: +1 904 244 3915; fax: +1 904 244 3870. E-mail address: [email protected] (J.J. Tepas). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.10.089
Effect of delay in rehabilitation
369
children with most severe injury (GCS scores 3,4,5), the correlation of ΔFIM was significant (−0.38; P = .035); however, RE was not. Conclusions: These data demonstrate the price of delay of comprehensive rehabilitation, especially for the most vulnerable TBI children with best potential for salvage. The “golden hour,” which has become the mantra for continued refinement of systems of emergency and trauma care, must progress without interruption to the “golden day,” during which comprehensive critical care seamlessly transitions to timely and aggressive rehabilitation to effect the greatest functional recovery. © 2009 Elsevier Inc. All rights reserved.
Emergency medical services exist to provide trained personnel and appropriate resources to patients in need, regardless of circumstances. The heart of trauma systems is a similar commitment of surgical personnel and resources constantly ready to intervene and interrupt the injured patient's spiral toward death or disability. The latter has been framed in the concept of “preventable mortality” and has been the mantra for trauma system development around the world. That trauma systems do save lives is no longer in question [1-3]. That special preparation and training to address the unique needs of injured children yields additional salvage has likewise been documented [4,5]. The investment of expense and commitment to save lives and rescue quality of life is only partially returned, however, if the process of care is not a seamless continuum dedicated to timely and complete progression from emergency resuscitation to comprehensive care. This seemingly self-evident fact implies that barriers to this progression of care interrupt the process of recovery and potentially limit extent of salvage. An injured child whose life has been saved by the miracles of modern emergency and trauma care may be doomed to a life of avoidable impairment if access to timely and comprehensive rehabilitation is unavailable or delayed [6,7]. Instead of nurturing a functioning future citizen, this limitation of care begets a needy recipient of ongoing social support. By extending outcome assessment beyond crude mortality and by including objective metrics of timely and effective rehabilitation, the entire continuum of care for the injured child can be framed in clinically relevant terms that reflect the quality of the child's life as well as adequacy of system performance. Our hypothesis in this review of our experience with pediatric survivors of severe traumatic brain injury (TBI) was that delay in progression from acute intensive care to comprehensive rehabilitation was associated with diminished extent of functional recovery. Delay in this continuum at the point of transition from intensive care to rehabilitation adversely affects outcome and diminishes completeness of recovery.
1. Methods After approval of the University of Florida, Jacksonville's Institutional Review Board, the trauma registry of our regional level I pediatric trauma center was queried for all
children with severe blunt TBI (initial Glasgow Coma Scale [GCS] score ≤8). Survivors who required inpatient rehabilitation comprised the study population. Intensity of acute care was defined by need for mechanical ventilation and length of ICU stay. Delay (DLY) was defined as the period in days between release from intensive care and initiation of comprehensive inpatient rehabilitation. Outcome was defined by functional independence measurement (FIM) score at time of transfer to inpatient rehabilitation. The FIM and WeeFIM are standardized systems that measure and document functional performance in children and adolescents with either acquired or congenital disabilities. It is a reliable outcomes measurement instrument that can be applied uniformly across inpatient, outpatient, and community-based settings [8,9]. As such, it is a benchmarked outcomes management system that provides a method of evaluating individual patients, population-based assessment of patients, and overall medical rehabilitation programs. In the last application, many rehabilitation programs have adopted change in FIM (ΔFIM) as an objective metric for patient progress. Analyzing the ratio of ΔFIM and length of inpatient rehabilitation (rehabilitation efficiency [RE]) is used to assess patient and/or program performance. Linear regression was used to compare DLY to ΔFIM and RE individually, accepting P b .05 as a statistically significant correlation. Because GCS is an ordinal scale that reflects combinations of eye, verbal, and motor function, the study cohort was then stratified and reanalyzed as catastrophic (GCS scores 3, 4, 5) and severe (GCS scores 6, 7, 8).
2. Results Between January 2000 and December 2006, 60 children (38 males, mean age, 11.2 years; and 22 females, mean age, 10.6 years) with blunt TBI and an initial GCS score of 8 or lower required resuscitation, comprehensive critical care, and inpatient rehabilitation. Fig. 1 is a histogram of age by sex. Mechanisms of injury are listed in Table 1, and were all blunt trauma, including one child with a blast injury from a gunshot wound. Mean length of stay in the ICU was 11.1 ± 7.4 days. Fifty-two children required an average of 9.4 ± 6.8 days of mechanical ventilation. Table 2 demonstrates injury severity in terms of resource consumption and injury severity score stratified by initial GCS score.
370
J.J. Tepas III et al. Table 2 Mean resource consumption and severity by sex and GCS GCS Male
Female
No. LOSICU Vent ISS days
Fig. 1
Age distribution of study cohort stratified by sex.
For the entire study group, delay ranged between 0 and 24 days (mean, 4.1 days) and was significantly correlated with both RE and ΔFIM (correlation coefficient = −0.346, P = .0068 both). For children with the highest potential for salvage (GCS scores 6, 7, 8), there was an even stronger correlation between DLY and RE (correlation coefficient = −0. 457, P = .011). However, the correlation between DLY and ΔFIM weakened (correlation coefficient = −0.232, P = −.217). As depicted on Table 3, children with catastrophic injury (GCS scores 3, 4, 5) demonstrated a weak correlation between DLY and RE that was not significant; however, the relationship between DLY and ΔFIM, for example, degree of recovery, was highly significant (correlation coefficient = −0.38, P = .035). Although mean FIM of catastrophically injured children at transfer to rehabilitation was not significantly lower than those with severe injury (30.1 vs 36.2, respectively; P = .21), median FIM of the catastrophically injured was considerably lower (18.5) than for the severe group (28). Because the FIM is a nonlinear scale, this difference reflects that the deficit in functional impairment, or, stated differently, the degree of loss to be overcome, was greater in the children with catastrophic TBI.
3. Discussion In this study, we have demonstrated a relationship between the timeliness of initiation of rehabilitation and Table 1
3 10 4 6 5 3 6 9 7 5 8 5 Total 38
11.4 13.8 20.0 9.1 5.6 5.2 10.3
8.2 8.2 18.0 8.2 3.8 3.2 7.7
No. LOSICU Vent ISS days
28.6 7 28.7 2 25.0 2 27.6 4 25.2 3 23.2 4 26.9 22
15.4 16.5 6.0 12.8 12.0 8.0 12.4
12.3 3.0 4.5 11.0 9.7 5.3 8.9
28.9 25.5 37.5 37.3 27.3 28.5 30.6
Illustrates the severity of injury of the study cohort be listing resource consumption and ISS, stratified by presenting GCS. LOSICU indicates length of stay in the ICU; ISS, injury severity score.
outcome after traumatic brain injury. We have shown that delays in comprehensive rehabilitation, especially for children with severe TBI, diminish outcome and efficiency of rehabilitative care. When patients are stratified by their initial GCS, an additional dimension emerges, implying that those with less severe injuries and the greatest potential for recovery are most efficiently rehabilitated if delays to rehabilitation are minimized. Experience in our regional trauma system demonstrates that most pediatric trauma fatalities die within seconds at the scene, or shortly after arrival at the trauma center. Most of these fatalities are failures of prevention rather than preventable errors in the process of care. What has also been consistently demonstrated is that the incidence of severe morbidity, especially from TBI, is at least equal in volume to the number of fatalities. When considered in concert with the proportion of children with moderate TBI, focus on better system performance in providing timely and effective rehabilitation is clearly a meaningful and relevant metric of outcome. Multiple measures have been developed to measure impairment and track progress toward recovery [10-12], all of which are flawed to some degree. However, by measuring objective change over time and relating it to a point on the continuum of care where delay is common and potentially avoidable, an opportunity for process measurement and performance improvement becomes glaringly
Mechanisms of injury
Mechanism
No.
Table 3
Motor vehicle crash Pedestrian ATV crash Motorcycle crash Bicycle crash Struck Beaten Blast from gun shot wound Machine related
24 17 6 6 2 2 1 1 1
GCS
ΔFIM
RE
3 4 5 6 7 8
−0.38, P = .035
−0.249, P = .183
−0.232, P = .217
−0.457, P = .01
All mechanisms were characterized as blunt injury.
Correlation between delay and outcomes
Correlation coefficients for the subcohort analysis, stratified by TBI severity. ΔFIM = inpatient rehabilitation admission to discharge FIM score changes.
Effect of delay in rehabilitation apparent. The “golden hour,” which has become the mantra for continued refinement of systems of emergency and trauma care, must progress without interruption to a definable interval, during which comprehensive critical care seamlessly transitions to timely and aggressive rehabilitation. The role of comprehensive rehabilitation in transforming a life saved into livelihood salvaged is well documented and accepted [7,13]. Factors that impact the efficacy of this critical next step have not been as well defined or validated. These data clearly demonstrate a relationship does exist between outcome and timeliness of initiation of this increasingly important component of care. The implication is that there is a definable window of opportunity to optimize recovery from traumatic brain injury, especially for young children with very plastic, developing brains [14]. The stimulus for this investigation was frustration in getting legislative support for enhancement of regulations that would guarantee every injured child at least 4 weeks of aggressive rehabilitation. This would begin as soon as the physicians managing the acute phase of injury determined, in concert with rehabilitation consultants, that the child was stable enough to tolerate initiation of this phase of recovery. The primary premise is that denial or delay of this opportunity undermines recovery and unnecessarily diverts salvageable children to lives of misery with avoidable impairment. It is a classic case of pay now for rehabilitation or pay later for long-term societal support. This premise is further validated by the inverse relationship between delay to rehabilitation and both outcome and efficiency of rehabilitative care. By stratifying patients according to presenting GCS score, an additional dimension of cost efficiency emerges, demonstrating that the less severe injuries, which, by definition, should have the greatest potential for recovery, are most efficiently rehabilitated if delay to this care is minimized. This finding, in concert with the inverse correlation between degree of recovery and time of delay for children with severe TBI, clearly demonstrates that, like the “golden hour,” there is a second “golden interval” that must be addressed if the true return on investment in trauma systems is to be realized. We propose that the ideal starting benchmark for this transition from critical care to rehabilitation be set at 24 hours, thereby defining a “golden day.” A limitation of this investigation is that it is a retrospective, uncontrolled study conducted in a trauma system where access to outstanding rehabilitation is readily available. The study design arbitrarily defined delay as the interval between completion of critical care and initiation of inpatient rehabilitation. The events that actually transpired during this interval cannot be accurately defined in this retrospective analysis. Some trauma centers without access to rehabilitation may routinely wait much longer for transfer of recovering children into rehabilitation. Thus, the definition of a 24-hour “golden day” is an arbitrary benchmark intended to define a period of avoidable delay in the
371 continuum of care that may directly impact efficiency and completeness of recovery. Our experience indicates that the relationship between delay to rehabilitation and outcome is statistically significant. This has stimulated initiation of a prospective multiinstitutional investigation designed to define currently unmeasured causes for delay and catalog reasons for these causes. Our experience, and that of many of our colleagues, suggests that common causes for delay to rehabilitation fall into 2 basic categories related to (1) bed availability and (2) financial support. The former reflects the fact that there are not enough rehabilitation facilities qualified to treat children. These facilities are consistently full and, thus, bed availability is a chronic problem even for communities fortunate enough to have these facilities. Trauma centers that are remote from pediatric rehabilitation centers must also deal with the challenge of long-distance transport of these fragile patients once a bed is actually identified. In addition to validation of the effect of delay on outcome, the other major aim of the planned prospective multiinstitutional study is better definition of the appropriate capacity and distribution of pediatric rehabilitation beds throughout our region. The latter problem of financial support is unfortunately becoming more common and severe. Many health insurance plans have eliminated or significantly curtailed rehabilitation benefits. Government sponsored programs are becoming the default provider and often require extensive layers of administrative approval. These include assessment of family financial records, which some parents are loathe to reveal, as well as application of irrelevant, adult based utilization criteria. By cataloging the incidence and effect of each of these factors, strategies for elimination or improved control can be defined, tested and optimized. Once these contributory factors are better defined, the true metric of the “golden day” will be determined, and strategies for eliminating common causes for delay will drive the evolution of trauma systems to the next level of performance. Knowing that this will enhance cost efficiency of care is important for health policy planning. Realizing that this will salvage more children from the misery of decades of avoidable impairment and optimize their chances for restoration of a higher quality of life is a mandate to which everyone responsible for the care of children must commit.
References [1] Mullins RJ, Veum-Stone J, Helfand M, et al. Outcome of hospitalized injured patients after institution of a trauma system in an urban area. JAMA 1994;271(24):1919-24. [2] Durham R, Pracht E, Orban B, et al. Evaluation of a mature trauma system. Ann Surg 2006;243(6):775-83 [discussion 783-785]. [3] Mullins RJ, Mann NC, Hedges JR, et al. Preferential benefit of implementation of a statewide trauma system in one of two adjacent states. J Trauma 1998;44(4):609-16 [discussion 617]. [4] Pracht EE, Tepas III JJ, Langland-Orban B, et al. Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatr Surg 2008;43(1):212-21.
372 [5] Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000;49(2): 237-45. [6] Slomine BS, McCarthy ML, Ding R, et al. Health care utilization and needs after pediatric traumatic brain injury. Pediatrics 2006;117(4): 663-74. [7] Ylvisaker M, Adelson PD, Braga LW, et al. Rehabilitation and ongoing support after pediatric TBI: twenty years of progress. J Head Trauma Rehabil 2005;20(1):95-109. [8] Msall ME, DiGaudio K, Duffy LC, et al. WeeFIM: normative sample of an instrument for tracking functional independence in children. Clin Pediatr 1994;33(7):431-8. [9] Msall ME, DiGaudio K, Rogers BT, et al. The Functional Independence Measure for Children (WeeFIM): conceptual basis and pilot use in children with developmental disabilities. Clin Pediatr 1994;33(7):421-30.
J.J. Tepas III et al. [10] Gabbe BJ, Simpson PM, Sutherland AM, et al. Functional measures at discharge: are they useful predictors of longer term outcomes for trauma registries? Ann Surg 2008;247(5): 854-9. [11] Gabbe BJ, Sutherland AM, Wolfe R, et al. Can the modified functional independence measure be reliably obtained from the patient medial record by different raters? J Trauma 2007;63(6): 1374-9. [12] Willis CD, Gabbe BJ, Butt W, et al. Assessing outcomes in paediatric trauma populations. Injury 2006;37(12):1185-96. [13] Srivastava R, Downey EC, Feola P, et al. Quality of life of children with neurological impairment who receive a fundoplication for gastroesophageal reflux disease. J Hosp Med 2007;2(3): 165-73. [14] Kochanek PM. Pediatric traumatic brain injury: quo vadis? Dev Neurosci 2006;28(4-5):244-55.