Journal of Pediatric Surgery 50 (2015) 339–342
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Benchmarks for splenectomy in pediatric trauma: How are we doing?☆,☆☆,★,★★ Stephanie F. Polites a, Martin D. Zielinski a, Abdalla E. Zarroug a, Amy E. Wagie b, Steven Stylianos c, Elizabeth B. Habermann b,⁎ a b c
Department of Surgery, Mayo Clinic, Rochester, MN Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN Department of Surgery, Columbia University College of Physicians & Surgeons, Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY
a r t i c l e
i n f o
Article history: Received 1 September 2014 Accepted 2 September 2014 Key words: Pediatric trauma Spleen Splenectomy
a b s t r a c t Background/purpose: Following publication of American Pediatric Surgical Association (APSA) hospital benchmarks for the operative management of blunt splenic trauma in specialized centers, it was found that most hospitals exceeded these benchmarks. We sought to determine if benchmarks were being met a decade later and to identify factors associated with splenectomy in injured children. Methods: Rates of splenic procedures were calculated for children ≤19 with a blunt splenic injury (ICD-9 865) using the 2010–2011 National Trauma Data Bank. Multivariable analysis was performed to determine independent predictors of splenectomy. Results: Of 8597 children, 24.3% received care at pediatric trauma centers (PTC), 34.6% at adult trauma centers (ATC), and the remaining 41.2% at other centers (OTC). The overall operative rate was 9.2% (3.9% if age ≤ 14, 6.7% if ≤17). Operative rates were higher in children treated at ATC and OTC when compared to PTC. On multivariable analysis, age N14, coexisting injuries, severity of splenic injury, and care at ATC or OTC were predictive of undergoing operative treatment. Conclusions: Operative rates for splenic injuries meet APSA benchmarks at PTC yet remain high at other centers. Care at an ATC or OTC is associated with greater odds of operative management after adjustment for age and injury severity. © 2015 Elsevier Inc. All rights reserved.
Trauma is the most common cause of morbidity and mortality in children. To improve care for injured children, pediatric trauma centers (PTC) were developed and are now verified by the American College of Surgeons Committee on Trauma (ACSCOT) [1,2]. While children who receive care at PTC benefit from improved outcomes, many children do not have access to a PTC [2–5]. Differences in outcomes between PTC and other institutions are likely owing to variability in management. In children with blunt abdominal trauma, those treated at institutions without pediatric trauma specialization were more likely to receive operative management [4,5]. Since nonoperative management of most blunt splenic injuries has been shown to be safe and associated with improved outcomes including decreased hospital stay and need for
transfusion, management guidelines and benchmarks were developed by the American Pediatric Surgery Association (APSA) in 2000 [6]. Guidelines for nonoperative management were created based on review of 856 children treated at PTC and subsequently validated as effective in reducing resource utilization and improving outcomes [6–8]. Intensive care unit (ICU) admission was recommended only for children with grade IV injuries. Recommended hospital stay was 2–5 days and recommended activity restriction from 3 to 6 weeks depending on splenic injury grade. No predischarge or postdischarge imaging was advised. Though no guidelines for early operative intervention were published, benchmarks for operative rates were established based on rates at PTC — 0–3% for
Abbreviations: APSA, American Pediatric Surgical Association; PTC, pediatric trauma centers; ATC, adult trauma centers; OTC, other trauma centers; ICU, intensive care unit; ASCOT, American College of Surgeons Committee on Trauma; NTDB RDS, National Trauma Data Bank Research Data Set; AIS, Abbreviated Injury Scale; ISS, Injury Severity Score; OR, odds ratio; CI, confidence interval. ☆ This paper was accepted for oral presentation at the 2014 Western Pediatric Trauma Conference, July 2014, San Diego, CA. ☆☆ No external funding for this study was received and the authors have no disclosures. ★ This publication was made possible by CTSA grant number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH. ★★ The NTDB remains the full and exclusive copyrighted property of the American College of Surgeons. The American College of Surgeons is not responsible for any claims arising from works based on the original data, text, tables, or figures. ⁎ Corresponding author at: Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905. Tel.: +1 507 266 2743. E-mail address: [email protected] (E.B. Habermann). http://dx.doi.org/10.1016/j.jpedsurg.2014.09.001 0022-3468/© 2015 Elsevier Inc. All rights reserved.
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isolated splenic injuries and 5–11% for children with coexisting injuries [9]. Evaluation of four states' discharge data revealed operative rates at most hospitals exceeded PTC benchmarks and concluded that further disseminations of recommendations were needed, through peerreviewed publications, creation of audiovisual education materials, and incorporation into state and ACSCOT quality improvement or verification processes [9]. The purpose of this study was to determine (1) whether benchmarks are being met on a national level a decade later and (2) to determine patient and institution characteristics associated with splenectomy in injured children.
1. Methods 1.1. Patient identification Patients age ≤19 years with blunt splenic injuries (ICD-9-CM 865) were identified from the 2010–2011 National Trauma Data Bank Research Data Set (NTDB RDS). Patient characteristics including age, sex, and coexisting injuries, were determined. A coexisting injury was defined as any abbreviated injury scale (AIS) ≥ 2 in a nonabdominal region. Patients with coexisting spleen and liver injuries were identified using the ICD-9-CM codes for liver and spleen injuries (864 and 865, respectively). ICD-9-CM procedure codes were used to identify those who underwent transfusion (99.04), abdominal angiography (88.47), splenic repair (41.43), partial splenectomy (41.95), or splenectomy (41.5). Characteristics of the treating trauma center were recorded, including presence of a pediatric intensive care unit (ICU) and ACSCOT adult or pediatric trauma verification level. PTC was defined as a pediatric level I or II center, an adult trauma center (ATC) as an adult level I or II center without pediatric verification, and other trauma center (OTC) as a level III, level IV, or centers with state verification only.
1.2. Data source The NTDB RDS contains patient-level data provided voluntarily by trauma centers to the ACSCOT that is released on an annual basis. In 2011, the NTDB contained more than five million patient entries from more than 900 institutions in the United States and Puerto Rico [10]. All institutions have ACSCOT or state level verification. Participating institutions utilize standard inclusion criteria and variable definitions according the NTDB data dictionary and all contributed data are reviewed by the NTDB Validator prior to inclusion. The NTDB RDS includes all of the ICD-9-CM codes for each patient. AIS data were obtained from the NTDB RDS, which utilizes ICD-9-CM codes to calculate AIS in a standardized fashion using the ICDMAP-90 crosswalk.
1.3. Data analysis Rates of operative intervention for splenic injuries (splenectomy, partial splenectomy, splenic repair) were calculated for patients and by age categories (≤ 14, 15–17, and 18–19). Patient characteristics were compared between those who underwent operation and those who did not using t- and chi square tests. Children who underwent angiography were not placed in the splenectomy group unless they had a coexisting ICD-9 code for splenectomy. A multivariable logistic regression model for the risk of operation was created using variables both clinically and statistically significant on univariable analysis. These variables included patient age, coexisting injuries, type of trauma center (PTC, ATC, or OTC), and severity of splenic injury based on ICD-9-CM codes for capsular tear, parenchymal laceration, or massive parenchymal disruption. Results are reported as odds ratios (OR) with 95% confidence intervals (CI). Statistical significance was acknowledged when p b .05. All data analyses were completed in SAS (SAS Institute, Cary, NC).
2. Results 2.1. Characteristics of children with blunt splenic injuries Over the study period, 8597 children sustained a blunt splenic injury. The overall splenectomy rate was 8.4% and 3.0% underwent splenic repair or partial splenectomy for a total operative rate of 11.4%. Most children were male (69.7%), 44.4% were ≤14 years of age, while 30.1% were 15–17 years of age, and 25.5% were 18–19 years of age at the time of injury. Out of the full cohort, 24.3% received care at a PTC, while 34.6% received care at an ATC and the remaining 41.2% at an OTC. A pediatric ICU was available at the treating center for most children (70.9%). The most frequent splenic injury was capsular tear (37.0%), followed by parenchymal laceration (33.5%). Massive parenchymal disruption occurred in 9.8% and the remaining 19.6% sustained a contained hematoma or other unspecified injury. Most children sustained a coexisting nonabdominal injury (57.3%) while 15.4% had a coexisting liver injury. Angiography was attempted similarly across PTC, ATC, and OTC (2.9% vs. 2.4% vs. 2.1%, p = .13). Children who underwent a splenic operation had greater rates of transfusion (33.0% vs. 8.0%, p b .001) and were more likely to be hospitalized at least 10 days (41.5% vs. 14.4%, p b .001) than children managed nonoperatively. 2.2. Univariate analysis of children who underwent splenectomy The operative rates for splenic injuries varied with patient age; the youngest children were least likely to undergo operative intervention (age b14: 3.9%, age 15–17: 11.0%, age 18–19: 16.3%, p b .001). Median Injury Severity Score (ISS) and median abdominal AIS were greater in children who underwent operative intervention (ISS: 27 vs. 14, p b .001; AIS: 4 vs. 2, p b .001). Children with any coexisting injury were more likely to undergo operative intervention than those without (12.0% vs. 5.6%, p b .001), as were those with a coexisting head (12.8% vs. 7.9%, p b .001) or liver injuries (15.0% vs. 8.2%, p b .001). Operative rates were within benchmarks at PTC but exceeded them at ATC and OTC for children with and without coexisting injuries (coexisting injury: PTC 7.6% vs. ATC 15.3% vs. OTC 11.2%, p b .001; no coexisting injury: PTC 2.8% vs. ATC 8.5% vs. OTC 5.2%, p b .001). The operative rate was lower in children treated at hospitals with a pediatric ICU (7.8% vs. 12.7%, p b .001). When stratified by age, operative rates varied by type of trauma center for children ≤14 and 15–17 (Table 1). In the oldest children, operative rates did not vary by type of center. 2.3. Multivariable analysis of characteristics associated with splenectomy On multivariable analysis, patient age, the presence of coexisting injuries, severity of splenic injury, and type of trauma center independently impacted odds of undergoing a splenic operation (Table 2). Children age 18–19 (OR = 3.9, p b .001) and those with a parenchymal laceration (OR = 3.3, p b .001) or massive parenchymal disruption (OR = 17.0, p b .001) were at the greatest odds of undergoing an operation for their spleen injury. Care at a PTC was protective against splenectomy when compared to care at an ATC (OR = 2.2, p b .001) or OTC (OR = 1.8, p b .001). 3. Discussion Nonoperative management of blunt splenic injuries in pediatric trauma patients has been associated with improved outcomes including decreased transfusion and shorter hospitalization [11]. Since operative management was shown to be more likely at nonpediatric trauma centers, benchmarks and guidelines for the management of blunt splenic trauma were developed and disseminated in 2006 in order to improve these parameters [9]. Operative rates exceeded benchmarks at ATC and OTC and children treated at these centers were more likely to undergo operative intervention than those treated at a PTC after
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Table 1 Differences in splenectomy rates by age. Age group
≤14
Patient characteristic
Operative rate, %
Gender Any coexisting injury Coexisting head injury Coexisting liver injury Received a transfusion Trauma center (coexisting injury)
Trauma center (no coexisting injury)
Pediatric ICU
Male Female Yes No Yes No Yes No Yes No PTC ATC OTC PTC ATC OTC Yes No
15–17
3.7 4.4 6.0 2.3 7.0 3.1 7.6 3.4 18.3 2.7 4.0 9.9 5.0 1.8 3.7 1.8 3.8 4.5
P value .54 b.001 b.001 b.001 b.001 b.001
.039
.38
Operative rate, % 11.1 10.7 13.4 7.4 14.5 9.5 16.0 10.0 32.6 8.6 7.4 16.9 12.4 3.7 9.3 7.8 9.6 13.6
18–19 P value .79 b.001 b.001 b.001 b.001 b.001
.029
.002
Operative rate, % 17.0 15.2 16.7 15.3 17.0 16.0 21.2 15.1 36.8 12.6 15.9 17.1 16.4 11.7 16.8 14.5 15.9 16.9
P value .047 .46 .55 .002 b.001 .88
.56
.51
PTC, pediatric trauma center; ATC, adult trauma center; OTC, other trauma center. Any coexisting injury was defined as any nonabdominal AIS N2, coexisting head injury as head AIS N2, and coexisting liver injury as concurrent ICD-9 code of 864.
adjustment for age and injury severity. Given that the majority of injured children were not treated at PTCs, additional efforts are needed to ensure all children with blunt splenic injuries have access to nonoperative management when appropriate. Differences in care processes, expertise, and resources are thought to underlie much of the variation in treatment and outcomes between PTCs and other institutions that care for injured children [12]. Based on guidelines for the nonoperative management of splenic trauma, specialized resources are necessary to safely monitor children with these injuries [6,13]. We found that availability of a pediatric ICU was greater at PTCs and was univariately associated with a decreased rate of operative management. Furthermore, abdominal angiography was performed more frequently in children treated at PTCs. Children brought to centers lacking resources to safety manage blunt abdominal trauma should receive early and strong consideration for transfer, as following APSA guidelines has been shown to reduce the resources necessary to manage these injuries nonoperatively. For example, ICU admission is only recommended for grade IV injuries; thus, lack of a pediatric ICU should not preclude nonoperative management for most children. These results indicate that further dissemination of guidelines to centers and providers without pediatric specialization is needed to assure them of the feasibility of nonoperative management. APSA guidelines and benchmarks define ideal operative rates and guidelines for resource utilization in nonoperative management; however, they do not provide decision support for the initial determination of operative versus nonoperative management. Addition of criteria for immediate operative management would likely reduce splenectomy Table 2 Independent predictors of splenectomy in children with blunt splenic trauma. Patient characteristics Age (vs. 0–14) Coexisting injury Coexisting liver injury Trauma center (vs. PTC) Splenic injury severity (vs. hematoma or unknown)
15–17 18–19
ATC OTC Capsular tear Parenchymal laceration Massive parenchymal disruption
Odds ratio
P value
2.6 3.9 1.9 1.6 2.2 1.8 1.0 3.3 17.0
b.001 b.001 b.001 b.001 b.001 b.001 .91 b.001 b.001
PTC, pediatric trauma center; ATC, adult trauma center; OTC, other trauma center. Any coexisting injury was defined as any nonabdominal AIS N2 and coexisting liver injury as a concurrent ICD-9 code of 864. Splenic injury severity was determined using ICD-9 codes.
rates. These criteria could be determined by studying characteristics of children who failed nonoperative management. Potential criteria could include hemodynamic instability despite resuscitation, peritonitis, or coexisting pancreatic injuries [14,15]. Education about guidelines and benchmarks for nonoperative management of pediatric blunt splenic injuries through academic presentations and publications, audiovisual materials, and incorporation into verification processes was recommended in 2006; however, effectiveness has not been measured [9]. Identification of the most effective methods would facilitate expedited diffusion of management guidelines. Though some of the disparity in operative rates can be alleviated by transfer of children to PTCs, transfer of all children with blunt splenic injuries is neither necessary nor feasible. Leinwand et al. found that implementation of a practice management guideline based on APSA recommendations was effective in decreasing resource utilization in children with blunt splenic injuries [8]. The ACSCOT will soon require use of “clinical practice guidelines, protocols, and algorithms derived from evidenced-based validated resources” as part of the verification process for situations including massive transfusion, cervical spine clearance, and venous thromboembolism prophylaxis [16]. Though performance review of the care of children is required by the ACSCOT, there is no requirement for verified centers to create protocols for management of pediatric blunt splenic injuries. Addition of such a requirement in the future for all trauma centers that treat pediatric patients may improve compliance with APSA guidelines. Though the setting of care was a significant predictor of splenectomy on multivariable analysis in this study, patient age and injury severity, including coexisting injuries, were also significant predictors. This highlights the importance of taking into account patient case mix when studying hospital-level differences in management of pediatric trauma. Given that 22.8% of PTCs have a pediatric age cut off of b14 years and 71.6% define a pediatric patient as b17 years, many of the children who underwent splenectomy in this study were likely treated by adult trauma providers using adult guidelines and practices [12,17]. This may explain the narrowed variation in splenectomy rates between PTC, ATC, and OTC in older children in this study. There is room to improve upon care of older children with blunt splenic injuries and reduce operative rates in these patients even further, as existing data indicate that nonoperative management is safe in older children [15]. Benchmarks and guidelines for the management of pediatric blunt splenic injuries could be enhanced by taking these important factors into account. Our study has several limitations including use of an administrative data set that relies on ICD-9-CM diagnosis and procedure codes to
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identify patients of interest. The benefit of this data source over others is that it is representative of the national experience and it includes patients treated at the entire spectrum of facilities with respect to trauma verification and specialization. Selection bias is present, however, because the NTDB RDS only includes centers with state or ACSCOT verification. As previously mentioned, the age cut off for pediatric patients varies between centers that participate in NTDB and it is possible that children in this study received care from an adult trauma surgeon at a PTC. Lastly, there is no specific procedure code for angiographic evaluation and treatment of splenic injuries; thus, the code for abdominal angiography was used as a surrogate. More precise data on this as well as other resources including transfusion and computed tomography scanning would aid investigation of institutional variation in management of pediatric blunt splenic injuries. 4. Conclusions In conclusion, children with blunt splenic injuries treated at ATC or OTC are more likely to undergo an operation. Despite the dissemination of APSA benchmarks in the literature, operative rates in the oldest children exceed these benchmarks at PTCs. Further efforts to eliminate this treatment disparity, including early transfer of children with advanced blunt splenic injuries to PTCs and incorporation of APSA guideline-based management protocols into trauma center verification, are suggested. References [1] Hulka F. Pediatric trauma systems: critical distinctions. J Trauma 1999;47:S85–9. [2] Petrosyan M, Guner YS, Emami CN, et al. Disparities in the delivery of pediatric trauma care. J Trauma 2009;67:S114–9.
[3] Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med 2009;163:512–8. [4] Davis DH, Localio AR, Stafford PW, et al. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics 2005;115:89–94. [5] Matsushima K, Kulaylat AN, Won EJ, et al. Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database. J Surg Res 2013;183:808–13. [6] Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg 2000;35:164–7 [discussion 7–9]. [7] Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg 2002;37:453–6. [8] Leinwand MJ, Atkinson CC, Mooney DP. Application of the APSA evidence-based guidelines for isolated liver or spleen injuries: a single institution experience. J Pediatr Surg 2004;39:487–90 [discussion -90]. [9] Stylianos S, Egorova N, Guice KS, et al. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg 2006;202:247–51. [10] American College of Surgeons: National Trauma Data Bank NTDB Research Data Set Admission Year 2011 User Manual, American College of Surgeons. Accessed June 13, 2014 at http://www.facs.org/trauma/ntdb/pdf/ntdbmanual2011.pdf; 2011. [11] Davies DA, Pearl RH, Ein SH, et al. Management of blunt splenic injury in children: evolution of the nonoperative approach. J Pediatr Surg 2009;44:1005–8. [12] Stylianos S, Nathens AB. Comparing processes of pediatric trauma care at children's hospitals versus adult hospitals. J Trauma 2007;63:S96–S100 [discussion S6-12]. [13] Lynn KN, Werder GM, Callaghan RM, et al. Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol 2009;39:904–16 [quiz 1029–30]. [14] McVay MR, Kokoska ER, Jackson RJ, et al. Throwing out the “grade” book: management of isolated spleen and liver injury based on hemodynamic status. J Pediatr Surg 2008;43:1072–6. [15] Tataria M, Nance ML, Holmes JHT, et al. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007;63:608–14. [16] Committee on Trauma: Resources for Optimal Care of the Injured Patient 2014. In: Rotondo MF, Cribari C, Smith RS, editors. American College of Surgeons; 2014 [(pre-publication). Accessed June 13, 2014 at http://www.facs.org/trauma/ verification/resources-preview/resources.pdf]. [17] American College of Surgeons: National Trauma Data Bank 2012 Pediatric ReportIn: Nance ML, editor. ; 2012 [Accessed June 13, 2014 at http://www.facs.org/trauma/ ntdb/pdf/ntdb-pediatric-annual-report-2012.pdf].
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Benchmarks for splenectomy in pediatric trauma: How are we doing?☆,☆☆,★,★★ Stephanie F. Polites a, Martin D. Zielinski a, Abdalla E. Zarroug a, Amy E. Wagie b, Steven Stylianos c, Elizabeth B. Habermann b,⁎ a b c
Department of Surgery, Mayo Clinic, Rochester, MN Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN Department of Surgery, Columbia University College of Physicians & Surgeons, Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY
a r t i c l e
i n f o
Article history: Received 1 September 2014 Accepted 2 September 2014 Key words: Pediatric trauma Spleen Splenectomy
a b s t r a c t Background/purpose: Following publication of American Pediatric Surgical Association (APSA) hospital benchmarks for the operative management of blunt splenic trauma in specialized centers, it was found that most hospitals exceeded these benchmarks. We sought to determine if benchmarks were being met a decade later and to identify factors associated with splenectomy in injured children. Methods: Rates of splenic procedures were calculated for children ≤19 with a blunt splenic injury (ICD-9 865) using the 2010–2011 National Trauma Data Bank. Multivariable analysis was performed to determine independent predictors of splenectomy. Results: Of 8597 children, 24.3% received care at pediatric trauma centers (PTC), 34.6% at adult trauma centers (ATC), and the remaining 41.2% at other centers (OTC). The overall operative rate was 9.2% (3.9% if age ≤ 14, 6.7% if ≤17). Operative rates were higher in children treated at ATC and OTC when compared to PTC. On multivariable analysis, age N14, coexisting injuries, severity of splenic injury, and care at ATC or OTC were predictive of undergoing operative treatment. Conclusions: Operative rates for splenic injuries meet APSA benchmarks at PTC yet remain high at other centers. Care at an ATC or OTC is associated with greater odds of operative management after adjustment for age and injury severity. © 2015 Elsevier Inc. All rights reserved.
Trauma is the most common cause of morbidity and mortality in children. To improve care for injured children, pediatric trauma centers (PTC) were developed and are now verified by the American College of Surgeons Committee on Trauma (ACSCOT) [1,2]. While children who receive care at PTC benefit from improved outcomes, many children do not have access to a PTC [2–5]. Differences in outcomes between PTC and other institutions are likely owing to variability in management. In children with blunt abdominal trauma, those treated at institutions without pediatric trauma specialization were more likely to receive operative management [4,5]. Since nonoperative management of most blunt splenic injuries has been shown to be safe and associated with improved outcomes including decreased hospital stay and need for
transfusion, management guidelines and benchmarks were developed by the American Pediatric Surgery Association (APSA) in 2000 [6]. Guidelines for nonoperative management were created based on review of 856 children treated at PTC and subsequently validated as effective in reducing resource utilization and improving outcomes [6–8]. Intensive care unit (ICU) admission was recommended only for children with grade IV injuries. Recommended hospital stay was 2–5 days and recommended activity restriction from 3 to 6 weeks depending on splenic injury grade. No predischarge or postdischarge imaging was advised. Though no guidelines for early operative intervention were published, benchmarks for operative rates were established based on rates at PTC — 0–3% for
Abbreviations: APSA, American Pediatric Surgical Association; PTC, pediatric trauma centers; ATC, adult trauma centers; OTC, other trauma centers; ICU, intensive care unit; ASCOT, American College of Surgeons Committee on Trauma; NTDB RDS, National Trauma Data Bank Research Data Set; AIS, Abbreviated Injury Scale; ISS, Injury Severity Score; OR, odds ratio; CI, confidence interval. ☆ This paper was accepted for oral presentation at the 2014 Western Pediatric Trauma Conference, July 2014, San Diego, CA. ☆☆ No external funding for this study was received and the authors have no disclosures. ★ This publication was made possible by CTSA grant number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH. ★★ The NTDB remains the full and exclusive copyrighted property of the American College of Surgeons. The American College of Surgeons is not responsible for any claims arising from works based on the original data, text, tables, or figures. ⁎ Corresponding author at: Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905. Tel.: +1 507 266 2743. E-mail address: [email protected] (E.B. Habermann). http://dx.doi.org/10.1016/j.jpedsurg.2014.09.001 0022-3468/© 2015 Elsevier Inc. All rights reserved.
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isolated splenic injuries and 5–11% for children with coexisting injuries [9]. Evaluation of four states' discharge data revealed operative rates at most hospitals exceeded PTC benchmarks and concluded that further disseminations of recommendations were needed, through peerreviewed publications, creation of audiovisual education materials, and incorporation into state and ACSCOT quality improvement or verification processes [9]. The purpose of this study was to determine (1) whether benchmarks are being met on a national level a decade later and (2) to determine patient and institution characteristics associated with splenectomy in injured children.
1. Methods 1.1. Patient identification Patients age ≤19 years with blunt splenic injuries (ICD-9-CM 865) were identified from the 2010–2011 National Trauma Data Bank Research Data Set (NTDB RDS). Patient characteristics including age, sex, and coexisting injuries, were determined. A coexisting injury was defined as any abbreviated injury scale (AIS) ≥ 2 in a nonabdominal region. Patients with coexisting spleen and liver injuries were identified using the ICD-9-CM codes for liver and spleen injuries (864 and 865, respectively). ICD-9-CM procedure codes were used to identify those who underwent transfusion (99.04), abdominal angiography (88.47), splenic repair (41.43), partial splenectomy (41.95), or splenectomy (41.5). Characteristics of the treating trauma center were recorded, including presence of a pediatric intensive care unit (ICU) and ACSCOT adult or pediatric trauma verification level. PTC was defined as a pediatric level I or II center, an adult trauma center (ATC) as an adult level I or II center without pediatric verification, and other trauma center (OTC) as a level III, level IV, or centers with state verification only.
1.2. Data source The NTDB RDS contains patient-level data provided voluntarily by trauma centers to the ACSCOT that is released on an annual basis. In 2011, the NTDB contained more than five million patient entries from more than 900 institutions in the United States and Puerto Rico [10]. All institutions have ACSCOT or state level verification. Participating institutions utilize standard inclusion criteria and variable definitions according the NTDB data dictionary and all contributed data are reviewed by the NTDB Validator prior to inclusion. The NTDB RDS includes all of the ICD-9-CM codes for each patient. AIS data were obtained from the NTDB RDS, which utilizes ICD-9-CM codes to calculate AIS in a standardized fashion using the ICDMAP-90 crosswalk.
1.3. Data analysis Rates of operative intervention for splenic injuries (splenectomy, partial splenectomy, splenic repair) were calculated for patients and by age categories (≤ 14, 15–17, and 18–19). Patient characteristics were compared between those who underwent operation and those who did not using t- and chi square tests. Children who underwent angiography were not placed in the splenectomy group unless they had a coexisting ICD-9 code for splenectomy. A multivariable logistic regression model for the risk of operation was created using variables both clinically and statistically significant on univariable analysis. These variables included patient age, coexisting injuries, type of trauma center (PTC, ATC, or OTC), and severity of splenic injury based on ICD-9-CM codes for capsular tear, parenchymal laceration, or massive parenchymal disruption. Results are reported as odds ratios (OR) with 95% confidence intervals (CI). Statistical significance was acknowledged when p b .05. All data analyses were completed in SAS (SAS Institute, Cary, NC).
2. Results 2.1. Characteristics of children with blunt splenic injuries Over the study period, 8597 children sustained a blunt splenic injury. The overall splenectomy rate was 8.4% and 3.0% underwent splenic repair or partial splenectomy for a total operative rate of 11.4%. Most children were male (69.7%), 44.4% were ≤14 years of age, while 30.1% were 15–17 years of age, and 25.5% were 18–19 years of age at the time of injury. Out of the full cohort, 24.3% received care at a PTC, while 34.6% received care at an ATC and the remaining 41.2% at an OTC. A pediatric ICU was available at the treating center for most children (70.9%). The most frequent splenic injury was capsular tear (37.0%), followed by parenchymal laceration (33.5%). Massive parenchymal disruption occurred in 9.8% and the remaining 19.6% sustained a contained hematoma or other unspecified injury. Most children sustained a coexisting nonabdominal injury (57.3%) while 15.4% had a coexisting liver injury. Angiography was attempted similarly across PTC, ATC, and OTC (2.9% vs. 2.4% vs. 2.1%, p = .13). Children who underwent a splenic operation had greater rates of transfusion (33.0% vs. 8.0%, p b .001) and were more likely to be hospitalized at least 10 days (41.5% vs. 14.4%, p b .001) than children managed nonoperatively. 2.2. Univariate analysis of children who underwent splenectomy The operative rates for splenic injuries varied with patient age; the youngest children were least likely to undergo operative intervention (age b14: 3.9%, age 15–17: 11.0%, age 18–19: 16.3%, p b .001). Median Injury Severity Score (ISS) and median abdominal AIS were greater in children who underwent operative intervention (ISS: 27 vs. 14, p b .001; AIS: 4 vs. 2, p b .001). Children with any coexisting injury were more likely to undergo operative intervention than those without (12.0% vs. 5.6%, p b .001), as were those with a coexisting head (12.8% vs. 7.9%, p b .001) or liver injuries (15.0% vs. 8.2%, p b .001). Operative rates were within benchmarks at PTC but exceeded them at ATC and OTC for children with and without coexisting injuries (coexisting injury: PTC 7.6% vs. ATC 15.3% vs. OTC 11.2%, p b .001; no coexisting injury: PTC 2.8% vs. ATC 8.5% vs. OTC 5.2%, p b .001). The operative rate was lower in children treated at hospitals with a pediatric ICU (7.8% vs. 12.7%, p b .001). When stratified by age, operative rates varied by type of trauma center for children ≤14 and 15–17 (Table 1). In the oldest children, operative rates did not vary by type of center. 2.3. Multivariable analysis of characteristics associated with splenectomy On multivariable analysis, patient age, the presence of coexisting injuries, severity of splenic injury, and type of trauma center independently impacted odds of undergoing a splenic operation (Table 2). Children age 18–19 (OR = 3.9, p b .001) and those with a parenchymal laceration (OR = 3.3, p b .001) or massive parenchymal disruption (OR = 17.0, p b .001) were at the greatest odds of undergoing an operation for their spleen injury. Care at a PTC was protective against splenectomy when compared to care at an ATC (OR = 2.2, p b .001) or OTC (OR = 1.8, p b .001). 3. Discussion Nonoperative management of blunt splenic injuries in pediatric trauma patients has been associated with improved outcomes including decreased transfusion and shorter hospitalization [11]. Since operative management was shown to be more likely at nonpediatric trauma centers, benchmarks and guidelines for the management of blunt splenic trauma were developed and disseminated in 2006 in order to improve these parameters [9]. Operative rates exceeded benchmarks at ATC and OTC and children treated at these centers were more likely to undergo operative intervention than those treated at a PTC after
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Table 1 Differences in splenectomy rates by age. Age group
≤14
Patient characteristic
Operative rate, %
Gender Any coexisting injury Coexisting head injury Coexisting liver injury Received a transfusion Trauma center (coexisting injury)
Trauma center (no coexisting injury)
Pediatric ICU
Male Female Yes No Yes No Yes No Yes No PTC ATC OTC PTC ATC OTC Yes No
15–17
3.7 4.4 6.0 2.3 7.0 3.1 7.6 3.4 18.3 2.7 4.0 9.9 5.0 1.8 3.7 1.8 3.8 4.5
P value .54 b.001 b.001 b.001 b.001 b.001
.039
.38
Operative rate, % 11.1 10.7 13.4 7.4 14.5 9.5 16.0 10.0 32.6 8.6 7.4 16.9 12.4 3.7 9.3 7.8 9.6 13.6
18–19 P value .79 b.001 b.001 b.001 b.001 b.001
.029
.002
Operative rate, % 17.0 15.2 16.7 15.3 17.0 16.0 21.2 15.1 36.8 12.6 15.9 17.1 16.4 11.7 16.8 14.5 15.9 16.9
P value .047 .46 .55 .002 b.001 .88
.56
.51
PTC, pediatric trauma center; ATC, adult trauma center; OTC, other trauma center. Any coexisting injury was defined as any nonabdominal AIS N2, coexisting head injury as head AIS N2, and coexisting liver injury as concurrent ICD-9 code of 864.
adjustment for age and injury severity. Given that the majority of injured children were not treated at PTCs, additional efforts are needed to ensure all children with blunt splenic injuries have access to nonoperative management when appropriate. Differences in care processes, expertise, and resources are thought to underlie much of the variation in treatment and outcomes between PTCs and other institutions that care for injured children [12]. Based on guidelines for the nonoperative management of splenic trauma, specialized resources are necessary to safely monitor children with these injuries [6,13]. We found that availability of a pediatric ICU was greater at PTCs and was univariately associated with a decreased rate of operative management. Furthermore, abdominal angiography was performed more frequently in children treated at PTCs. Children brought to centers lacking resources to safety manage blunt abdominal trauma should receive early and strong consideration for transfer, as following APSA guidelines has been shown to reduce the resources necessary to manage these injuries nonoperatively. For example, ICU admission is only recommended for grade IV injuries; thus, lack of a pediatric ICU should not preclude nonoperative management for most children. These results indicate that further dissemination of guidelines to centers and providers without pediatric specialization is needed to assure them of the feasibility of nonoperative management. APSA guidelines and benchmarks define ideal operative rates and guidelines for resource utilization in nonoperative management; however, they do not provide decision support for the initial determination of operative versus nonoperative management. Addition of criteria for immediate operative management would likely reduce splenectomy Table 2 Independent predictors of splenectomy in children with blunt splenic trauma. Patient characteristics Age (vs. 0–14) Coexisting injury Coexisting liver injury Trauma center (vs. PTC) Splenic injury severity (vs. hematoma or unknown)
15–17 18–19
ATC OTC Capsular tear Parenchymal laceration Massive parenchymal disruption
Odds ratio
P value
2.6 3.9 1.9 1.6 2.2 1.8 1.0 3.3 17.0
b.001 b.001 b.001 b.001 b.001 b.001 .91 b.001 b.001
PTC, pediatric trauma center; ATC, adult trauma center; OTC, other trauma center. Any coexisting injury was defined as any nonabdominal AIS N2 and coexisting liver injury as a concurrent ICD-9 code of 864. Splenic injury severity was determined using ICD-9 codes.
rates. These criteria could be determined by studying characteristics of children who failed nonoperative management. Potential criteria could include hemodynamic instability despite resuscitation, peritonitis, or coexisting pancreatic injuries [14,15]. Education about guidelines and benchmarks for nonoperative management of pediatric blunt splenic injuries through academic presentations and publications, audiovisual materials, and incorporation into verification processes was recommended in 2006; however, effectiveness has not been measured [9]. Identification of the most effective methods would facilitate expedited diffusion of management guidelines. Though some of the disparity in operative rates can be alleviated by transfer of children to PTCs, transfer of all children with blunt splenic injuries is neither necessary nor feasible. Leinwand et al. found that implementation of a practice management guideline based on APSA recommendations was effective in decreasing resource utilization in children with blunt splenic injuries [8]. The ACSCOT will soon require use of “clinical practice guidelines, protocols, and algorithms derived from evidenced-based validated resources” as part of the verification process for situations including massive transfusion, cervical spine clearance, and venous thromboembolism prophylaxis [16]. Though performance review of the care of children is required by the ACSCOT, there is no requirement for verified centers to create protocols for management of pediatric blunt splenic injuries. Addition of such a requirement in the future for all trauma centers that treat pediatric patients may improve compliance with APSA guidelines. Though the setting of care was a significant predictor of splenectomy on multivariable analysis in this study, patient age and injury severity, including coexisting injuries, were also significant predictors. This highlights the importance of taking into account patient case mix when studying hospital-level differences in management of pediatric trauma. Given that 22.8% of PTCs have a pediatric age cut off of b14 years and 71.6% define a pediatric patient as b17 years, many of the children who underwent splenectomy in this study were likely treated by adult trauma providers using adult guidelines and practices [12,17]. This may explain the narrowed variation in splenectomy rates between PTC, ATC, and OTC in older children in this study. There is room to improve upon care of older children with blunt splenic injuries and reduce operative rates in these patients even further, as existing data indicate that nonoperative management is safe in older children [15]. Benchmarks and guidelines for the management of pediatric blunt splenic injuries could be enhanced by taking these important factors into account. Our study has several limitations including use of an administrative data set that relies on ICD-9-CM diagnosis and procedure codes to
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identify patients of interest. The benefit of this data source over others is that it is representative of the national experience and it includes patients treated at the entire spectrum of facilities with respect to trauma verification and specialization. Selection bias is present, however, because the NTDB RDS only includes centers with state or ACSCOT verification. As previously mentioned, the age cut off for pediatric patients varies between centers that participate in NTDB and it is possible that children in this study received care from an adult trauma surgeon at a PTC. Lastly, there is no specific procedure code for angiographic evaluation and treatment of splenic injuries; thus, the code for abdominal angiography was used as a surrogate. More precise data on this as well as other resources including transfusion and computed tomography scanning would aid investigation of institutional variation in management of pediatric blunt splenic injuries. 4. Conclusions In conclusion, children with blunt splenic injuries treated at ATC or OTC are more likely to undergo an operation. Despite the dissemination of APSA benchmarks in the literature, operative rates in the oldest children exceed these benchmarks at PTCs. Further efforts to eliminate this treatment disparity, including early transfer of children with advanced blunt splenic injuries to PTCs and incorporation of APSA guideline-based management protocols into trauma center verification, are suggested. References [1] Hulka F. Pediatric trauma systems: critical distinctions. J Trauma 1999;47:S85–9. [2] Petrosyan M, Guner YS, Emami CN, et al. Disparities in the delivery of pediatric trauma care. J Trauma 2009;67:S114–9.
[3] Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med 2009;163:512–8. [4] Davis DH, Localio AR, Stafford PW, et al. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics 2005;115:89–94. [5] Matsushima K, Kulaylat AN, Won EJ, et al. Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database. J Surg Res 2013;183:808–13. [6] Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg 2000;35:164–7 [discussion 7–9]. [7] Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg 2002;37:453–6. [8] Leinwand MJ, Atkinson CC, Mooney DP. Application of the APSA evidence-based guidelines for isolated liver or spleen injuries: a single institution experience. J Pediatr Surg 2004;39:487–90 [discussion -90]. [9] Stylianos S, Egorova N, Guice KS, et al. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg 2006;202:247–51. [10] American College of Surgeons: National Trauma Data Bank NTDB Research Data Set Admission Year 2011 User Manual, American College of Surgeons. Accessed June 13, 2014 at http://www.facs.org/trauma/ntdb/pdf/ntdbmanual2011.pdf; 2011. [11] Davies DA, Pearl RH, Ein SH, et al. Management of blunt splenic injury in children: evolution of the nonoperative approach. J Pediatr Surg 2009;44:1005–8. [12] Stylianos S, Nathens AB. Comparing processes of pediatric trauma care at children's hospitals versus adult hospitals. J Trauma 2007;63:S96–S100 [discussion S6-12]. [13] Lynn KN, Werder GM, Callaghan RM, et al. Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol 2009;39:904–16 [quiz 1029–30]. [14] McVay MR, Kokoska ER, Jackson RJ, et al. Throwing out the “grade” book: management of isolated spleen and liver injury based on hemodynamic status. J Pediatr Surg 2008;43:1072–6. [15] Tataria M, Nance ML, Holmes JHT, et al. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007;63:608–14. [16] Committee on Trauma: Resources for Optimal Care of the Injured Patient 2014. In: Rotondo MF, Cribari C, Smith RS, editors. American College of Surgeons; 2014 [(pre-publication). Accessed June 13, 2014 at http://www.facs.org/trauma/ verification/resources-preview/resources.pdf]. [17] American College of Surgeons: National Trauma Data Bank 2012 Pediatric ReportIn: Nance ML, editor. ; 2012 [Accessed June 13, 2014 at http://www.facs.org/trauma/ ntdb/pdf/ntdb-pediatric-annual-report-2012.pdf].
