The Pediatric Guideline Adherence and Outcomes (PEGASUS) programme in severe traumatic brain injury: a single-centre hybrid implementation and effectiveness study

被引：33

作者：

Vavilala, Monica S. ^{[1
,2
,3
]}

King, Mary A. ^{[1
,3
]}

Yang, Jen-Ting ^{[1
,2
]}

Erickson, Scott L. ^{[1
,4
]}

Mills, Brianna ^{[1
]}

Grant, Rosemary M. ^{[8
]}

Blayney, Carolyn ^{[8
]}

Qiu, Qian ^{[1
]}

Chesnut, Randall M. ^{[1
,5
]}

Jaffe, Kenneth M. ^{[1
,6
]}

Weiner, Bryan J. ^{[7
]}

Johnston, Brian D. ^{[1
,3
]}

机构：

[1] Univ Washington, Harborview Injury Prevent & Res Ctr, Seattle, WA 98195 USA

[2] Univ Washington, Dept Anesthesiol & Pain Med, Seattle, WA 98195 USA

[3] Univ Washington, Dept Pediat, Seattle, WA 98195 USA

[4] Univ Washington, Dept Epidemiol, Seattle, WA 98195 USA

[5] Univ Washington, Dept Neurol Surg & Global Hlth Med, Seattle, WA 98195 USA

[6] Univ Washington, Dept Rehabil Med, Seattle, WA 98195 USA

[7] Univ Washington, Dept Global Hlth, Seattle, WA 98195 USA

[8] Univ Washington, Harborview Med Ctr, Clin Educ, 325 9Th Ave, Seattle, WA 98104 USA

来源：

LANCET CHILD & ADOLESCENT HEALTH | 2019年 / 3卷 / 01期

基金：

美国国家卫生研究院;

关键词：

CLINICAL CARE; CHILDREN; MANAGEMENT;

D O I：

10.1016/S2352-4642(18)30341-9

中图分类号：

R72 [儿科学];

学科分类号：

100202 ;

摘要：

Background As far as we know, there are no tested in-hospital care programmes for paediatric traumatic brain injury We aimed to assess implementation and effectiveness of the Pediatric Guideline Adherence and Outcomes (PEGASUS) programme in children with severe traumatic brain injury. Methods We did a prospective hybrid implementation and effectiveness study at the Harborview Medical Center (Seattle, WA, USA). We included children (aged <18 years) with traumatic brain injury (trauma mechanism and image findings). We assessed service provision, adherence to three key performance indicators, and discharge outcomes associated with the PEGASUS programme. The three key performance indicators were early initiation of enteral (oral or tube feeds) or parenteral nutrition; avoidance of any unwanted hypocarbia (PaCO2 <30 mm Hg) without brain herniation; and maintenance of cerebral perfusion pressure (>40 mm Hg) for 72 h after the diagnosis of severe traumatic brain injury. Poisson regression with robust standard errors was used to estimate the association between adhering to key performance indicators and discharge outcomes. Findings Between May 1, 2011, and July 1, 2017, 199 children (median age 11.9 years [IQR 3.4-16.1]) participated in the PEGASUS programme, of whom 193 (97%) had severe traumatic brain injury and six (3%) had moderate traumatic brain injury. 105 patients contributed data for all three key performance indicators. Adherence to at least one key performance indicator was achieved by 101 (96%) of 105 participants, and 44 (42%) achieved adherence to all three key performance indicators. Programme participants achieved adherence to the key performance indicators of hypocarbia (76 of 105 [72%]), nutrition (162 of 199 [81%]), and cerebral perfusion pressure (128 of 199 [64%]). Adherence to the nutrition key performance indicator was associated with higher discharge survival (relative risk [RR] 2.70, 95% CI 1.54-4.73) and a more favourable discharge disposition (3.05, 1.52-6.11). Adherence to the cerebral perfusion pressure key performance indicator was also associated with higher discharge survival (RR 1.33, 95% CI 1.12-1.59) and favourable disposition (1.53, 1.19-1.96). Adherence to each additional key performance indicator was associated with higher survival (RR 1.27,1.12-1.44) and a more favourable discharge disposition (1.46, 1.23-1.72), in a dose-response manner. Interpretation The multilevel, hospital-wide, high-fidelity PEGASUS programme might benefit children and adolescents admitted to the emergency department with severe traumatic brain injury. Cerebral perfusion pressure, nutrition, and hypocarbia targets are essential components of the PEGASUS programme and are associated with favourable discharge outcomes. Copyright (C) 2018 Elsevier Ltd. All rights reserved.

引用

页码：23 / 34

页数：12

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