Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury,☆☆

Presented at the 30th Annual Meeting of the American Pediatric Surgical Association, Rancho Mirage, California, May 16-19, 1999.
https://doi.org/10.1016/S0022-3468(00)90003-4Get rights and content

Abstract

Purpose: This study is intended to resolve the disparity and reach consensus on issues regarding the treatment of children with isolated spleen or liver injuries. To maximize patient safety and assure efficient, cost-effective utilization of resources, it was essential to determine current practice. Methods: Data from the case records of 856 children with isolated spleen or liver injury treated at 32 pediatric surgical centers from July 1995 to June 1997 were collected. The severity of injury was classified by computed tomography (CT) grade and the data analyzed for intensive care unit (ICU) stay, length of hospital stay, transfusion requirement, need for operation, pre- and postdischarge imaging, and restriction of physical activity. Patients with grade V injuries (2.8%) were excluded leaving 832 patients for detailed review. These data and available literature were analyzed for consensus by the 1998 APSA Trauma Committee. Results: Resource utilization increased with injury severity (see Table 2). Based on the data analysis, literature search, and consensus conference, the authors propose guidelines (see Table 3) for the safe and optimal utilization of resources in routine cases. It is important to emphasize that no recommendation falls outside the 25th percentile of current practice at participating centers. Conclusions: Diversity of treatment, with attendant variation in resource utilization in children with isolated spleen and liver injury of comparable severity is confirmed. This analysis has stimulated a prospective outcomes study with the objective of validating the evidence-based guidelines proposed. This evidence-based study design can bring order and conformity to patient management resulting in optimal utilization of resources while maximizing patient safety. J Pediatr Surg 35:164-169. Copyright © 2000 by W.B. Saunders Company.

Section snippets

Materials and methods

Data from the case records of 856 children with isolated spleen or liver injury treated at 32 pediatric surgical centers from July 1995 to June 1997 were collected (Appendix). Twenty-six of 32 centers (81%) reported at least 15 patients. Patients with minor, remote injuries such as nondisplaced, noncomminuted fractures; soft tissue injuries; or less severe solid abdominal organ injuries were included as long as the associated injuries did not influence the variables in this study. The patients

Results

Clinical parameters in the 832 patients are described in Tables 1 and 2.

. Clinical Parameters in 832 Children With Isolated Spleen or Liver Injury

Age
 1-9 yr474 (57%)
 10-15 yr308 (37%)
 >15 yr50 (6%)
Gender65% boys
Diagnosis by CT99.0% (8 patients taken directly to operating room without imaging)
CT grade
 I116 (14%)
 II341 (41%)
 III275 (33%)
 IV100 (12%)
Mean Injury Severity Score12.1

. Resource Utilization and Activity Restriction in 832 Children With Isolated Spleen or Liver Injury

Empty CellCT Grade
Empty CellIIIIIIIV
Admitted to ICU

Discussion

Evidence-based medicine involves integrating current best evidence (medical literature) with clinical expertise and patient preferences in making decisions about the care of individual patients. Evidence-based methodology is the emerging cornerstone of the clinical practice guideline process. Recently, several trauma societies have developed practice guidelines using evidence-based methodology.10

There are no randomized, controlled trials (Class I evidence) regarding optimal resource utilization

Acknowledgements

The author appreciates the many contributions of the 1997-98 APSA Trauma Committee members (Bonnie Beaver, Mary Fallat, Dennis Lund, Tres Scherer, David Meagher, Ron Sharp, Tim Canty, Robert Foglia, Enrique Grisoni, Richard Weiss, Marc Cullen) and the statistical expertise of Shirley Chuang.

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Supported in part by the APSA Foundation and the Arnold P. Gold Foundation.

☆☆

Address reprint requests to Steven Stylianos, MD, Babies & Children's Hospital of NY—Rm 207N, 3959 Broadway, New York, NY 10032.

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