Program improves care for children with brain injury

A study involving 16 South American hospitals has shown that a program developed at a Level I Trauma Center in the United States to promote guideline adherence can improve care of children with severe traumatic brain injury.

The study appeared March 27 in the journal Critical Care Medicine.

"The lesson here is this approach can be adapted for and adopted by hospitals that are not Level I Trauma Centers, be they in South America, Asia, Europe or the U.S.," said first author Dr. Monica Vavilala, professor of anesthesiology, pain medicine and of pediatrics at the University of Washington School of Medicine. 

The program, called the Pediatric Guideline Adherence and Outcomes (PEGASUS) program, was designed at Harborview Medical Center, a Level I Trauma Center affiliated with the UW School of Medicine. PEGASUS was created to help their teams implement new standards of care for pediatric traumatic brain injury. Currently, it can take years for new guidelines to become part of patient care — a delay often called the "know-do" gap. 

Changing practice is far more difficult than introducing a new drug, said co-author Dr. Gustav Petroni, clinical research director of the Center for Informatics and Clinical Research in Rosario, Argentina.

 "A new drug is something you can just pull out from the cabinet and use," Petroni said. "But to change practice requires a culture change. It means convincing people who have been doing things one way for years that what they're doing is not evidence-based and then working with them to find a better way to do it."

The need to bring about such cultural changes has led to a relatively new field of medical research called implementation science, which develops methods and strategies to help make treatments, guidelines, or interventions proven to work in research part of routine clinical care.

The PEGASUS program uses guidelines developed by the Brain Trauma Foundation for the management of pediatric brain trauma. Those guidelines recommend 14 practices shown to improve patient survival and outcomes. These practices include the proper use of medications, brain scans, ventilators and devices used to monitor pressure within the skull.

The PEGASUS approach identifies key staff to drive change, works with them to find the best ways to implement guidelines within their systems and workflows and provides ongoing coaching. Harborview Medical Center conducted a study that showed the method improved guideline adherence and patient survival and outcomes.

In a new study, UW Medicine researchers worked with South American colleagues through the PEGASUS Argentina Study Group. Because the researchers excluded interventions requiring technology that was unavailable, they cut the practices to be implemented to nine. After being trained by the Seattle team, their South American colleagues implemented the program by training staff at participating hospitals.

Sixteen hospitals were recruited — 14 in Argentina, one in Chile and one in Paraguay. Researchers randomly assigned the hospitals to PEGASUS or standard care. Patients were children under 18 admitted to intensive care units (ICU) with severe traumatic brain injury. Many were unresponsive; some required ventilator support.

To assess effectiveness, researchers measured guideline adherence during the first 72 hours after ICU admission. 

"It's a critical time for survival," Vavilala said. "It's also when there's the most chaos, so it's a real test of whether it's possible to implement the program."

Overall adherence levels were nearly identical — 83.7% at control hospitals and 84.4% at PEGASUS hospitals. But those results included patients with multiple injuries, which complicated care. Among patients with isolated traumatic brain injury and no other major injuries, adherence was 8 percentage points higher at PEGASUS hospitals. 

“This is the first randomized trial of an implementation science approach to improving care in adult or pediatric TBI and the first to show that increasing guideline adherence is possible in a real world setting during ICU care for TBI,” Petroni said. “It shows that we can provide much better care for patients with isolated severe traumatic brain injury."

The PEGASUS Argentina study has also greatly expanded capacity of the participating institutions, Petroni said. 

“In addition to helping their staff develop strategies to adopt evidence-based guidelines and improve their teamwork,” he noted, “participation has provided them with hands-on experience in the conduct of clinical research, which will prove invaluable going forward.”

The study was supported by grants from U.S. National Institute of Neurological Disorders and Stroke (5R01NS106560). 

Written by Michael McCarthy.

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