Pediatric Solid Organ Injury Operative Interventions at Harborview Medical Center, 2001 to 2012
To evaluate the effectiveness of the Pediatric Solid Organ Injury Pathway at Harborview Medical Center (HMC): to determine what proportion of pediatric solid organ injury patients qualify for care under this pathway by having isolated injury, and to determine whether the proportion of patients receiving abdominal operative interventions, including splenectomy, changed at HMC after institution of the pathway in 2005.
Retrospective cohort study Setting: Harborview Medical Center, Seattle, Washington Intervention: None Subjects: Pediatric (0-18 years) trauma patients at HMC with solid organ (liver or spleen) injury during 2001-2012.
Methods and main results:
Patients were identified in the Harborview Trauma Registry via ICD-9 codes for the presence of liver and spleen injuries. Demographic information, clinical characteristics and ICD-9 procedure codes were also obtained from the Harborview Trauma Registry. A minority of patients had isolated organ injury (less than 30%,) and were thus eligible for pathway care beginning in 2005. The operative proportion was low before and after institution of the pathway in 2005; a slight decrease in the operative proportion was observed after adjusting for the increase in Injury Severity Score (ISS) observed over time. Among patients with isolated splenic injury, 3.1% received splenectomy in 2001-2004 (5.6% adjusted for ISS,) compared to 3.3% in 2005-2012. Among patients with isolated spleen or liver injury, 6.3% (adjusted for ISS; 6.1% unadjusted) underwent a related abdominal surgery (exploratory laparotomy, spleen or liver repair, or splenectomy) in 2001-2004, vs. 4.4% in 2005-2012. Among patients with non-isolated splenic injury, who would not have been eligible for pathway care but whose care may have been influenced by a general change in practice over time, 9.8% (adjusted for ISS; 7.9% unadjusted) received splenectomy in 2001-2004, vs. 8.7% in 2005-2012. In patients with non-isolated liver or spleen injury, 11.5% (adjusted for ISS; 11.0% unadjusted) underwent abdominal surgery in 2001-2004, vs. 13.8% in 2005-2012.
The proportion of patients who had isolated splenic or hepatic injury, thereby qualifying for pathway care, was relatively low. In both time periods, receipt of splenectomy was infrequent, and appeared to meet nationally published guidelines for care of isolated splenic injury. Patient severity of injury increased over time. Adjusting for ISS, slightly fewer splenectomies occurred in the post-pathway period compared to the pre-pathway period.