Significant Disparities in Adolescents With Severe Traumatic Brain Injury Across Trauma Center Types: Wide Variation of Tracheostomy and Gastrostomy.

Abstract

Objectives: To explore practice variations in the rate and timing of tracheostomy and gastrostomy for adolescent with severe traumatic brain injury (TBI) across trauma center types.

Design: Retrospective cohort study.

Setting: Trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (2017-2021) included adult (ATC), mixed (MTC), and pediatric trauma centers (PTC).

Patients: Adolescent 14-18 years old with severe TBI (Head Abbreviated Injury Scale: 3-5 and Glasgow Coma Scale: 3-8) requiring mechanical ventilation.

Interventions: None.

Measurements and main results: A multilevel mixed-effect Poisson regression model assessed the association between trauma center type and tracheostomy/gastrostomy rates. Effect sizes for fixed effects were reported as adjusted incidence rate ratio (IRR) with 95% CI. Secondary analyses were performed to assess the association between trauma center types and ventilator-associated pneumonia (VAP). Of 6978 patients, tracheostomy and gastrostomy were performed in 22.5% and 21.3% at ATC, 20.8% and 21.3% at MTC, and 6.9% and 11.1% at PTC, respectively. The median time to tracheostomy was 10 days (interquartile range [IQR], 7-13 d) at ATC, 11 days (IQR, 7-15 d) at MTC, and 15 days (IQR, 11-23 d) at PTC, demonstrating a significantly later timing of tracheostomy at PTC. In the regression model adjusting for potential confounders, treatment at PTC was significantly associated with a decreased likelihood of tracheostomy and gastrostomy placement compared with ATC (adjusted IRR, 0.38; 95% CI, 0.28-0.52; p < 0.001 and adjusted IRR, 0.58; 95% CI, 0.44-0.75; p < 0.001, respectively). There was no significant difference in the occurrence rate of VAP between ATC, MTC, and PTC.

Conclusions: Our results offer insights into the existing current practice variations between ATC, MTC, and PTC in tracheostomy and gastrostomy placement for adolescent with severe TBI. Further research is warranted to examine the impact of these observed disparities on short- and long-term outcomes and to standardize the care process for adolescent patients.