MAKING THE GRADE FOR PEDIATRIC TRAUMA THE REVIEW AND IMPLEMENTATION OF COMPUTED TOMOGRAPHIC (CT) GRADING FOR SOLID ABDOMINAL ORGAN INJURY

MAKING THE GRADE FOR PEDIATRIC TRAUMA THE REVIEW AND IMPLEMENTATION OF COMPUTED TOMOGRAPHIC (CT) GRADING FOR SOLID ABDOMINAL ORGAN INJURY

AUTHORS & DISCLOSURE OF COMMERCIAL INTEREST: Jennifer Thomas 1 MD Jeffrey Gnerre 1 MD Angela Tong 1 MD Adele Brudnicki 1 MD Lesli LeCompte 1 MD 1. New York Medical College Westchester Medical Center, White Plains, NY We, or any members of our immediate family, do not now have or have not had a financial interest or other relationship with a commercial organization that may have a direct or indirect interest in the content of this educational activity.

PURPOSE Interdepartmental initiative with pediatric trauma and radiology to implement grading of solid organ injury on final interpretations of CT examinations for pediatric trauma, including: Liver Spleen Kidneys Assess grading scheme based on descriptions and recommendations determined by the American Association for the Surgery of Trauma (AAST) Educate and review with residents and supervising faculty the accepted categorization of trauma grading in the assessment of solid abdominal organ injuries Implement CT grading of solid abdominal organ injuries in radiology reports

CLINICAL APPLICATION Pediatric trauma surgery applying for accreditation and promotion to a pediatric level 1 trauma center, previously a level 2 trauma center for pediatrics Trauma review committee cited the radiology department for absence of traumatic grading to solid organ injuries American Pediatric Surgical Association (APSA) defined consensus guidelines for resource utilization in hemodynamically stable pediatric patients based on CT grading Reports with radiographic categorization of traumatic injury has vital importance in nonoperative management 1 Non-operative Management Bed rest Level X + 1 day i.e. Level 2 + 1 day = 3 days of bed rest No physical activity Level X + 2 weeks i.e. Level 3 + 2 week = 5 weeks of no physical activity

MATERIALS/METHODS Three Phase Initiative 1 st 2 nd 3 rd Interdepartmental meeting among radiology and pediatric trauma surgery Retrospective review of CT studies conducted in pediatric trauma workup in patients up to age 14 years over a 5-year period Assessment of finalized reports on the use or nonuse of CT grading schemes of solid abdominal organs Educational exhibit, discussion of universal CT grading schemes, as per AAST, presented to both radiology residents and supervising faculty Immediate enactment of grading solid abdominal injury for all future pediatric trauma CT examinations Retrospective review of CT studies conducted in pediatric trauma workup in patients up to age 14 years following education exhibit over a 3-year period Assessment of finalized reports on the use or nonuse of CT grading schemes of solid abdominal organs

CT EXAMINATIONS Evaluation dates: Phase 1: January 1, 2008 to December 31, 2012 Phase 3: January 1, 2013 to December 31, 2015 Inclusions Suspected solid abdominal trauma CT thorax/abdomen/pelvis C+ CT head C- or C+ Exclusions Only head and/or extremity trauma CT thorax/abdomen/pelvis C-/C+ CT extremity C- or C+ CT abdomen/pelvis C+ CT thorax/abdomen/pelvis C- CT abdomen/pelvis C-/C+ CT abdomen/pelvis C- Pediatric patients up to 14 years old Examinations performed at (1) our institution and (2) outside intuitions All examinations interpreted with finalized reports by our institution's radiology department

RESULTS PHASE 1 CT CAP (C+ and C-/C+) CT AP (C+ and C-/C+) Total Traumas 262 51 313 Positive scans 38 11 49 Total of solid abdominal traumatic injuries - Liver - Spleen - Kidney Number of exams with AAST grades Percentage of exams with AAST grades January 1, 2008 to December 31, 2012 44-20 - 21-3 11-6 - 2-3 55-26 - 23-6 11 0 11 25.0% 0.0% 20%

RESULTS PHASE 2 Educational exhibit to discuss universal CT grading schemes as per AAST presented to both radiology residents and supervising pediatric and general body faculty Immediate enactment of grading solid abdominal injury of all future pediatric trauma CT examinations

RESULTS PHASE 3 CT CAP (C+ and C-/C+) CT AP (C+ and C-/C+) Total Traumas 362 57 419 Positive scans 32 14 46 Total of solid abdominal traumatic injuries - Liver - Spleen - Kidney Number of exams with AAST grades Percentage of exams with AAST grades January 1, 2013 to December 31, 2015 35-19 - 14-2 14-4 - 8-2 49-23 - 22-4 26 11 37 74.3% 78.6% 75.5%

RESULTS - SUMMARY Phase 1: Percentage of CT exams with AAST grades 20.0% 2008-2012 Phase 2: Education and implementation of AAST grades 2012 Phase 3: Percentage of CT exams with AAST grades 75.5% 2013-2015

CONCLUSIONS Consensus guidelines defined by American Pediatric Surgical Association call for resource utilization in hemodynamically stable pediatric patients based on CT grading Prior to interdisciplinary education efforts, only 20.0% of finalized CT reports in pediatric trauma patients offered conclusive grading of traumatic solid abdominal injury over a 5-year period Following dedicated educational guidance, substantial increase in official CT report grading over 3 years, to 75.5%. Because of quality initiative, a successful and unified interdisciplinary approach was employed in assessing traumatic injury in our pediatric patients Our institution was able to obtain both accreditation and promotion by the American Association of the Surgery of Trauma to a pediatric level 1 trauma center thereby allowing our healthcare family to serve a greater subset of our neighboring population

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