Factors Associated With Functional Impairment After Pediatric Injury | Adolescent Medicine | JAMA Surgery | JAMA Network
[Skip to Navigation]
Sign In
Figure.  Distribution of the Domains of New Morbidity in Each Injury Category
Distribution of the Domains of New Morbidity in Each Injury Category
Table 1.  Associations of New Domain Morbidity With Demographic and Baseline Characteristics
Associations of New Domain Morbidity With Demographic and Baseline Characteristics
Table 2.  Associations of New Domain Morbidity With Injury Characteristics and Outcomes
Associations of New Domain Morbidity With Injury Characteristics and Outcomes
Table 3.  Level of Impairment and Outcomes Among Children and Adolescents With Body Regions With at Least 1 Serious Injurya
Level of Impairment and Outcomes Among Children and Adolescents With Body Regions With at Least 1 Serious Injurya
Table 4.  Comparisons Between the Odds of New Domain Morbidity Among Injury Categories Using Multivariable Logistic Regression
Comparisons Between the Odds of New Domain Morbidity Among Injury Categories Using Multivariable Logistic Regression
1.
Cassidy  LD, Cook  A, Ertl  A, Gourlay  D, Osler  T.  Is the Trauma Mortality Prediction Model (TMPM-ICD-9) a valid predictor of mortality in pediatric trauma patients?   J Pediatr Surg. 2014;49(1):189-192. doi:10.1016/j.jpedsurg.2013.09.055PubMedGoogle ScholarCrossref
2.
Chang MC, ed; American College of Surgeons Committee on Trauma Leadership. National Trauma Data Bank: pediatric annual report. Published 2016. Accessed October 1, 2020. https://www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdb%20pediatric%20annual%20report%202016.ashx
3.
Gabbe  BJ, Simpson  PM, Sutherland  AM,  et al.  Functional and health-related quality of life outcomes after pediatric trauma.   J Trauma. 2011;70(6):1532-1538. doi:10.1097/TA.0b013e31820e8546PubMedGoogle Scholar
4.
Cooper  CG, Santana  MJ, Stelfox  HT.  A comparison of quality improvement practices at adult and pediatric trauma centers.   Pediatr Crit Care Med. 2013;14(8):e365-e371. doi:10.1097/PCC.0b013e3182917a4cPubMedGoogle ScholarCrossref
5.
McCarthy  A, Curtis  K, Holland  AJ.  Paediatric trauma systems and their impact on the health outcomes of severely injured children: an integrative review.   Injury. 2016;47(3):574-585. doi:10.1016/j.injury.2015.12.028PubMedGoogle ScholarCrossref
6.
Sakran  JV, Ezzeddine  H, Schwab  CW,  et al. Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures.  J Am Coll Surg. 2020;230(5):819-835.
7.
Ryder  C, Mackean  T, Hunter  K, Williams  H,  et al.  Equity in functional and health related quality of life outcomes following injury in children—a systematic review.   Crit Public Health. 2020;30(3):352-366. doi:10.1080/09581596.2019.1581918Google ScholarCrossref
8.
Bennett  TD, Dixon  RR, Kartchner  C,  et al.  Functional Status Scale in children with traumatic brain injury: a prospective cohort study.   Pediatr Crit Care Med. 2016;17(12):1147-1156. doi:10.1097/PCC.0000000000000934PubMedGoogle ScholarCrossref
9.
Williams  KS, Young  DK, Burke  GAA, Fountain  DM.  Comparing the WeeFIM and PEDI in neurorehabilitation for children with acquired brain injury: a systematic review.   Dev Neurorehabil. 2017;20(7):443-451. doi:10.1080/17518423.2017.1289419PubMedGoogle ScholarCrossref
10.
Winthrop  AL, Brasel  KJ, Stahovic  L, Paulson  J, Schneeberger  B, Kuhn  EM.  Quality of life and functional outcome after pediatric trauma.   J Trauma. 2005;58(3):468-473. doi:10.1097/01.TA.0000153940.23471.B7PubMedGoogle ScholarCrossref
11.
Ahmed  OZ, Holubkov  R, Dean  JM,  et al.  Change in functional status among children treated in the intensive care unit after injury.   J Trauma Acute Care Surg. 2019;86(5):810-816. doi:10.1097/TA.0000000000002120PubMedGoogle ScholarCrossref
12.
van Baar  ME, Polinder  S, Essink-Bot  ML,  et al.  Quality of life after burns in childhood (5-15 years): children experience substantial problems.   Burns. 2011;37(6):930-938. doi:10.1016/j.burns.2011.05.004PubMedGoogle ScholarCrossref
13.
Durand  MB, McLaughlin  CM, Imagawa  KK, Upperman  JS, Jensen  AR.  Identifying targets to improve coding of child physical abuse at a pediatric trauma center.   J Trauma Nurs. 2019;26(5):239-242. doi:10.1097/JTN.0000000000000461PubMedGoogle ScholarCrossref
14.
Bonafide  CP, Brady  PW, Keren  R, Conway  PH, Marsolo  K, Daymont  C.  Development of heart and respiratory rate percentile curves for hospitalized children.   Pediatrics. 2013;131(4):e1150-e1157. doi:10.1542/peds.2012-2443PubMedGoogle ScholarCrossref
15.
de Swiet  M, Fayers  P, Shinebourne  EA.  Systolic blood pressure in a population of infants in the first year of life: the Brompton study.   Pediatrics. 1980;65(5):1028-1035.PubMedGoogle Scholar
16.
Rabbia  F, Grosso  T, Cat Genova  G,  et al.  Assessing resting heart rate in adolescents: determinants and correlates.   J Hum Hypertens. 2002;16(5):327-332. doi:10.1038/sj.jhh.1001398PubMedGoogle ScholarCrossref
17.
Pollack  MM, Holubkov  R, Glass  P,  et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network.  Functional Status Scale: new pediatric outcome measure.   Pediatrics. 2009;124(1):e18-e28. doi:10.1542/peds.2008-1987PubMedGoogle ScholarCrossref
18.
Pollack  MM, Holubkov  R, Funai  T,  et al.  Relationship between the Functional Status Scale and the Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scales.   JAMA Pediatr. 2014;168(7):671-676. doi:10.1001/jamapediatrics.2013.5316PubMedGoogle ScholarCrossref
19.
Pollack  MM, Holubkov  R, Funai  T,  et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network.  Simultaneous prediction of new morbidity, mortality, and survival without new morbidity from pediatric intensive care: a new paradigm for outcomes assessment.   Crit Care Med. 2015;43(8):1699-1709. doi:10.1097/CCM.0000000000001081PubMedGoogle ScholarCrossref
20.
O’Reilly  GM, Cameron  PA, Jolley  DJ.  Which patients have missing data? an analysis of missingness in a trauma registry.   Injury. 2012;43(11):1917-1923. doi:10.1016/j.injury.2012.07.185PubMedGoogle ScholarCrossref
21.
Raghunathan  T, Lepkowski  J, Van Hoewyk  J, Solenberger  P.  A multivariate technique for multiply imputing missing values using a sequence of regression models.   Surv Methodol. 2001;27(1):85-95.Google Scholar
22.
Rubin  DB.  Multiple Imputation for Nonresponse in Surveys. John Wiley & Sons, Inc; 1987. doi:10.1002/9780470316696
23.
Rios-Diaz  AJ, Lam  J, Zogg  CK.  The need for postdischarge, patient-centered data in trauma.   JAMA Surg. 2016;151(12):1101-1102. doi:10.1001/jamasurg.2016.2343PubMedGoogle ScholarCrossref
24.
Marson  BA, Craxford  S, Deshmukh  SR, Grindlay  D, Manning  J, Ollivere  BJ.  Outcomes reported in trials of childhood fractures: a systematic review.   Bone Jt Open. 2020;1(5):167-174. doi:10.1302/2633-1462.15.BJO-2020-0031PubMedGoogle ScholarCrossref
25.
Arguelles  GR, Shin  M, Lebrun  DG, Kocher  MS, Baldwin  KD, Patel  NM.  The majority of patient-reported outcome measures in pediatric orthopaedic research are used without validation.   J Pediatr Orthop. 2021;41:e74-e79. doi:10.1097/BPO.0000000000001659PubMedGoogle ScholarCrossref
26.
Gabbe  BJ, Simpson  PM, Lyons  RA,  et al.  Association between the number of injuries sustained and 12-month disability outcomes: evidence from the Injury-VIBES study.   PLoS One. 2014;9(12):e113467. doi:10.1371/journal.pone.0113467PubMedGoogle Scholar
27.
Leong  BK, Mazlan  M, Abd Rahim  RB, Ganesan  D.  Concomitant injuries and its influence on functional outcome after traumatic brain injury.   Disabil Rehabil. 2013;35(18):1546-1551. doi:10.3109/09638288.2012.748832PubMedGoogle ScholarCrossref
28.
Prince  C, Bruhns  ME.  Evaluation and treatment of mild traumatic brain injury: the role of neuropsychology.   Brain Sci. 2017;7(8):105. doi:10.3390/brainsci7080105PubMedGoogle Scholar
29.
Notrica  DM, Linnaus  ME.  Nonoperative management of blunt solid organ injury in pediatric surgery.   Surg Clin North Am. 2017;97(1):1-20. doi:10.1016/j.suc.2016.08.001PubMedGoogle ScholarCrossref
30.
Flynn-O’Brien  KT, Fallat  ME, Rice  TB,  et al.  Pediatric Trauma Assessment and Management Database: leveraging existing data systems to predict mortality and functional status after pediatric injury.   J Am Coll Surg. 2017;224(5):933-944.e5. doi:10.1016/j.jamcollsurg.2017.01.061PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    June 2, 2021

    Factors Associated With Functional Impairment After Pediatric Injury

    Randall S. Burd, MD, PhD1; Aaron R. Jensen, MD, MEd, MS2; John M. VanBuren, PhD3; et al Rachel Richards, MStat3; Richard Holubkov, PhD3; Murray M. Pollack, MD4; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network Assessment of Health-Related Quality of Life and Functional Outcomes After Pediatric Trauma Investigators
    Author Affiliations
    • 1Division of Trauma and Burn Surgery, Children’s National Medical Center, Washington, DC
    • 2University of California San Francisco Benioff Children’s Hospital Oakland, Oakland
    • 3Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
    • 4Department of Pediatrics, Children’s National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC
    JAMA Surg. 2021;156(8):e212058. doi:10.1001/jamasurg.2021.2058
    Key Points

    Question  Are certain categories of injury associated with higher prevalence of functional impairment among children and adolescents at hospital discharge?

    Findings  In this cohort study, 17.3% of seriously injured children and adolescents had functional impairment at hospital discharge. After adjusting for oversampled injuries, the prevalence of functional impairment at discharge among all patients admitted for serious injuries at participating centers was 14.4%, with this prevalence being highest among patients with extremity injuries and severe traumatic brain injuries.

    Meaning  The findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.

    Abstract

    Importance  Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown.

    Objective  To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers.

    Design, Setting, and Participants  This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020.

    Exposure  At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5).

    Main Outcomes and Measures  New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites.

    Results  This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge.

    Conclusions and Relevance  In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.

    Introduction

    More than 100 000 children annually are admitted to trauma centers in the US, with almost half having a serious injury.1,2 Up to 40% of these children have a residual functional impairment 1 month after injury.3 Despite the frequency of acquired disability, evaluating care in this population depends mainly on mortality assessment.4,5 The percentage of children with a serious injury not surviving to discharge is low; thus, mortality is limited as a metric for assessing quality of care.2 Measures that are more granular than mortality are needed as health care quality indicators for injured children.

    Despite this need for more granular measures of quality, several factors have limited the assessment of functional status as standard practice at trauma centers, including a lack of consensus regarding the optimal measure and the required resources for obtaining assessments.6 A single method for functional status assessment has not been identified for children with a range of injury types or multiple injuries,6,7 with current assessments usually focused on single injury types, such as traumatic brain injury.8,9 Studies reporting functional outcomes in children with injuries to multiple body regions have had small samples, have not evaluated those treated outside the intensive care unit (ICU), or have excluded populations such as infants.3,10,11

    This study aimed to (1) identify categories of injuries among children and adolescents that are associated with higher prevalence of functional impairment at hospital discharge and (2) estimate the number of children and adolescents with injuries in these categories who received treatment at pediatric trauma centers. We conducted a 2-year, multicenter study evaluating functional status at hospital discharge in a sample of children and adolescents hospitalized for at least 1 serious injury. We applied these results to the trauma populations at the participating sites to estimate the overall prevalence of functional impairment. We hypothesized that the change in functional status from preinjury baseline to hospital discharge would be associated with the body regions injured and the number of body regions injured.

    Methods
    Study Overview

    This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) was performed from March 2018 to February 2020 at 7 sites participating in the National Institutes of Health–funded Collaborative Pediatric Critical Care Research Network. Each site is a designated level 1 pediatric trauma center. The institutional review board at the University of Utah approved this study through a central mechanism. Written informed consent for participation was attained from parents or guardians of the patients. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Enrollment

    Children and adolescents injured by a blunt or penetrating mechanism who survived to discharge were eligible if treated for a serious, severe, or critical injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) in a major body region (head, thorax, abdomen, spine, or upper or lower extremity). We included only individuals younger than 15 years because the individuals in this age group were the most frequently seen at the trauma centers at all sites. We excluded patients with burn injuries because of their unique functional outcomes12 as well as children and adolescents with caregivers who did not speak English or Spanish to ensure the applicability of surveys and assessments.

    We used an enrollment approach that promoted sampling of children and adolescents with less commonly injured body regions and injuries in more than 1 body region. All patients meeting eligibility criteria were considered. Potential participants were distributed into predefined enrollment categories based on (1) the body region or regions with a severe injury (head, extremity, thorax, abdomen, and spine) and (2) the presence of severe injury in 1 or more body region. The first 5 enrollment categories were used for patients with 1 or more serious injury in only 1 of the 5 body regions (ie, single body region). The remaining 5 enrollment categories were used for those with a serious injury in more than 1 body region (ie, multiple body regions). These 5 multiple-injury categories were labeled with each body region. When a patient had injuries to multiple body regions, we identified which body region had the lowest relative prevalence of injuries, with the lowest being the spine followed by the thorax, abdomen, extremities, and head.2 We then assigned the patient to the multiple-injury category labeled with the body region with the lowest prevalence of injuries. For example, a child or adolescent with a serious injury in the head and spine regions was placed in the spine multiple-injury category because spine injuries are less frequent than head injuries. Every 3 months, enrollment was adjusted across all sites to enhance sampling. Enrollment targets were 50 patients per site per year, with a goal of 70% of participants with 1 injured body region and 30% with multiple injured body regions.

    Data Collection

    Research coordinators were trained centrally to ensure consistent enrollment, data collection practices, and outcome measurement. A data coordinating center monitored enrollment, validated collated data, and conducted statistical analyses. Self-reported race/ethnicity and insurance status of the participants were obtained from parents or guardians. We identified preinjury comorbidities using the medical record (eAppendix 1 in the Supplement). Discharge disposition was grouped as going home with parents or guardians, to foster care, to an inpatient rehabilitation facility, to a long-term care or skilled nursing facility, or to another acute care hospital. Additional data were obtained from the trauma registry, including injury type (blunt vs penetrating) and mechanism, initial systolic blood pressure and heart rate, initial Glasgow Coma Scale (GCS) score, and ICU and hospital length of stay. Child physical abuse was designated as the mechanism regardless of other assignments. Owing to inconsistencies and lack of standardization of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes or external cause codes for child abuse in trauma registries, we used medical record review to assess for an abuse mechanism.13 Child physical abuse was designated by research coordinators if health care professional, child advocacy team, or social work records showed that it was suspected to be the primary mechanism of injury. Blood pressure and heart rate were standardized to z scores using age-based means and SDs.14-16

    The Functional Status Scale (FSS) was used for assessments before injury and at discharge, and the Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) scales were used at discharge. These measures were acquired using the medical record as well as parent or guardian and clinical care team interviews. The FSS is a validated, rapidly performed, and age-independent objective measure applicable for large-scale studies of critically ill children.17 The FSS assesses function in 6 domains: mental status, sensory, communication, motor, feeding, and respiratory. Scores range from 1 (normal) to 5 (very severe dysfunction) for each domain. The overall FSS scores range from 1 to 30; less than 8 is considered normal, whereas a score of 8 or 9 indicates mild impairment and a score greater than 9 indicates moderate or greater impairment. The POPC and PCPC scales are rapidly performed, subjective assessments applicable to large-scale studies.18 Scores range from 1 to 5, with scores greater than 2 indicating more than mild impairment.

    Statistical Analysis

    The primary outcome was a change of 2 or more in any FSS domain between preinjury and discharge status (ie, new domain morbidity); this change indicates marked new impairment.19 Secondary outcomes included discharge POPC and PCPC scale scores. We placed each patient into 1 of 9 injury categories based on (1) the body region injured, (2) whether single or multiple body regions were injured, and (3) the severity of the head injury when applicable. We used a GCS total score less than 9 or a GCS motor score less than 5 to define severe head injury. We classified head injuries with a missing GCS value as severe because of associations of missingness with abnormal GCS and mortality.20 The 9 injury categories included (1) multiple body regions including a severe head injury, (2) multiple body regions with a less than severe head injury, (3) multiple body regions excluding the head, (4) isolated severe head injury, (5) isolated less than severe head injury, (6) isolated thoracic injury, (7) isolated abdominal injury, (8) isolated spinal injury, and (9) isolated extremity injury.

    Estimates of impairment among seriously injured children at the sites were calculated using the number of children and adolescents in each injury category in the trauma registry and the percentage of impairment associated with each category among the sampled patients. We performed univariate comparisons using the χ2 and Wilcoxon rank sum tests. Logistic regression assessing new domain morbidity at discharge used the 9 injury categories, demographic variables (age, race/ethnicity, and insurance status), physiological measures (systolic blood pressure, heart rate), injury type (blunt or penetrating), child physical abuse, and study site. We selected covariates for multivariate modeling a priori based on assessment of the potential for influencing functional outcomes based on a literature review and domain knowledge. We used inverse probability weights to allow inferences for the population of children in the trauma registry. To address missing data (Table 1 and Table 2), we imputed 10 data sets using chained regressions under the assumption of a missing-at-random pattern, combining results using standard techniques.21,22 To make comparisons between all possible pairs of injury categories, we varied the injury category used as the reference group in the multivariate model. We then constructed a matrix representing the odds ratios (ORs) using different reference and comparison injury categories. Using these pairwise ORs, we ranked the risk of new domain morbidity among injury categories. We defined significance at 2-sided P < .05. Analyses were performed used SAS, version 9.4 (SAS Institute Inc).

    Results

    Among the 835 patients assessed for eligibility, 654 met the inclusion criteria; 493 of their parents or guardians were approached for consent, and 428 provided consent. One patient was withdrawn because of the absence of a qualifying injury. The final sample included 427 patients (median age, 7.2 years [interquartile range, 2.5-11.7 years]). A median of 59 patients (range, 28-88 patients) were enrolled per site. Most patients were male (271 [63.5%]), White (277 [64.9%]), and non-Hispanic (376 [88.1%]) and had either private insurance (188 [44.0%]) or Medicaid or Medicare (198 [46.4%]) as primary coverage (Table 1). Among the enrolled patients, blunt trauma was the predominant injury type (380 injuries [89.0%]), with falls being the most frequent injury mechanism (125 [29.3%]) (Table 2). Most patients had a single body region injury (354 [82.9%]), which was usually an extremity or head injury. Most patients presented with normal physiological parameters as assessed by systolic blood pressure, heart rate, and GCS. Preinjury comorbidities were observed in 66 children and adolescents (15.5%), with asthma being the most frequent (13 patients [3.0%]) (Table 1). The preinjury functional status was normal for most patients (414 [97.0%]). A total of 174 patients (40.8%) were admitted to the ICU, with a median ICU length of stay of 4.0 days (range, 2.0-7.0 days) (Table 2). The median hospital length of stay for all patients in the study was 3.0 days (range, 2.0-8.0 days). Most patients were discharged to their home or to foster care (373 [87.4%]). Overall, 45 patients (10.5%) required inpatient rehabilitation after discharge, and 1 patient (0.2%) was admitted to a skilled nursing facility.

    Although most patients returned to or continued to have normal functional status at hospital discharge (353 [82.7%]), new domain morbidity occurred in 74 patients (17.3%) (Table 1 and Table 2). Patients with multiple injured body regions that included a severe head injury had the highest percentage of new domain morbidity (83.3% [20 of 24 patients]), and those with isolated mild or moderate head injuries had the lowest percentage (1.2% [1 of 84]) (Table 3). New domain morbidity was also common among patients with multiple injured body regions with less severe head injury (30.8% [4 of 13]), those with multiple injured body regions not including head injury (27.8% [10 of 36]), those with isolated severe head injury (30.4% [7 of 23]), and those with isolated spine injury (28.6% [6 of 21]). New domain morbidity was similar among children with isolated extremity injury (16.5% [19 of 115]) and those with isolated thoracic injury (13.3% [4 of 30]). Among the 13 patients with at least mild impairment before injury, only 2 had new domain morbidity at discharge. Analysis of POPC and PCPC scale scores showed more than mild impairment (score >2) at discharge in 99 patients (23.2%) and 27 patients (6.3%) patients, respectively. The proportions of patients in each injury category with more than mild impairment on the POPC scale were similar to the proportions of patients with new domain morbidity (Table 3). Consistent with its value for measuring of neurologic function, the PCPC scale score more often showed more than abnormal impairment among those with a severe head injury alone or combined with another body region (36.2% [17 of 47]). The domains of FSS with morbidity were associated with injury category (Figure). Patients with isolated spinal (5 of 7 [71.4%]), extremity (18 of 19 [94.7%]), or abdominal (2 of 3 [66.7%]) injuries had most new motor deficits. Those with isolated thoracic injuries had new morbidity in the motor and feeding domain (2 of 4 [50%] and 2 of 4 [50%], respectively). Morbidities among those with isolated nonsevere head injuries were limited to the sensory domain (1 of 1 [100%]).

    The registry at the sites during the study period contained records for 20 612 children and adolescents, of whom 5195 (25.2%) had at least 1 serious or greater injury. On the basis of the prevalence of injuries in each category among the sampled patients (Table 3), we estimated that 749 of 5195 patients (14.4%) would have discharge functional impairment. The most common injury categories among those with a serious injury were isolated extremity injury (1828 patients [35.2%]) followed by isolated nonsevere head injury (1738 [33.5%]) (Table 3). Patients with extremity injuries (302 of 749 [40.3%]) followed by those with multiple injured body regions including a severe head injury (146 of 749 [19.5%]) accounted for the largest proportions of those estimated to have new domain morbidity. Patients with severe head injuries in isolation or with another injured body region accounted for 544 of 5195 patients (10.5%) with a serious injury in the registry but 258 of 749 cases (34.4%) of new domain morbidity.

    Multivariate analysis showed an association between new domain morbidity and injury category (eAppendix 2 in the Supplement). For example, compared with nonsevere isolated head injury, the OR for severe isolated head injury was 54.57 (95% CI, 26.68-111.60; P < .001) and the OR for injuries to multiple body regions including severe head injury was 1503 (95% CI, 598.20-3775.00; P < .001). We first used isolated mild or moderate head injury as the reference group because these injuries were associated with the lowest domain morbidity (Table 2). By varying the reference injury category used in this regression, we found ORs that represented comparisons among all possible injury categories (Table 4). Using these ORs, we ranked the risk for new domain morbidity among the 9 categories (highest to lowest risk): multiple injured body regions including a severe head injury; other types of multiple injured body region patterns (excluding head, head not severe), isolated severe head injuries, and isolated spinal injuries; isolated extremity injuries and isolated thoracic injuries; isolated abdominal injuries; and isolated mild or moderate head injuries.

    Discussion

    The need for assessing nonmortality outcomes after injury is well recognized.6,23 Although substantial resources are allocated for maintaining trauma registries, resources for obtaining postdischarge evaluations have been limited.23 One approach for addressing these resource challenges is to perform postdischarge evaluations only for patients with a high risk of impairment. In this study, we used FSS scores to identify categories of injured children and adolescents at high risk for functional impairment who should be targeted for these assessments.

    Few studies have described categories of injuries associated with risk for functional impairment in a general population of injured children and adolescents. Previous studies3,10,11 have had small samples, have limited their assessments to those with the most severe injuries, or have excluded individuals in specific age groups. Functional impairment was observed in all domains using the Functional Independence Measure system in a cohort of 162 children with at least 1 serious injury.10 The functional status of 149 seriously injured children was evaluated using this system, the King’s Outcome Scale for Childhood Head Injury, and the modified Glasgow Outcome Scale. One month after discharge, impairment was observed in the 4 body regions evaluated, but infants were excluded from some assessments.3 In an analysis of 553 injured children treated in an ICU, new FSS domain morbidity was observed in 17% of patients.11 Our study addressed some of the limitations of these studies. We evaluated a larger sample of children, including those hospitalized outside the ICU, and oversampled those with uncommon injuries. We estimated that new domain morbidity occurred in 17.3% of seriously injured children treated at the participating sites. We observed similar findings using the POPC scale, a measure also used for functional status assessment in large-scale studies.19 The impairment using new FSS domain morbidity exceeded by approximately 4-fold the reported mortality after severe injury in children,2 supporting the FSS as a more granular and potentially more robust measure of quality.

    We estimated impairment within each injury category at the participating sites using the proportions of new domain morbidity in the sampled population. Isolated extremity injury was the most frequently reported category and accounted for an estimated 40.3% of new domain morbidities. Children hospitalized for extremity injuries are a population at high risk for functional impairment.3,10,11 Recent studies have identified the need to implement validated functional outcome assessments for pediatric orthopedic injuries.24,25 Although children and adolescents with severe head injuries accounted for 11.0% of patients with a serious injury, those with severe head injuries accounted for 36.5% of those estimated to have impairment at the time of discharge. We also observed an association between the number of injured body regions and functional outcome.11,26 Children and adolescents with multiple injured body regions including severe head injury had the highest proportion of functional impairment, a finding observed in adult trauma patients.27 Almost half (49.5%) of children and adolescents with multiple injured body regions with or without a head injury also had discharge impairment.

    Injuries in some body regions were associated with low percentages of impairment, including isolated mild or moderate head injuries and isolated thoracic or abdominal injuries. Although we used the FSS scale, a range of other measures can be used to assess impairment in children with a traumatic brain injury.28 Although a population of interest from a resource perspective,29 children and adolescents with isolated abdominal injuries had infrequent functional impairment at discharge. Consistent with previous findings, isolated thoracic injuries in the sample in the present study were associated with a low frequency of impairment at discharge.3 Our results highlight the need to define specific injuries in the abdominal and thoracic regions that are associated with risk for disability.

    Limitations

    This study has several limitations. First, we used the FSS to define functional status rather than more extensive functional assessments such as the Vineland Adaptive Behavior Scale III. Although it has advantages for large-scale studies, FSS may not be sufficiently granular to detect additional aspects of function at hospital discharge. Second, patients within each category used in this study had different injury profiles based on the organs injured and the occurrence of multiple injuries within the same body region. Third, we did not consider physiological differences not represented by initial vital signs and GCS. The integration of trauma registries and clinical data sets has been proposed for managing this limitation.30 Fourth, we observed wide 95% CIs for several ORs in the multivariate model when comparing injury categories. Although potentially arising from comparison of categories with small sample sizes or infrequent new domain morbidity, it is also possible that the wide 95% CIs reflect high variability in the observed associations. Fifth, we did not consider the causation of new domain morbidity. New discharge impairment may be associated with a combination of primary injury and complications related to management.

    Conclusions

    In this cohort study, most injured children and adolescents returned to baseline functional status, as assessed using the FSS, by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.

    Back to top
    Article Information

    Accepted for Publication: March 3, 2021.

    Published Online: June 2, 2021. doi:10.1001/jamasurg.2021.2058

    Correction: This article was corrected on July 7, 2021, to add an author affiliation.

    Corresponding Author: Randall S. Burd, MD, PhD, Division of Trauma and Burn Surgery, Children’s National Medical Center, 111 Michigan Ave NW, Washington, DC 20010 (rburd@childrensnational.org).

    The Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network Assessment of Health-Related Quality of Life and Functional Outcomes After Pediatric Trauma Investigators: Robert A. Berg, MD; Joseph A. Carcillo, MD; Todd C. Carpenter, MD; J. Michael Dean, MD; Barbara Gaines, MD; Mark W. Hall, MD; Patrick S. McQuillen, MD; Kathleen L. Meert, MD; Peter M. Mourani, MD; Michael L. Nance, MD; Andrew R. Yates, MD.

    Affiliations of The Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network Assessment of Health-Related Quality of Life and Functional Outcomes After Pediatric Trauma Investigators: Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (Dean); Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Berg); Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Carcillo); Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora (Carpenter); Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Gaines); Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio (Hall); Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco (McQuillen); Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (Meert); Central Michigan University, Mt Pleasant (Meert); Arkansas Children’s Research Institute, Arkansas Children’s Hospital, Little Rock (Mourani); Division of Pediatric Trauma, Department of Surgery, College of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Nance); Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus (Yates).

    Author Contributions: Dr Burd had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Burd, Jensen, VanBuren, Pollack, Berg, Carcillo, Dean, Hall, Meert, Mourani.

    Acquisition, analysis, or interpretation of data: Burd, Jensen, VanBuren, Richards, Holubkov, Pollack, Berg, Carcillo, Carpenter, Gaines, Hall, McQuillen, Meert, Mourani, Nance, Yates.

    Drafting of the manuscript: Burd, Jensen, VanBuren, Richards, Pollack.

    Critical revision of the manuscript for important intellectual content: Burd, Jensen, VanBuren, Holubkov, Pollack, Berg, Carcillo, Carpenter, Dean, Gaines, Hall, McQuillen, Meert, Mourani, Nance, Yates.

    Statistical analysis: Burd, VanBuren, Richards, Holubkov.

    Obtained funding: Burd, Pollack, Berg, Carcillo, Carpenter, Dean, Meert, Mourani.

    Administrative, technical, or material support: Burd, Pollack, Carcillo, Carpenter, Dean, Gaines, Hall, Mourani, Yates.

    Supervision: Burd, Holubkov, Pollack, Carcillo, Dean, Meert, Mourani.

    Conflict of Interest Disclosures: Dr Burd reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr VanBuren reported receiving grants from the NIH during the conduct of the study. Dr Holubkov reported receiving grants from the NIH during the conduct of the study. Dr Pollack reported receiving grants from the NIH during the conduct of the study. Dr Berg reported receiving grants from the NIH during the conduct of the study. Dr Carcillo reported receiving grants from the NIH paid to the University of Pittsburgh during the conduct of the study and receiving grants from the NIH paid to the University of Pittsburgh outside the submitted work. Dr Carpenter reported receiving grants from the NIH during the conduct of the study and outside the submitted work. Dr Dean reported receiving grants from the NIH during the conduct of the study. Dr Hall reported receiving grants from the NIH during the conduct of the study. Dr McQuillen reported receiving grants from the NIH during the conduct of the study. Dr Meert reported receiving grants from the NIH during the conduct of the study. Dr Yates reported receiving grants from NIH during the conduct of the study. No other disclosures were reported.

    Funding/Support: This study was supported, in part, by cooperative agreements UG1HD050096 (Dr Meert), UG1HD049981 (Drs Burd and Pollack), U10HD049983 (Dr Carcillo), UG1HD083170 (Drs Hall and Yates), UG1HD083166 (Dr McQuillen), UG1HD083171 (Dr Mourani), and U01HD049934 (Drs VanBuren, Richards, Holubkov, and Dean) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network, NIH, Department of Health and Human Services.

    Role of the Funder/Sponsor: The NIH had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

    Additional Contributions: We thank the research coordinators and trauma administrative teams at each site for assisting with the data acquisition.

    References
    1.
    Cassidy  LD, Cook  A, Ertl  A, Gourlay  D, Osler  T.  Is the Trauma Mortality Prediction Model (TMPM-ICD-9) a valid predictor of mortality in pediatric trauma patients?   J Pediatr Surg. 2014;49(1):189-192. doi:10.1016/j.jpedsurg.2013.09.055PubMedGoogle ScholarCrossref
    2.
    Chang MC, ed; American College of Surgeons Committee on Trauma Leadership. National Trauma Data Bank: pediatric annual report. Published 2016. Accessed October 1, 2020. https://www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdb%20pediatric%20annual%20report%202016.ashx
    3.
    Gabbe  BJ, Simpson  PM, Sutherland  AM,  et al.  Functional and health-related quality of life outcomes after pediatric trauma.   J Trauma. 2011;70(6):1532-1538. doi:10.1097/TA.0b013e31820e8546PubMedGoogle Scholar
    4.
    Cooper  CG, Santana  MJ, Stelfox  HT.  A comparison of quality improvement practices at adult and pediatric trauma centers.   Pediatr Crit Care Med. 2013;14(8):e365-e371. doi:10.1097/PCC.0b013e3182917a4cPubMedGoogle ScholarCrossref
    5.
    McCarthy  A, Curtis  K, Holland  AJ.  Paediatric trauma systems and their impact on the health outcomes of severely injured children: an integrative review.   Injury. 2016;47(3):574-585. doi:10.1016/j.injury.2015.12.028PubMedGoogle ScholarCrossref
    6.
    Sakran  JV, Ezzeddine  H, Schwab  CW,  et al. Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures.  J Am Coll Surg. 2020;230(5):819-835.
    7.
    Ryder  C, Mackean  T, Hunter  K, Williams  H,  et al.  Equity in functional and health related quality of life outcomes following injury in children—a systematic review.   Crit Public Health. 2020;30(3):352-366. doi:10.1080/09581596.2019.1581918Google ScholarCrossref
    8.
    Bennett  TD, Dixon  RR, Kartchner  C,  et al.  Functional Status Scale in children with traumatic brain injury: a prospective cohort study.   Pediatr Crit Care Med. 2016;17(12):1147-1156. doi:10.1097/PCC.0000000000000934PubMedGoogle ScholarCrossref
    9.
    Williams  KS, Young  DK, Burke  GAA, Fountain  DM.  Comparing the WeeFIM and PEDI in neurorehabilitation for children with acquired brain injury: a systematic review.   Dev Neurorehabil. 2017;20(7):443-451. doi:10.1080/17518423.2017.1289419PubMedGoogle ScholarCrossref
    10.
    Winthrop  AL, Brasel  KJ, Stahovic  L, Paulson  J, Schneeberger  B, Kuhn  EM.  Quality of life and functional outcome after pediatric trauma.   J Trauma. 2005;58(3):468-473. doi:10.1097/01.TA.0000153940.23471.B7PubMedGoogle ScholarCrossref
    11.
    Ahmed  OZ, Holubkov  R, Dean  JM,  et al.  Change in functional status among children treated in the intensive care unit after injury.   J Trauma Acute Care Surg. 2019;86(5):810-816. doi:10.1097/TA.0000000000002120PubMedGoogle ScholarCrossref
    12.
    van Baar  ME, Polinder  S, Essink-Bot  ML,  et al.  Quality of life after burns in childhood (5-15 years): children experience substantial problems.   Burns. 2011;37(6):930-938. doi:10.1016/j.burns.2011.05.004PubMedGoogle ScholarCrossref
    13.
    Durand  MB, McLaughlin  CM, Imagawa  KK, Upperman  JS, Jensen  AR.  Identifying targets to improve coding of child physical abuse at a pediatric trauma center.   J Trauma Nurs. 2019;26(5):239-242. doi:10.1097/JTN.0000000000000461PubMedGoogle ScholarCrossref
    14.
    Bonafide  CP, Brady  PW, Keren  R, Conway  PH, Marsolo  K, Daymont  C.  Development of heart and respiratory rate percentile curves for hospitalized children.   Pediatrics. 2013;131(4):e1150-e1157. doi:10.1542/peds.2012-2443PubMedGoogle ScholarCrossref
    15.
    de Swiet  M, Fayers  P, Shinebourne  EA.  Systolic blood pressure in a population of infants in the first year of life: the Brompton study.   Pediatrics. 1980;65(5):1028-1035.PubMedGoogle Scholar
    16.
    Rabbia  F, Grosso  T, Cat Genova  G,  et al.  Assessing resting heart rate in adolescents: determinants and correlates.   J Hum Hypertens. 2002;16(5):327-332. doi:10.1038/sj.jhh.1001398PubMedGoogle ScholarCrossref
    17.
    Pollack  MM, Holubkov  R, Glass  P,  et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network.  Functional Status Scale: new pediatric outcome measure.   Pediatrics. 2009;124(1):e18-e28. doi:10.1542/peds.2008-1987PubMedGoogle ScholarCrossref
    18.
    Pollack  MM, Holubkov  R, Funai  T,  et al.  Relationship between the Functional Status Scale and the Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scales.   JAMA Pediatr. 2014;168(7):671-676. doi:10.1001/jamapediatrics.2013.5316PubMedGoogle ScholarCrossref
    19.
    Pollack  MM, Holubkov  R, Funai  T,  et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network.  Simultaneous prediction of new morbidity, mortality, and survival without new morbidity from pediatric intensive care: a new paradigm for outcomes assessment.   Crit Care Med. 2015;43(8):1699-1709. doi:10.1097/CCM.0000000000001081PubMedGoogle ScholarCrossref
    20.
    O’Reilly  GM, Cameron  PA, Jolley  DJ.  Which patients have missing data? an analysis of missingness in a trauma registry.   Injury. 2012;43(11):1917-1923. doi:10.1016/j.injury.2012.07.185PubMedGoogle ScholarCrossref
    21.
    Raghunathan  T, Lepkowski  J, Van Hoewyk  J, Solenberger  P.  A multivariate technique for multiply imputing missing values using a sequence of regression models.   Surv Methodol. 2001;27(1):85-95.Google Scholar
    22.
    Rubin  DB.  Multiple Imputation for Nonresponse in Surveys. John Wiley & Sons, Inc; 1987. doi:10.1002/9780470316696
    23.
    Rios-Diaz  AJ, Lam  J, Zogg  CK.  The need for postdischarge, patient-centered data in trauma.   JAMA Surg. 2016;151(12):1101-1102. doi:10.1001/jamasurg.2016.2343PubMedGoogle ScholarCrossref
    24.
    Marson  BA, Craxford  S, Deshmukh  SR, Grindlay  D, Manning  J, Ollivere  BJ.  Outcomes reported in trials of childhood fractures: a systematic review.   Bone Jt Open. 2020;1(5):167-174. doi:10.1302/2633-1462.15.BJO-2020-0031PubMedGoogle ScholarCrossref
    25.
    Arguelles  GR, Shin  M, Lebrun  DG, Kocher  MS, Baldwin  KD, Patel  NM.  The majority of patient-reported outcome measures in pediatric orthopaedic research are used without validation.   J Pediatr Orthop. 2021;41:e74-e79. doi:10.1097/BPO.0000000000001659PubMedGoogle ScholarCrossref
    26.
    Gabbe  BJ, Simpson  PM, Lyons  RA,  et al.  Association between the number of injuries sustained and 12-month disability outcomes: evidence from the Injury-VIBES study.   PLoS One. 2014;9(12):e113467. doi:10.1371/journal.pone.0113467PubMedGoogle Scholar
    27.
    Leong  BK, Mazlan  M, Abd Rahim  RB, Ganesan  D.  Concomitant injuries and its influence on functional outcome after traumatic brain injury.   Disabil Rehabil. 2013;35(18):1546-1551. doi:10.3109/09638288.2012.748832PubMedGoogle ScholarCrossref
    28.
    Prince  C, Bruhns  ME.  Evaluation and treatment of mild traumatic brain injury: the role of neuropsychology.   Brain Sci. 2017;7(8):105. doi:10.3390/brainsci7080105PubMedGoogle Scholar
    29.
    Notrica  DM, Linnaus  ME.  Nonoperative management of blunt solid organ injury in pediatric surgery.   Surg Clin North Am. 2017;97(1):1-20. doi:10.1016/j.suc.2016.08.001PubMedGoogle ScholarCrossref
    30.
    Flynn-O’Brien  KT, Fallat  ME, Rice  TB,  et al.  Pediatric Trauma Assessment and Management Database: leveraging existing data systems to predict mortality and functional status after pediatric injury.   J Am Coll Surg. 2017;224(5):933-944.e5. doi:10.1016/j.jamcollsurg.2017.01.061PubMedGoogle ScholarCrossref
    ×