Variation in Intracranial Pressure Monitoring and Outcomes in Pediatric Traumatic Brain Injury

Objectives: To describe between-hospital and patient-level variation in intracranial pressure (ICP) monitoring and to evaluate ICP monitoring in association with hospital features and outcome in children with traumatic brain injury (TBI). Design: Retrospective cohort study. Setting: Children's hospitals participating in the Pediatric Health Information System database (January 2001 to June 2011). Participants: Children (aged <18 years) with TBI and head Abbreviated Injury Scale scores of at least 3 who were ventilated for at least 96 consecutive hours or who died in the first 4 days after hospital admission. Main Outcome Measures: Monitoring of ICP. Results: A total of 4667 children met the study criteria. Hospital mortality was 41% (n=1919). Overall, 55% of patients (n=2586) received ICP monitoring. Expected hospital ICP monitoring rates after adjustment for patient age, cardiac arrest, inflicted injury, craniotomy or craniectomy, head Abbreviated Injury Scale score, and Injury Severity Score were 47% to 60%. Observed hospital ICP monitoring rates were 14% to 83%. Hospitals with more observed ICP monitoring, relative to expected, and hospitals with higher patient volumes had lower rates of mortality or severe disability. After adjustment for between-hospital variation and patient severity of injury, ICP monitoring was independently associated with age 1 year and older (odds ratio, 3.1; 95% CI, 2.5-3.8) vs age younger than 1 year. Conclusions: There was significant between-hospital variation in ICP monitoring that cannot be attributed solely to differences in case mix. Hospitals that monitor ICP more frequently and hospitals with higher patient volumes had better patient outcomes. Infants with TBI are less likely to receive ICP monitoring than are older children.