Functional Status Scale in Children With Traumatic Brain Injury: A Prospective Cohort Study

Abstract

Objectives: In children with traumatic brain injury, 1) to describe the hospital discharge functional outcome and change from baseline function using the Functional Status Scale and 2) to determine any associations between discharge Functional Status Scale and age, injury mechanism, neurologic examination, imaging, and other predictors of outcome.

Design: Prospective observational cohort study, May 2013 to November 2015.

Setting: Two U.S. children's hospitals designated as American College of Surgeons level 1 pediatric trauma centers.

Patients: Children less than 18 years old admitted to an ICU with acute traumatic brain injury and either a surgical or critical care intervention within the first 24 hours or in-hospital mortality.

Interventions: None.

Measurements and main results: The primary outcome was hospital discharge Functional Status Scale. Most, 133 of 196 (68%), had severe traumatic brain injury (admission Glasgow Coma Scale, 3-8). Overall hospital mortality was 14%; 20% among those with severe traumatic brain injury. Hospital discharge Functional Status Scale had an inverse relationship with Glasgow Coma Scale: for each increase in admission Glasgow Coma Scale by 1, the discharge Functional Status Scale decreased by 0.5 (95% CI, 0.7-0.3). Baseline Functional Status Scale was collected at one site (n = 75). At that site, nearly all (61/62) of the survivors had normal or near-normal (≤ 7) preinjury Functional Status Scale. More than one-third, 23 of 62 (37%), of survivors had new morbidity at hospital discharge (increase in Functional Status Scale, ≥ 3). Among children with severe traumatic brain injury who had baseline Functional Status Scale collected, 21 of 41 survivors (51%) had new morbidity at hospital discharge. The mean change in Functional Status Scale from baseline to hospital discharge was 3.9 ± 4.9 overall and 5.2 ± 5.4 in children with severe traumatic brain injury.

Conclusions: More than one-third of survivors, and approximately half of survivors with severe traumatic brain injury, will have new morbidity. Hospital discharge Functional Status Scale, change from baseline Functional Status Scale, and new morbidity acquisition can be used as outcome measures for hospital-based care process improvement initiatives and interventional studies of children with traumatic brain injury.

Figure 1. FSS Domain Scores at Hospital Discharge

Histograms of Functional Status Scale (FSS) domain scores at hospital discharge. A score of 1 in each category represents no dysfunction.

Figure 2. Discharge FSS by Admission GCS and GCS - Motor

FSS = Functional Status Scale; GCS = Glasgow Coma Scale. A FSS score of 6 represents no dysfunction.

Figure 3. Discharge FSS by Intracranial Hemorrhage Type

EDH = epidural hematoma; SDH = subdural hematoma; IVH = intraventricular hemorrhage; SAH = subarachnoid hemorrhage; IPH = intraparenchymal hemorrhage. A FSS score of 6 represents no dysfunction.

Figure 4. Discharge FSS by New Gastrostomy status

FSS = Functional Status Scale; G-Tube = gastrostomy tube; TBI = traumatic brain injury. A FSS score of 6 represents no dysfunction.