Provider perceptions of severe pediatric traumatic brain injury care priorities across hospitals in South America before and during the COVID-19 pandemic

Abstract

Background: To understand provider perceptions of the COVID-19 pandemic on priorities of severe pediatric traumatic brain injury (TBI) care across hospitals in South America.

Methods: Site principal investigators (PIs) from 17 hospitals in South America enrolled in the PEGASUS-Argentina randomized controlled trial completed questionnaires regarding order of tasks performed in the care of a typical pediatric patient with severe TBI before (2019) and during (2021) the COVID-19 pandemic. Acute care processes were examined by quintiles to identify early, mid, and late actions and were categorized and compared. Associations of hospital volume and subspecialty resource availability with prioritization of key process actions were examined.

Finding: Site PIs from 15 and 16 hospitals completed the surveys in 2019 and 2021, respectively, including 14 who completed both. Action category order was stable between 2019 and 2021 and were ranked in priorities as: initial encounter, primary survey, interventions and invasive monitors, diagnostics, medications, staff communication, then disposition (in 2019) or nutrition (in 2021). There was variation in specific action order between hospitals at both timepoints, with only a few initial encounter and disposition actions limited to a single quintile. There was no reported association between hospital volume or subspecialty resource availability with prioritization of key process actions.

Interpretation: Despite novel healthcare challenges presented by the COVID-19 pandemic, providers in South America perceived maintaining standard severe pediatric TBI care consistent with BTF guidelines. There was large variability in specific action order between individual hospitals reported.

Fig 1. Variation in number of severe pediatric traumatic brain injury process care actions across 17 South American hospitals at two timepoints: 2019 and 2021.

Fig 2

Heat maps of hospital process order in severe pediatric traumatic brain injury care in 2019 (a) and 2021 (b). Hospitals on x-axis. Events grouped by category on y-axis. Raw survey data for each hospital ranked in sequential order to account for survey responses that skipped steps. Ties reported as the same rank with subsequent rank numbers accounting for the number of ties. Rank order batched into quintile order for each hospital. Box grayscale = order quintile of each event for a hospital. Empty boxes = events not included in a hospital’s survey response. ECG = electrocardiogram. ETCO2 = end tidal carbon dioxide. ICP = intracranial pressure. EEG = electroencephalogram. CSF = cerebrospinal fluid. CT = computed tomography. IV = intravenous. OR = operating room. PT = physical therapy. NPO = nil per os.

Fig 3

Variability of specific action order in severe pediatric traumatic brain injury care across South American hospitals in 2019 (a) and 2021 (b). X-axis represents earliest to latest actions reported. Larger bubble size and lighter grayscale represent greater occurrence of hospitals ranking an action in a specific quintile. ECG = electrocardiogram. ETCO2 = end tidal carbon dioxide. ICP = intracranial pressure. EEG = electroencephalogram. CSF = cerebrospinal fluid. CT = computed tomography. IV = intravenous. OR = operating room. PT = physical therapy. NPO = nil per os.