YJPSU-58925; No of Pages 4

Journal of Pediatric Surgery xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Reduction of resource utilization in children with blunt solid

organ injury☆
Micah G. Katz a, Zachary J. Kastenberg b, Mark A. Taylor a, Carol D. Bolinger c, Eric R. Scaife b,
Stephen J. Fenton b, Katie W. Russell b,⁎
a
Department of Surgery, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
b
Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 North Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84113
c
Primary Children's Hospital, 100 North Mario Capecchi Drive, Suite 3800, Salt Lake City, UT 84113

a r t i c l e i n f o a b s t r a c t

Article history: Background/purpose: Nonoperative management of blunt solid organ injuries continues to progress and improve
Received 25 October 2018 cost-effective utilization of resources while maximizing patient safety. The purpose of this study is to compare
Accepted 25 October 2018 resource utilization and patient outcomes after changing admission criteria from a grade-based protocol to one
Available online xxxx based on hemodynamic stability.
Methods: A retrospective review of isolated liver and spleen injuries was done using prospectively collected
Key words:
trauma registry data from 2013 to 2017. The 2 years preceding the change were compared to the 2 years after
Trauma
Pediatric trauma
protocol change. All analyses were performed using SAS 9.4.
Blunt abdominal trauma Results: There were 121 patients in the preprotocol cohort and 125 patients in the postprotocol cohort.
Solid organ injury Baseline demographics were similar along with injury mechanisms and severity. The ICU admission rate de-
Resource utilization creased from 40% to 22% (p = 0.002). There were no adverse events on the floor and no patient needed to be
transferred to the ICU.
Conclusions: A protocol for ICU admission based on physiologic derangement versus solely on radiologic grade
significantly reduced admission rates to the ICU in children with solid organ injury. The protocol was safe and ef-
fectively reduced resource utilization.
Level of evidence: Level II, prospective comparison study.
© 2018 Published by Elsevier Inc.

The nonoperative, conservative management of blunt, traumatic
solid organ injuries has expanded in recent decades. Once considered
controversial, nonoperative management has become the standard of
care, with surgical intervention being considered “almost history” [1].
As nonoperative treatment of children with blunt, solid organ injury
has spread, so too have recommended treatment algorithms.
In 2000, the American Pediatric Surgical Association sought to detail
the state of treatment for isolated, blunt spleen or liver injury at pediat-
ric centers [2]. The APSA Trauma Committee found a correlation of re-
source utilization with increasing injury severity, but a wide variation
☆ Funding: This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
⁎ Corresponding author at: 100 North Mario Capecchi Drive, Suite 3800, Salt Lake City,
UT 84113.
E-mail addresses: Micah.Katz@hsc.utah.edu (M.G. Katz),
Zachary.Kastenberg@hsc.utah.edu (Z.J. Kastenberg), Mark.Taylor@hsc.utah.edu
(M.A. Taylor), Carol.Bolinger@imail.org (C.D. Bolinger), Eric.Scaife@hsc.utah.edu
(E.R. Scaife), Stephen.Fenton@hsc.utah.edu (S.J. Fenton), Katie.Russell@hsc.utah.edu
(K.W. Russell).
in treatment. Therefore, they proposed several guidelines, including
ward admission for stable patients with isolated spleen or liver injury,
CT grades I, II or III. In a later publication, the APSA Study Group demon-
strated improved compliance and decreased resource utilization after
the release of the guidelines [3]. More recently high rates of ICU admis-
sion for low-grade, isolated injuries have been demonstrated [4].
However, the reliability of imaging to predict management of blunt
abdominal trauma is uncertain [5–7]. Around the time of APSA guide-
line release, other research demonstrated that pediatric solid organ in-
juries could be safely managed based on hemodynamic status,
regardless of injury grade on CT [8]. A subsequent study modeled re-
source utilization and patient safety based on management by APSA
guidelines versus CT grading, favoring the latter [9]. Later, a retrospec-
tive study of 171 pediatric patients with blunt liver trauma demon-
strated that CT grading did not correlate with the receipt of blood
products and that admission to the ICU led to the unnecessary ICU utili-
zation for stable patients [10]. Management based on hemodynamic
status would later be recommended by the ATOMAC guidelines,
which sought to update management guidelines in a safe, cost-
effective manner [11].

https://doi.org/10.1016/j.jpedsurg.2018.10.066
0022-3468/© 2018 Published by Elsevier Inc.

Please cite this article as: M.G. Katz, Z.J. Kastenberg, M.A. Taylor, et al., Reduction of resource utilization in children with blunt solid organ injury,
Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.066
2 M.G. Katz et al. / Journal of Pediatric Surgery xxx (xxxx) xxx

In 2015, secondary to the release of the ATOMAC guidelines and in Table 1

conjunction with a literature review, our group developed a blunt solid Demographics and mechanism of injury.

organ injury protocol based on hemodynamic stability. Our updated pro- Grading Cohort Hemodynamics Cohort p-value
tocol determined ICU admission based on hemodynamic status rather 2013/14 (n = 121) 2016/17 (n = 125)
than a protocol based on imaging findings. The purpose of this study is Gender (male) 69% 73% 0.46
to assess patient outcomes and resource utilization after implementation Age (median, range) 10.3 (0.1–17.9) 11.3 (0.3–17.9) 0.56
of a blunt solid organ injury protocol based on hemodynamic stability. Mechanism of injury 0.76
Fall 20% 18%
Sport-related 17% 20%
1. Methods Bike 16% 14%
Pedestrian vs MVA 14% 8%
1.1. Setting MVA 12% 18%
Animal 5% 4%
Other 16% 18%
Primary Children's Hospital is a level I trauma center in Salt Lake
City, Utah. In 2015 we implemented a solid organ injury protocol, Data are presented as percentages or as numerical values with associated median and in-
terquartile range, unless otherwise noted.
which based ICU admission solely on hemodynamic stability. Prior to
IQR = interquartile range, MVA = motor vehicle accident.
this, ICU admission was utilized for American Association for the Sur-
gery of Trauma (AAST) grades of injury IV or V.
1.4. Description of variables
1.2. Patient population
Variables included basic demographics (sex, age), mechanism of in-
We conducted a single-center retrospective review of all children jury (e.g. fall, sports-related injury, auto vs. pedestrian, motor vehicle
less than 18 years, with isolated liver or spleen injuries, identified accident), admitting vitals, organs of injury and associated AAST Organ
from a prospectively collected trauma database. To limit the effect of pa- Injury Scale score. Outcomes included intensive care unit (ICU) admis-
tients who would otherwise be admitted to the ICU, we excluded pa- sion, length of ICU admission, need for surgical intervention, length of
tients with an American AAST grade of injury greater than 2 in any stay, and mortality.
organ other than liver or spleen. We also excluded the cohort admitted
in the year of 2015 as this was during implementation of our new pro- 1.5. Statistical analysis
tocol. We then compared patients during the 2 years preceding imple-
mentation (2013–2014) to the 2 years succeeding (2016–2017). Data were analyzed using the Chi-Square test for categorical vari-
ables and the Student's T-test for continuous variables. All analyses
1.3. Blunt abdominal trauma protocol were performed using SAS 9.4.

The blunt abdominal trauma protocol was developed through review 2. Results
of literature promoting nonoperative, abbreviated management of blunt,
solid organ injury [11]. An abbreviated version is demonstrated in Fig. 1. There were 121 patients in the preprotocol cohort and 125 patients
The protocol dictates admission to the ICU after computed tomography in the postprotocol cohort. Their demographics and mechanisms of in-
of the abdomen and pelvis, based on hemodynamic stability. Hemody- jury were similar (Table 1). Patients in the 2013/2014 and 2016/17 co-
namic stability was determined by the trauma and emergency medicine horts were 69% and 73% male (p = 0.46) with median ages 10.3 and
teams using age-appropriate ranges for heart rate and blood pressure
measurements. Algorithms to determine hemodynamic instability have
been shown to be unreliable and were not used [11]. Hemodynamically Table 2
Vitals and injuries.
stable patients were candidates for floor admission. Patients were then
followed closely with serial hematocrit levels, frequent vitals, bed rest Grading Cohort Hemodynamics Cohort p-value
for a period, and a clear liquid diet. Prior to the blunt abdominal trauma 2013/14 (n = 121) 2016/17 (n = 125)
protocol, patients with grade IV and V injuries were generally admitted Admit SBP 116 (106–121) 116 (108–124) 0.54
to the ICU, regardless of hemodynamic stability. ED pulse 102 (87–122) 98 (84–116) 0.26
ED RR 20 (18–24) 20 (18–24) 0.60
ISS (median, IQR) 14 (9–21) 14 (9–21) 0.62
1–9 39% 38%
10–16 31% 33%
17–25 31% 25%
N26 29% 24%
Splenic injury 55% 50% 0.44
Splenic AAST grade 0.32
I 0% 0%
II 32% 17%
III 43% 47%
IV 20% 33%
V 5% 3%
Liver injury 53% 49% 0.54
Liver AAST grade 0.37
I 0% 0%
II 53% 31%
III 27% 44%
IV 17% 20%
V 3% 5%

Data are presented as percentages or as numerical values with associated median and in-
terquartile range, unless otherwise noted.
SBP = systolic blood pressure, ED = emergency department, ISS = injury severity scale,
Fig. 1. Blunt abdominal trauma protocol. AAST = American Association for the Surgery of Trauma.

Please cite this article as: M.G. Katz, Z.J. Kastenberg, M.A. Taylor, et al., Reduction of resource utilization in children with blunt solid organ injury,
Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.066
 M.G. Katz et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
Table 3
Interventions and outcomes.
Grading Cohort Hemodynamics
2013/14 Cohort
(n = 121) 2016/17 (n = 125)
Intubated 9.9% 13.6%
Transfusion 8.3% 8.8%
Operation 13% 7.2%
Admitted to ICU 40% 22%
Average ICU h/pt 0 (0–19) 0 (0–0)
Average ICU LOS among 22 (17–48) 24 (14–48)
patients admitted to ICU
Overall LOS 3 (2–4) 2 (1–4)
Death 0% 0%
Data are presented as percentages or as numerical values with associated median and in-
terquartile range, unless otherwise noted.
ICU = intensive care unit, LOS = length of stay, IQR = interquartile range.
11.3 (p = 0.56), respectively. Mechanism of injury in the pre- vs
postprotocol cohorts were also similar (p = 0.76): the most common
were fall (20 vs 18%), sports-related injury (17 vs 20%), bicycle accident
(16 vs 14%), pedestrian vs motor vehicle accident (14 vs 10%), motor ve-
hicle accident (12 vs 18%), and other (16 vs 18%).
Vitals at the time of admission, ISS, rates of liver and splenic injuries,
along with AAST grades were all equivalent in the two cohorts (Table 2).
Table 3 demonstrates interventions, and outcomes, which were similar
except for the number of patients admitted to the ICU (40 vs 22%, p =
0.002). Of patients with Grade 4 or 5 liver and/or spleen injuries, 24/
28 (86%) of patients in the 2013/14 period were admitted to the ICU,
compared to 16/34 (47%) of patients in the 2016/17 cohort.
The operative rate during the pre- and postintervention periods was
13% and 7.2%, respectively. Of these, one patient in the 2013/14 cohort
underwent laparotomy, and 2 in the 2016/17 cohort underwent lapa-
rotomies, all diagnostic and for concern of peritonitis. Each patient
underwent washout without any further intervention.
3. Discussion
The origins of nonoperative management of solid organ injuries can
be found in the 1960s with the observation that children with splenic
injuries often heal on their own [12]. In the following years the recogni-
tion that children without spleens (either congenital or surgically re-
moved) were at increased risk for overwhelming postsplenectomy
infection reinforced this concept. In the 1970s Ein and colleagues pub-
lished their early “very satisfactory” experience with nonoperative
management of traumatized spleen in children [13]. Since that time, cli-
nicians have increasingly appreciated that children with blunt, solid
organ injuries often do not require operative management [2,14–16].
Additionally, surgeons have embraced the role of non-formalin-based
organ preservation in the adult population [17–23].
Nonoperative management of children with isolated, blunt spleen
injury has been universally successful with expanded utility. A major
consideration for nonoperative management of solid organ injuries is
cost-effective utilization of resources while maximizing patient safety.
Clinicians continue to narrow criteria for transfusion, ambulation, LOS,
and in the current study, ICU admission. Our protocol led to a reduction
of ICU admissions from 40% to 22% without apparent harm. We found an
average decrease in ICU time from 14 to 8.5 h. Expense savings are dif-
ficult to calculate but, at our institution, this led to an estimated savings
of over $100,000 over the two-year period. The current study supports
the shift away from using CT Grading to determine ICU admission, and
supports the ATOMAC Guideline, which bases management on hemo-
dynamic status [11]. In fact, the ATOMAC Guidelines still recommend
that grade 5 injuries be admitted to the ICU. Our protocol dictates that
a hemodynamically stable patient with grade 5 injury is still considered
Please cite this article as: M.G. Katz, Z.J. Kastenberg, M.A. Taylor, et al., Reduction of resource utilization in children with blunt solid organ injury,
Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.066
3
for floor admission, which occurred in 9/12 (75%) of patients with grade
5 injuries without adverse outcome.
p-value The current study builds on previous literature that supports conser-
vative admission to the ICU. In 2008, McVay and colleagues published
their findings of 101 patients managed using a pathway based on hemo-
0.36 dynamic status [9]. Their cohort had a lower ISS than our own (7.8 vs
0.88 15.8), but similar rates of ICU admission (16% vs 22%) transfusion
0.12
(10% vs 9%) and mean LOS (3.2 vs 3.2 days). While McVay and col-
0.002
0.67 leagues modeled decreased resource utilization compared to a grade-
0.67 based protocol for ICU admission, our study was able to directly com-
pare admission rates based on two different admission criteria.
0.07 This study is limited by its retrospective nature. During the 2013/14
N/A
period, 14% of patients with Grade 4 or 5 injuries were admitted to the
ward, which was not consistent with our protocol at the time. Defining
hemodynamic stability by using a limited number of descriptors is prob-
lematic [11], and we were unable to determine compliance with the
blunt abdominal trauma protocol using our prospectively collected da-
tabase. Regardless, the implementation of the protocol led to decreased,
unnecessary ICU admissions and represents the real-world impact ef-
fects. This study is also limited by its relatively small number of patients.
Finally, Primary Children's covers a large geographic area and serves a
population that might differ from other Level I trauma centers.
4. Conclusion
A protocol for ICU admission based on physiologic derangement ver-
sus solely on radiologic grade significantly and safely reduced admission
rates to the ICU in children with solid organ injury. Hemodynamically
stable children with isolated Grade IV or V blunt liver or spleen injury
do not require ICU admission.
References
[1] Koyoma T, Skattum J, Engelsen P, et al. Surgical intervention for paediatric liver inju-
ries is almost history - a 12-year cohort from a major Scandanavian trauma centre.
Scand J Trauma Resusc Emerg Med 2016;29:139–43.
[2] Stylianos S, APSA Trauma Committee. Evidence-based guidelines for resource utili-
zation in children with isolated spleen or liver injury. The APSA Trauma Committee.
J Pediatr Surg 2000;35:164–9.
[3] Stylianos S, APS Liver/Spleen Trauma Study Group. Compliance with evidence-based
guidelines in children with isolated spleen or liver injury: a prospective study. J
Pediatr Surg 2002;37:453–6.
[4] Wisner DH, Kuppermann N, Cooper A, et al. Management of children with solid
organ injuries after blunt torso trauma. J Trauma Acute Care Surg 2015;79:207–14.
[5] Bond SJ, Eichelberger MR, Randolph JG, et al. Nonoperative management of blunt he-
patic and splenic injury in children. Ann Surg 1996;223:286–9.
[6] Hackam DJ, Potoka D, Ford H, et al. Utility of radiographic hepatic injury grade in
predicting outcome for children after blunt abdominal trauma. J Pediatr Surg
2002;37:386–9.
[7] Poletti PA, Wintermark M, Becker CD, et al. Traumatic injuries: role of imaging in the
management of the polytrauma victim (conservative expectation). Eur Radiol 2002;
12:969–78.
[8] Mehall JR, Ennis JS, Saltzman DA, et al. Prospective results of a standardized algo-
rithm based on hemodynamic status for managing pediatric solid organ injury. J
Am Coll Surg 2001;193:347–53.
[9] McVay MR, Kokoska ER, Jackson RJ, et al. Throwing out the “grade” book: manage-
ment of isolated spleen and liver injury based on hemodynamic status. J Pediatr
Surg 2008;43:1072–6.
[10] Fremgen HE, Bratton SL, Metzger RR, et al. Pediatric liver lacerations and intensive
care: evaluation of ICU triage strategies. Pediatr Crit Care Med 2014;15:e183–91.
[11] Notrica DM, Eubanks JW, Tuggle DW, et al. Nonoperative management of blunt liver
and spleen injury in children: Evaluation of the ATOMAC guidelines using GRADE. J
Trauma Acute Care Surg 2015;79:683–93.
[12] Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet 1968;
126:781–90.
[13] Ein SH, Shandling B, Simpson JS, et al. Nonoperative management of traumatized
spleen in children: how and why. J Pediatr Surg 1978;13:117–9.
[14] Gaines BA, Ford HR. Abdominal and pelvic trauma in children. Crit Care Med 2002;
30:416–23.
[15] Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J
Trauma 2009;67:135–9.
[16] Lynn KN, Callaghan RM, Jafri ZH. Pediatric blunt splenic trauma: a comprehensive
review. Pediatr Radiol 2009;39:904–16.
[17] Croce MA, Fabian TC, Menke PG, et al. Nonoperative management of blunt hepatic
trauma is the treatment of choice for hemodynamically stable patients. Results of
a prospective trial. Ann Surg 1985;221:744–55.
4 M.G. Katz et al. / Journal of Pediatric Surgery xxx (xxxx) xxx

[18] Cogbll TH, Moore EE, Jurkovich GJ, et al. Nonoperative management of blunt splenic
trauma: a multicenter experience. J Trauma 1989;29:1312–7.
[19] Mooney DP. Multiple trauma: liver and spleen injury. Curr Opin Pediatr 2002;14:
482–5.
[20] Rutledge R, Hunt JP, Lentz CW, et al. A statewide, population-based time-series anal-
ysis of the increasing frequency of nonoperative management of abdominal solid
organ injury. Ann Surg 1995;222:311–22.
[21] Schroeppel TJ, Croce MA. Diagnosis and management of blunt abdominal solid organ
injury. Curr Opin Crit Care 2007;13:399–404.
[22] Olthof DC, van der Vlies CH, Joosse P, et al. On behalf of the PYTHIA Collaboration
Group. Consensus strategies for the nonoperative management of patients with
blunt splenic injury: a Delphi study. J Trauma Acute Care Surg 2013;74:1567–74.
[23] Kozar RA, Feliciano DV, Moore EE, et al. Western Trauma Association/critical decisions in
trauma: operative management of adult blunt hepatic trauma. J Trauma 2011;71:1–5.

Please cite this article as: M.G. Katz, Z.J. Kastenberg, M.A. Taylor, et al., Reduction of resource utilization in children with blunt solid organ injury,
Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.066