St. Louis hospital uses step-by-step approach to triumph over brain injuries
St. Louis Post-Dispatch
Three years ago, after a snowfall during a sleepover with a friend, Drew Mitchem rolled off a sled pulled by his friend’s big sister on an ATV. His head hit the bumper of a truck parked in the driveway.
An ambulance drove the disoriented 11-year-old from his hometown of Oran, Mo., to the nearest hospital in Cape Girardeau, where tests revealed his skull was fractured behind his right ear. A helicopter took him to St. Louis Children’s Hospital.
Doctors quickly placed a sensor through his skull to monitor dangerous brain swelling. A week later, Drew needed a shunt to drain fluid away from his brain and relieve pressure that could cause irreversible damage. He was in a medically induced coma, hooked up to life support, to help his brain heal.
The pressure returned to normal about a week later. And after two weeks of intense speech and physical therapy, Drew returned home. Now 14, he shows no signs of his injury.
“I was so worried about how he was going to turn out,” said his mother, Sherry Mitchem, 39. “When he was in (intensive care) and seeing all the tubes and machines he was hooked up to, I was worried he wasn’t even going to make it.”
Drew’s injury was treated as part of a new approach that has produced markedly better outcomes for children with severe traumatic brain injuries — the leading killer of children over the age of 1, according to a study led by Washington University School of Medicine assistant professor Dr. Jose Pineda, director of the neurocritical program at Children’s.
A team of experts in neurology and trauma developed step-by-step plans on how to respond to specific symptoms and when to escalate care based on the latest research. Following the plans has helped doctors provide quicker and more aggressive treatment in the critical first few days.
“The main difference is that before, everybody knew what to do … the knowledge was there; but there was no complete, written map on how to apply that knowledge and to do so in an efficient and timely manner,” Pineda said. “We grabbed all the medical evidence available and created a pathway of care.”
The new approach also requires continual monitoring, he said, with a nurse whose job is to make sure all protocols are being followed.
“You have to make sure everyone is educated about the plan, and the plan is updated,” Pineda said. “You have to be evaluating all the time how it is being implemented, and if it is still making sense in reality.”
With more severely injured children able to walk out the doors of the hospital, doctors felt the approach was making a difference. But they wanted to know for sure. They dug into the past 12 years of severe cases, and their findings were published last month in the journal The Lancet Neurology.
Doctors studied the outcomes of 123 patients before and after launching the neurocritical care program in September 2005. In the six years before the hospital created the program, 52 percent of patients either died or were admitted to a long-term care facility, compared to 33 percent in the six years afterward.
“It was dramatic,” Pineda said. “Mortality for these children was dramatically reduced, and we also noted a meaningful improvement in outcomes for survivors. We know that children who suffer traumatic brain injuries have long lives ahead and must reintegrate into society and be independent. That’s where we set the bar.”
Only a handful of other hospitals have implemented similar programs, and no one had yet to study the outcomes, he said. “We are the first ones to report that having a program actually does make a difference. We hope to help other institutions implement similar plans and see what happens with their outcomes.”
The Children’s Hospital of Pittsburgh was among the first hospitals to implement such protocols in the mid-1990s. But it has not been able to study the results, said Dr. Michael Bell, the hospital’s neurocritical care director, who applauded the in-depth study led by Pineda.
“It emphasizes that adopting evidence-based protocols within a multidisciplinary team of physicians can substantially improve outcomes of children with severe traumatic brain injury ...,” Bell said. “This is a very laudable achievement.”
“Showing that what you are doing works is going to be increasingly important” in health care, Bell said. Children treated using the protocol described by Pineda had better outcomes but also required longer stays in intensive care and in the hospital.
“I think parents and caregivers should happily accept a slightly longer length of stay in order to get a child who is more fully recovered in the end,” Bell said. “However, reimbursement agents now and in the future will need evidence that these expenses are worth the cost — and Dr. Pineda’s group provides such evidence.”
Maureen Cunningham, the director of the Brain Injury Association of Missouri, was encouraged by the findings. She sees families dealing with devastating outcomes. “Getting a child through that first stage provides health and hope for the child and for the family,” she said. “This really opens up doors and gives children better opportunities for a quality life in the future. ... It gives them a chance to walk to school, to communicate, to give hugs.”
Traumatic brain injury is the leading cause of disability and death in the U.S. It’s often caused by car crashes, falls, sports injuries or abuse. Among children up to age 14, brain injury results in nearly 2,700 deaths and 37,000 hospitalizations a year, federal figures show.
What often causes complications is the “secondary damage” from brain swelling, Pineda said, which can cause more damage than the injury itself.
“There’s no space inside the skull, so the pressure inside the head goes up. This creates a cascade of a second wave of injury — injury on top of injury,” he said. “Not only do you have to apply the correct therapies, but you have to apply them as soon as possible. The brain doesn’t have any room for error. The brain doesn’t forgive delays when it comes to progression of injury.”
Pineda said it may seem obvious to have collaboration, written plans and monitoring in place when dealing with complex cases where timeliness is critical, but it’s not always easy to transfer medical knowledge into an effective practice at the bedside. This emerging field of medicine is called “implementation science,” and it’s taking lessons from other industries, such as aviation and the military, where protecting lives requires optimal teamwork.
“How do we grab all the latest scientific information and embed it in the culture, so everyone is doing everything that they want to do and doing it effectively?” Pineda said.
Mitchem said a team of specialists and nurses met every morning to discuss her son’s care. “There were so many people on his case, yet they all worked together. It was never one doc said one thing, and another said something else ... Everybody knew what the other one was doing. Everybody was on the same page.”
When she and her husband first drove to St. Louis, following the helicopter their son was on, the injury did not seem serious, she said. She expected to stay a couple days in the hospital.
“I never thought it would be 32 days,” Mitchem said. “Now I look back and think, ‘Wow, it was only 32 days.’ That was probably lucky.”