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Article Summary:
Bennett TD, Dixon RR, Kartchner C, et al. Functional Status Scale in Children with Traumatic Brain Injury: A Prospective Cohort Study. Pediatr Crit Care Med. 2016; 17(12):1147-1156
The objective of this study was twofold. First off, the researchers wanted to describe and assess changes in children with traumatic brain injuries (TBI) in the intensive care unit (ICU) using the functional status scale (FSS). This change was to be assessed from baseline function which was attained on admission at one of the two, level 1 pediatric trauma centers participating in the study. Secondly, to examine correlations between the FSS and age, mechanism of injury, exam/imaging, and known outcomes for children 0-18 years old who had sustained a TBI. Inclusion in the study was limited to individuals admitted to the ICU with a diagnosis of acute TBI and a Glasgow Coma Scale (GCS) score <12 or a neurosurgic procedure. All 196 individuals who participated in the study were under the age of 18 and must have met the criteria within 24 hours of admission. This was a prospective cohort study and data was collected through review of documentation and provider discussions as appropriate. No interventions were performed and the child’s discharge FSS was either obtained when discharged from the hospital or on the day they were transferred to inpatient rehab in order to maintain consistency between the two participating sites.
The results indicated that a third of all individuals assessed from baseline developed new morbidity at discharge. The mean change in FSS for all survivors was 3.9, and 5.2 in those with severe TBI. Functional impairments were present in all 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory function) with the respiratory domain demonstrating the least amount of change. The FSS score change was highest in the motor, feeding, and communication domains. No correlation was found between patient age and discharge FSS. An inverse relationship was found between admission GCS for total/motor scores and the FSS at discharge. Imaging (CT scan) showed that individuals who presented with an epidural hematoma had good functional status at discharge where as individuals with a subdural hematoma, intraventricular hemorrhage, subarachnoid hemorrhage, or intraparenchymal hemorrhage had worse outcomes. New gastrostomy tube placement was associated with moderately impaired functional status when replaced during their acute hospitalization.
Overall strengths of this article included its reproducibility as the FSS has good construct validity, is consistent with activities of daily living, tracks adaptive behaviors, has a wide age range (0-18 years), has good interrater reliability, and pertinent information can be easily and quickly obtained. Limitations included the use of only two hospitals and the fact that the FSS is not sensitive to family functioning or quality of life. It also does not account for pre/post morbidities and is not as specific in detail as other neurological outcome measures. Long-term effects of the study are difficult to generalize as data was not collected post discharge, and CT scans were read by the facilities radiologists rather than standardized. Overall, it was determined that the FSS is appropriate for use with children who have sustained a TBI. It appropriately measures change in preinjury functional status and can be used for hospital improvement initiatives and interventional studies.