Compliance with evidence-based guidelines in children with isolated spleen or liver injury: A prospective study

Purpose: This prospective study is designed to disseminate and apply 5 previously defined, evidence-based guidelines in children with isolated spleen or liver injuries. The desired outcomes are to standardize treatment, promote consensus, and utilize resources in a safe and efficient manner. Methods: Guidelines on intensive care unit (ICU) stay, hospital stay, imaging, and physical activity restriction for children with isolated spleen or liver injuries were defined by retrospective analysis of 832 children treated nonoperatively at 32 centers from 1995 to 1997. The guidelines were based on severity of injury by computed tomography (CT) grade. These guidelines were applied prospectively in 312 children treated nonoperatively at 16 centers from 1998 to 2000. Compliance was analyzed for age, gender, organ injured, and CT grade. All patients underwent follow-up for 4 months. In addition, the authors compared ICU stay, hospital stay, follow-up imaging, and interval of activity restriction in the retrospective historical group (1995 through 1997) with the current prospective group (1998 through 2000). Results: Specific guideline compliance was 81% for ICU stay, 82% for hospital stay, 87% for follow-up imaging, and 78% for interval of activity restriction. There was a significant improvement in compliance from year 1 to year 2 for ICU stay (77% v 88%; P < 02) and interval of activity restriction (73% v 87%; P<.01). Compliance with proposed intervals for activity restriction was greater for those with less severe injuries (87% in grades I and II v 72% in grades III and IV; P < .01). There were no differences in compliance by age, gender, or organ injured. Deviation from guidelines was surgeon's choice in 90% and patient related in 10%. Six (1.9%) patients were readmitted, although none required operation. Compared with the previously studied 832 patients, the 312 patients who had prospective application of the proposed guidelines had a significant reduction in ICU stay (P < .0001), hospital stay (P < .0006), follow-up imaging (P < .0001), and interval of physical activity restriction (P < .05) within each grade of injury. Conclusions: Prospective application of specific treatment guidelines based on injury severity has resulted in conformity in patient management, improved utilization of resources, and validation of guideline safety. Significant reduction of ICU stay, hospital stay, follow-up imaging, and length of activity restriction has been achieved without adverse sequelae when compared with our retrospective database.