Background There are no tested in-hospital traumatic brain injury (TBI) care programs. We examined the implementation and effectiveness of the Pediatric Guideline Adherence and Outcomes (PEGASUS) program in severe pediatric TBI. Methods In this prospective hybrid implementation-effectiveness study, we examined service provision, achieving key performance indicator (KPI) adherence, and discharge outcomes in children (age < 18 years) with severe (GCS ≤ 8) TBI (trauma mechanism and imaging findings) associated with the PEGASUS program. Implementation outcomes and achieving KPI adherence are described. Poisson regression with robust standard errors estimate the association between achieving KPI adherence and discharge outcomes. Findings Among the 199 participants 11·9 (12·7) years who received the PEGASUS program between 2011-2017, 193 (97%) program recipients had severe TBI. Adherence to at least one KPI was achieved in 101 (96·2%), and 44 (41·9%) achieved adherence to all three KPIs. Program participants achieved KPI adherence to hypocarbia KPI (72·4%), nutrition KPI (81 ·4%), and cerebral perfusion pressure KPI (64·3%). Adherence to KPI-nutrition was associated with 2·70-fold (95% CI 1·54-4·73) higher discharge survival and 3 05-fold (95% CI 1·52-6·11) more favorable discharge disposition. Adherence to KPI-CPP was also associated with higher discharge survival (RR 1 ·33; 95% CI 1 · 12-1·59) and favorable disposition (RR 1 ·53; 95% CI 1 · 19·1-96). Adherence to each additional KPI was significantly associated with 1·27 (95% CI, 1 · 12-1·44) times higher survival rate and 1·46 (95% CI, 1 ·23-1·72) times higher favorable discharge disposition in a dose-response fashion. Interpretation The new multilevel hospital-wide high fidelity and comprehensive PEGASUS program achieved favorable levels of service provision, KPI adherence and was associated with favorable discharge outcomes across the full spectrum of pediatric patients with severe TBI. Adherence to CPP, nutrition and hypocarbia KPI targets are essential program components and associated with favorable discharge outcomes. The PEGASUS program may benefit children and adolescents hospitalized with severe TBI.

Key Points Question Is end-tidal carbon dioxide (EtCO 2 ) a reliable surrogate for partial pressure of carbon dioxide, arterial (Pa co 2 ) in children admitted to the intensive care unit with traumatic brain injury? Findings In this secondary analysis of a prospective cohort study that included 445 paired Pa co 2 -EtCO 2 values from 137 patients, only 42.0% of Pa co 2 values were within 0 to 5 mm Hg of paired EtCO 2 values. Development of pediatric acute respiratory distress syndrome within 24 hours after admission was associated with significantly lower likelihood of Pa co 2 -EtCO 2 agreement than was no development of pediatric acute respiratory distress syndrome. Meaning This study suggests that EtCO 2 values are not a reliable substitute for Pa co 2 values during the first 24 hours after pediatric traumatic brain injury, especially in the presence of pediatric acute respiratory distress syndrome.

BACKGROUND: Many students return to school after concussion with symptoms but without formal support. OBJECTIVE: To examine concussion symptoms and temporary academic accommodations during school use of a four-week student-centered return to learn (RTL) care plan. METHODS: Five public high schools used the RTL care plan and contributed student-level data after student report of concussion. Data on concussion symptoms, temporary academic accommodations corresponding to reported symptoms, and accommodations provided during RTL care plan use were examined. RESULTS: Of 115 students, 55%used the RTL care plan for three (34%) or four (21%) weeks. Compared to students whose symptoms resolve within the first two weeks, students who used the RTL care plan for three or four weeks reported more unique symptoms (P = 0.038), higher total severity score (P = 0.005), and higher average severity per symptom (P = 0.007) at week one. Overall, 1,127 weekly accommodations were provided. While least reported, emotional symptoms received corresponding accommodations most often (127/155 reports: 82%of occurrences). CONCLUSIONS: Use of an RTL care plan can facilitate the RTL of students with a concussion and may aid in the identification of students who are in need of longer-term support.