The goals of the current study were (1) to develop valid and feasible quality indicators of care for children with TBI and (2) to survey a sample of rehabilitation units in the United States to measure the quality of the structure and organization of acute inpatient rehabilitation being delivered currently to children with TBI. Substantial variations in the quality of structure and organization of rehabilitation delivered to children after TBI were identified, with volume of children with TBI and the pediatric focus of the unit emerging as important determinants of the total number of quality indicators met.
Structure of care, encompassing material and human resources as well as the organization of these resources, is one of the key elements of the structure-process-outcome framework proposed by Donabedian26
and is recognized as a useful quality assessment system for establishing, monitoring and improving the current state of post acute care.6
Hoenig and colleagues applied this model to evaluate post-stroke rehabilitation, demonstrating that structural characteristics independently predicted processes of care (e.g., family involvement or multidisciplinary care coordination), which in turn influenced six-month functional outcomes.27
The findings from our study provide a measure of the current structure of rehabilitation for children, a critical step toward understanding the complex interactions between structure and processes of care for this population.
The finding that pediatric specialty units were more likely to meet a higher number of quality indicators, such as having a higher percentage of staff with pediatric-specific training, is consistent with extant literature on the importance of children’s-specific care structures for the acute treatment of traumatic injuries and critical illness in children. 28–30
A number of studies suggest that children admitted to pediatric specific trauma centers have lower mortality rates and improved overall functional outcomes compared to those children treated at trauma centers without pediatric specific resources.29, 31
The influence of a pediatric rehabilitation unit on patient outcomes has not been explored, and tools for categorizing and measuring the structure of rehabilitation previously have been lacking.
Pediatric specialty units unexpectedly were found to be less likely to have a certified rehabilitation registered nurse on staff. While the underlying factors for the difference in CRRN representation is not clear, barriers may include exposure to the field, certification and experience requirements.32
The pediatric specialty units in this study also were less likely than all age units to report CARF accreditation, and CRRN certification is strongly encouraged by CARF. On the other hand, pediatric units were more likely to have nursing to patient ratio policies in place, and higher staffing levels have been associated with lower rates of patient mortality and adverse events, improved nursing job satisfaction and higher patient satisfaction in hospital settings.33–36
Units with a pediatric focus were also better structured to deliver services to children given the availability of child-specific equipment and classrooms to continue educational services during the inpatient rehabilitation stay. These services may be important indicators of other components of care structure or quality of care. For example, Hoenig and colleagues demonstrated that VA hospitals with rehabilitation-specific structures, including a higher diversity (number and type) of specialized rehabilitation equipment or a simulated home environment, had longer lengths of stay for adults post-stroke.37
The specialized units studied, while having a longer length of stay, also were 91% more likely to have patients discharged to home rather than to a skilled facility. It is likely that such structural characteristics influence functional outcomes indirectly via the interactions between structure and processes of care. For instance, a classroom permits a careful and functional assessment of a child’s needs and a realistic trial of school to be employed in a natural setting, thereby optimizing the likelihood of a successful and timely school reintegration.
Another important finding in our study was that rehabilitation units admitting a high volume of children with TBI met a higher number of quality indicators when compared with hospitals of intermediate and low volumes. For many medical services, including trauma care and surgical procedures, increased volume of patients often is associated with better quality of care.9, 38–40
For example, a strong association has been documented between high volume trauma centers and improvements in mortality and length of stay in patients at high risk for adverse outcomes.38
An association between institutional volume and recovery from brain injury has not been investigated to date, and future work should focus on examining the association of high volume rehabilitation centers with positive functional outcomes in children with TBI.