Modeling the Impact of the Updated American Pediatric Surgery Association Blunt Liver and Spleen Injury Guidelines: A Solid Improvement in Care

Introduction The American Pediatric Surgery Association blunt liver and spleen injury (BLSI) guidelines were updated in 2019 to avoid unnecessary intensive care unit (ICU) admission, phlebotomy, bed rest, and diet restriction. This study sought to evaluate these guidelines using a counterfactual model applied to BLSI patients of the previous era. Methods A single-institution review was performed of isolated BLSI patients ≤17 y old from 2011 to 2020, prior to adoption of the new guidelines. A counterfactual model was created to retrospectively apply the guidelines based on vital signs following initial fluid resuscitation. Differences between actual and modeled care were analyzed using Fisher's exact and paired Wilcoxon tests. Results A total of 117 patients were identified, comprising 41 (35%) liver, 72 (62%) spleen, and 4 (3%) liver-spleen injuries. Of patients with normal vitals following resuscitation, 11 (9%) were managed in accordance with updated guidelines. When applied, the guidelines would have reduced rates of ICU admission (17% versus 67%, P < 0.001), median ICU days (0 versus 2, P < 0.001), blood draws (2 versus 5, P < 0.001), days of diet restriction (0 versus 1, P < 0.001) and bed rest (0 versus 2, P < 0.001), follow-up imaging (0% versus 6%, P < 0.01), and median charges ($75,462 versus $29,855, P < 0.0001). No patients initially admitted to the ward would have required ICU transfer. Conclusions Counterfactual implementation of the American Pediatric Surgery Association BLSI guidelines was shown to reduce ICU admissions, length of ICU stay, blood draws, dietary restrictions, bed rest duration, frequency of follow-up imaging, and hospitalization charges, without evidence of undertriage or undertreatment of children with BLSI.