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Alberto EC, Jagannath S, McCusker ME, Keller S, Marsic I, Sarcevic A, O’Connell KJ, Burd RS. Classification strategies for non-routine events occurring in high-risk patient care settings: A scoping review. J Eval Clin Pract 2021; 27:464-471. [PMID: 33249690 PMCID: PMC7961264 DOI: 10.1111/jep.13456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Non-routine events (NREs) are atypical or unusual occurrences in a pre-defined process. Although some NREs in high-risk clinical settings have no adverse effects on patient care, others can potentially cause serious patient harm. A unified strategy for identifying and describing NREs in these domains will facilitate the comparison of results between studies. METHODS We conducted a literature search in PubMed, CINAHL, and EMBASE to identify studies related to NREs in high-risk domains and evaluated the methods used for event observation and description. We applied The Joint Commission on Accreditation of Healthcare Organization (JCAHO) taxonomy (cause, impact, domain, type, prevention, and mitigation) to the descriptions of NREs from the literature. RESULTS We selected 25 articles that met inclusion criteria for review. Real-time documentation of NREs was more common than a retrospective video review. Thirteen studies used domain experts as observers and seven studies validated observations with interrater reliability. Using the JCAHO taxonomy, "cause" was the most frequently applied classification method, followed by "impact," "type," "domain," and "prevention and mitigation." CONCLUSIONS NREs are frequent in high-risk medical settings. Strengths identified in several studies included the use of multiple observers with domain expertise and validation of the event ascertainment approach using interrater reliability. By applying the JCAHO taxonomy to the current literature, we provide an example of a structured approach that can be used for future analyses of NREs.
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Abdulbaqi J, Gu Y, Xu Z, Gao C, Marsic I, Burd RS. Speech-Based Activity Recognition for Trauma Resuscitation. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS 2021; 2020. [PMID: 33738430 DOI: 10.1109/ichi48887.2020.9374372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We present a speech-based approach to recognize team activities in the context of trauma resuscitation. We first analyzed the audio recordings of trauma resuscitations in terms of activity frequency, noise-level, and activity-related keyword frequency to determine the dataset characteristics. We next evaluated different audio-preprocessing parameters (spectral feature types and audio channels) to find the optimal configuration. We then introduced a novel neural network to recognize the trauma activities using a modified VGG network that extracts features from the audio input. The output of the modified VGG network is combined with the output of a network that takes keyword text as input, and the combination is used to generate activity labels. We compared our system with several baselines and performed a detailed analysis of the performance results for specific activities. Our results show that our proposed architecture that uses Mel-spectrum spectral coefficients features with a stereo channel and activity-specific frequent keywords achieve the highest accuracy and average F1-score.
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McFall C, Beier AD, Hayward K, Alberto EC, Burd RS, Farr BJ, Mooney DP, Gee K, Upperman JS, Escobar MA, Coufal NG, Harvey HA, Gollin G. Contemporary management of pediatric open skull fractures: a multicenter pediatric trauma center study. J Neurosurg Pediatr 2021; 27:533-537. [PMID: 33711805 DOI: 10.3171/2020.10.peds20486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to evaluate the contemporary management of pediatric open skull fractures and assess the impact of variations in antibiotic and operative management on the incidence of infectious complications. METHODS The records of children who presented from 2009 to 2017 to 6 pediatric trauma centers with an open calvarial skull fracture were reviewed. Data collected included mechanism and anatomical site of injury; presence and depth of fracture depression; antibiotic choice, route, and duration; operative management; and infectious complications. RESULTS Of the fractures among the 138 patients included in the study, 48.6% were frontal and 80.4% were depressed; 58.7% of patients underwent fragment elevation. The average duration of intravenous antibiotics was 4.6 (range 0-21) days. Only 53 patients (38.4%) received a single intravenous antibiotic for fewer than 4 days. and 56 (40.6%) received oral antibiotics for an average of 7.3 (range 1-20) days. Wounds were managed exclusively in the emergency department in 28.3% of patients. Two children had infectious complications, including a late-presenting hardware infection and a superficial wound infection. There were no cases of meningitis or intracranial abscess. Neither antibiotic spectrum or duration nor bedside irrigation was associated with the development of infection. CONCLUSIONS The incidence of infectious complications in this population of children with open skull fractures was low and was not associated with the antibiotic strategy or site of wound care. Most minimally contaminated open skull fractures are probably best managed with a short duration of a single antibiotic, and emergency department closure is appropriate unless there is significant contamination or fragment elevation is necessary.
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Zhang Y, Gu Y, Marsic I, Zheng Y, Burd RS. Video-based Concurrent Activity Recognition for Trauma Resuscitation. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS 2021; 2020. [PMID: 33748692 DOI: 10.1109/ichi48887.2020.9374399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We introduce a video-based system for concurrent activity recognition during teamwork in a clinical setting. During system development, we preserved patient and provider privacy by pre-computing spatio-temporal features. We extended the inflated 3D ConvNet (i3D) model for concurrent activity recognition. For the model training, we tuned the weights of the final stages of i3D using back-propagated loss from the fully-connected layer. We applied filtering on the model predictions to remove noisy predictions. We evaluated the system on five activities performed during trauma resuscitation, the initial management of injured patients in the emergency department. Our system achieved an average value of 74% average precision (AP) for these five activities and outperformed previous systems designed for the same domain. We visualized feature maps from the model, showing that the system learned to focus on regions relevant to performance of each activity.
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Patterson KN, Fabia R, Giles S, Verlee SN, Marx D, Aguayo P, Ziegfeld S, Parrish C, Stewart FD, Fritzeen J, Burd RS, Vitale L, Cloutier D, Shanti C, Klein J, Thakkar RK. Defining Benchmarks in Pediatric Burn Care: Inception of the Pediatric Injury Quality Improvement Collaborative (PIQIC). J Burn Care Res 2021; 43:277-280. [PMID: 33677547 DOI: 10.1093/jbcr/irab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Pediatric burn care is highly variable nationwide. Standardized quality and performance benchmarks are needed for guiding performance improvement within pediatric burn centers. A network of pediatric burn centers was established to develop and evaluate pediatric-specific best practices. A multi-disciplinary team including pediatric surgeons, nurses, advanced practice providers, pediatric intensivists, rehabilitation staff, and child psychologists from five pediatric burn centers established a collaborative to share and compare performance improvement data, evaluate outcomes, and exchange best care practices. In December 2016, the Pediatric Injury Quality Improvement Collaborative (PIQIC) was established. PIQIC members chose quality improvement indicators, drafted and approved a memorandum of understanding (MOU), data use agreement (DUA) and charter, formalized the multidisciplinary membership, and established a steering committee. Since inception, PIQIC has conducted monthly teleconferences and biannual in-person or virtual group meetings. A centralized data repository has been established where data is collated and analyzed for benchmarking in a blinded fashion. PIQIC has shown the feasibility of multi-institutional data collection, implementation of performance improvement metrics, publication of research, and enhancement of aggregate and institution-specific pediatric burn care.
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Alberto EC, Harvey AR, Amberson MJ, Zheng Y, Thenappan AA, Oluigbo C, Marsic I, Sarcevic A, O'Connell KJ, Burd RS. Assessment of Non-Routine Events and Significant Physiological Disturbances during Emergency Department Evaluation after Pediatric Head Trauma. Neurotrauma Rep 2021; 2:39-47. [PMID: 33748812 PMCID: PMC7962792 DOI: 10.1089/neur.2020.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Outcomes following pediatric traumatic brain injury (TBI) are dependent on initial injury severity and prevention of secondary injury. Hypoxia, hypotension, and hyperventilation following TBI are associated with increased mortality. The purpose of this study was to determine the association of non-routine events (NREs) during the initial resuscitation phase with these physiological disturbances. We conducted a video review of pediatric trauma resuscitations of patients with suspected TBI and Glasgow Coma Scale (GCS) scores <13. NREs were rated as "momentary" if task progression was delayed by <1 min and "moderate" if delayed by >1 min. Vital sign monitor data were used to identify periods of significant physiological disturbances. We calculated the association between the rate of overall and moderate NREs per case and the proportion of cases with abnormal vital signs using multi-variate linear regression, controlling for GCS score and need for intubation. Among 26 resuscitations, 604 NREs were identified with a median of 23 (interquartile range [IQR] 17-27.8, range 5-44) per case. Moderate delay NREs occurred in 19 resuscitations (n = 32, median 1 NRE/resuscitation, IQR 0.3-1, range 0-5). Oxygen desaturation and respiratory depression were associated with a greater rate of moderate NREs (p = 0.008, p < 0.001, respectively). We observed no association between duration of hypotension, desaturation, and respiratory depression and overall NRE rate. NREs are common in the initial resuscitation of children with moderate to severe TBI. Episodes of hypoxia and respiratory depression are associated with NREs that cause a moderate delay in task progression. Conformance with resuscitation guidelines is needed to prevent physiological events associated with adverse outcomes following pediatric TBI.
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Pisano C, Fabia R, Shi J, Wheeler K, Giles S, Puett L, Stewart D, Ziegfeld S, Flint J, Miller J, Aguayo P, Alberto EC, Burd RS, Vitale L, Klein J, Thakkar RK. Variation in acute fluid resuscitation among pediatric burn centers. Burns 2020; 47:545-550. [PMID: 33707085 DOI: 10.1016/j.burns.2020.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/13/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Accurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates. METHODS Five pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received. RESULTS Differences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers' resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35ml/kg/% TBSA, p<0.001), (4.90 versus 6.35ml/kg/TBSA, p=0.002) and (3.38 versus 6.35ml/kg/TBSA, p<0.0001). CONCLUSIONS This variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.
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Alberto EC, Waterhouse LJ, Fritzeen JL, DiAngelo CR, Scheidt VH, Burd RS. Assessment of the Need for Immediate Trauma Team Presence for Infants Presenting in Cardiac Arrest. South Med J 2020; 113:55-58. [PMID: 32016433 DOI: 10.14423/smj.0000000000001060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Out-of-hospital cardiac arrest (OHCA) is rare in infants, with the cause of arrest often unknown upon presentation. Nonaccidental trauma is a potential etiology of OHCA among infants, but its occult presentation makes this etiology challenging to diagnose. In the absence of apparent injuries, identifying the need for trauma team activation is difficult during the initial resuscitation of infants with OHCA. METHODS We performed a retrospective chart review of infants younger than 1 year old who presented to Children's National Health System from 2012 to 2016 with cardiopulmonary resuscitation in progress. Medical records and the trauma registry were reviewed for relevant resuscitation information. Autopsy records provided the cause and manner of death, contributing factors to death, and evidence of injury. RESULTS Among 592 infants undergoing resuscitation during the study period, 34 infants (5.7%) presented in cardiac arrest. The average age on presentation was 101.2 days (standard deviation 78.7). Most of the patients (n = 32, 94.1%) died in the emergency department, with none surviving to discharge. Among the 32 infants for whom autopsy records were available, the cause of death was nonaccidental trauma in one patient (3.1%). CONCLUSIONS Infant OHCA had poor outcomes, with trauma as a rare etiology. In the absence of external signs of injury or known injury mechanism, immediate trauma team presence was not beneficial for these infants during the initial resuscitation phase.
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Sakran JV, Ezzeddine H, Schwab CW, Bonne S, Brasel KJ, Burd RS, Cuschieri J, Ficke J, Gaines BA, Giacino JT, Gibran NS, Haider A, Hall EC, Herrera-Escobar JP, Joseph B, Kao L, Kurowski BG, Livingston D, Mandell SP, Nehra D, Sarani B, Seamon M, Yonclas P, Zarzaur B, Stewart R, Bulger E, Nathens AB. Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures. J Am Coll Surg 2020; 230:819-835. [PMID: 32201197 DOI: 10.1016/j.jamcollsurg.2020.01.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 11/24/2022]
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McLaughlin C, Barry W, Barin E, Kysh L, Auerbach MA, Upperman JS, Burd RS, Jensen AR. Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review. JOURNAL OF SURGICAL EDUCATION 2019; 76:1669-1680. [PMID: 31105006 DOI: 10.1016/j.jsurg.2019.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/05/2019] [Accepted: 05/05/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Simulation-based training as an educational intervention for healthcare providers has increased in use over the past 2 decades. The simulation community has called for standardized reporting of methodologies and outcomes. The purpose of this review was to (1) summarize existing data on the use of simulation-based team training for acute trauma resuscitation, and (2) describe differences in training methodologies, outcomes reporting, and gaps in the literature to inform research priorities. DESIGN We performed a scoping review of Ovid Medline, Embase, Cochrane Library, CINAHL, Web of Science, ERIC, and Google Scholar for studies evaluating simulation-based team training for acute trauma resuscitation. Full-text review was performed by 2 reviewers and variables related to study design, training methodology, outcomes reported, and impact of training were abstracted. RESULTS Forty-seven out of 3,911 screened studies met criteria for inclusion. Only 2 studies were randomized. The most frequent design was a pre-post study (64%). Eleven studies did not report their simulated scenario design. Interventions occurred most frequently in a laboratory-based setting (45%). Simulation-based training was associated with greater knowledge (n = 5/6), higher nontechnical skills (n = 12/13), greater number of resuscitation tasks completed (n = 10/13), and faster time to resuscitation task completion (n = 11/11). No differences in patient outcomes were found (n = 3/3). CONCLUSIONS Simulation-based training for trauma resuscitation is associated with improved measures of teamwork, task performance and speed, knowledge, and provider satisfaction. Type of reported outcomes and training methodologies are variable. Standardized reporting of training methodology and outcomes is needed to address the impact of this intervention.
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Rubens JH, Ahmed OZ, Yenokyan G, Stewart D, Burd RS, Ryan LM. Mode of Transport and Trauma Activation Status in Admitted Pediatric Trauma Patients. J Surg Res 2019; 246:153-159. [PMID: 31586889 DOI: 10.1016/j.jss.2019.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/13/2019] [Accepted: 08/15/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS). MATERIALS AND METHODS We performed a retrospective cohort study at two level I pediatric trauma centers. INCLUSION CRITERIA <15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics. RESULTS We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82). CONCLUSIONS Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.
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MESH Headings
- Child
- Child, Preschool
- Emergency Service, Hospital/organization & administration
- Emergency Service, Hospital/standards
- Emergency Service, Hospital/statistics & numerical data
- Facilities and Services Utilization/organization & administration
- Facilities and Services Utilization/standards
- Facilities and Services Utilization/statistics & numerical data
- Female
- Humans
- Injury Severity Score
- Length of Stay/statistics & numerical data
- Male
- Patient Admission/statistics & numerical data
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Registries/statistics & numerical data
- Retrospective Studies
- Transportation of Patients/statistics & numerical data
- Trauma Centers/organization & administration
- Trauma Centers/standards
- Trauma Centers/statistics & numerical data
- Triage/organization & administration
- Triage/standards
- Triage/statistics & numerical data
- United States
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/therapy
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/therapy
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Alberto EC, Amberson MJ, Cheng M, Xu Z, Sarcevic A, O’Connell KJ, Burd RS. Assessment of Non-Routine Events During Intubation for Pediatric Trauma. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jensen AR, Bullaro F, Falcone RA, Daugherty M, Young LC, McLaughlin C, Park C, Lane C, Prince JM, Scherzer DJ, Maa T, Dunn J, Wining L, Hess J, Santos MC, O'Neill J, Katz E, O'Bosky K, Young T, Christison-Lagay E, Ahmed O, Burd RS, Auerbach M. EAST multicenter trial of simulation-based team training for pediatric trauma: Resuscitation task completion is highly variable during simulated traumatic brain injury resuscitation. Am J Surg 2019; 219:1057-1064. [PMID: 31421895 DOI: 10.1016/j.amjsurg.2019.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/24/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Best practices for benchmarking the efficacy of simulation-based training programs are not well defined. This study sought to assess feasibility of standardized data collection with multicenter implementation of simulation-based training, and to characterize variability in pediatric trauma resuscitation task completion associated with program characteristics. METHODS A prospective multicenter observational cohort of resuscitation teams (N = 30) was used to measure task completion and teamwork during simulated resuscitation of a child with traumatic brain injury. A survey was used to measure center-specific trauma volume and simulation-based training program characteristics among participating centers. RESULTS No task was consistently performed across all centers. Teamwork skills were associated with faster time to computed tomography notification (r = -0.51, p < 0.01). Notification of the operating room by the resuscitation team occurred more frequently in in situ simulation than in laboratory-based simulation (13/22 versus 0/8, p < 0.01). CONCLUSIONS Multicenter implementation of a standardized pediatric trauma resuscitation simulation scenario is feasible. Standardized data collection showed wide variability in simulated resuscitation task completion.
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Gu Y, Zhang R, Zhao X, Chen S, Abdulbaqi J, Marsic I, Cheng M, Burd RS. Multimodal Attention Network for Trauma Activity Recognition from Spoken Language and Environmental Sound. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS 2019; 2019:10.1109/ichi.2019.8904713. [PMID: 32201857 PMCID: PMC7085888 DOI: 10.1109/ichi.2019.8904713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Trauma activity recognition aims to detect, recognize, and predict the activities (or tasks) during a trauma resuscitation. Previous work has mainly focused on using various sensor data including image, RFID, and vital signals to generate the trauma event log. However, spoken language and environmental sound, which contain rich communication and contextual information necessary for trauma team cooperation, are still largely ignored. In this paper, we propose a multimodal attention network (MAN) that uses both verbal transcripts and environmental audio stream as input; the model extracts textual and acoustic features using a multi-level multi-head attention module, and forms a final shared representation for trauma activity classification. We evaluated the proposed architecture on 75 actual trauma resuscitation cases collected from a hospital. We achieved 72.4% accuracy with 0.705 F1 score, demonstrating that our proposed architecture is useful and efficient. These results also show that using spoken language and environmental audio indeed helps identify hard-to-recognize activities, compared to previous approaches. We also provide a detailed analysis of the performance and generalization of the proposed multimodal attention network.
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Kulp L, Sarcevic A, Cheng M, Zheng Y, Burd RS. Comparing the Effects of Paper and Digital Checklists on Team Performance in Time-Critical Work. PROCEEDINGS OF THE SIGCHI CONFERENCE ON HUMAN FACTORS IN COMPUTING SYSTEMS. CHI CONFERENCE 2019; 2019. [PMID: 31633126 DOI: 10.1145/3290605.3300777] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This mixed-methods study examines the effects of a tablet-based checklist system on team performance during a dynamic and safety-critical process of trauma resuscitation. We compared team performance from 47 resuscitations that used a paper checklist to that from 47 cases with a digital checklist to determine if digitizing a checklist led to improvements in task completion rates and in how fast the tasks were initiated for 18 most critical assessment and treatment tasks. We also compared if the checklist compliance increased with the digital design. We found that using the digital checklist led to more frequent completions of the initial airway assessment task but fewer completions of ear and lower extremities exams. We did not observe any significant differences in time to task performance, but found increased compliance with the checklist. Although improvements in team performance with the digital checklist were minor, our findings are important because they showed no adverse effects as a result of the digital checklist introduction. We conclude by discussing the takeaways and implications of these results for effective digitization of medical work.
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McLaughlin C, Wieck MM, Barin E, Rake A, Burke RV, Roesly HB, Young LC, Chang TP, Cleek EA, Morton I, Goodhue CJ, Burd RS, Ford HR, Upperman JS, Jensen AR. Impact of Simulation-Based Training on Perceived Provider Confidence in Acute Multidisciplinary Pediatric Trauma Resuscitation. Pediatr Surg Int 2018; 34:1353-1362. [PMID: 30324569 PMCID: PMC6353611 DOI: 10.1007/s00383-018-4361-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients. METHODS An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children's hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation. RESULTS Survey response rate was 49% (n = 93/190) pre-simulation, 22% (n = 42/190) post-simulation, and 79% (n = 150/190) at 2-year follow-up. These providers reported more anxiety (p = 0.01) and less confidence (p = 0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p = 0.02) and greater confidence (p = 0.01), compared to untrained providers. CONCLUSIONS Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence. LEVEL OF EVIDENCE II, Prospective cohort.
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Yang S, Sarcevic A, Farneth RA, Chen S, Ahmed OZ, Marsic I, Burd RS. An approach to automatic process deviation detection in a time-critical clinical process. J Biomed Inform 2018; 85:155-167. [PMID: 30071317 PMCID: PMC6167602 DOI: 10.1016/j.jbi.2018.07.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/13/2018] [Accepted: 07/29/2018] [Indexed: 11/17/2022]
Abstract
MOTIVATION Prior research has shown that minor errors and deviations from recommended guidelines in complex medical processes can accumulate to increase the likelihood that a major error will go uncorrected and lead to an adverse outcome. Real-time automatic and accurate detection of process deviations may help medical teams better prevent or mitigate the effect of errors and improve patient outcomes. Our goal was to develop an approach for automatic detection of errors and process deviations in trauma resuscitation. METHODS Using video review, we coded activity traces of 95 pediatric trauma resuscitations collected in a Level 1 trauma center over two years (2014-2016). Twenty-four randomly selected activity traces were compared with a knowledge-driven model of trauma resuscitation workflow using a phase-based conformance checking algorithm for detecting true and false deviations (alarms). An analysis of false alarms identified three types of causes: (1) model gaps or discrepancies between the model ("work as imagined") and actual practice ("work as done"), (2) errors in activity traces coding, and (3) algorithm limitations. We repaired the system to remove model gaps, reduce coding errors, and address algorithm limitations. The repaired system was first evaluated with another 20 traces and then applied to the entire dataset of 95 traces. RESULTS During the training, we detected 573 process deviations in 24 activity traces that include 1099 activities. Among these deviations, only 27% represented true deviations and the remaining 73% were false alarms. This initial deviation detection accuracy was only 66.6%, with a F1-score of 0.42. Detection accuracy of the repaired system increased to 95.2% (0.85 F1-score) during system validation and to 98.5% (0.96 F1-score) during testing. After deploying the repaired deviation detection system to all 95 activity traces, we detected 1060 process deviations in 5659 activities (11.2 deviations per resuscitation). Among the 5659 activities in these traces, 4893 fit the repaired knowledge-driven workflow model, 294 were errors of omission, 538 were errors of commission, and 228 were scheduling errors. CONCLUSION Our approach to automatic deviation detection provides a method for identifying repeated, omitted and out-of-sequence activities that can be included in the design of decision support systems for complex medical processes. Our findings show the importance of assessing detected deviations for repairing a knowledge-driven model that best represents "work as done."
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Rosenfeld EH, Vogel A, Russell RT, Maizlin I, Klinkner DB, Polites S, Gaines B, Leeper C, Anthony S, Waddell M, St Peter S, Juang D, Thakkar R, Drews J, Behrens B, Jafri M, Burd RS, Beaudin M, Carmant L, Falcone RA, Moody S, Naik-Mathuria BJ. Comparison of diagnostic imaging modalities for the evaluation of pancreatic duct injury in children: a multi-institutional analysis from the Pancreatic Trauma Study Group. Pediatr Surg Int 2018; 34:961-966. [PMID: 30074080 DOI: 10.1007/s00383-018-4309-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Determining the integrity of the pancreatic duct is important in high-grade pancreatic trauma to guide decision making for operative vs non-operative management. Computed tomography (CT) is generally an inadequate study for this purpose, and magnetic resonance cholangiopancreatography (MRCP) is sometimes obtained to gain additional information regarding the duct. The purpose of this multi-institutional study was to directly compare the results from CT and MRCP for evaluating pancreatic duct disruption in children with these rare injuries. METHODS Retrospective study of data obtained from eleven pediatric trauma centers from 2010 to 2015. Children up to age 18 with suspected blunt pancreatic duct injury who had both CT and MRCP within 1 week of injury were included. Imaging findings of both studies were directly compared and analyzed using descriptive statistics, Chi square, Wilcoxon rank-sum, and McNemar's tests. RESULTS Data were collected for 21 patients (mean age 7.8 years). The duct was visualized more often on MRCP than CT (48 vs 5%, p < 0.05). Duct disruption was confirmed more often on MRCP than CT (24 vs 0%), suspected based on secondary findings equally (38 vs 38%), and more often indeterminate on CT (62 vs 38%). Overall, MRCP was not superior to CT for determining duct integrity (62 vs 38%, p = 0.28). CONCLUSIONS In children with blunt pancreatic injury, MRCP is more useful than CT for identifying the pancreatic duct but may not be superior for confirmation of duct integrity. Endoscopic retrograde cholangiogram (ERCP) may be necessary to confirm duct disruption when considering pancreatic resection. LEVEL OF EVIDENCE III.
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Hunziker S, O'Connell KJ, Ranniger C, Su L, Hochstrasser S, Becker C, Naef D, Carter E, Stockwell D, Burd RS, Marsch S. Effects of designated leadership and team-size on cardiopulmonary resuscitation: The Basel-Washington SIMulation (BaWaSim) trial. J Crit Care 2018; 48:72-77. [PMID: 30172964 DOI: 10.1016/j.jcrc.2018.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE During cardiopulmonary resuscitation (CPR), it remains unclear whether designating an individual person as team leader compared with emergent leadership results in better team performance. Also, the effect of CPR team size on team performance remains understudied. METHODS This randomized-controlled trial compared designated versus emergent leadership and size of rescue team (3 vs 6 rescuers) on resuscitation performance. RESULTS We included 90 teams with a total of 408 students. No difference in mean (±SD) hands-on time (seconds) were observed between emergent leadership (106 ± 30) compared to designated leadership (103 ± 27) groups (adjusted difference - 2.97 (95%CI -15.75 to 9.80, p = 0.645), or between smaller (103 ± 30) and larger teams (106 ± 26, adjusted difference 3.53, 95%CI -8.47 to 15.53, p = 0.56). Emergent leadership groups had a shorter time to circulation check and first defibrillation, but the quality of CPR based on arm and shoulder position was lower. No differences in CPR quality measures were observed between smaller and larger teams. CONCLUSIONS Within this international US/Swiss trial, leadership designation and larger team size did not improve hands-on time, but emergent leadership teams initiated defibrillation earlier. Improvements in performance may be more likely to be achieved by optimization of emergent leadership than increasing the size of cardiac arrest teams.
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Jensen AR, McLaughlin C, Wong CF, McAuliff K, Nathens AB, Barin E, Meeker D, Ford HR, Burd RS, Upperman JS. Simulation-based training for trauma resuscitation among ACS TQIP-Pediatric centers: Understanding prevalence of use, associated center characteristics, training factors, and implementation barriers. Am J Surg 2018; 217:180-185. [PMID: 29934123 DOI: 10.1016/j.amjsurg.2018.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/28/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Simulation-based training (SBT) for pediatric trauma resuscitation can improve team performance. The purpose of this study was to describe the nationwide trend in SBT use and barriers to SBT implementation. METHODS Trauma centers that participated in ACS TQIP Pediatric in 2016 (N = 125) were surveyed about SBT use. Center characteristics and reported implementation barriers were compared between centers using and not using SBT. RESULTS Survey response rate was 75% (94/125) with 78% (73/94) reporting SBT use. The frequency of pediatric SBT use increased from 2014 to 2016 (median 5.5 vs 6.5 annual sessions, p < 0.01). Funding barriers were negatively associated with number of annual SBT sessions (r ≤ -0.34, p < 0.05). Centers not using SBT reported lack of technical expertise (p = 0.01) and lack of data supporting SBT (p = 0.03) as significant barriers. CONCLUSIONS Simulation use increased from 2014 to 2016, but significant barriers to implementation exist. Strategies to share resources and decrease costs may improve usage. LEVEL OF EVIDENCE Level 3, epidemiological.
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Yang S, Ni W, Dong X, Chen S, Farneth RA, Sarcevic A, Marsic I, Burd RS. Intention Mining in Medical Process: A Case Study in Trauma Resuscitation. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS 2018; 2018:36-43. [PMID: 30443647 PMCID: PMC6231398 DOI: 10.1109/ichi.2018.00012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In medical processes such as surgical procedures and trauma resuscitations, medical teams perform treatment activities according to underlying invisible goals or intentions. In this study, we present an approach to uncover these intentions from observed treatment activities. Developed on top of a hierarchical hidden Markov model (H-HMM), our approach can identify multi-level intentions. To accurately infer the H-HMM, we used state splitting method with maximum a posteriori probability (MAP) as the scoring function. We evaluated our approach in both qualitative and quantitative ways, using a case study of the trauma resuscitation process. This dataset includes 123 trauma resuscitation cases collected at a level 1 trauma center. Our results show our intention mining achieved an accuracy of 86.6% in classifying medical teams' intentions. This work is an exploration of unsupervised intention mining of complex real-world medical processes.
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Yang S, Tao F, Li J, Wang D, Chen S, Marsic I, Ahmed OZ, Burd RS. Process Mining the Trauma Resuscitation Patient Cohorts. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS 2018; 2018:29-35. [PMID: 30506061 PMCID: PMC6262881 DOI: 10.1109/ichi.2018.00011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In this study, we present a framework for analyzing associations between patient cohorts and the trauma resuscitation procedures their patients received. Our framework works by quantifying associations between discovered patient cohorts and treatment patterns. We evaluated our framework on a trauma resuscitation dataset collected in a level 1 trauma center. Our experimental results show that using weights learned by our algorithm improves measurements of patient similarity. Four patient cohorts were then found via clustering, and statistically significant resuscitation patterns were discovered using process mining techniques. Though only tested on the trauma resuscitation process, our framework can be generalized to analyze other medical processes.
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Li J, Yang S, Chen S, Tao F, Marsic I, Burd RS. Discovering Interpretable Medical Workflow Models. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS 2018; 2018:437-439. [PMID: 30393784 PMCID: PMC6207188 DOI: 10.1109/ichi.2018.00089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Ahmed OZ, Webman RB, Sheth PD, Donnenfield JI, Yang J, Sarcevic A, Marsic I, Burd RS. Errors in cervical spine immobilization during pediatric trauma evaluation. J Surg Res 2018; 228:135-141. [PMID: 29907202 DOI: 10.1016/j.jss.2018.02.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/17/2018] [Accepted: 02/14/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study was to identify factors during trauma evaluation that increase the likelihood of errors in cervical spine immobilization ('lapses'). MATERIALS AND METHODS Multivariate analysis was used to identify the associations between patient characteristics, event features, and tasks performed in proximity to the head and neck and the occurrence and duration of a lapse in maintaining cervical spine immobilization during 56 pediatric trauma evaluations. RESULTS Lapses in cervical spine immobilization occurred in 71.4% of patients (n = 40), with an average of 1.2 ± 1.3 lapses per patient. Head and neck tasks classified as oxygen manipulation occurred an average of 12.2 ± 9.7 times per patient, whereas those related to neck examination and cervical collar manipulation occurred an average of 2.7 ± 1.7 and 2.1 ± 1.2 times per patient, respectively. More oxygen-related tasks were performed among patients who had than those who did not have a lapse (27.3 ± 16.5 versus 11.5 ± 8.0 tasks, P = 0.001). Patients who had cervical collar placement or manipulation had a two-fold higher risk of a lapse than those who did not have these tasks performed (OR 1.92, 95% CI 0.56, 3.28, P = 0.006). More lapses occurred during evaluations on the weekend (P = 0.01), when more tasks related to supplemental oxygen manipulation were performed (P = 0.02) and when more tasks associated with cervical collar management were performed (P < 0.001). CONCLUSIONS Errors in cervical spine immobilization were frequently observed during the initial evaluation of injured children. Strategies to reduce these errors should target approaches to head and neck management during the primary and secondary phases of trauma evaluation.
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McLaughlin C, Zagory JA, Fenlon M, Park C, Lane CJ, Meeker D, Burd RS, Ford HR, Upperman JS, Jensen AR. Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis. J Pediatr Surg 2018; 53:344-351. [PMID: 29111081 PMCID: PMC5828917 DOI: 10.1016/j.jpedsurg.2017.10.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND/PURPOSE The classic "trimodal" distribution of death has been described in adult patients, but the timing of mortality in injured children is not well understood. The purpose of this study was to define the temporal distribution of mortality in pediatric trauma patients. METHODS A retrospective cohort of patients with mortality from the National Trauma Data Bank (2007-2014) was analyzed. Categorical comparison of 'dead on arrival', 'death in the emergency department', and early (≤24h) or late (>24h) inpatient death was performed. Secondary analyses included mortality by pediatric age, predictors of early mortality, and late complication rates. RESULTS Children (N=5463 deaths) had earlier temporal distribution of death compared to adults (n=104,225 deaths), with 51% of children dead on arrival or in ED compared to 44% of adults (p<0.001). For patients surviving ED resuscitation, children and adolescents had a shorter median time to death than adults (1.2 d and 0.8 days versus 1.6 days, p<0.001). Older age, penetrating mechanism, bradycardia, hypotension, tube thoracostomy, and thoracotomy were associated with early mortality in children. CONCLUSIONS Injured children have higher incidence of early mortality compared to adults. This suggests that injury prevention efforts and strategies for improving early resuscitation have potential to improve mortality after pediatric injury. LEVEL OF EVIDENCE Level III: Retrospective cohort study.
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