Where Are the Sick Kids?

A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study

INTRODUCTION

Most injured children receive trauma care outside of a pediatric trauma center. Differences in physiology, dosing, and injury pattern limit extrapolation of adult trauma principles to pediatrics. We compare US trauma center experience with pediatric and adult trauma resuscitation.

MATERIALS AND METHODS

We queried the 2019 Trauma Quality Improvement Program to describe the experience of US trauma centers with pediatric (<15 y) and adult trauma. We quantified blunt, penetrating, burn, and unspecified traumas and compared minor, moderate, severe, and critical traumas (ISS 1-8 Minor, ISS 9-14 Moderate, ISS 15-24 Severe, ISS 25+ Critical). We estimated center-level volumes for adults and children. Institutional identifiers were generated based on unique center specific factors including hospital teaching status, hospital type, verification level, pediatric verification level, state designation, state pediatric designation, and bed size.

RESULTS

A total of 755,420 adult and 76,449 pediatric patients were treated for traumatic injuries. There were 21 times as many critical or major injuries in adults compared to children, 17 times more moderate injuries, and 6 times more minor injuries. Children and adults presented with similar rates of blunt trauma, but penetrating injuries were more common in adults and burn injuries were more common in children. Comparing center-level data, adult trauma exceeded pediatric for every severity and mechanism.

CONCLUSIONS

There is relatively limited exposure to high-acuity pediatric trauma at US centers. Investigation into pediatric trauma resuscitation education and simulation may promote pediatric readiness and lead to improved outcomes.

"Sim One, Do One, Teach One": A Simulation-Based Trauma Orientation for Pediatric Residents in the Emergency Department

OBJECTIVES

The objective of this study was to determine the effectiveness of a simulation-based curriculum in improving confidence in trauma resuscitation skills and increasing attendance during trauma resuscitations for pediatric residents during their emergency medicine rotation.

METHODS

A simulation-based orientation curriculum was implemented for the 2017-2018 academic year. Participants completed a qualitative survey before and after each session to assess their comfort level with skills required in a trauma resuscitation. Responses were compared using the Wilcoxon ranked sum test. Nursing documentation was reviewed for the 2016-2017 and 2017-2018 academic years to determine the frequency of resident attendance at trauma resuscitations. Pediatric resident attendance before and after intervention were compared via χ2 analysis.

RESULTS

Survey responses showed a significant increase in confidence in all skills assessed, including primary and secondary survey performance, knowledge of pediatric resident role, knowledge of necessary equipment, ability to determine acuity of patient illness or injury, and ability to differentiate between modes of oxygen delivery (P < 0.01). There was no statistically significant change in the frequency of pediatric resident attendance at trauma bay resuscitations before and after curriculum implementation (21.2% vs 25.7%, P = 0.09).

CONCLUSIONS

Through the implementation of a simulation-based trauma orientation for pediatric residents, we were able to improve self-reported confidence in trauma resuscitation skills. This improvement did not result in an increased attendance at trauma resuscitations. Next steps include identifying additional barriers to pediatric resident attendance at trauma bay resuscitations.

A Descriptive Analysis of the Cumulative Experiences of Emergency Medicine Residents in the Pediatric Emergency Department

OBJECTIVES

Most children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine.

METHODS

Retrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition.

RESULTS

Twenty-five EM residents evaluated 17,642 patients (median = 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median = 22) medical resuscitations and 483 (median = 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses.

CONCLUSIONS

Emergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.

Multiprofessional perspectives on the identification of latent safety threats via in situ simulation: a prospective cohort pilot study

Objectives

To describe the association between participant profession and the number and type of latent safety threats (LSTs) identified during in situ simulation (ISS). Secondary objectives were to describe the association between both (a) participants’ years of experience and LST identification and (b) type of scenario and number of identified LSTs.

Methods

Emergency staff physicians (MDs), registered nurses (RNs) and respiratory therapists (RTs) participated in ISS sessions in the emergency department (ED) of a tertiary care teaching hospital. Adult and paediatric scenarios were designed to be high-acuity, low-occurrence resuscitation cases. Simulations were 10 min in duration. A written survey was administered to participants immediately postsimulation, collecting demographic data and perceived LSTs. Survey data was collated and LSTs were grouped using a previously described framework.

Results

Thirteen simulation sessions were completed from July to November 2018, with 59 participants (12 MDs, 41 RNs, 6 RTs). Twenty-four unique LSTs were identified from survey data. RNs identified a median of 2 (IQR 1, 2.5) LSTs, significantly more than RTs (0.5 (IQR 0, 1.25), p=0.04). Within respective professions, MDs and RTs most commonly identified equipment issues, and RNs most commonly identified medication issues. Participants with ≤10 years of experience identified a median of 2 (IQR 1, 3) LSTs versus 1 (IQR 1, 2) LST in those with >10 years of experience (p=0.06). Adult and paediatric patient scenarios were associated with the identification of a median of 4 (IQR 3.0, 4.0) and 5 LSTs (IQR 3.5, 6.5), respectively (p=0.15).

Conclusions

Inclusion of a multidisciplinary team is important during ISS in order to gain a breadth of perspectives for the identification of LSTs. In our study, participants with ≤10 years of experience and simulations with paediatric scenarios were associated with a higher number of identified LSTs; however, the difference was not statistically significant.

Critically Ill Children in a Swiss Pediatric Emergency Department With an Interdisciplinary Approach: A Prospective Cohort Study

Objective: Delivery of prompt and adequate care for critically ill and injured children presenting to the pediatric emergency department (PED) is paramount for optimal outcomes. Knowledge of the local epidemiology, patient profile, and presentation modes are key for organizational planning, staff education strategy, and optimal care in a PED. Our aim was to analyze the profile of critically ill and injured children admitted to a tertiary, non-academic Swiss PED, to investigate potential risk factors associated with admission to the pediatric intensive care unit (PICU), and the outcomes mortality and PICU admission. Methods: Prospective cohort study of critically ill and injured children presenting to the PED over a two-year period (2018-2019). Inclusion criteria were Australasian triage scale category (ATS) 1, trauma team activation (TTA), medical emergency response (MER) activation, additional critical care consult, and transfer to an outside hospital. Results: Of 42,579 visits during the two-year period, 347 presentations matched the inclusion criteria (0.81%). Leading presentations were central nervous system (CNS) disorders (26.2%), trauma (25.1%), and respiratory emergencies (24.2%). 288 out of 347 cases (83%) arrived during the day or evening with an even distribution over the days of the week. 128 out of 347 (37%) arrived unexpectedly as walk-ins. 233 (67.15%) were ATS category 1. 51% of the cohort was admitted to PICU. Australasian triage scale category 1 was significantly more common in this group (p = 0.0001). Infants with respiratory disease had an increased risk of PICU transfer compared to other age groups (OR 4.18 [95%CI 2.46, 7.09] p = 0.0001), and this age group presented mainly as walk-in (p = 0.0001). Pediatric intensive care unit admissions had a longer hospital stay (4 [2, 8] days vs. 2 [1, 4] days, p = 0.0001) compared to other patients. 0.045% of all PED patients had to be transferred out. Three deaths (0.86%) occurred in the PED, 10 patients died in the PICU (2.9%). Conclusions: High acuity presentations in the PED were rare, more likely to be young with CNS disorders, trauma and respiratory diseases. A significant proportion were unexpected walk-in presentations, mainly during day and evening shifts. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED.

Low-Fidelity, In-Situ Pediatric Resuscitation Simulation Improves RN Competence and Self-Efficacy

PROBLEM

ED staff lack adequate exposure to critical pediatric patients to develop competence and confidence in resuscitation scenarios. Simulations of various designs have shown success at increasing health care staff performance and self-efficacy.

METHODS

We developed a nurse-led, low-fidelity in situ simulation of a pediatric sepsis scenario. The primary goal was to improve staff adherence to resuscitation guidelines, as measured by the Clinical Performance Tool, a set of checklists designed to measure adherence to Pediatric Advanced Life Support algorithms by multidisciplinary teams during simulations. The secondary goal was to improve staff confidence, measured by the Confidence Scale, a 5-item Likert-type scale that can measure any psychomotor skill.

RESULTS

A total of 43 RNs participated in 12 simulations over a period of 3 months. Mean Clinical Performance score improved by 74%, from 5.3 to 9.2 (P < 0.001). Mean confidence score for RNs improved by 56%, from 2.48 (standard deviation [SD] 0.83) to 3.88 (SD 0.66) (P < 0.001). Several systems issues were identified and addressed by multidisciplinary teams, such as increasing respiratory therapist response to the emergency department and updating of the Broselow cart.

DISCUSSION

In situ low-fidelity simulations led by RNs contributed to significant improvement in adherence to resuscitation guidelines and in staff confidence. The simulation design had minimal impact on staffing and budget and enabled identification and correction of systems issues.