Pediatric Patients in the Adult Trauma Bay—Comfort Level and Challenges

Transitions from short to long-term outcomes in pediatric critical care: considerations for clinical practice

Most children are surviving critical illness in highly resourced pediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development over many years, termed post-intensive care syndrome-pediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations. In research studies, primary and secondary outcomes are largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized vs. individualized, but some PICU centers are discovering how to overcome them and are providing this service to families-sometimes specific populations-in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU. Finally, we should seek the strong backing of the PICU community and families to insist that long-term outcomes become our new clinical standard of care. PICUs should consider development of a multicenter, multinational collaborative to assess clinical outcomes and optimize care delivery and patient and family outcomes. The aim of this review is to present the potential considerations of implementing long-term clinical follow-up following pediatric critical illness.

Perspectives of health professionals on the best care settings for pediatric trauma casualties: a qualitative study

BACKGROUND

Critically-injured children are frequently treated by providers who lack specialty pediatric training in facilities that have not been modified for the care of children. We set out to understand the attitudes and perspectives of policy makers, and senior nursing and medical managers in the Israeli healthcare system, concerning the provision of medical care to pediatric trauma casualties in emergency departments.

METHODS

We conducted semi-structured interviews with 17 health professionals from medical centers across Israel and the Ministry of Health. The interviews were analyzed by qualitative methods.

RESULTS

There was lack of clarity and uniformity concerning the definition of a pediatric trauma casualty. All of the participants attributed extreme importance to the professional level of the care team manager, and most suggested that this should be a pediatric emergency medicine specialist. They emphasized the importance of around-the-clock availability of pediatric medical teams to care for young trauma casualties, and the crucial need for caregivers to be equipped with a wide variety of professional skills for the adequate treatment of a broad spectrum of injuries. All participants described significant variability in pediatric-care training and experience among physicians and nurses working in emergency departments. Most participants believe that pediatric trauma casualties should be treated in designated pediatric emergency departments, in a limited number of medical centers across the country.

CONCLUSIONS

Our findings indicate that specialized pediatric EDs would constitute the best location for intake of children with major traumatic injuries. Pediatric emergency medicine specialists should manage trauma cases using pediatric surgeons as ad-hoc consultants. The term 'pediatric patient' should be defined to allow trauma patients to be referred to the most appropriate ED. Teams working at these EDs should undergo specialized pediatric emergency medicine training. Finally, to regulate the key aspects of trauma care, clear statutory guidelines should be formulated at national and local levels.

Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community

BACKGROUND

Providing acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport.

METHODS

We conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls.

RESULTS

Fourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days).

CONCLUSIONS

RPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.

Paediatric-appropriate facilities in emergency departments of community hospitals in Ontario: A cross-sectional study

BACKGROUND

We assessed whether the paediatric-appropriate facilities were available at Emergency Departments (ED) in community hospitals in a Canadian province.

METHODS

We conducted a cross-sectional survey of EDs in community hospitals in Ontario, Canada that had inpatient paediatric facilities and a neonatal intensive care unit. Key informants were ED chiefs, clinical educators, or managers. The survey included questions about paediatric facilities related to environment, triage, training, and staff in EDs.

RESULTS

Of 52 hospitals, 69% (n=36) responded to our survey. Of them, 14% EDs (n=5) had some separated spaces available for paediatric patients. About 53% (n=19) of EDs lacked children activities, e.g., toys. Only 11% (n=4) EDs were using paediatric triage scales and 42% (n=15) had a designated paediatric resuscitation bay. Only half of the ED (n=18) required from their staff to update paediatric life support training. Only 31% (n=11) had a designated liaison paediatrician for the ED. Paediatric social worker was present in only 8% (n=3) of EDs in community hospitals.

CONCLUSION

Most of the Ontario community hospital EDs included in this survey had inadequate facilities for paediatric patients such as specific waiting and treatment areas.

The availability, spatial accessibility, service utilisation and retrieval cost of paediatric intensive care services for children in rural, regional and remote Queensland: study protocol

Background

Specialist health services are often organised on a regionalised basis whereby clinical resources and expertise are concentrated in areas of high population. Through a high volume caseload, regionalised facilities may provide improved clinical outcomes for patients. In some cases, regionalisation may be the only economically viable way to organise specialist care. While regionalisation may have benefits, it may also disadvantage some population groups, particularly in circumstances where distance and time are impediments to access.

Queensland is a large Australian state with a distributed population. Providing equitable access to specialist healthcare services to the population is challenging. Specialist care for critically ill or injured children is provided by the Queensland Paediatric Intensive Care Service which comprises two tertiary paediatric intensive care units. The two units are located 6 km (3.7 miles) apart by road in the state capital of Brisbane and provide state-wide telephone advice and specialist retrieval services. Services also extend into the northern area of the adjacent state of New South Wales. In some cases children may be managed locally in adult intensive care units in regional hospitals.

The aim of this study is to describe the effect of geography and service organisation for children who need intensive care services but who present outside of metropolitan centres in Queensland.

Methods/design

Using health services and population data, the availability and spatial accessibility to paediatric intensive care services will be analysed. Retrieval utilisation and the associated costs to the health service will be analysed to provide an indication of service utilisation by non-metropolitan patients.

Discussion

While the regionalisation or centralisation of specialist services is recognised as an economical way to provide specialist health services, the extent to which these models serve critically ill children who live some distance from tertiary care has not been described. This study will provide new information on the effect of the regionalisation of specialist healthcare for critically ill children in Queensland and will have relevance to other regionalised health services. This study, which is focussed on describing the organisation, supply and demands on the health service, will provide the foundation for future work to explore clinical outcomes for non-metropolitan children who require intensive care.

Treatment outcomes of injured children at adult level 1 trauma centers: are there benefits from added specialized care?

BACKGROUND

Accidental traumatic injury is the leading cause of morbidity and mortality in children. The authors hypothesized that no mortality difference should exist between children seen at ATC (adult trauma centers) versus ATC with added qualifications in pediatrics (ATC-AQ).

METHODS

The National Trauma Data Bank, version 7.1, was analyzed for patients aged <18 years seen at level 1 trauma centers. Bivariate analysis compared patients by ATC versus ATC-AQ using demographic and injury characteristics. Multivariate analysis adjusting for injury and demographic factors was then performed.

RESULTS

A total sample of 53,702 children was analyzed, with an overall mortality of 3.9%. The adjusted odds of mortality was 20% lower for children seen at ATC-AQ (odds ratio, .80; 95% confidence interval, .68-.94). Children aged 3 to 12 years, those with injury severity scores > 25, and those with Glasgow Coma Scale scores < 8 all had significant reductions in the odds of death at ATC-AQ.

CONCLUSIONS

Improved overall survival is associated with pediatric trauma patients treated at ATC-AQ.