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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Ricci AM, Emeny RT, Bagley PJ, Blunt HB, Butow ME, Morgan A, Alford-Teaster JA, Titus L, Walston RR, Rees JR. Causes of Childhood Cancer: A Review of the Recent Literature: Part I-Childhood Factors. Cancers (Basel) 2024; 16:1297. [PMID: 38610975 PMCID: PMC11011156 DOI: 10.3390/cancers16071297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 04/14/2024] Open
Abstract
PURPOSE To review the childhood risk factors for pediatric cancer (diagnosis before age 20). METHODS We conducted literature searches using Ovid Medline and Scopus to find primary research studies, review articles, and meta-analyses published from 2014 to 3 March 2021. RESULTS Strong evidence indicates that an array of genetic and epigenetic phenomena, structural birth defects, and chromosomal anomalies are associated with an increased risk of various childhood cancers. Increased risk is also associated with prior cancer, likely due to previous treatment agents and therapeutic ionizing radiation. Convincing evidence supports associations between several pediatric cancers and ionizing radiation, immunosuppression, and carcinogenic virus infection both in healthy children and in association with immune suppression following organ transplantation. Breastfeeding and a childhood diet rich in fruits and vegetables appears to reduce the risk of pediatric leukemia but the evidence is less strong. Childhood vaccination against carcinogenic viruses is associated with a lower risk of several cancers; there is less strong evidence that other childhood vaccinations more broadly may also lower risk. Ultraviolet (UV) radiation is associated with increased melanoma risk, although most melanomas following childhood UV exposure occur later, in adulthood. Evidence is weak or conflicting for the role of body mass index, other childhood infections, allergies, and certain treatments, including immunomodulator medications and human growth therapy.
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Affiliation(s)
- Angela M. Ricci
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Dartmouth Health Childrens, Lebanon, NH 03756, USA
| | - Rebecca T. Emeny
- Department of Internal Medicine, Division of Molecular Medicine, UNM Comprehensive Cancer Center, Cancer Control & Population Sciences Research Program, University of New Mexico Health Sciences, Albuquerque, NM 87131, USA;
| | - Pamela J. Bagley
- Biomedical Libraries, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA; (P.J.B.); (H.B.B.)
| | - Heather B. Blunt
- Biomedical Libraries, Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA; (P.J.B.); (H.B.B.)
| | - Mary E. Butow
- New Hampshire Department of Environmental Services, Concord, NH 03302, USA
| | - Alexandra Morgan
- Department of Obstetrics and Gynecology, Dartmouth Health, Lebanon, NH 03756, USA
| | | | - Linda Titus
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Dartmouth Cancer Center, Hanover, NH 03755, USA
| | - Raymond R. Walston
- Department of Pediatric Hematology Oncology, Children’s Hospital Colorado, Aurora, CO 80045, USA;
| | - Judy R. Rees
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth Cancer Center, Hanover, NH 03755, USA
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Groszman L, McCook KM, Xiang L, Parker L, Villamor LL, Koganti D, Smith RN, Sola R. Understanding Chest CT Scan Usage Among Adolescent Blunt Trauma Patients at Adult Trauma Centers. Am Surg 2024; 90:220-224. [PMID: 37619987 DOI: 10.1177/00031348231198121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE The utility of chest computed tomography (CCT) is not well established in the diagnostic algorithm of adolescent blunt trauma patients. Our study's aim was to review CCT usage in the initial evaluation of adolescent blunt trauma. METHODS We retrospectively reviewed adolescent blunt trauma patients treated at our urban level 1 adult trauma center from 2015 to 2019. Our primary outcome was the rate of positive CCT findings. Univariate and multivariate logistic regression analyses were performed. RESULTS There were 288 patients that met our inclusion criteria and 153 positive CCT and 135 negative CCT. There was no statistically significant difference between both groups in terms of age, gender, and race. Those with a positive CCT were found to have a statistically significant higher ISS than the negative CCT group (20.6 ± 12.3 vs 12.3 ± 7.6; P < .01). Those with a positive CCT were more likely to have a GCS <15 (40% vs 25%), have a positive CXR (38% vs 2%), have chest pain (16% vs 7%), and have an abnormal chest exam (27% vs 7%) than those with a negative CCT (P < .01). On multivariate analysis, positive CXR (P < .05, OR = 13.96) and ISS (P < .05, OR = 3.10) were independently associated with a positive CCT. CONCLUSION While CCT may provide valuable information, clinical exam coupled with low-ionizing radiographic imaging (i.e., CXR) may sufficiently identify chest trauma after blunt mechanisms. This shift in management can potentially reduce the risk of radiation without compromising the care of adolescent trauma patients at adult trauma centers.
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Affiliation(s)
- Lilly Groszman
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | - Kem-Maria McCook
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | - Laurel Xiang
- Center for Data Science, New York University, New York, NY, USA
| | - Laurel Parker
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
| | | | - Deepika Koganti
- Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
| | | | - Richard Sola
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
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Freire GC, Beno S, Yanchar N, Weiss M, Stang A, Stelfox T, Bérubé M, Beaulieu E, Gagnon IJ, Zemek R, Berthelot S, Tardif PA, Moore L. Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review. Ann Surg 2023; 278:858-864. [PMID: 37325908 DOI: 10.1097/sla.0000000000005966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps. BACKGROUND Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care. METHODS We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II." RESULTS We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning. CONCLUSIONS We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.
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Affiliation(s)
- Gabrielle C Freire
- Division of Emergency Medicine at University of Toronto
- Child Health Evaluative Sciences
| | - Suzanne Beno
- Division of Emergency Medicine at University of Toronto
| | | | | | | | - Thomas Stelfox
- Department of Critical Care Medicine at University of Calgary
| | - Melanie Bérubé
- Population Health at Laval University
- Faculty of nursing at Laval University
| | | | | | - Roger Zemek
- Department of Pediatrics at Children's Hospital of Eastern Ontario
| | - Simon Berthelot
- Department of social and preventative medicine at Laval University
| | - Pier-Alexandre Tardif
- Population Health at Laval University
- Department of social and preventative medicine at Laval University
| | - Lynne Moore
- Population Health at Laval University
- Department of social and preventative medicine at Laval University
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Moore L, Freire G, Turgeon AF, Bérubé M, Boukar KM, Tardif PA, Stelfox HT, Beno S, Lauzier F, Beaudin M, Zemek R, Gagnon IJ, Beaulieu E, Weiss MJ, Carsen S, Gabbe B, Stang A, Ben Abdeljelil A, Gnanvi E, Yanchar N. Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2334266. [PMID: 37721752 PMCID: PMC10507486 DOI: 10.1001/jamanetworkopen.2023.34266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Importance Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking. Objective To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma. Data Sources MEDLINE, Embase, and Web of Science through March 2023. Study Selection Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years). Data Extraction and Synthesis This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence. Main Outcome(s) and Measure(s) Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI). Results A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes. Conclusions and Relevance In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.
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Affiliation(s)
- Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Khadidja Malloum Boukar
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Henry T. Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Suzanne Beno
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Marianne Beaudin
- Sainte-Justine Hospital, Department of Paediatric Surgery, Université de Montréal, Montréal, Québec, Canada
| | - Roger Zemek
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Isabelle J. Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children’s Hospital, Montréal, Québec, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Emilie Beaulieu
- Département de pédiatrie, Faculté de médecine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec City, Québec, Canada
| | - Matthew John Weiss
- Centre Mère-Enfant Soleil du CHU de Québec, Transplant Québec, Québec, Québec, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Antonia Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anis Ben Abdeljelil
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Eunice Gnanvi
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec–Université Laval (Hôpital de l’Enfant-Jésus), Québec City, Québec, Canada
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Canada
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Herren A, Palmer CS, Landolt MA, Lehner M, Neuhaus TJ, Simma L. Pediatric Trauma and Trauma Team Activation in a Swiss Pediatric Emergency Department: An Observational Cohort Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1377. [PMID: 37628376 PMCID: PMC10453385 DOI: 10.3390/children10081377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/02/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Trauma is one of the most common causes of death in childhood, but data on severely injured Swiss children are absent from existing national registries. Our aim was to analyze trauma activations and the profiles of critically injured children at a tertiary, non-academic Swiss pediatric emergency department (PED). In the absence of a national pediatric trauma database, this information may help to guide the design of infrastructure, processes within organizations, training, and policies. METHODS A retrospective analysis of pediatric trauma patients in a prospective resuscitation database over a 2-year period. Critically injured trauma patients under the age of 16 years were included. Patients were described with established triage and injury severity scales. Statistical evaluation included logistic regression analysis. RESULTS A total of 82 patients matched one or more of the study inclusion criteria. The most frequent age group was 12-15 years, and 27% were female. Trauma team activation (TTA) occurred with 49 patients (59.8%). Falls were the most frequent mechanism of injury, both overall and for major trauma. Road-traffic-related injuries had the highest relative risk of major trauma. In the multivariate analysis, patients receiving medicalized transport were more likely to trigger a TTA, but there was no association between TTA and age, gender, or Injury Severity Score (ISS). Nineteen patients (23.2%) sustained major trauma with an ISS > 15. Injuries of Abbreviated Injury Scale severity 3 or greater were most frequent to the head, followed by abdomen, chest, and extremities. The overall mortality rate in the cohort was 2.4%. Conclusions: Major trauma presentations only comprise a small proportion of the total patient load in the PED, and trauma team activation does not correlate with injury severity. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED. Our findings indicate that high priority should be given to training in the management of severely injured children in the PED. The leading major trauma mechanisms were preventable, which should prompt further efforts in injury prevention.
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Affiliation(s)
- Anouk Herren
- Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Department of Pediatrics, University’s Children Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
| | - Cameron S. Palmer
- Trauma Service, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Markus A. Landolt
- Department of Psychosomatics and Psychiatry and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Binzmuehlestrasse 14, CH-8050 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital of Zurich, University of Zurich, CH-8032 Zurich, Switzerland
| | - Markus Lehner
- Department of Pediatric Surgery, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Thomas J. Neuhaus
- Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Leopold Simma
- Children’s Research Center, University Children’s Hospital of Zurich, University of Zurich, CH-8032 Zurich, Switzerland
- Emergency Department, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Emergency Department, University’s Children Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
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Gerber N, Munnangi S, Vengalasetti Y, Gupta S. Trauma center variation of head computed tomography utilization in children presenting with mild traumatic brain injury. Clin Imaging 2023; 94:125-131. [PMID: 36529077 DOI: 10.1016/j.clinimag.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/16/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although published clinical decision rules have identified indications for the use of head CT in children with mild traumatic brain injury, practices vary. OBJECTIVE This study seeks to evaluate whether the utilization of head CT in pediatric trauma patients presenting with mTBI varies between American College of Surgeons verified pediatric trauma centers (ACS-PTC) and adult-only trauma centers (ACS-AOTC). MATERIAL AND METHODS A retrospective cohort study of 24,104 trauma patients, ≤17, who presented to the emergency department at 337 ACS verified level I/II trauma centers with isolated mTBI was conducted using National Trauma Data Bank records (2011-2015). Multivariable logistic regression was used to compare the odds of a patient receiving a head CT when treated at an ACS-PTC vs. an ACS-AOTC, controlling for demographic, injury, and hospital-level confounders. Effect modification by loss of consciousness was assessed and adjusted head CT odds were recalculated in patients stratified by LOC status. RESULTS There was no significant difference in the adjusted odds of receiving a head CT at an ACS-PTC vs. an ACS-AOTC (odds ratio: 0.98, 95% confidence interval: 0.92-1.04). However, in patients who had a LOC, the adjusted OR of receiving a head CT at an ACS-PTC vs ACS-AOTC was 0.71 (95% confidence interval: 0.65-0.78). CONCLUSION Children presenting to the emergency department of an ACS-verified level I or II trauma center with mTBI who had a loss of consciousness are less likely to receive a head CT at an ACS verified pediatric trauma center than at an ACS verified adult-only trauma center.
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Affiliation(s)
- Noam Gerber
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America.
| | - Swapna Munnangi
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America
| | - Yasaswi Vengalasetti
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Sameer Gupta
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America
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9
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Miyagawa T, Saga M, Sasaki M, Shimizu M, Yamaura A. Statistical and machine learning approaches to predict the necessity for computed tomography in children with mild traumatic brain injury. PLoS One 2023; 18:e0278562. [PMID: 36595496 PMCID: PMC9810188 DOI: 10.1371/journal.pone.0278562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/18/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Minor head trauma in children is a common reason for emergency department visits, but the risk of traumatic brain injury (TBI) in those children is very low. Therefore, physicians should consider the indication for computed tomography (CT) to avoid unnecessary radiation exposure to children. The purpose of this study was to statistically assess the differences between control and mild TBI (mTBI). In addition, we also investigate the feasibility of machine learning (ML) to predict the necessity of CT scans in children with mTBI. METHODS AND FINDINGS The study enrolled 1100 children under the age of 2 years to assess pre-verbal children. Other inclusion and exclusion criteria were per the PECARN study. Data such as demographics, injury details, medical history, and neurological assessment were used for statistical evaluation and creation of the ML algorithm. The number of children with clinically important TBI (ciTBI), mTBI on CT, and controls was 28, 30, and 1042, respectively. Statistical significance between the control group and clinically significant TBI requiring hospitalization (csTBI: ciTBI+mTBI on CT) was demonstrated for all nonparametric predictors except severity of the injury mechanism. The comparison between the three groups also showed significance for all predictors (p<0.05). This study showed that supervised ML for predicting the need for CT scan can be generated with 95% accuracy. It also revealed the significance of each predictor in the decision tree, especially the "days of life." CONCLUSIONS These results confirm the role and importance of each of the predictors mentioned in the PECARN study and show that ML could discriminate between children with csTBI and the control group.
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Affiliation(s)
- Tadashi Miyagawa
- Department of Pediatric Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
- * E-mail:
| | - Marina Saga
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Minami Sasaki
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Miyuki Shimizu
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Akira Yamaura
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
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Kolousek A, Sharma B, Lian B, Koganti D, Smith RN, Sola R. Understanding abdominal pelvic computerized tomography scan usage amongst adolescent blunt trauma patients treated at adult trauma centers. Injury 2023; 54:100-104. [PMID: 35999064 DOI: 10.1016/j.injury.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The algorithm for evaluating adolescent patients with blunt trauma includes abdominal pelvic CT (APCT). The aim of this study is to evaluate the utility of APCT in this context. METHODS We performed a retrospective review of adolescent (11 to 18 years of age) blunt trauma patients at an urban adult level 1 trauma center from January 2015 to December 2019. The primary outcome was the prevalence of positive findings on APCT scan. Additionally, clinical risk factors concerning for intra-abdominal injury were analyzed. RESULTS There were 546 patients evaluated for blunt trauma and the prevalence of APCT within the population was 59.3% (95% CI 54.2%-64.9%). Of the patients who received APCT, 123 (37.9%) had positive findings on APCT. Only 25 patients (7.7% of those who underwent APCT) required abdominal surgery while 40 patients (12.3%) had intraabdominal injury that did not require surgery. Risk factors were present in 100% of patients with intraabdominal injury and absent in 28.7% of patients without intraabdominal injury. Abnormal abdominal exam, abnormal FAST, positive chest x-ray and elevated transaminases were independently associated with intraabdominal injury. CONCLUSIONS Our study found that adolescent blunt trauma patients treated at our trauma center had a higher rate of APCT usage, but a comparable rate of positive findings when compared with the most recent literature. Future studies should focus on reducing the number of patients who undergo APCT despite an absence of clinical risk factors.
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Affiliation(s)
- Anastasia Kolousek
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
| | - Bharath Sharma
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
| | - Brad Lian
- Mercer University School of Medicine, Department of Community Medicine, 1501 Mercer University Drive, Macon, GA 30341, United States.
| | - Deepika Koganti
- Emory University School of Medicine, Department of Surgery, 69 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, United States.
| | - Randi N Smith
- Emory University School of Medicine, Department of Surgery, 69 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, United States.
| | - Richard Sola
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
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11
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Rees JR, Weiss JE, Riddle BL, Craver K, Zens MS, Celaya MO, Peacock JL. Pediatric Cancer By Race, Ethnicity and Region in the United States. Cancer Epidemiol Biomarkers Prev 2022; 31:1896-1906. [PMID: 35861625 PMCID: PMC9578755 DOI: 10.1158/1055-9965.epi-22-0317] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/25/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In a 2018 descriptive study, cancer incidence in children (age 0-19) in diagnosis years 2003 to 2014 was reported as being highest in New Hampshire and in the Northeast region. METHODS Using the Cancer in North America (CiNA) analytic file, we tested the hypotheses that incidence rates in the Northeast were higher than those in other regions of the United States either overall or by race/ethnicity group, and that rates in New Hampshire were higher than the Northeast region as a whole. RESULTS In 2003 to 2014, pediatric cancer incidence was significantly higher in the Northeast than other regions of the United States overall and among non-Hispanic Whites and Blacks, but not among Hispanics and other racial minorities. However, there was no significant variability in incidence in the states within the Northeast overall or by race/ethnicity subgroup. Overall, statistically significantly higher incidence was seen in the Northeast for lymphomas [RR, 1.15; 99% confidence interval (CI), 1.10-1.19], central nervous system neoplasms (RR, 1.12; 99% CI, 1.07-1.16), and neuroblastoma (RR, 1.13; 99% CI, 1.05-1.21). CONCLUSIONS Pediatric cancer incidence is statistically significantly higher in the Northeast than in the rest of the United States, but within the Northeast, states have comparable incidence. Differences in cancer subtypes by ethnicity merit further investigation. IMPACT Our analyses clarify and extend previous reports by statistically confirming the hypothesis that the Northeast has the highest pediatric cancer rates in the country, by providing similar comparisons stratified by race/ethnicity, and by assessing variability within the Northeast.
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Affiliation(s)
- Judy R. Rees
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- New Hampshire State Cancer Registry, Hanover, NH, USA
| | | | - Bruce L. Riddle
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- New Hampshire State Cancer Registry, Hanover, NH, USA
| | - Karen Craver
- New Hampshire Department of Environmental Services, Concord, NH, USA
| | - Michael Scot Zens
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- New Hampshire State Cancer Registry, Hanover, NH, USA
| | - Maria O. Celaya
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- New Hampshire State Cancer Registry, Hanover, NH, USA
| | - Janet L. Peacock
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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12
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Kornblith AE, Singh C, Devlin G, Addo N, Streck CJ, Holmes JF, Kuppermann N, Grupp-Phelan J, Fineman J, Butte AJ, Yu B. Predictability and stability testing to assess clinical decision instrument performance for children after blunt torso trauma. PLOS DIGITAL HEALTH 2022; 1:e0000076. [PMID: 36812570 PMCID: PMC9931266 DOI: 10.1371/journal.pdig.0000076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/14/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The Pediatric Emergency Care Applied Research Network (PECARN) has developed a clinical-decision instrument (CDI) to identify children at very low risk of intra-abdominal injury. However, the CDI has not been externally validated. We sought to vet the PECARN CDI with the Predictability Computability Stability (PCS) data science framework, potentially increasing its chance of a successful external validation. MATERIALS & METHODS We performed a secondary analysis of two prospectively collected datasets: PECARN (12,044 children from 20 emergency departments) and an independent external validation dataset from the Pediatric Surgical Research Collaborative (PedSRC; 2,188 children from 14 emergency departments). We used PCS to reanalyze the original PECARN CDI along with new interpretable PCS CDIs developed using the PECARN dataset. External validation was then measured on the PedSRC dataset. RESULTS Three predictor variables (abdominal wall trauma, Glasgow Coma Scale Score <14, and abdominal tenderness) were found to be stable. A CDI using only these three variables would achieve lower sensitivity than the original PECARN CDI with seven variables on internal PECARN validation but achieve the same performance on external PedSRC validation (sensitivity 96.8% and specificity 44%). Using only these variables, we developed a PCS CDI which had a lower sensitivity than the original PECARN CDI on internal PECARN validation but performed the same on external PedSRC validation (sensitivity 96.8% and specificity 44%). CONCLUSION The PCS data science framework vetted the PECARN CDI and its constituent predictor variables prior to external validation. We found that the 3 stable predictor variables represented all of the PECARN CDI's predictive performance on independent external validation. The PCS framework offers a less resource-intensive method than prospective validation to vet CDIs before external validation. We also found that the PECARN CDI will generalize well to new populations and should be prospectively externally validated. The PCS framework offers a potential strategy to increase the chance of a successful (costly) prospective validation.
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Affiliation(s)
- Aaron E. Kornblith
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Chandan Singh
- Department of Electrical Engineering & Computer Science, University of California, Berkeley, Berkeley, United States of America
| | - Gabriel Devlin
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Newton Addo
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Christian J. Streck
- Department of Surgery, Medical University of South Carolina, Children’s Hospital, Charleston, United States of America
| | - James F. Holmes
- Department of Emergency Medicine, University of California, Davis, Davis, United States of America
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis, Davis, United States of America
- Department of Pediatrics, University of California, Davis, Davis, United States of America
| | - Jacqueline Grupp-Phelan
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Jeffrey Fineman
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Atul J. Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, United States of America
| | - Bin Yu
- Department of Electrical Engineering & Computer Science, University of California, Berkeley, Berkeley, United States of America
- Departments of Statistics, University of California, Berkeley, Berkeley, United States of America
- * E-mail:
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Simma L, Fornaro J, Stahr N, Lehner M, Roos JE, Lima TVM. Optimising whole body computed tomography doses for paediatric trauma patients: a Swiss retrospective analysis. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2022; 42:021521. [PMID: 35354135 DOI: 10.1088/1361-6498/ac6274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/30/2022] [Indexed: 06/14/2023]
Abstract
We aimed to evaluate the impact of a low-dose whole-body computed tomography (WBCT) protocol on radiation doses in paediatric major trauma patients. Retrospective cohort study of paediatric trauma patients (<16 years) at a national level 1 paediatric trauma centre (PTC) over a 6 year period prior and post introduction of a low-dose WBCT protocol (2014-2019). Demographic data, patient characteristics, CT device, and exposure information including scan range, dose-length product, and volume CT dose index were collected. Effective dose (ED) and exposure parameters were compared before and after protocol introduction. Forty-eight patients underwent WBCT during the study period. Prior to introduction of the low-dose protocol (n= 18), the ED was 20.6 mSv (median 20.1 ± 5.3 mSv [range 12.5-30.7]). After introduction of the low-dose WBCT protocol (n= 30), mean ED was 4.8 mSv (median 2.6 ± 5.0 [range: 0.8-19.1]). This resulted in a reduction of 77% in mean ED (pvalue <0.001). Significant radiation dose reduction of 77% can be achieved with low-dose WBCT protocols in PTCs.
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Affiliation(s)
- Leopold Simma
- Emergency Department, Children's Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Emergency Department, University Children's Hospital Zurich, University of Zurich, Steinwiessstrasse 75, Zurich, CH 8032, Switzerland
| | - Juergen Fornaro
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Nikolai Stahr
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Pediatric Radiology Department, Children's Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Markus Lehner
- Pediatric Surgery Department, Children's Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Justus E Roos
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Thiago Viana Miranda Lima
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Institute of Radiation Physics, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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14
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Çaylak ST, Yaka E, Yilmaz S, Doğan NÖ, Ozturan IU, Pekdemir M. Comparison of PECARN clinical decision rule and clinician suspicion in predicting intra-abdominal injury in children with blunt torso trauma in the emergency department. ULUS TRAVMA ACIL CER 2022; 28:529-536. [PMID: 35485505 PMCID: PMC10521006 DOI: 10.14744/tjtes.2020.40156] [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: 08/27/2021] [Accepted: 02/17/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule to identify children at low risk for intra-abdominal injury requiring acute intervention (IAI-I) for reducing unnecessary radiation exposure of ab-dominal computed tomography (CT) after blunt torso trauma. This study aimed to compare the PECARN decision rule with clinician suspicion in identifying children at low risk of intra-abdominal injuries that an abdominal CT scan can be safely avoided. METHODS This study is a retrospective review of children with blunt torso trauma in an academic emergency department (ED) between 2011 and 2019. Patients were considered positive for the PECARN rule if they exhibited any of the variables. Clinician suspi-cion was defined as actual CT ordering of the treating physician. The primary outcome was IAI-I detected by imaging or surgery within 1 month after the trauma, and the secondary outcome was any intra-abdominal injury (IAI) presence. RESULTS Among the 768 children included, 48 (6.25%) had intra-abdominal injuries and 21 (2.73%) of whom underwent acute in-tervention. Four hundred and fifty-three (59%) children underwent abdominal CT scanning. If the PECARN rule had been applied, 232 patients would have undergone abdominal CT. The rule revealed 90.48% (95% CI=68.17-98.33%) sensitivity for IAI-I and 81.25% (95% CI=66.9-90.56%) for IAI. Clinician suspicion revealed sensitivities of 100% (95% CI=80.76-00%) and 93.75% (95% CI=81.79-98.37%) for IAI-I and IAI, respectively. Sensitivities of the rule and clinician suspicion were statistically similar for both IAI-I (p=0.5) and IAI (p=0.146). CONCLUSION In this study, the PECARN abdominal rule and clinician suspicion performed similarly in identifying intra-abdominal injuries in children with blunt torso trauma. However, our study supports the use of PECARN abdominal rule in addition to clinical judgment to limit unnecessary abdominal CT use in pediatric patients with blunt torso trauma in the ED.
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Affiliation(s)
- Sevinç Taş Çaylak
- Department of Emergency Medicine, Gebze Fatih State Hospital, Kocaeli-Turkey
| | - Elif Yaka
- Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli-Turkey
| | - Serkan Yilmaz
- Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli-Turkey
| | - Nurettin Özgür Doğan
- Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli-Turkey
| | - Ibrahim Ulas Ozturan
- Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli-Turkey
| | - Murat Pekdemir
- Department of Emergency Medicine, Kocaeli University Faculty of Medicine, Kocaeli-Turkey
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15
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Marin JR, Hollander MAG, Ray KN, Donohue JM, Cole ES. Low-Value Diagnostic Imaging in Children with Medicaid. J Pediatr 2021; 235:253-263.e14. [PMID: 33556364 PMCID: PMC8316256 DOI: 10.1016/j.jpeds.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To estimate rates and settings of low-value imaging among pediatric Medicaid beneficiaries and estimate the associated expenditures. STUDY DESIGN Retrospective longitudinal cohort study from 2014 to 2016 of children <18 years enrolled in Pennsylvania Medicaid. Outcomes were rates of low-value imaging for 5 conditions identified by diagnosis codes, healthcare settings of imaging performance, and cost based on paid amounts. RESULTS Of the 645 767 encounters for the 5 conditions, there were 37 525 (5.8%) low-value imaging services. Per 1000 encounters, there were 246.0 radiographs for bronchiolitis, 174.0 head computed tomography (CT) studies for minor head trauma, 155.0 and 33.3 neuroimaging studies for headache and simple febrile seizure, respectively, and 19.5 abdominal CT scans (without prior ultrasound examination) for abdominal pain. Rates of low-value imaging were highest in non-Hispanic White children and those in rural areas. In adjusted analysis, non-Hispanic White children were more likely to receive a CT scan for abdominal pain, and Black children were more likely to have imaging for bronchiolitis and minor head trauma. For individual conditions, up to 87.9% of low-value imaging (CT scan for minor head trauma) was in the emergency department (ED), with most imaging across all conditions occurring in nonpediatric EDs, up to 42.2% was in the outpatient setting (neuroimaging for headache), and up to 20.7% was during inpatient encounters (neuroimaging for febrile seizure). Outpatient and ED low-value imaging resulted in more than $7 million in Medicaid expenditures. CONCLUSIONS Among the studied conditions, more than 1 in 20 encounters included low-value imaging, mostly in nonpediatric EDs and for bronchiolitis, head trauma, and headache. Interventions are needed to decrease the future performance of these low-value services.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, and Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Mara A G Hollander
- Center for Mental Health and Addiction Policy Research, Department of Health Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin N Ray
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Evan S Cole
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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16
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Marin JR, Rodean J, Mannix RC, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury. J Pediatr 2021; 235:178-183.e1. [PMID: 33894265 DOI: 10.1016/j.jpeds.2021.04.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/22/2021] [Accepted: 04/14/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT). STUDY DESIGN We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits. RESULTS There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS. CONCLUSIONS Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.
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Affiliation(s)
- Jennifer R Marin
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | | | - Rebekah C Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the USC, Los Angeles, CA
| | - Eyal Cohen
- Division of Pediatric Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children and Department of Pediatrics, Toronto, Ontario, Canada; Institute of Health Policy, Management & Evaluation, The University of Toronto, Toronto, Ontario, Canada
| | - Stephen B Freedman
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Harold K Simon
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Velasco R, Moore CM, Deiratany S, D'Elia F, Tourteau LB, Zuiani C, Bognar Z, Erdelyi K, Fadgyas B, Fejes M, Teksam O, Mirzeyev Y, Esmeray P, Fernández SM, Ricondo A, Da Dalt L, Bressan S, Priante E, Snoeck E, Broers M, Castman-Berrevoets CE, Fernandes RM, Borges J, Obieta A, Alcalde M, Piñol S, González J, Azzali A, Gioè D, La Spina L, Bianconi M, Arribas M, Parri N. Variability in the management and imaging use in paediatric minor head trauma in European emergency departments. A Research in European Pediatric Emergency Medicine study. Eur J Emerg Med 2021; 28:196-201. [PMID: 33079737 DOI: 10.1097/mej.0000000000000763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of the study was to assess the variability in the management of paediatric MHT in European emergency departments (EDs). METHODS This was a multicentre retrospective study of children ≤18 years old with minor head trauma (MHT) (Glasgow Coma Scale ≥14) who presented to 15 European EDs between 1 January 2013 and 31 December 31. Data on clinical characteristics, imaging tests, and disposition of included patients were collected at each hospital over a 3-year period. RESULTS We included 11 212 patients. Skull radiography was performed in 3416 (30.5%) patients, range 0.4-92.3%. A computed tomography (CT) was obtained in 696 (6.2%) patients, range 1.6-42.8%. The rate of admission varied from 0 to 48.2%. CONCLUSION We found great variability in terms of the type of imaging and rate of CT scan obtained. Our study suggests opportunity for improvement in the area of paediatric head injury and the need for targeted individualised ED interventions to improve management of MHT.
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open 2021; 4:e2033710. [PMID: 33512517 PMCID: PMC7846940 DOI: 10.1001/jamanetworkopen.2020.33710] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. OBJECTIVE To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. EXPOSURES Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. RESULTS A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. CONCLUSIONS AND RELEVANCE In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.
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Affiliation(s)
- Jennifer R. Marin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Azari S, Hoover T, Dunstan M, Harrison TJ, Browne M. Review, monitor, educate: A quality improvement initiative for sustained chest radiation reduction in pediatric trauma patients. Am J Surg 2020; 220:1327-1332. [PMID: 32928539 DOI: 10.1016/j.amjsurg.2020.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We hypothesize that in pediatric trauma patients, CT scans after normal chest x-rays do not add information that alters clinical decision making. METHODS A retrospective review of trauma patients < 15 years with chest imaging evaluated at a pediatric trauma center between 1/2013 and 6/2019 was performed. Imaging was reviewed for significant findings that could affect care. A guideline was established in January 2017 which emphasized x-rays prior to CTs and no CTs after normal x-rays. A prospective review was performed from 1/2017-6/2019. Pre and post guideline groups were compared. RESULTS From 2013 to 2016, 246 patients met inclusion. 29.5% had a chest CT after a normal x-ray, only 1.8% (1/57) had a significant result. From 2017 to 2019, 188 patients were reviewed post guideline; only 9.4% received a CT after normal x-ray, of which 6.3% (1/16) were significant. Neither changed clinical management. CONCLUSIONS Chest CT following normal chest x-ray does not change clinical management in pediatric trauma patients. Monitoring and education following guideline implementation improves long term outcomes.
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Affiliation(s)
- Sarah Azari
- Department of Education, Lehigh Valley Health Network, 1247 S Cedar Crest Blvd, Allentown, PA, 18103, USA.
| | - Travis Hoover
- Department of Education, Lehigh Valley Health Network, 1247 S Cedar Crest Blvd, Allentown, PA, 18103, USA.
| | - Michele Dunstan
- Division of Bariatric and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA, 18103, USA.
| | - Timothy J Harrison
- Division of Bariatric and Trauma Surgery, Department of Surgery, Lehigh Valley Health Network, 1240 S Cedar Crest Blvd, Suite 308, Allentown, PA, 18103, USA.
| | - Marybeth Browne
- Division of Pediatric Surgical Specialties, Lehigh Valley Reilly Children's Hospital, Department of Surgery, Lehigh Valley Health Network, Allentown, PA, 18103, USA.
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Sources of Variability in Pediatric Head Computed Tomography Use Among Emergency Departments in New Jersey. Pediatr Emerg Care 2020; 36:21-25. [PMID: 31895199 DOI: 10.1097/pec.0000000000002016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Published guidelines have been developed to limit ionizing radiation exposure in children related to diagnostic computed tomography (CT). This study examines the sources of variability in head CT use in children in emergency departments (EDs) in New Jersey despite the presence of such consensus recommendations. METHODS The New Jersey Hospital Association (NJHA) Clinical Repository was queried for study data on all patients younger than 18 years discharged from the ED over a 1-year period. Patient information collected included: treating hospital, patient age, discharge diagnosis, use of head CT, children's hospital (CH) certification, presence of licensed in-patient pediatric beds, association with a hospital system and hospital annual pediatric ED volume. A potential diagnosis requiring a head CT (PDRCT) was defined as one of the following discharge diagnoses: Head Injury, Seizure, Syncope or Headache. Analysis of CT use per 10,000 ED visits was performed through ANOVA, analysis of means for variances, and χ. RESULTS A total of 735,866 ED visits were examined with 16,942 (2.3%) undergoing head CTs. Mean Pediatric Head CT use per 10,000 ED visits for the state was 275 (±16; range, 27-640). During the study period 47,169 (6.4%) ED visits met the PDRCT criteria, 11,495 (27%) of which underwent head CTs. Mean Pediatric Head CT use in this group per 10,000 PDRCT visits was 2948 (±152; range, 728-5806). Characteristics associated with lowest use of head CTs in the PDRCT group included: ED census greater than 10,000 visits per year, CH designation, and younger patient. The presence of in-patient pediatric beds and association with a hospital system with or without an in system CH were not associated with lower head CT use. CONCLUSIONS Despite existing recommendation regarding head CTs in children, there exists a large degree of variability in use of this diagnostic study in EDs in New Jersey.
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Lodwick DL, Cooper JN, Gonzalez DO, Lawrence AE, Lee C, Krishnamurthy R, Minneci PC, Deans KJ. Disparities in Radiation Burden from Trauma Evaluation at Pediatric Versus Nonpediatric Institutions. J Surg Res 2018; 232:475-483. [DOI: 10.1016/j.jss.2018.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/13/2018] [Accepted: 04/12/2018] [Indexed: 10/28/2022]
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Ishimine P, Adelgais K, Barata I, Klig J, Kou M, Mahajan P, Merritt C, Stoner MJ, Cloutier R, Mistry R, Denninghoff KR. Executive Summary: The 2018 Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps. Acad Emerg Med 2018; 25:1317-1326. [PMID: 30461127 DOI: 10.1111/acem.13667] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 11/29/2022]
Abstract
Emergency care providers share a compelling interest in developing an effective patient-centered, outcomes-based research agenda that can decrease variability in pediatric outcomes. The 2018 Academic Emergency Medicine Consensus Conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps (AEMCC)" aimed to fulfill this role. This conference convened major thought leaders and stakeholders to introduce a research, scholarship, and innovation agenda for pediatric emergency care specifically to reduce health outcome gaps. Planning committee and conference participants included emergency physicians, pediatric emergency physicians, pediatricians, and researchers with expertise in research dissemination and translation, as well as comparative effectiveness, in collaboration with patients, patient and family advocates from national advocacy organizations, and trainees. Topics that were explored and deliberated through subcommittee breakout sessions led by content experts included 1) pediatric emergency medical services research, 2) pediatric emergency medicine (PEM) research network collaboration, 3) PEM education for emergency medicine providers, 4) workforce development for PEM, and 5) enhancing collaboration across emergency departments (PEM practice in non-children's hospitals). The work product of this conference is a research agenda that aims to identify areas of future research, innovation, and scholarship in PEM.
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Affiliation(s)
- Paul Ishimine
- Departments of Emergency Medicine and Pediatrics University of California at San Diego School of Medicine San Diego CA
| | - Kathleen Adelgais
- Department of Pediatrics and Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Isabel Barata
- Departments of Pediatrics and Emergency Medicine Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead NY
| | - Jean Klig
- Departments of Emergency Medicine and Pediatrics Harvard Medical School Boston MA
| | - Maybelle Kou
- Department of Emergency Medicine George Washington University School of Medicine and Health Sciences Washington DC
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics University of Michigan Medical School Ann Arbor MI
| | - Chris Merritt
- Departments of Emergency Medicine and Pediatrics Alpert Medical School of Brown University Providence RI
| | - Michael J. Stoner
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
| | - Robert Cloutier
- Departments of Emergency Medicine and Pediatrics Oregon Health & Science University Portland OR
| | - Rakesh Mistry
- Department of Pediatrics and Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Kurt R. Denninghoff
- Department of Emergency Medicine University of Arizona College of Medicine Tucson AZ
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Traub SJ, Saghafian S, Judson K, Russi C, Madsen B, Cha S, Tolson HC, Sanchez LD, Pines JM. Interphysician Differences in Emergency Department Length of Stay. J Emerg Med 2018; 54:702-710.e1. [PMID: 29454714 DOI: 10.1016/j.jemermed.2017.12.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 11/27/2017] [Accepted: 12/17/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Emergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS). OBJECTIVE To describe how ED LOS differs among physicians. METHODS We performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOSO/E); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year. RESULTS Three hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106-184 min), and the average longest observed LOS was 232 min (range 196-270 min); the average difference was 81 min (range 69-90 min). For LOSO/E, the average lowest LOSO/E was 0.801 (range 0.702-0.887), and the average highest LOSO/E was 1.210 (range 1.186-1.275); the average difference between the lowest LOSO/E and the highest LOSO/E was 0.409 (range 0.305-0.493). CONCLUSION There are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOSO/E for physicians with the lowest LOSO/E at each site averaged approximately 20% less than predicted, and that the LOSO/E for physicians with the highest LOSO/E at each site averaged approximately 20% more than predicted.
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Affiliation(s)
- Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Soroush Saghafian
- Harvard Kennedy School, Harvard University, Cambridge, Massachusetts
| | - Kurtis Judson
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona; College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher Russi
- College of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bo Madsen
- College of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Stephen Cha
- Division of Health Systems Informatics, Mayo Clinic Arizona, Phoenix, Arizona
| | - Hannah C Tolson
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Leon D Sanchez
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts
| | - Jesse M Pines
- Department of Emergency Medicine and Health Policy & Management, George Washington University, Washington, DC
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Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol 2018; 91:20170434. [PMID: 29271231 DOI: 10.1259/bjr.20170434] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The aim of this review is to survey CT and MRI overuse in the paediatric emergency department (ED) population. CT is one of the most important modalities employed in the ED. Not surprisingly, its high accuracy, rapid acquisition and availability have resulted in overuse. An obvious limitation of CT is ionizing radiation; in addition there are economic implications to overuse. Studies from the last two decades have shown increase in paediatric ED CT utilization in the first decade, reaching a plateau forming around 2008, followed by a decrease in the last decade. This decrease occurred in conjunction with campaigns raising awareness to the risks of radiation exposure. Although a trend of decrease in overuse have been observed, great variability has been shown across different facilities, as well as among physicians, with more pronounced overuse in non-teaching and non-children dedicated EDs. The leading types of paediatric ED CTs are head and abdominal scans. Decision rules, such as PECARN for head injury and the Alvarado score for abdominal pain, as well as using alternative imaging modalities, have been shown to reduce CT overuse in these two categories. MRI has the obvious benefit of avoiding radiation exposure, but the disadvantages of higher costs, less availability and less tolerability in younger children. Although anecdotally paediatric ED MRI usage has increased in recent years, only scarce reports have been published. In our opinion, there is need to conduct up-to-date studies covering paediatric CT and MRI overuse trends, usage variability and adherence to clinical protocols.
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Affiliation(s)
- Orly Ohana
- 1 Tel Aviv University, Sackler Faculty of Medicine , Tel Aviv , Israel
| | - Shelly Soffer
- 1 Tel Aviv University, Sackler Faculty of Medicine , Tel Aviv , Israel
| | - Eyal Zimlichman
- 1 Tel Aviv University, Sackler Faculty of Medicine , Tel Aviv , Israel.,2 The Chaim Sheba Medical Center, Tel Hashomer, Hospital Management , Ramat Gan , Israel
| | - Eyal Klang
- 1 Tel Aviv University, Sackler Faculty of Medicine , Tel Aviv , Israel.,3 Department of radiology, The Chaim Sheba Medical Center, Tel Hashomer , Ramat Gan , Israel
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25
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Influence of guidelines on management of paediatric mild traumatic brain injury: CT-assessment and admission policy. Eur J Paediatr Neurol 2017; 21:816-822. [PMID: 28811137 DOI: 10.1016/j.ejpn.2017.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/08/2017] [Accepted: 07/27/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The annual number of paediatric injury-related emergency visits and application of computed tomography (CT) has substantially increased, with associated higher risk of malignancies. In 2010, a guideline for CT-assessment based on risk factors for patients with mild traumatic brain injury (mTBI) became effective in all Emergency Departments (ED) in the Netherlands. This study evaluated the influence of this guideline on the frequency of CT-assessments, hospital admissions and factors that are related to guideline adherence. METHODS Retrospective cohort study of paediatric mTBI (<18 years), defined by Glasgow Coma Scale score of 13-15 admitted to the ED of the University Medical Center Groningen from 2008 to 2014. Data before (pre-GL) and after (post-GL) introduction of the guideline were evaluated. Primary outcome parameters were frequency of CT-assessments and hospital admissions after ED. RESULTS In total 633 patients were enrolled and data from pre-GL (n = 216) and post-GL (n = 315) were compared. Mean age was 7.9 years (SD 5.9), 59% were male. CT-assessments increased from 32% to 46% (p = .001), mostly in children aged 6-18 years. Hospital admissions increased from 38% to 54% (p < .001), mostly in children <6 years. No significant increase in CT-abnormalities is seen. Guideline adherence was 57%, although CT-assessments varied from 44 to 100% depending on presence of specific major risk factors. CONCLUSIONS Introduction of a new guideline on management of paediatric mTBI showed significant increase in CT-assessments and more hospital admissions. In clinical practice, despite increase of guideline adherence the applications of cranial CT-scan varies within age groups and depends on the weighing of risk factors.
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Henry MK, Zonfrillo MR, French B, Song L, Feudtner C, Wood JN. Hospital Variation in Cervical Spine Imaging of Young Children With Traumatic Brain Injury. Acad Pediatr 2016; 16:684-91. [PMID: 26854208 PMCID: PMC4974148 DOI: 10.1016/j.acap.2016.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/15/2016] [Accepted: 01/21/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Cervical imaging practices are poorly understood in young children with traumatic brain injury (TBI). We therefore sought to identify child-level and hospital-level factors associated with performance of cervical imaging of children with TBI from falls and abusive head trauma (AHT) and to describe across-hospital variation in cervical imaging performance. We hypothesized that imaging decisions would be influenced by hospital volume of young injured children. METHODS We performed a retrospective study of children younger than 2 years of age with TBI from 2009 to 2013 in the Premier Perspective Database. After adjustment for observed patient characteristics, we evaluated variation in advanced cervical imaging (computed tomography or magnetic resonance imaging) in children with AHT and TBI from falls. RESULTS Of 2347 children with TBI, 18.7% were from abuse and 57.1% were from falls. Fifteen percent of children with TBI underwent advanced cervical imaging. Moderate or severe head injuries were associated with increased odds of cervical imaging in AHT (odds ratio 7.10; 95% confidence interval 2.75, 18.35) and falls (odds ratio 2.25; 95% confidence interval 1.19, 4.27). There was no association between annual hospital volume of injured children and cervical imaging performance. The adjusted probability of imaging across hospitals ranged from 4.3% to 84.3% in AHT and 3.1 to 39.0% in TBI from falls (P < .001). CONCLUSIONS These results highlight variation across hospitals in adjusted probability of cervical imaging in AHT (nearly 20-fold) and TBI from falls (over 10-fold) not explained by observed patient characteristics. This variation suggests opportunities for further research to inform imaging practices.
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Affiliation(s)
- M Katherine Henry
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Mark R Zonfrillo
- Department of Emergency Medicine and Injury Prevention Center, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
| | - Benjamin French
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pa
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pa; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chris Feudtner
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Joanne N Wood
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pa; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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Cullison K, Milne WK, Crocco AG. Hot Off the Press: Comparison of Clinical Suspicion Versus a Clinical Prediction Rule When Evaluating Children Following Blunt Torso Trauma. Acad Emerg Med 2016; 23:110-2. [PMID: 26720745 DOI: 10.1111/acem.12851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kevin Cullison
- Department of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - William K. Milne
- Department of Emergency Medicine; University of Western Ontario School of Medicine; London Ontario Canada
| | - Anthony G. Crocco
- Division of Pediatric Emergency Medicine; McMaster University; Montreal Quebec Canada
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