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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: Policy Statement. Ann Emerg Med 2024; 84:e13-e23. [PMID: 39032991 DOI: 10.1016/j.annemergmed.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 07/23/2024]
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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: Policy Statement. J Am Coll Radiol 2024; 21:1108-1118. [PMID: 38944444 DOI: 10.1016/j.jacr.2024.03.015] [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 imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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: Policy Statement. Pediatrics 2024; 154:e2024066854. [PMID: 38932710 DOI: 10.1542/peds.2024-066854] [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] [Received: 03/28/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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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Loftus CJ, Schmidt JC, Nguyen AM, Skokan AJ, Hagedorn JC. Evaluating Adherence to Guideline-based Injury Grading in Pediatric Renal Trauma: How Are Patients Being Worked Up Prior to Transfer to a Level 1 Trauma Center? Urology 2024; 183:236-243. [PMID: 37866649 DOI: 10.1016/j.urology.2023.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE To determine whether children with renal trauma who are transferred to a level I trauma center (TC) receive appropriate imaging studies before transfer and whether this impacts care. The American Urologic Association (AUA) Urotrauma guidelines state clinicians should perform IV contrast-enhanced CT with immediate and delayed images when renal trauma is suspected. Adherence to these guidelines in pediatric patients is unknown. METHODS Children treated for renal trauma at our TC between 2005 and 2019 were identified. Comparisons between patients with initial imaging at a transferring hospital (TH) and patients with initial imaging at our TC were performed using logistic regression. RESULTS Of the included 293 children, 67% (197/293) were transferred into our TC and 61% (180/293) received initial imaging at the TH. Patients with initial imaging at the TH were more likely to have higher-grade renal injuries (P = .001) and were less likely to have guideline-recommended imaging (31% vs 82%, P < .001). Of patients who were imaged at the TH, 28% (50/180) underwent an additional CT imaging shortly after transfer. When imaging was incomplete at the TH, having an additional scan upon transfer was associated with emergent urologic surgery (P = .004). CONCLUSION Adherence to the AUA Urotrauma guidelines is low, with most pediatric renal trauma patients not receiving complete staging with delayed-phase imaging before transfer to a TC. Furthermore, patients initially imaged at THs were more likely to receive more CT scans per admission and were exposed to higher amounts of radiation. There is a need to improve imaging protocols for complete staging of renal trauma in children before transfer.
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Affiliation(s)
| | - Jackson C Schmidt
- Department of Urology, Oregon Health & Sciences University, Portland, OR
| | - Amanda M Nguyen
- University of Washington School of Medicine, Salt Lake City, UT
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Roos J, Loy T, Ploeger MM, Weinhold L, Schmid M, Mewes M, Prangenberg C, Gathen M. It is (not) always on Friday: inter-hospital patient transfers in orthopedic and trauma surgery. Eur J Trauma Emerg Surg 2023; 49:2605-2613. [PMID: 37599307 PMCID: PMC10728266 DOI: 10.1007/s00068-023-02335-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND While inter-hospital transfers for patients who have suffered major trauma have been well investigated, patient flows for other injured patients, or cases with orthopedic complications, are rarely described. This study aims to analyze the affected collective and to show possible reasons, patterns, and pitfalls to optimize the process in future. MATERIALS AND METHODS In a prospective cohort study, all consecutive transfers to a Level I trauma center in Germany were documented and assessed. Patients suffering a major trauma were excluded. Data on the primary treating hospital, patient characteristics, and differences between emergency and elective surgery were analyzed. RESULTS A total of 227 patients were included; 162 were injured, while 65 had suffered a complication after elective orthopedic surgery or had a complex orthopedic pathology. The most common diagnoses leading to transfer were pathologies of the extremities (n = 62), pathologies of the spine (n = 50), and infections (n = 18). The main reasons stated by the transferring hospitals were a lack of expertise (137 cases) and a lack of capacity (43 cases). There was a significantly higher rate of transfers due to trauma (n = 162) than for orthopedic patients (n = 65), p < 0.0001. CONCLUSION There is currently no structured procedure or algorithm for transferring patients in orthopedics and trauma surgery.
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Affiliation(s)
- Jonas Roos
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Thomas Loy
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Milena M Ploeger
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Leonie Weinhold
- Institute for Medical Biometrics, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometrics, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Moritz Mewes
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christian Prangenberg
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Martin Gathen
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Stephens CQ, Ashok A, Gee A, Jafri M, Hamilton NA, Lehrfeld D, Newgard C, Krishnaswami S. Pediatric Trauma Care Standardization: A Statewide Survey of Trauma Providers and Program Managers. J Surg Res 2023; 288:178-187. [PMID: 36989834 DOI: 10.1016/j.jss.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/09/2023] [Accepted: 02/19/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Rural-urban disparities in pediatric trauma outcomes are well documented. However, few studies examine how differences in setting and resources impact rural providers' approach to trauma. We sought to understand the provider experience in managing injured children across our state and assess the potential for standardization of care. METHODS A statewide cross-sectional survey was distributed to trauma providers and program managers through the American College of Surgeons, the Oregon Medical Board lists, and the State Trauma Advisory Board. Topics included pediatric management processes, challenges, and transfer or admission procedures. Rural-urban commuting codes were used to categorize responses. RESULTS Of the 350 individuals who sent the survey, 68 responded (response rate 19%), representing 67% of trauma-verified hospitals and 72% of Oregon counties. Fifty-six respondents (82%) care for injured children, with 58% practicing rurally and 22% at critical access hospitals. Rural providers experienced lower trauma volumes (<1 patient/month, 63% versus 0%, P < 0.001), more difficulties obtaining pediatric-appropriate material resources (44% versus 30%), and challenges caring for infants/toddlers (25% versus 17%). Despite 77% of rural providers stating that <10% of patients had multisystem injuries, they described using full-body CT often (41% versus 10%, P = 0.007). Transfer interruptions were common (93%), with 44% having cancelled a transfer. The majority supported admission/transfer (85%) and imaging (82%) protocols. CONCLUSIONS Rural providers experience lower pediatric trauma volumes, greater material-resource issues, and discomfort with traumatically injured small children. Lack of care standardization may lead to reliance on full-body CT, and potentially complex/avoidable transfers. Adoption of standardized protocols could facilitate a state-wide collaborative approach to pediatric trauma management.
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Affiliation(s)
| | - Arjun Ashok
- New York Medical College, Valhalla, New York
| | - Arvin Gee
- Oregon Health and Science University, Portland, Oregon
| | - Mubeen Jafri
- Oregon Health and Science University, Portland, Oregon
| | | | | | - Craig Newgard
- Oregon Health and Science University, Portland, Oregon
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Reddan T, Halligan T, Corness J. An audit of inter‐hospital transfers of children with abdominal pain and their associated medical imaging findings. SONOGRAPHY 2021. [DOI: 10.1002/sono.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Tristan Reddan
- Medical Imaging and Nuclear Medicine Queensland Children's Hospital South Brisbane Australia
- School of Clinical Sciences Queensland University of Technology Brisbane Australia
| | - Toni Halligan
- Allied Health Professions' Office Queensland Queensland Health Herston Australia
| | - Jonathan Corness
- Medical Imaging and Nuclear Medicine Queensland Children's Hospital South Brisbane Australia
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Baygin M, Dogan S, Tuncer T, Datta Barua P, Faust O, Arunkumar N, Abdulhay EW, Emma Palmer E, Rajendra Acharya U. Automated ASD detection using hybrid deep lightweight features extracted from EEG signals. Comput Biol Med 2021; 134:104548. [PMID: 34119923 DOI: 10.1016/j.compbiomed.2021.104548] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Autism spectrum disorder is a common group of conditions affecting about one in 54 children. Electroencephalogram (EEG) signals from children with autism have a common morphological pattern which makes them distinguishable from normal EEG. We have used this type of signal to design and implement an automated autism detection model. MATERIALS AND METHOD We propose a hybrid lightweight deep feature extractor to obtain high classification performance. The system was designed and tested with a big EEG dataset that contained signals from autism patients and normal controls. (i) A new signal to image conversion model is presented in this paper. In this work, features are extracted from EEG signal using one-dimensional local binary pattern (1D_LBP) and the generated features are utilized as input of the short time Fourier transform (STFT) to generate spectrogram images. (ii) The deep features of the generated spectrogram images are extracted using a combination of pre-trained MobileNetV2, ShuffleNet, and SqueezeNet models. This method is named hybrid deep lightweight feature generator. (iii) A two-layered ReliefF algorithm is used for feature ranking and feature selection. (iv) The most discriminative features are fed to various shallow classifiers, developed using a 10-fold cross-validation strategy for automated autism detection. RESULTS A support vector machine (SVM) classifier reached 96.44% accuracy based on features from the proposed model. CONCLUSIONS The results strongly indicate that the proposed hybrid deep lightweight feature extractor is suitable for autism detection using EEG signals. The model is ready to serve as part of an adjunct tool that aids neurologists during autism diagnosis in medical centers.
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Affiliation(s)
- Mehmet Baygin
- Department of Computer Engineering, College of Engineering, Ardahan University, Ardahan, Turkey.
| | - Sengul Dogan
- Department of Digital Forensics Engineering, College of Technology, Firat University, Elazig, Turkey.
| | - Turker Tuncer
- Department of Digital Forensics Engineering, College of Technology, Firat University, Elazig, Turkey.
| | - Prabal Datta Barua
- School of Management & Enterprise, University of Southern Queensland, Australia.
| | - Oliver Faust
- Department of Engineering and Mathematics, Sheffield Hallam University, Sheffield, United Kingdom.
| | - N Arunkumar
- Department of Electronics and Instrumentation, SASTRA University, Thirumalaisamudram, Thanjavur, 613401, India.
| | - Enas W Abdulhay
- Biomedical Engineering Department, Faculty of Engineering, Jordan University of Science and Technology, P.O.Box 3030, Irbid, 22110, Jordan.
| | - Elizabeth Emma Palmer
- Department of Medical Genetics, Sydney Children's Hospital, High Street, Randwick, NSW, Australia.
| | - U Rajendra Acharya
- Ngee Ann Polytechnic, Department of Electronics and Computer Engineering, 599489, Singapore; Department of Biomedical Engineering, School of Science and Technology, SUSS University, Singapore; Department of Biomedical Informatics and Medical Engineering, Asia University, Taichung, Taiwan.
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Computed tomography scans prior to transfer to a pediatric trauma center: Transfer time effects, neurosurgical interventions, and practice variability. J Trauma Acute Care Surg 2020; 87:808-812. [PMID: 30865159 DOI: 10.1097/ta.0000000000002258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many nontrauma centers perform computed tomography (CT) on injured children prior to transfer to a pediatric trauma center (PTC), but the institutional variability and clinical impact of this practice is unclear. This study evaluated the association of pretransfer CT with transfer delays, the likelihood of emergent neurosurgical intervention among patients who underwent pretransfer head CT, and the effects of transfer distance on prevalence and regional variability of pretransfer CT. METHODS All injured children transferred from outlying nontrauma centers to a single freestanding PTC from 2009 to 2017 were included. Patients were categorized by undergoing pretransfer CT head alone, CT of multiple/other areas, or no CT. Transfer time (referring hospital arrival to PTC arrival) was compared between CT groups, using multivariable modeling to adjust for covariates. Neurosurgical interventions were compared between patients with normal and abnormal Glasgow Coma Scale (GCS) scores. The prevalence of pretransfer CT among referring centers was compared, with stratification by transfer distance. RESULTS Of 2,947 transfer patients, 1,225 (42%) underwent pretransfer CT (29%, head CT alone; 13%, other/multiple CT). Transfer times were significantly longer for patients who underwent pretransfer head CT or multiple CT (287 or 298 minutes vs. 260 minutes, p < 0.0001) after adjustment for baseline characteristics, injury severity, and transfer distance. Among patients with normal pretransfer GCS who received a pretransfer head CT, the likelihood of urgent neurosurgical intervention was 1.3%. Prevalence rates of pretransfer CT by referring center varied from 15% to 94%; prevalence increased with increasing transfer distance but demonstrated wide variability among centers of similar distance. CONCLUSION Pretransfer CT, whether of the head alone or multiple areas, is associated with delays in transfer to definitive care. Among patients with pretransfer GCS 15, the risk of urgent neurosurgical intervention is very low. Wide variability in pretransfer CT use between referring centers suggests opportunity for development of standardized protocols. LEVEL OF EVIDENCE Economic/decision, level III.
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Louie JP, Alfano J, Nguyen-Tran T, Nguyen-Tran H, Shanley R, Holm T, Furnival RA. Reduction of paediatric head CT utilisation at a rural general hospital emergency department. BMJ Qual Saf 2020; 29:912-920. [PMID: 32111643 DOI: 10.1136/bmjqs-2019-010322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Blunt head injury is a common pediatric injury and often evaluated in general emergency departments. It estimated that 50% of children will undergo a head computed tomography (CT), often unnecessarily exposing the child to ionizing radiation. Pediatric academic centers have shown quality improvement (QI) measures can reduce head CT rates within their emergency departments. We aimed to reduce head CT utilization at a rural community emergency department. METHODS Children presenting with a complaint of blunt head injury and were evaluated with or without a head CT. Head CT rate was the primary outcome. We developed a series of interventions and presented these to the general emergency department over the duration of the study. The pre and intervention data was analysed with control charts. RESULTS The preintervention and intervention groups consisted of 576 children: 237 patients with a median age of 8.0 years and 339 patients with a median age of 9.00 years (p=0.54), respectively. The preintervention HCT rate was 41.8% (95% CI 35.6% to 48.1%) and the postintervention rate was 27.7% (95% CI 23.3% to 32.7%), a decrease of 14.1% (95% CI 6.2% to 21.9%, p=0.0004). During the intervention period, there was a decrease in HCT rate of one per month (OR 0.96, 95% CI 0.92 to 1.00, p=0.07). The initial series of interventions demonstrated an incremental decrease in HCT rates corresponding with a special cause variation. CONCLUSION The series of interventions dispersed over the intervention period was an effective methodology and successfully reduced HCT utilisation among children with blunt head injury at a rural community emergency department.
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Affiliation(s)
| | - Joseph Alfano
- Emergency Medicine, Fairview Lakes Medical Center, Wyoming, Minnesota, USA
| | | | - Hai Nguyen-Tran
- Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ryan Shanley
- Masonic Cancer Center, Biostatistics Core, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tara Holm
- Radiology, University of Minnesota, Minneapolis, Minnesota, USA
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Shanshou L, Wei Z, Xianqi W, Jiangang X, Chaojuan Z, Qianmei W, Wen Y, Junjie L. Composition and Associated Factors of Radiological Examination in Major Trauma Patients: A Prospective Observational Study. Pediatr Emerg Care 2020; 36:34-38. [PMID: 29210887 PMCID: PMC6946093 DOI: 10.1097/pec.0000000000001363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The care of major trauma patients continues to be a challenge for emergency physicians and trauma surgeons. We found that the total number of radiological examinations for major trauma patients in this study was high and mainly comprised radiography and computed tomography (CT), with CT being more commonly adopted. The number of CT scans was positively correlated with severity of injury and intensive care unit length of stay. Further study is warranted to optimize radiological examinations involving major trauma patients.
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Affiliation(s)
- Liu Shanshou
- From the Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi China
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Emprechtinger R, Fischer S, Holzer LA, Klimek P, Stanak M, Oikarinen H, Wild C. Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2018; 137-138:20-26. [PMID: 30413357 DOI: 10.1016/j.zefq.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/20/2018] [Accepted: 09/20/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system. DESIGN Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations. ELIGIBILITY CRITERIA FOR SELECTING STUDIES English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded. RESULTS 47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data. CONCLUSIONS We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.
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Affiliation(s)
| | - Stefan Fischer
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria
| | - Lukas A Holzer
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz; AUVA Trauma Center, Klagenfurt am Wörthersee, Austria
| | - Peter Klimek
- Section for Science of Complex Systems, CeMSIIS, Medical University of Vienna, Vienna; Complexity Science Hub Vienna, Vienna, Austria
| | - Michal Stanak
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria
| | - Heljä Oikarinen
- Department of Diagnostic Radiology, Oulu University Hospital, OYS, Oulu, Finland
| | - Claudia Wild
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria
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Mangus CW, Klein BL, Miller M, Stewart D, Ryan LM. Repeat radiographic imaging in patients with long bone fractures transferred to a pediatric trauma center. J Investig Med 2018; 67:59-62. [PMID: 30367008 DOI: 10.1136/jim-2018-000877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2018] [Indexed: 11/04/2022]
Abstract
This study sought to determine the proportion of children with long bone fractures who undergo duplicate radiographic imaging after transfer to a pediatric trauma center (PTC) for further management. The secondary objective was to explore provider rationale and diagnostic yield of repeat X-rays. This was a single-site, retrospective cohort study conducted at a PTC. All patients, aged 0-21 years, who were transferred to the PTC for management of a long bone fracture were included. Electronic medical records were reviewed to determine the proportion of children who had repeat radiographic imaging and the provider rationale for obtaining this. T-test and Χ2 analyses were used to compare patients who had repeat X-rays with those who did not. During the study period, 309 patients (63% male, mean age 7.2±4.3 years) were transferred from 30 referring hospitals. Of these, 43% (n=133) underwent repeat radiographs. Patient age (p=0.9), gender (p=0.7), fracture location (p=0.19), and type of referring emergency department (pediatric vs general, p=0.3) were not significantly associated with repeat imaging. Rationale for repeat imaging could be ascertained in 31% of cases (n=41); the most common reasons were request by orthopedist (17%, n=23) and suboptimal original imaging (10%, n=13). Repeat imaging at the PTC did not reveal new or additional diagnoses in any case. Nearly half of the children in our study population undergo repeat and likely unnecessary imaging. Strategies to reduce repeat radiographs should be developed, as redundant imaging exposes patients to additional radiation and increases medical expense.
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Affiliation(s)
- Courtney W Mangus
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bruce L Klein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marlene Miller
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dylan Stewart
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leticia M Ryan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Plasma D-dimer safely reduces unnecessary CT scans obtained in the evaluation of pediatric head trauma. J Pediatr Surg 2018; 53:752-757. [PMID: 29555324 DOI: 10.1016/j.jpedsurg.2017.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/31/2017] [Accepted: 08/21/2017] [Indexed: 11/22/2022]
Abstract
PURPOSE Serum D-dimer has been proposed as a biomarker to aid in the diagnosis of pediatric traumatic brain injury (TBI). We investigated the accuracy of D-dimer in predicting the absence of TBI and evaluated the degree by which D-dimer could limit unnecessary computed tomography scans of the head (CTH). METHODS Retrospective review of patients with suspected TBI from 2011 to 2013 who underwent evaluation with CTH and quantitative D-dimer. D-dimer levels were compared among patients with clinically-important TBI (ciTBI), TBI, isolated skull fracture and no injury. RESULTS Of the 663 patients evaluated for suspected TBI, ciTBI was identified in 116 (17.5%), TBI in 77 (11.6%), skull fracture in 61 (9.2%) and no head injury in 409 (61.7%). Patients with no head injury had significantly lower D-dimer values (1531±1791pg/μL) compared to those with skull fracture, TBI and ciTBI (2504±1769, 2870±1633 and 4059±1287pg/μL, respectively, p<0.005). Using a D-dimer value <750pg/μL as a negative screen, no ciTBIs would be missed and 209 CTHs avoided (39.7% of total). CONCLUSION Low plasma D-dimer predicts the absence of ciTBI for pediatric patient with suspected TBI. Incorporating D-dimer into current diagnostic algorithms may significantly limit the number of unnecessary CTHs performed in this population. TYPE OF STUDY Study of diagnostic test. LEVEL OF EVIDENCE I.
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15
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Blazak P, Hacking C, Presneill J, Reade M. Early repeat computed tomographic imaging in transferred trauma and neurosurgical patients: Incidence, indications and impact. J Med Imaging Radiat Oncol 2018; 62:480-486. [PMID: 29399974 DOI: 10.1111/1754-9485.12711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Computed tomographic (CT) imaging is widely available in Australian rural and remote hospitals and is often performed prior to patient transfer to definitive tertiary hospital care. We hypothesised that critically ill trauma and neurosurgical patients might have CT scans repeated after interhospital transfer and that the utility of this practice might be low in relation to the additional financial cost and radiation exposure. METHODS We conducted a retrospective review of clinical records to determine the proportion of trauma and neurosurgical patients transferred to our tertiary ICU from other hospitals between 1 June 2013 and 30 June 2014 who underwent a repeat CT scan. The additional effective radiation dose was estimated using the dose length product method and the Australian Medicare Benefits Schedule was used to estimate the associated cost. RESULTS Of the 247 patients transferred for trauma and neurosurgical indications, many (144; 58%) had undergone CT imaging at the referring hospital. Repeat scans were performed in 60 (42%) already imaged patients (24% of all transferred patients), most frequently for changed clinical indications. While in 11 (18%) of those 60 already imaged patients the repeat scan led to an identifiable change in management, for another 13 (22%) patients the repeat scans appeared to be potentially avoidable. The median cost of a repeat scan was AU$250 and the median additional effective radiation dose was 2.74 mSv per patient. CONCLUSION Repeat CT scans for patients already imaged prior to transfer were relatively common, occurring mostly for apparently valid clinical reasons. However, the additional radiation risk and financial cost of these repeat scans appeared on retrospective audit to be potentially avoidable in approximately one in five cases.
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Affiliation(s)
- Penni Blazak
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Craig Hacking
- Department of Radiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jeffrey Presneill
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael Reade
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- University of Queensland & Australian Defence Force Joint Health Command, Brisbane, Queensland, Australia
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Tonui PM, Spilman SK, Pelaez CA, Mankins MR, Sidwell RA. Head CT before Transfer Does Not Decrease Time to Craniotomy for TBI Patients. Am Surg 2018. [DOI: 10.1177/000313481808400225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Rural trauma education emphasizes that radiologic imaging should be discouraged if it delays transfer to definitive care. With increased capacity for image sharing, however, radiography obtained at referring hospitals (RH) could help providers at trauma centers (TC) prepare for patients with traumatic brain injury. We evaluated whether a head CT prior to transfer accelerated time to neurosurgical intervention at the TC. The study was conducted at a combined adult Level I and pediatric Level II TC with a catchment area that includes rural hospitals within a 150 mile radius. The trauma registry was used to identify patients with traumatic brain injury who went to surgery for a neurosurgical procedure immediately after arrival at the TC. All patients were transferred in from a RH. Differences between groups were assessed using analysis of variance and chi-square. Fifty-six patients met study criteria during the study period (2010-2015). The majority (86%) of patients received head CT imaging at the RH, including a significant percentage of patients (18%) who presented with GCS ≤8. There was no statistically significant decrease in time to surgery when patients received imaging at the RH. CTimaging was associated with a delay in transfer that exceeded 90 minutes. Findings demonstrate that imaging at the RH delayed transfer to definitive care and did not improve time to neurosurgical intervention at the TC. Transfer to the TC should not be obstructed by imaging, especially for patients with severe TBI.
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Affiliation(s)
- Peter M. Tonui
- The Iowa Clinic, Des Moines, Iowa
- Department of Trauma Services, UnityPoint Health, Des Moines, Iowa
| | - Sarah K. Spilman
- Department of Trauma Services, UnityPoint Health, Des Moines, Iowa
| | - Carlos A. Pelaez
- The Iowa Clinic, Des Moines, Iowa
- Department of Trauma Services, UnityPoint Health, Des Moines, Iowa
| | - Mark R. Mankins
- General Surgery Residency Program, UnityPoint Health, Des Moines, Iowa
| | - Richard A. Sidwell
- The Iowa Clinic, Des Moines, Iowa
- Department of Trauma Services, UnityPoint Health, Des Moines, Iowa
- General Surgery Residency Program, UnityPoint Health, Des Moines, Iowa
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Da Dalt L, Parri N, Amigoni A, Nocerino A, Selmin F, Manara R, Perretta P, Vardeu MP, Bressan S. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr 2018; 44:7. [PMID: 29334996 PMCID: PMC5769508 DOI: 10.1186/s13052-017-0442-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury. METHODS These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text. CONCLUSIONS Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.
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Affiliation(s)
- Liviana Da Dalt
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Niccolo' Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Angela Amigoni
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Agostino Nocerino
- Department of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, Udine, Italy
| | - Francesca Selmin
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Renzo Manara
- Department of Radiology, Neuroradiology Unit, University of Salerno, Salerno, Italy
| | - Paola Perretta
- Neurosurgery Unit, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Maria Paola Vardeu
- Pediatric Emergency Department, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Silvia Bressan
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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18
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Sheppard CW, Groll AL, Austin CL, Thompson SJ. Impact of duplicate CT scan rate after implementation of transfer image repository system at a level 1 trauma center. Emerg Radiol 2018; 25:275-280. [PMID: 29330668 PMCID: PMC5940706 DOI: 10.1007/s10140-017-1575-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/27/2017] [Indexed: 12/01/2022]
Abstract
Purpose The regionalization of trauma in the USA results in frequent transfers of patients from a primary hospital ED to a higher level trauma facility. While many hospitals have a Picture Archive Communication System (PACS) which captures digital radiological images, these are often not available to the receiving institution resulting in duplicate imaging. The state of Arkansas instituted a trauma image repository (TIR) in July 2013. We examined whether implementation of this repository would impact CT scan duplication in the trauma system. Methods This was a retrospective analysis of trauma patients transferred from outlying hospitals in Arkansas and Missouri to a single level 1 trauma hospital in Missouri between July 2012 and June 2015. We compared the duplicate CT rate for patients transferred from Arkansas and Missouri hospitals before and after the repository was implemented for Arkansas. Results Prior to implementation (July 2012–June 2013) of Arkansas TIR, duplicate CT rates were similar for patients transferred from Arkansas (11.5% ± 2.8) or Missouri (16.3% ± 7.5). Following implementation (July 2013–June 2014), the duplicate CT rate for patients transferred from Arkansas was significantly lower (Arkansas = 10.1% vs. Missouri 16.2%; CI 95%, p = 0.02), and significance continued (Arkansas = 9.0% vs. Missouri = 17.8%; CI 95%, p = 0.02) during follow-up (July 2014–June 2015). Conclusion Fewer patients received duplicated scans within the Arkansas as compared with the Missouri-based trauma referral systems regardless of Injury Severity Scores (ISS). Our findings suggest that TIR adoption coupled with PACS improved transferability of radiographic studies and could improve patient care while reducing costs in trauma transfers.
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Affiliation(s)
- Charles W Sheppard
- Department of Emergency Medicine, Mercy Hospital Springfield, 1235 E Cherokee St, Springfield, MO, 65804, USA
| | - Amy L Groll
- Emergency Department, Mercy Hospital Springfield, 1235 E Cherokee St, Springfield, MO, 65804, USA
| | - Cindy L Austin
- Trauma and Burn Research, Mercy Hospital Springfield, 1235 E Cherokee St, 7H, Springfield, MO, 65804, USA.
| | - Simon J Thompson
- Trauma and Burn Research, Mercy Hospital Springfield, 1235 E Cherokee St, 7H, Springfield, MO, 65804, USA
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Lichstein PM, Wilson SC, Ward WG. Compromise of Radiology Studies From Nonstandardized Viewing Platforms. Orthopedics 2018; 41:e136-e141. [PMID: 29257194 DOI: 10.3928/01477447-20171213-03] [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] [Received: 08/18/2017] [Accepted: 11/13/2017] [Indexed: 02/03/2023]
Abstract
There is no standardization of proprietary radiology viewing software platform functions allowing recorded digital radiographic imaging studies on compact discs (CDs) to be viewed in a standardized manner at subsequent institutions. Primary concerns include the following: (1) a large number of image viewing software platforms with a wide variety of features making familiarity with use difficult, (2) an inordinate amount of time required to load imaging data, (3) imaging data may not upload or be viewed with the care center's picture archiving and communication system, (4) navigation through imaging studies is inconsistent and tedious, and (5) image viewing requires additional software downloads. Additionally, images generated from "outside CDs" are frequently of low quality and resolution, eliminating the ability to render a reliable diagnosis. The authors sought to determine the frequency and extent of these functional problems by analyzing a sample of 50 consecutive radiology CDs containing imaging studies referred to a university orthopedic oncology practice. Eighteen different viewing software platforms were encountered. Only 24 (48%) of the CDs met all optimal system criteria. Mean time required to load the studies was 3.4 seconds using the picture archiving and communication system and 37.9 seconds using the proprietary viewing software (P<.001). Fifteen (30%) of the CDs did not upload to the institution's picture archiving and communication system, and 18 (36%) required additional downloads and/or license agreements. Four CDs did not contain Digital Imaging and Communications in Medicine images. Physicians using radiology studies on CDs encounter numerous difficulties in evaluating patients' imaging data because of the plethora of viewing software platforms. These difficulties add time and cost and compromise patient care. [Orthopedics. 2018; 41(1):e136-e141.].
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20
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Mok Y, Ma H, Leung M, Yeung H, Lit A, Luk H. Clinical Outcomes of Trauma Patients after Implementation of a Standardised Diversion Protocol for Trauma Patients in Two Regional Hospitals in Hong Kong. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791502200401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Despite recent advance in prehospital trauma diversion, patients are triaged to the nearest medical facility before transferred to designated trauma centre. A new standardised diversion protocol for trauma patients was implemented on 1st April 2011 to facilitate trauma care. Severely-injured patients were transferred to designated trauma centre directly from emergency department of the regional hospital after initial resuscitation. Objective This study was undertaken to examine clinical outcomes of trauma patients after implementation of the new standardised diversion protocol for trauma patients in the emergency department. Method This was a before-and-after interventional study on trauma patients presenting to the emergency department in critical or emergency conditions during the study period from 1st April 2011 to 31st March 2012. Patients presented in the two-year period before implementation of the trauma protocol were used as historical control. Medical records of eligible cases were reviewed. Main outcome measures were 30-day mortality, length of hospital stay and time to definitive care. Mortality data was compared with oversea standard by TRISS methodology. Results There were 153 eligible patients in the study group and 355 in the historical control group. After new arrangement of trauma diversion, W-statistics improves from -1.26 to 0.09. Z-statistics was -2.03 before and 0.09 after implementation. M-statistics were 0.91 before and 0.88 after the new protocol. Mean time to definitive care was shortened by 33.4 minutes in the subgroup who were transferred to trauma centre after trauma team activation (p=0.005). Conclusion A trend of improved outcomes and shorter time to definitive care are observed after implementation of the new trauma diversion protocol. (Hong Kong j.emerg.med. 2015;22:201-209)
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Affiliation(s)
- Yt Mok
- Yan Chai Hospital, Accident and Emergency Department, 7-11 Yan Chai Street, Tsuen Wan, New Territories, Hong Kong
| | - Hm Ma
- Yan Chai Hospital, Accident and Emergency Department, 7-11 Yan Chai Street, Tsuen Wan, New Territories, Hong Kong
| | - M Leung
- Yan Chai Hospital, Accident and Emergency Department, 7-11 Yan Chai Street, Tsuen Wan, New Territories, Hong Kong
| | - Hc Yeung
- Yan Chai Hospital, Accident and Emergency Department, 7-11 Yan Chai Street, Tsuen Wan, New Territories, Hong Kong
| | - Ach Lit
- Yan Chai Hospital, Accident and Emergency Department, 7-11 Yan Chai Street, Tsuen Wan, New Territories, Hong Kong
| | - Ht Luk
- Yan Chai Hospital, Accident and Emergency Department, 7-11 Yan Chai Street, Tsuen Wan, New Territories, Hong Kong
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21
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Reinke CE, Thomason M, Paton L, Schiffern L, Rozario N, Matthews BD. Emergency general surgery transfers in the United States: a 10-year analysis. J Surg Res 2017; 219:128-135. [DOI: 10.1016/j.jss.2017.05.058] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/08/2017] [Accepted: 05/18/2017] [Indexed: 02/03/2023]
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22
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Holmes JF, Siglock BG, Corwin MT, Johnson MA, Salcedo ES, Espinoza GS, Lamba R. Rate and Reasons for Repeat CT Scanning in Transferred Trauma Patients. Am Surg 2017. [DOI: 10.1177/000313481708300519] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To describe the reasons and additional radiation for CT scans repeated after transfer to a trauma center. Retrospective study of patients transferred to a trauma center. Patients had repeat CT if a CTof the same region was repeated at the trauma center's emergency department. Indications for repeat CT scanning were abstracted. Radiation dosage was calculated in millisieverts. A total of 370 had CT scans and were transferred. Mean age was 39.1 ± 28.0 years. Seventy-four [20.0%, 95% confidence interval (CI) 16.0–24.4%] had 103 CTs repeated. Adults (64/254, 25.2%) were more likely than children (10/116, 8.6%) to undergo repeat CT (difference 16.6%, 95% CI 9.2–24.0%). Types of CTs repeated included: head 48 (47%), face 6 (6%), cervical spine/neck 21 (20%), thoracolumbar spine 4 (4%), chest 4 (4%), and abdominal/pelvic 20 (19%). Reasons for repeat CT were outside CT unavailable 31 (42%), insufficient image quality/additional details needed 15 (20%), disease progression 16 (22%), unknown 10 (14%), and consult request unknown reason 2 (3%). Median dose for the repeat CT scans was 4.19 mSv (interquartile range 1.98, 6.28) and was 4.79 mSv (interquartile range 2.47, 8.22) when the CTs were unavailable. Effective dose of the repeat scans was greater than 10 mSv in 13 (3.5%) patients. Patients transferred to a trauma center often undergo repeat CT. The most common reason for repeated imaging was failure to transport original CT scans with the patient or images that were unable to be viewed. Trauma centers should work with their catchment areas to establish systems that ensure transfer of all radiographic imaging.
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Streck CJ, Vogel AM, Zhang J, Huang EY, Santore MT, Tsao K, Falcone RA, Dassinger MS, Russell RT, Blakely ML, Mauldin PD, Calder BW, Savoie KB, Haynes JH, Naik-Mathuria BJ, St Peter SD, Mooney DP, Onwubiko C, Upperman JS. Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. J Am Coll Surg 2017; 224:449-458.e3. [DOI: 10.1016/j.jamcollsurg.2016.12.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 11/29/2022]
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Bledsoe J, Liepert AE, Allen TL, Dong L, Hemingway J, Majercik S, Gardner S, Stevens MH. The salutary effect of an integrated system on the rate of repeat CT scanning in transferred trauma patients: Improved costs and efficiencies. Am J Surg 2017; 214:198-200. [PMID: 28283179 DOI: 10.1016/j.amjsurg.2016.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/05/2016] [Accepted: 10/24/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety. METHODS This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital. RESULTS We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals. CONCLUSION The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment.
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Affiliation(s)
- Joseph Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.
| | - Amy E Liepert
- Department of Surgery: Trauma, Acute Care Surgery and Critical Care, University of Wisconsin Medical Center, Madison, WI, USA
| | - Todd L Allen
- Institute for Health Care Delivery and Research, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Li Dong
- Institute for Health Care Delivery and Research, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jamon Hemingway
- Institute for Health Care Delivery and Research, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Sarah Majercik
- Department of Surgery & Division of Trauma, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Scott Gardner
- Department of Surgery & Division of Trauma, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Mark H Stevens
- Department of Surgery & Division of Trauma, Intermountain Medical Center, Salt Lake City, UT, USA
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Anderson KT, Greenfield S, Putnam LR, Hamilton E, Kawaguchi A, Austin MT, Kao LS, John SD, Lally KP, Tsao K. Don't forget the dose: Improving computed tomography dosing for pediatric appendicitis. J Pediatr Surg 2016; 51:1944-1948. [PMID: 27692347 DOI: 10.1016/j.jpedsurg.2016.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 09/12/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND A pediatric computed tomography (CT) radiation dose reduction program was implemented throughout our children's associated hospital system in 2010. We hypothesized that the CT dose received for evaluation of appendicitis in children would be significantly higher among the 40 referral, nonmember hospitals (NMH) than the 9 member hospitals (MH). METHODS Preoperative CTs of pediatric (<18years) appendectomy patients between April 2012 and April 2015 were reviewed. Size specific dose estimate (SSDE), an approximation of absorbed dose incorporating patient diameter, and Effective Dose (ED) were calculated for each scan. RESULTS 1128 (65%) of 1736 appendectomy patients underwent preoperative CT. 936 patients seen at and 102 children evaluated at NMH had dosing and patient diameter data for analysis. SSDE and ED were significantly higher with greater variance at NMH across all ages (all p<0.05, Figure). NMH's SSDE and ED also exceeded reference levels. CONCLUSION Radiation exposure in CT scans for evaluation of pediatric appendicitis is significantly higher and more variable in NMH. A proactive approach to reduce dose, in addition to frequency, of CT scans in pediatric patients is essential. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- K Tinsley Anderson
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Susan Greenfield
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Luke R Putnam
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Emma Hamilton
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Akemi Kawaguchi
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Mary T Austin
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Susan D John
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Kevin P Lally
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX.
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Vreeland A, Persons KR, Primo HR, Bishop M, Garriott KM, Doyle MK, Silver E, Brown DM, Bashall C. Considerations for Exchanging and Sharing Medical Images for Improved Collaboration and Patient Care: HIMSS-SIIM Collaborative White Paper. J Digit Imaging 2016; 29:547-58. [PMID: 27351992 PMCID: PMC5023527 DOI: 10.1007/s10278-016-9885-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The need for providers and patients to exchange and share imaging has never been more apparent, yet many organizations are only now, as a part of a larger enterprise imaging initiative, taking steps to streamline an important process that has historically been facilitated with the use of CDs or insecure methods of communication. This paper will provide an introduction to concepts and common-use cases for image exchange, outline challenges that have hindered adoption to date, and describe standards for image exchange that show increasing promise of being adopted by vendors and providers.
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Affiliation(s)
- Amy Vreeland
- Imaging Strategies, 30 Locke Road, Waban, MA, 02468, USA.
| | | | - Henri Rik Primo
- Siemens Medical Solutions USA, Inc., Digital Health Services, 60 Valley Stream Parkway, Malvern, PA, 19355, USA
| | - Matthew Bishop
- UnityPoint Health IT, 4500 Utica Ridge Road, Bettendorf, IA, 52722, USA
| | - Kimberley M Garriott
- Logicalis, Inc, Healthcare Strategies Division, 9225 Priority Way, Suite 115, Indianapolis, IN, 46240, USA
| | | | - Elliott Silver
- McKesson Imaging and Workflow Solutions Division, 475 Allendale Road, King of Prussia, PA, 19406, USA
| | - Danielle M Brown
- Aspirus IT, 2800 Westhill Drive, Suite 102, Wausau, WI, 54401, USA
| | - Chris Bashall
- Sir Charles Gairdner Hospital Radiology Dept, 1 Hospital Avenue, Nedlands, 6009, WA, Australia
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27
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Imaging before transfer to designated pediatric trauma centers exposes children to excess radiation. J Trauma Acute Care Surg 2016; 81:229-35. [DOI: 10.1097/ta.0000000000001074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Watson JJ, Moren A, Diggs B, Houser B, Eastes L, Brand D, Bilyeu P, Schreiber M, Kiraly L. A statewide teleradiology system reduces radiation exposure and charges in transferred trauma patients. Am J Surg 2016; 211:908-12. [DOI: 10.1016/j.amjsurg.2016.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/19/2016] [Accepted: 01/23/2016] [Indexed: 11/28/2022]
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Rapid MRI evaluation of acute intracranial hemorrhage in pediatric head trauma. Neuroradiology 2016; 58:793-9. [DOI: 10.1007/s00234-016-1686-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/04/2016] [Indexed: 11/24/2022]
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Onwubiko C, Mooney DP. The value of official reinterpretation of trauma computed tomography scans from referring hospitals. J Pediatr Surg 2016; 51:486-9. [PMID: 26342629 DOI: 10.1016/j.jpedsurg.2015.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 07/23/2015] [Accepted: 08/02/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Historically, computed tomography (CT) scans of injured children obtained at referring emergency departments were not reinterpreted by trauma center radiologists at our institution, creating a dilemma for trauma physicians: rescan, use the outside interpretation, or interpret scans themselves. In 2010, our radiologists began reinterpreting all referring hospital trauma CT scans; this study examines the effect of that change. METHODS Transferred patients who had undergone an abdomen/pelvis CT (CTAP) scan between December 2010 and December 2012 were identified in our trauma registry. Pediatric radiologist reinterpretations were compared to referring hospital radiologist reports. RESULTS We identified 168 patients transferred to our institution with a CTAP. Seventy patients were excluded owing to lack of: complete study, referring hospital interpretation, or reinterpretation. Of the remaining 98 cases, 12 new injuries were identified: 3 splenic and 3 liver injuries, 1 adrenal hematoma, 2 pelvic fractures, 1 spinal fracture, 1 duodenal hematoma and 1 jejunal perforation. Three patients had solid organ injuries upgraded (grade II to III liver laceration; 2 renal lacerations with active extravasation initially missed), and 4 patients downgraded to no injury. CONCLUSION Reinterpretation of referring hospital CT scans by pediatric radiologists is beneficial to appropriate management of pediatric trauma patients with concern for blunt abdominal trauma.
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Affiliation(s)
- Chinwendu Onwubiko
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - David P Mooney
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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McCarthy A, Curtis K, Holland AJA. Paediatric trauma systems and their impact on the health outcomes of severely injured children: An integrative review. Injury 2016; 47:574-85. [PMID: 26794709 DOI: 10.1016/j.injury.2015.12.028] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/18/2015] [Accepted: 12/22/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear. AIMS This research aims to identify the impact of trauma systems on the health outcomes of children following severe injury. METHODS Integrative review with data sourced from Medline, Embase, CINAHL, Scopus and hand searched references. Abstracts were screened for inclusion/exclusion criteria with fifty nine articles appraised for quality, analysed and synthesised into 3 main categories. RESULTS The key findings from this review include: (1) a lack of consistency of prehospital and inhospital triage criteria for severely injured children leading to missed injuries, secondary transfer and poor utilisation of finite resources; (2) severely injured children treated at paediatric trauma centres had improved outcomes when compared to those treated at adult trauma centres, particularly younger children; (3) major causes of delays to secondary transfer are unnecessary imaging and failure to recognise the need for transfer; (4) a lack of functional or long term outcomes measurements identified in the literature. CONCLUSIONS Research designed to identify the best processes of care and describe the impacts of trauma systems on the long term health outcomes of severely injured children is required. Ideally all phases of care including prehospital, paediatric triage trauma criteria, hospital type and interfacility transfer should be included, focusing on timeliness and appropriateness of care. Outcome measures should include long term functional outcomes in addition to mortality.
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Affiliation(s)
- Amy McCarthy
- Sydney Nursing School, The University of Sydney, NSW, Australia; Wollongong Hospital, Wollongong, NSW, Australia.
| | - Kate Curtis
- Sydney Nursing School, The University of Sydney, NSW, Australia; St George Hospital, Kogarah, NSW, Australia
| | - Andrew J A Holland
- Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead Clinical School, Sydney Medical School, The University of Sydney, NSW, Australia; The Children's Hospital at Westmead Burns Research Institute, NSW, Australia
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Puckett Y, To A. Pediatric Trauma Transfer Imaging Inefficiencies-Opportunities for Improvement with Cloud Technology. AIMS Public Health 2016; 3:49-53. [PMID: 29546145 PMCID: PMC5690262 DOI: 10.3934/publichealth.2016.1.49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/23/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND This study examines the inefficiencies of radiologic imaging transfers from one hospital to the other during pediatric trauma transfers in an era of cloud based information sharing. METHODS Retrospective review of all patients transferred to a pediatric trauma center from 2008–2014 was performed. Imaging was reviewed for whether imaging accompanied the patient, whether imaging was able to be uploaded onto computer for records, whether imaging had to be repeated, and whether imaging obtained at outside hospitals (OSH) was done per universal pediatric trauma guidelines. RESULTS Of the 1761 patients retrospectively reviewed, 559 met our inclusion criteria. Imaging was sent with the patient 87.7% of the time. Imaging was unable to be uploaded 31.9% of the time. CT imaging had to be repeated 1.8% of the time. CT scan was not done per universal pediatric trauma guidelines 1.2% of the time. CONCLUSION Our study demonstrated that current imaging transfer is inefficient, leads to excess ionizing radiation, and increased healthcare costs. Universal implementation of cloud based radiology has the potential to eliminate excess ionizing radiation to children, improve patient care, and save cost to healthcare system.
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Affiliation(s)
- Yana Puckett
- Saint Louis University College of Public Health and Social Justice, Saint Louis, MO, USA
| | - Alvin To
- Saint Louis University School of Medicine, Saint Louis, MO, USA
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Fahy AS, Antiel RM, Polites SF, Ishitani MB, Moir CR, Zielinski MD. Pretransfer computed tomography delays arrival to definitive care without affecting pediatric trauma outcomes. J Pediatr Surg 2016; 51:323-5. [PMID: 26778842 PMCID: PMC4882110 DOI: 10.1016/j.jpedsurg.2015.10.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 10/26/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Children with thoracic or abdominal trauma, presenting to referring hospitals, may undergo CT imaging prior to transfer to a pediatric trauma center (PTC). We sought to determine if children who undergo pretransfer imaging experience a delay in definitive care and worse clinical outcomes. METHODS Pediatric blunt trauma patients transferred to our level I PTC were identified in this IRB approved study. Those transferred with CT imaging of the chest or abdomen/pelvis prior to transfer were compared to those transferred without imaging. RESULTS Of 246 patients with a mean age of 12.4±5.3years (64% male), 128 patients (52%) underwent chest (n=85) and/or abdominal (n=115) CT studies prior to transfer. Among those patients with pretransfer CT, 14% of CT scans were repeated. On multivariate analysis accounting for distance, time from injury to arrival at our PTC was significantly greater in children who underwent pretransfer CT (320±216 vs. 208±149minutes, p<0.001). Median length of stay (3 vs. 3days) and mortality (3% vs. 3%) were similar between groups (all p>0.05). CONCLUSIONS A substantial number of pediatric blunt trauma patients underwent CT scans prior to transfer, which is associated with a delay in transfer but not worse outcomes.
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Affiliation(s)
- Aodhnait S. Fahy
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA,Division of Pediatric Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA
| | - Ryan M. Antiel
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA,Division of Pediatric Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA
| | - Stephanie F. Polites
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA,Division of Pediatric Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA
| | - Michael B. Ishitani
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA,Division of Pediatric Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA
| | - Christopher R. Moir
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA,Division of Pediatric Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA
| | - Martin D. Zielinski
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA,Division of Trauma, Critical Care and General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55901, USA,Correspondence to: M.D. Zielinski, Division of Trauma, Critical Care and General Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA., (M.D. Zielinski)
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Farach SM, Danielson PD, Amankwah EK, Chandler NM. Repeat computed tomography scans after pediatric trauma: results of an institutional effort to minimize radiation exposure. Pediatr Surg Int 2015; 31:1027-33. [PMID: 26276424 DOI: 10.1007/s00383-015-3757-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many pediatric trauma patients are initially evaluated at non-pediatric, non-trauma centers where they undergo CT prior to transfer to a pediatric trauma center. The purpose of this study is to quantify the number of repeat CT and assess the risk of delayed or missed injuries. METHODS The institutional pediatric trauma registry was queried for patients evaluated from January 2001 to March 2012. All patients who underwent repeat CT within 24 h after transfer were included. General admission, demographic, and outcome data were analyzed. RESULTS A total of 6041 patients were transferred from a referring hospital after undergoing CT scans. Five percent of patients underwent repeat CT with a mean age of 6.3 ± 5.7 years. Patients who underwent repeat CT scans had significantly higher Injury Severity Scores and lower Glasgow Coma Scale. CT head was the most commonly repeated. Comparing results of referring CT scans to repeated scans, there was good agreement between results for head CT (κ = 0.69) and moderate agreement for abdominopelvic CT (κ = 0.59). The overall incidence of delayed diagnosis of injuries was 0.7%. CONCLUSION The low incidence of missed or delayed injuries justifies limiting additional radiation exposure to pediatric trauma patients based on clinical status.
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Affiliation(s)
- Sandra M Farach
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, Saint Petersburg, FL, 33701, USA.
| | - Paul D Danielson
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, Saint Petersburg, FL, 33701, USA.
| | - Ernest K Amankwah
- Clinical and Translational Research Organization, All Children's Hospital Johns Hopkins Medicine, 501 6th Avenue South, Saint Petersburg, FL, 3701, USA.
| | - Nicole M Chandler
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Outpatient Care Center, 601 5th Street South, Dept 70-6600, 3rd Floor, Saint Petersburg, FL, 33701, USA.
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Computed tomography-related radiation exposure in children transferred to a Level I pediatric trauma center. J Trauma Acute Care Surg 2015; 78:1134-7. [PMID: 26151513 DOI: 10.1097/ta.0000000000000645] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Pediatric trauma patients presenting to referring facilities (RF) often undergo computed tomography (CT) scans to identify injuries before transfer to a Level I pediatric trauma center (PTC). The purpose of our study was to evaluate RF compliance with the American College of Radiology (ACR) guidelines to minimize ionizing radiation exposure in pediatric trauma patients and to determine the frequency of additional or repeat CT imaging after transfer to a PTC. METHODS After institutional review board approval, a retrospective review of all pediatric trauma admissions from January 2010 to December 2011 at our American College of Surgeons Level I PTC was performed. Patient demographics, means of arrival, Injury Severity Score, and disposition were analyzed. Patients who underwent CT were grouped by means of arrival: those who were transferred from an RF versus those who presented primarily to the PTC. Compliance with ACR guidelines and need for additional or repeat CT scans were assessed for both groups. RESULTS Six hundred ninety-seven children (aged <18 years) were identified, with a mean age of 10.6 years. Three hundred twenty-one (46%) patients presented primarily to the PTC. Three hundred seventy-six (54%) were transferred from an RF, of which 90 (24%) patients underwent CT imaging before transfer. CT radiation dosing information was available for 79 (88%) of 90 patients. After transfer, 8 (9%) of 90 of children imaged at an RF required additional CT scans. In comparison, 314 (98%) of 321 patients who presented primarily to the PTC and underwent CT received appropriate pediatric radiation dosing. Mean radiation dose at PTC was approximately half of that at RF for CT scans of the head, chest, and abdomen/pelvis (p < 0.01). CONCLUSION Pediatric trauma patients transferred from RF often undergo CT scanning with higher than recommended radiation doses, potentially placing them at an increased carcinogenic risk. Fortunately, few RF patients required additional CT scans after PTC transfer. Finally, compliance with ACR radiation dose limit guidelines is better achieved at a PTC. LEVEL OF EVIDENCE Care management study, level IV.
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Clinical and Economic Impact of Duplicated Radiographic Studies in Trauma Patients Transferred to a Regional Trauma Center. J Orthop Trauma 2015; 29:e214-8. [PMID: 25536213 DOI: 10.1097/bot.0000000000000279] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Many trauma patients are evaluated at community hospitals and rural emergency departments before transfer to regional trauma centers. Radiographic studies are often duplicated, leading to significant additional costs to the healthcare system. Our purpose is to identify the reasons for duplicate studies, the costs associated with this practice, and potential clinical effects to patients. METHODS The institutional trauma database was queried to identify patients with orthopaedic injuries transferred to our regional trauma center. Patient demographics, mechanism of injury, referring hospital, reason for transfer, payor source, injury severity score, and Glasgow Coma Score (GCS) were recorded. Duplicate imaging studies were identified and confirmed with each outlying hospital radiology department. The radiation exposure was estimated based on average reported values. The cost of duplicated studies was derived from the Medicare fee schedule. RESULTS In 1 calendar year, a total of 513 patients were accepted in transfer from 36 outlying facilities. Almost half of the patients (47.7%) had at least 1 radiographic study repeated. There was a significant association between repeated study and age (P < 0.0001), Injury Severity Score (P < 0.0001), and GCS (P < 0.0001). No association was identified for size of transferring institution, injury mechanism, or payor status. Reasons listed for duplication included inadequate data transfer, poor quality, inadequate study, and physician preference. The additional cost to the healthcare system is estimated to be $94,000. CONCLUSIONS The duplication of imaging studies at regional trauma centers is a common problem that represents a significant opportunity for cost savings and reduction of patient exposure to radiation by implementing imaging protocols at outlying facilities and improving the transfer of imaging data through information technology solutions. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Hospital support. J Orthop Trauma 2014; 28:S47-9. [PMID: 24918831 DOI: 10.1097/bot.0000000000000141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Setting up a successful trauma system requires a significant amount of hospital support. This includes personnel and programs to assist with quality assurance programs, clinical compliance, and rural support and development. It is imperative that orthopaedic trauma surgeons are well versed in the types of hospital support available and the costs associated with each support measure. With this understanding, a strong, sustainable physician-hospital relationship can be created.
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Benedict LA, Paulus JK, Rideout L, Chwals WJ. Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center? J Pediatr Surg 2014; 49:184-7; discussion 187-8. [PMID: 24439606 DOI: 10.1016/j.jpedsurg.2013.09.056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging. METHODS A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry. RESULTS A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score <14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%). CONCLUSION The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging.
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Affiliation(s)
- Leo Andrew Benedict
- Department of Pediatric Surgery, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Jessica K Paulus
- Tufts Clinical and Translational Science Institute, Boston, MA 02111
| | - Leslie Rideout
- Department of Pediatric Surgery, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Walter J Chwals
- Department of Pediatric Surgery, Floating Hospital for Children, Tufts Medical Center, Boston, MA.
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Airway, breathing, computed tomographic scanning: duplicate computed tomographic imaging after transfer to trauma center. J Trauma Acute Care Surg 2013; 74:813-7. [PMID: 23425740 DOI: 10.1097/ta.0b013e3182789399] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Trauma patients imaged at community hospitals often receive duplicate computed tomographic (CT) imaging after transfer to regional trauma centers (RTCs). CT scanning is expensive, is resource intensive, and has acknowledged radiation risk to the patient. The objective of this study was to review and evaluate the frequency, indications, impact on patient management, as well as associated radiation and charges for duplicate CT imaging of trauma patients transferred to our RTC from outside hospitals (OSH). METHODS Patients transferred to our RTC between September 2009 and August 2010 were evaluated prospectively. The OSH patients' charts and provider interviews were used to determine the reasons for repeated scans. The primary outcome was frequency of duplicate CT scan, defined as a repeated CT image of the same body part within 24 hours. The reason for duplicate imaging and impact on patient management was categorized. Radiation exposure and charges for duplicate scans were also determined. RESULTS Of the 185 patients transferred to our facility, 177 were eligible. CT examinations at the OSH were performed on 137 patients (77%). A duplicate CT examination occurred in 38 patients (28%). The most common reason for duplicate CT scanning was lack of thin-section multiplanar data, on images sent via CD-ROM (37%). There was a change in management in 16 patients (42%). The patients with duplicate scanning received a median of 10.2 mSv (interquartile range, 6.6-15.7 mSv) of additional radiation, with a median charge of $409 (interquartile range, $307-$734). CONCLUSION More than one third of duplicated scans performed on transferred trauma patients were potentially avoidable, primary owing to inadequate transfer of data from the OSH CT scan. The capacity of a single CD-ROM is insufficient to contain full imaging data from a trauma scan, and establishing direct links to imaging data from OSHs would decrease the number of repeated CT scans performed on transferred trauma patients. LEVEL OF EVIDENCE Care management study, level III.
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Psoter KJ, Roudsari BS, Vaughn M, Fine GC, Jarvik JG, Gunn ML. Effect of an image-sharing network on CT utilization for transferred trauma patients: a 5-year experience at a level I trauma center. J Am Coll Radiol 2013; 11:616-22. [PMID: 23769646 DOI: 10.1016/j.jacr.2013.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 02/15/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the influence of an image-sharing network established between referring hospitals and a level I trauma center on CT utilization at the trauma center. METHODS This retrospective study was approved by the local institutional review board. The requirement for informed consent was waived. Harborview Medical Center's trauma registry was linked to billing department data, and detailed information on all resources utilized during each patient's hospitalization was obtained. Negative binomial regression was used to evaluate body region-specific CT utilization between direct-admit and transfer patients after adjustment for potential confounding variables. Special attention was paid to 2005 as the year internet-based image sharing between Harborview Medical Center and referring hospitals was established. RESULTS A total of 81,159 trauma patients were admitted to Harborview Medical Center (44% transfers) during the study period. The utilization of head CT slightly increased from 1996 to 2005, with no significant difference between direct-admit and transfer patients. Between 2005 and 2010, utilization remained relatively unchanged; however, significantly higher utilization rates were observed for direct-admit patients. A relatively similar pattern was observed for pelvic CT; however, between 2005 and 2010, CT use was greater for direct-admit compared with transfer patients. Abdominal and thoracic CT was relatively unchanged between 2005 and 2010. However, both studies had significantly higher utilization rates for direct-admit patients. CONCLUSIONS The utilization rates of CT of different body regions have been higher for direct-admit trauma patients compared with transfer patients since 2005; however, decreasing utilization trends have been observed in recent years.
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Affiliation(s)
- Kevin J Psoter
- Department of Epidemiology, University of Washington, Seattle, Washington.
| | - Bahman S Roudsari
- Department of Radiology, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, Washington
| | - Matthew Vaughn
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington
| | - Gabriel C Fine
- Department of Radiology, University of Washington, Seattle, Washington
| | - Jeffrey G Jarvik
- Department of Radiology, University of Washington, Seattle, Washington; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, Washington; Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Martin L Gunn
- Department of Radiology, University of Washington, Seattle, Washington
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McNeeley MF, Gunn ML, Robinson JD. Transfer patient imaging: current status, review of the literature, and the Harborview experience. J Am Coll Radiol 2013; 10:361-7. [PMID: 23415656 DOI: 10.1016/j.jacr.2012.09.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 09/24/2012] [Indexed: 11/28/2022]
Abstract
Patients transferred for higher levels of care often arrive with medical imaging from the outside facility, with or without accompanying radiology reports. The handling of pretransfer studies by receiving radiologists introduces several concerns regarding resource utilization, medicolegal risk, and technical quality control. The authors review the current status of transfer patient imaging, with an emphasis on the role of the receiving emergency radiologist. Practice solutions developed at the authors' level I trauma center are described.
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Affiliation(s)
- Michael F McNeeley
- Department of Radiology, University of Washington, Harborview Medical Center, Seattle, Washington 98195, USA.
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Abstract
PURPOSE Although computed tomographic (CT) scans are accurate in diagnosing solid-organ injuries, their ability to diagnose a blunt intestinal injury (BII) is limited, occasionally requiring repeated imaging. The purpose of this study was to evaluate the role of clinical findings as well as original and repeated CT imaging in the ultimate decision to operate for BII. METHODS An 18-institution record review of children (≤ 15 years) diagnosed with a BII confirmed during surgery between 2002 and 2007 was conducted by the American Pediatric Surgery Association Trauma Committee. The incidence of imaging, repeated imaging, and final reported indications for operative exploration were evaluated. RESULTS Among 331 patients identified with a BII, 292 (88%) underwent at least 1 abdominal CT scan. Sixty-two (19%) underwent at least 1 repeated scan before operation. Forty-seven percent of children who underwent a CT scan were taken to the operating room based primarily on clinical indications (fever, abdominal pain, shock or elevated white blood cell count), whereas 31% were operated on based on both a clinical and CT indication and 22% were operated on based on a CT indication alone (P < 0.001). Although free air was the most common radiographic indication for surgery, 13% of patients with a repeated scan had free air diagnosed on their first CT. Most children undergoing a repeated CT (84%) had findings on the original scan suggesting a BII. Among the 10 patients whose first CT scan result was normal, only 1 went to the operating room based only on radiographic findings. Children who had their first CT scan at a referring hospital were more likely to have a repeated study compared with those imaged at a trauma center (33% vs 13%, P < 0.0001). CONCLUSIONS Although abdominal CT imaging may contribute to diagnosing intestinal injury after blunt trauma, most children undergo operation based on clinical findings. Repeated imaging should be limited to select patients with diagnostic uncertainty to avoid unneeded delay and radiation exposure.
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Assessment of factors associated with the delayed transfer of pediatric trauma patients: an emergency physician survey. Pediatr Emerg Care 2012; 28:758-63. [PMID: 22858741 DOI: 10.1097/pec.0b013e318262414b] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to identify, among emergency department (ED) physicians, the potential barriers impacting the appropriate and timely transfer of injured children to pediatric trauma centers. METHODS Surveys assessed pediatric trauma knowledge and experience, transfer and imaging decisions, and perceived barriers to patient transfer. Two scenarios were created; one with a child meeting the state trauma triage criteria and one who did not. In April 2010, 936 surveys were mailed to randomly selected ED physicians. Respondents could answer by mail or online until June 30, 2010. RESULTS A total of 486 surveys were returned, and 109 were excluded, leaving 377 included in the study. A majority reported limited experience in the care of the critically ill child, with 93%, 99%, 99%, and 100% respectively, having performed less than 5 intubations, intraosseous line, central line, or chest tube placements in the last year. In the scenario in which the child met criteria to be transferred, 74% appropriately transferred the patient, whereas in the other scenario, 34% transferred the patient. As much as 56% of the respondents reported they would perform a head computed tomography before transfer, mainly to avoid missed injuries and medicolegal concerns. Among those who would not transfer either patient, 27% reported not having an on-call surgeon at all times. CONCLUSIONS Innovative measures should be developed so that ED physicians gain a greater understanding of the proper identification of pediatric patients requiring a timely transfer to a pediatric trauma center.
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Abstract
PURPOSE OF REVIEW This review will examine the current evidence regarding pediatric blunt abdominal trauma and the physical exam findings, laboratory values, and radiographic imaging associated with the diagnosis of intra-abdominal injuries (IAI), as well as review the current literature on pediatric hollow viscus injuries and emergency department disposition after diagnosis. RECENT FINDINGS The importance of the seat belt sign on physical examination and screening laboratory data remains controversial, although screening hepatic enzymes are recommended in the evaluation of nonaccidental trauma to identify occult abdominal organ injuries. Focused Assessment with Sonography for Trauma (FAST) has modest sensitivity for hemoperitoneum and IAI in the pediatric trauma patient. Patients with concern for undiagnosed IAI, including bowel injury, may be considered for hospital admission and serial abdominal exams without an increased risk of complications, if an exploratory laparotomy is not performed emergently. SUMMARY Although the FAST exam is not recommended as the sole screening tool to rule out IAI in hemodynamically stable trauma patients, it may be used in conjunction with the physical exam and laboratory findings to identify children at risk for IAI. Children with a normal physical exam and normal abdominal CT may not require routine hospitalization after blunt abdominal trauma.
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Computed tomography scanning in pediatric trauma: opportunities for performance improvement and radiation safety. J Surg Res 2012; 180:226-31. [PMID: 22578856 DOI: 10.1016/j.jss.2012.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/24/2012] [Accepted: 04/11/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recently, pediatric CT scanning protocols have reduced radiation exposure in children. Because evaluation with CT scan after trauma contributes to significant radiation exposure, we reviewed the CT scans in children at both initial presentation at a non-pediatric facility and subsequent transfer to a level I pediatric trauma center (PTC) to determine the number of scans, body area scanned, radiation dosage, and proportion of scans at each facility. METHODS The trauma database was retrospectively reviewed for children aged 0 to 17 y initially evaluated for trauma at another facility and then transferred to our PTC for pediatric specialty care between January 2000 and December 2010. RESULTS A total of 1562 patients with 1335 CT scans were reviewed over an 11-y period. The majority of CT scans occur at the referring facility compared to the PTC in a ratio of 7:3. CT of the head was the most frequent scan obtained (52%), and 17.9% of CT scans were repeated at the PTC. Less than 1% of CT scans performed at the non-pediatric centers contained radiation dosage information, precluding analysis of radiation exposure. CONCLUSIONS The majority of CT scans for trauma occur at non-pediatric facilities, which demonstrates the need for referring facilities to perform optimal CT scans with the least amount of radiation exposure to the child. We believe this provides an opportunity for PTC performance improvement by facilitating the transfer of images and educating referring facilities about indications for CT scans, dosage amounts, and radiation reduction protocols.
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Beer M, Wirth C, Neubauer H, Wirbelauer J. Bildgebung auf der Kinderintensivstation. Med Klin Intensivmed Notfmed 2011; 106:103-10. [DOI: 10.1007/s00063-011-0056-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 08/08/2011] [Indexed: 10/15/2022]
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Visvanathan A, Gibb AP, Brady RRW. Increasing clinical presence of mobile communication technology: avoiding the pitfalls. Telemed J E Health 2011; 17:656-61. [PMID: 21780941 DOI: 10.1089/tmj.2011.0018] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mobile communication technologies are employed in many diverse areas of healthcare delivery to provide improved quality and efficiency of communication and facilitate increased rapidity of data or information transfer. Mobile phones enable healthcare professionals to possess a portable platform from which to provide many healthcare-related applications and are a popular means to directly communicate with colleagues and patients. As involvement of mobile communication technology in healthcare delivery continues to rapidly expand, there are also important considerations of relevance to patient safety and security as a result. Here, we review the previous evidence of reported clinical risks associated with mobile communication technology, such as electromagnetic interference, confidentiality and data security, distraction/noise, infection control, and cross contamination. In conclusion, although mobile phones provide much putative potential improvement to healthcare delivery, further evaluation and research are required to both inform and protect health professionals and users of such technology in the healthcare environment and provide the evidence base to support the provision of clear and comprehensive guidelines.
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Affiliation(s)
- Akila Visvanathan
- Department of Laboratory Medicine, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, Scotland, United Kingdom
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CT utilization in transferred trauma patients. J Surg Res 2011; 170:309-13. [PMID: 21816435 DOI: 10.1016/j.jss.2011.06.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 06/03/2011] [Accepted: 06/07/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Trauma systems were designed to optimize care of critically injured patients. CT scanning and its duplication demonstrate waste, inefficiency, and harm to the patient. We define the frequency at which this occurs and identify areas of inefficiency within our system that may be present in other systems. MATERIALS AND METHODS Patients transferred to a level I trauma center were prospectively identified at the time of transfer. All imaging completed at either the referring center or the level I center was recorded. The reason for CT scanning at the level I center was captured at the time of decision and recorded in one of four categories. RESULTS A total of 207 transferred trauma patients with CT imaging were reviewed. Of these, 127 patients (61%) had CT scans obtained at both the referring and accepting facilities; 99 patients (48%) had one or more of the same body regions imaged at both centers; 28 (13%) patients did not have repeated body region scans, but received additional imaging at the Trauma Center. CT scans of the head (34%) and c-spine (35%) were most commonly obtained at both the referring center and the trauma center. The most common reason for repeat or additional imaging at the trauma center was improper image selection or poor image quality. CONCLUSION Repeat and additional imaging of transferred trauma patients is a common practice. The reasons for this include image quality and selection. This provides necessary information for improvement in the quality of the trauma transfer process.
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Kanal KM, Vavilala MS, Raelson C, Mohan A, Cohen W, Jarvik J, Rivara FP, Stewart BK. Variation in Pediatric Head CT Imaging Protocols in Washington State. J Am Coll Radiol 2011; 8:242-50. [DOI: 10.1016/j.jacr.2010.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 11/08/2010] [Indexed: 10/24/2022]
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Abstract
PURPOSE The purpose of the study was to determine if first rib fractures are associated with an increased incidence of thoracic vascular injury in pediatric patients. METHODS The medical records of all children diagnosed with a first rib fracture or a central vascular injury after blunt trauma treated at a state-designated level 1 pediatric trauma center from 2000 to 2009 were reviewed. RESULTS Thirty-three children (0.27% of patients; mean age, 10.9 ± 0.9 years) were identified with either a first rib fracture or thoracic vascular injury owing to blunt trauma. Thirty-two children had a first rib fracture, and only 1 child (3%) had significant thoracic vascular injury. Mediastinal abnormalities (indistinct aortic knob) were identified in 3 children, 2 with first rib fracture on initial chest radiograph. Despite a normal cardiovascular examination result, 25 (74%) children with a normal mediastinum on screening chest radiograph underwent computed tomography. No child with a normal mediastinum on initial chest radiograph was found to have associated intrathoracic injuries requiring further intervention. In children with first rib fractures and a normal mediastinum by screening chest x-ray, the negative predictive value for thoracic vascular injury was 100%. CONCLUSIONS Children with first rib fractures without mediastinal abnormality on chest radiograph require no further workup for thoracic vascular injury.
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