1
|
Marlor D, Juang D, Pruitt L, Cruz-Centeno N, Stewart S, Senna J, Flint J. Factors Associated With Early Discharge in Pediatric Trauma Patients Transported by Rotor: A Retrospective Analysis. Air Med J 2024; 43:37-41. [PMID: 38154838 DOI: 10.1016/j.amj.2023.09.010] [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: 07/04/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Helicopter emergency medical services (HEMS) play a crucial role in providing timely transport for pediatric trauma patients. This service carries the highest risk of any mode of medical transport and a high financial burden, and patient outcomes are seldom investigated. This study evaluated the characteristics of pediatric trauma patients discharged within 24 hours after transport by HEMS. METHODS This was a single-center, retrospective analysis on pediatric trauma patients transported by HEMS from 2019 to 2022. Analyses were performed to identify factors associated with discharge within 24 hours. Factors analyzed included vital signs, Shock Index, Pediatric Age-Adjusted scores, management details, and clinical outcomes. RESULTS A total of 466 pediatric trauma patients were transported by HEMS, including 171 patients (36.7%) who were discharged within 24 hours. There were no differences in the rates of blunt and penetrating injury (P = .583). Patients discharged within 24 hours were more likely to have a higher Glasgow Coma Scale score (14 vs. 11, P < .001) and a lower Injury Severity Score (4.9 vs. 14.7, P < .001), required less prehospital fluid resuscitation (5.5 vs. 11.7 mL/kg, P = .039), and had higher levels of serum calcium (9.3 vs. 8.9 mg/dL, P < .001). They were also less likely to meet criteria for level 1 trauma activation (13.0% vs. 40%, P < .001) or to require prehospital respiratory support of any kind (4.1% vs. 31.1%, P < .001). After arrival at the hospital, they were less likely to require blood transfusions (2.9% vs. 29.8%, P < .001) or tranexamic acid (2.9% vs. 11.5%, P = .001). CONCLUSION Trauma patients with a high Glasgow Coma Scale score and a low Injury Severity Score who do not require critical care or meet the criteria for high-level trauma activation may be suitable for transportation with lower acuity. Further studies aimed at improving triage and implementing improved criteria for the use of HEMS are paramount.
Collapse
Affiliation(s)
| | | | | | | | | | - Jack Senna
- Kansas City University School of Medicine, Kansas City, MO
| | | |
Collapse
|
2
|
Lulla A, Lumba-Brown A, Totten AM, Maher PJ, Badjatia N, Bell R, Donayri CTJ, Fallat ME, Hawryluk GWJ, Goldberg SA, Hennes HMA, Ignell SP, Ghajar J, Krzyzaniak BP, Lerner EB, Nishijima D, Schleien C, Shackelford S, Swartz E, Wright DW, Zhang R, Jagoda A, Bobrow BJ. Prehospital Guidelines for the Management of Traumatic Brain Injury - 3rd Edition. PREHOSP EMERG CARE 2023:1-32. [PMID: 37079803 DOI: 10.1080/10903127.2023.2187905] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Affiliation(s)
- Al Lulla
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Annette M Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Patrick J Maher
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neeraj Badjatia
- Department of Neurocritical Care, Neurology, Anesthesiology, Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randy Bell
- Uniformed Services University, Bethesda, Maryland
| | | | - Mary E Fallat
- Hiram C. Polk Jr Department of Pediatric Surgery, University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Cleveland Clinic and Akron General Hospital, Fairlawn, Ohio
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Halim M A Hennes
- Department of Pediatric Emergency Medicine, UT Southwestern Medical Center, Dallas Children's Medical Center, Dallas, Texas
| | - Steven P Ignell
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford University, Stanford, California
| | | | - E Brooke Lerner
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Daniel Nishijima
- Department of Emergency Medicine, UC Davis, Sacramento, California
| | - Charles Schleien
- Pediatric Critical Care, Cohen Children's Medical Center, Hofstra Northwell School of Medicine, Uniondale, New York
| | - Stacy Shackelford
- Trauma and Critical Care, USAF Center for Sustainment of Trauma Readiness Skills, Seattle, Washington
| | - Erik Swartz
- Department of Physical Therapy and Kinesiology, University of Massachusetts, Lowell, Massachusetts
| | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Rachel Zhang
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Andy Jagoda
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| |
Collapse
|
3
|
Gurien LA, Nichols L, Williamson P, Letton RW. Rethinking pediatric trauma triage. Semin Pediatr Surg 2022; 31:151214. [PMID: 36371842 DOI: 10.1016/j.sempedsurg.2022.151214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Despite advances in the delivery of trauma care, trauma remains the leading cause of death amongst the pediatric population within the United States and is one of the leading causes of death in children worldwide. Accurately triaging pediatric trauma patients is essential to minimize preventable mortality without burdening the system by utilizing unnecessary resources. This article will review the accuracy of current pediatric trauma triage practices and how it will evolve in the future including moving away from mechanism of injury towards physiologic scoring tools such as the pediatric age-adjust shock index, and intervention-based systems including. Need for Surgeon Presence and Need For Trauma Intervention. This paper will also present evidence regarding over-utilization of air transport for pediatric trauma patients and the associated unnecessary costs placed on the trauma system.
Collapse
Affiliation(s)
- Lori A Gurien
- Nemours Children's Healthcare, 807 Children's Way, Jacksonville, FL 32207, United States; Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, United States.
| | - Lisa Nichols
- Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, United States
| | - Patsy Williamson
- Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, United States
| | - Robert W Letton
- Nemours Children's Healthcare, 807 Children's Way, Jacksonville, FL 32207, United States; Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, United States
| |
Collapse
|
4
|
Choi PM, Fraser J, Briggs KB, Dekonenko C, Aguayo P, Juang D. Air transportation over-utilization in pediatric trauma patients. J Pediatr Surg 2021; 56:1035-1038. [PMID: 33008637 DOI: 10.1016/j.jpedsurg.2020.08.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/12/2020] [Accepted: 08/27/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Air transportation can be a life-saving transfer modality for trauma patients. However, it is also costly and carries risk for air-crews and patients. We sought to examine the incidence of air transportation among pediatric trauma patients as well as the rate of over-triage in utilizing this intervention. METHODS We conducted a single-institution retrospective review of all pediatric trauma patients who utilized air transportation, either from scene to hospital or hospital to hospital Emergency Department (ED) transfers, between 2013 and 2018. RESULTS There were 348 pediatric trauma patients who utilized air transport. More than half of all patients (n = 186, 55.9%) were discharged from the hospital within 48 h, 121 (36.3%) were discharged within 24 h, and 34 (10.2%) were discharged home from the ED. The mean ISS was 11.2 ± 0.5 while only 31% had an ISS ≥15. There were 97 patients (27.9%) with elevated age adjusted shock index, and 101 patients (29.0%) who required time sensitive interventions. More than half of patients (59.3%) were initially taken to an outside hospital (OSH) and were then transferred to our facility by air while 40.4% were transported directly from scene to our institution by air. Patients who were transferred from an OSH were younger (6.8 ± 0.4 vs 11.2 ± 0.4, p < 0.01) and had a higher incidence of an elevated age-adjusted shock index (32.4% vs 19.1%, p = 0.006) as well as mortality (6.3% vs 1.4%, p = 0.03). However, ultimately there were no differences in ISS, rates of operative intervention, PICU utilization, or time sensitive intervention. Both groups had similarly high rates of discharge within 48 h, 24 h, and from the ED. CONCLUSIONS Air transportation among pediatric trauma patients from scene to hospital and hospital to hospital is over-utilized based on multiple metrics including low rates of ISS ≥15, elevated age-adjusted shock indexes, low rates of time sensitive intervention, as well as high rates of discharge within 24 and 48 h. LEVEL OF EVIDENCE III TYPE OF STUDY: Clinical Research-retrospective review.
Collapse
Affiliation(s)
- Pamela M Choi
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108; LCDR, US Navy, Navy Medicine Professional Development Center, Bethesda, MD 20889
| | - James Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108
| | - Kayla B Briggs
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108
| | - Charlene Dekonenko
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108.
| |
Collapse
|
5
|
Nacoti M, Fazzi F, Biroli F, Zangari R, Barbui T, Kochanek PM. Addressing Key Clinical Care and Clinical Research Needs in Severe Pediatric Traumatic Brain Injury: Perspectives From a Focused International Conference. Front Pediatr 2021; 8:594425. [PMID: 33537259 PMCID: PMC7849211 DOI: 10.3389/fped.2020.594425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/06/2020] [Indexed: 12/28/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Survivors of severe TBI are more prone to functional deficits, resulting in poorer school performance, poor health-related quality of life (HRQoL), and increased risk of mental health problems. Critical gaps in knowledge of pathophysiological differences between children and adults concerning TBI outcomes, the paucity of pediatric trials and prognostic models and the uncertain extrapolation of adult data to pediatrics pose significant challenges and demand global efforts. Here, we explore the clinical and research unmet needs focusing on severe pediatric TBI to identify best practices in pathways of care and optimize both inpatient and outpatient management of children following TBI.
Collapse
Affiliation(s)
- Mirco Nacoti
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Fazzi
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Biroli
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rosalia Zangari
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Tiziano Barbui
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G Rangos Research Center, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| |
Collapse
|
6
|
Helicopter transport in pediatric trauma: A new methodology using Need for Surgeon Presence to evaluate the necessity of air transport. Am J Surg 2020; 220:464-467. [DOI: 10.1016/j.amjsurg.2019.11.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 11/18/2022]
|
7
|
Dengler BA, Plaza-Wüthrich S, Chick RC, Muir MT, Bartanusz V. Secondary Overtriage in Patients with Complicated Mild Traumatic Brain Injury: An Observational Study and Socioeconomic Analysis of 1447 Hospitalizations. Neurosurgery 2020; 86:374-382. [PMID: 30953054 DOI: 10.1093/neuros/nyz092] [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: 05/13/2018] [Accepted: 02/27/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Secondary overtriage is a problematic phenomenon because it creates unnecessary expense and potentially results in the mismanagement of healthcare resources. The rates of secondary overtriage among patients with complicated mild traumatic brain injury (cmTBI) are unknown. OBJECTIVE To determine the rate of secondary overtriage among patients with cmTBI using the institutional trauma registry. METHODS An observational study using retrospective analysis of 1447 hospitalizations including all consecutive patients with cmTBI between 2004 and 2013. Data on age, sex, race/ethnicity, insurance status, GCS, Injury Severity Score (ISS), Trauma Injury Severity Score, transfer mode, overall length of stay (LOS), LOS within intensive care unit, and total charges were collected and analyzed. RESULTS Overall, the rate of secondary overtriage among patients with cmTBI was 17.2%. These patients tended to be younger (median: 41 vs 60.5 yr; P < .001), have a lower ISS (9 vs 16; P < .001), and were more likely to be discharged home or leave against medical advice. CONCLUSION Our findings provide evidence to the growing body of literature suggesting that not all patients with cmTBI need to be transferred to a tertiary care center. In our study, these transfers ultimately incurred a total cost of $13 294 ($1337 transfer cost) per patient.
Collapse
Affiliation(s)
- Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sonia Plaza-Wüthrich
- Division of Spine Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Robert C Chick
- Department of Surgery, Brooke Army Medical Center, San Antonio, Texas
| | - Mark T Muir
- Department of Surgery, University of Texas Health San Antonio, Texas
| | - Viktor Bartanusz
- Department of Neurosurgery, University of Texas Health San Antonio, Texas
| |
Collapse
|