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Snyder CW, Kristiansen KO, Jensen AR, Sribnick EA, Anders JF, Chen CX, Lerner EB, Conti ME. Defining pediatric trauma center resource utilization: Multidisciplinary consensus-based criteria from the Pediatric Trauma Society. J Trauma Acute Care Surg 2024; 96:799-804. [PMID: 37880842 DOI: 10.1097/ta.0000000000004181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND Pediatric trauma triage and transfer decisions should incorporate the likelihood that an injured child will require pediatric trauma center (PTC) resources. Resource utilization may be a better basis than mortality risk when evaluating pediatric injury severity. However, there is currently no consensus definition of PTC resource utilization that encompasses the full scope of PTC services. METHODS Consensus criteria were developed in collaboration with the Pediatric Trauma Society (PTS) Research Committee using a modified Delphi approach. An expert panel was recruited representing the following pediatric disciplines: prehospital care, emergency medicine, nursing, general surgery, neurosurgery, orthopedics, anesthesia, radiology, critical care, child abuse, and rehabilitation medicine. Resource utilization criteria were drafted from a comprehensive literature review, seeking to complete the following sentence: "Pediatric patients with traumatic injuries have used PTC resources if they..." Criteria were then refined and underwent three rounds of voting to achieve consensus. Consensus was defined as agreement of 75% or more panelists. Between the second and third voting rounds, broad feedback from attendees of the PTS annual meeting was obtained. RESULTS The Delphi panel consisted of 18 members from 15 institutions. Twenty initial draft criteria were developed based on literature review. These criteria dealt with airway interventions, vascular access, initial stabilization procedures, fluid resuscitation, blood product transfusion, abdominal trauma/solid organ injury management, intensive care monitoring, anesthesia/sedation, advanced imaging, radiologic interpretation, child abuse evaluation, and rehabilitative services. After refinement and panel voting, 14 criteria achieved the >75% consensus threshold. The final consensus criteria were reviewed and endorsed by the PTS Guidelines Committee. CONCLUSION This study defines multidisciplinary consensus-based criteria for PTC resource utilization. These criteria are an important step toward developing a criterion standard, resource-based, pediatric injury severity metric. Such metrics can help optimize system-level pediatric trauma triage based on likelihood of requiring PTC resources. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level II.
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Affiliation(s)
- Christopher W Snyder
- From the Division of Pediatric Surgery (C.W.S.), Johns Hopkins All Children's Hospital, St. Petersburg, Florida; Department of Anesthesia (K.O.K., M.E.C.), Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Lebanon, New Hampshire; Division of Pediatric Surgery (A.R.J.), Benioff Children's Hospital, University of California-San Francisco, San Francisco, California; Department of Pediatric Neurosurgery (E.A.S.), Nationwide Children's Hospital, Columbus, Ohio; Division of Pediatric Emergency Medicine (J.F.A.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pediatric Anesthesiology (C.X.C.), Seattle Children's Hospital, Seattle, Washington; and Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York
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Lerner EB, Drendel AL, Badawy M, Cushman JT, Fumo N, Jones CMC, Shah MN, Gourlay DM. Accuracy of the American College of Surgeons Minimum Criteria for Full Trauma Team Activation for Children. Pediatr Emerg Care 2024; 40:187-190. [PMID: 37308172 DOI: 10.1097/pec.0000000000002995] [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] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Pediatric trauma centers use reports from emergency medical service providers to determine if a trauma team should be sent to the emergency department to prepare to care for the patient. Little scientific evidence supports the current American College of Surgeons (ACS) indicators for trauma team activation. The objective of this study was to determine the accuracy of the ACS Minimum Criteria for Full Trauma Team Activation for children as well as the accuracy of the modified criteria used at the local sites for trauma activation. METHODS Emergency medical service providers who transported an injured child aged 15 years or younger to a pediatric trauma center in 1 of 3 cities were interviewed after emergency department arrival. Emergency medical service providers were asked if each of the activation indicators were present based on their evaluation. The need for full trauma team activation was determined through a medical record review using a published criterion standard definition. Undertriage and overtriage rates and positive likelihood ratios (+LRs) were calculated. RESULTS Emergency medical service provider interviews were conducted and outcome data were obtained for 9483 children. There were 202 (2.1%) cases that met the criterion standard for need for trauma team activation. Based on the ACS Minimum Criteria, 299 (3.0%) cases should have received a trauma activation. The ACS Minimum Criteria undertriaged 44.1% and overtriaged 20% (+LR, 27.9; 95% confidence interval, 23.1-33.7). Based on the actual activation status using the local criteria, 238 cases received a full trauma activation, 45% were undertriaged, and 1.4% were overtriaged (+LR, 40.1; 95% confidence interval, 32.4-49.7). There was 97% agreement between the ACS Minimum Criteria and the actual local activation status at the receiving institution. CONCLUSIONS The ACS Minimum Criteria for Full Trauma Team Activation for children have a high rate of undertriage. Changes that individual institutions have made to improve the accuracy of activations at their institutions seem to have had a limited effect on decreasing undertriage.
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Affiliation(s)
| | - Amy L Drendel
- Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Mohamed Badawy
- Section of Emergency Medicine, Department of Pediatrics, University of Texas-Southwestern, Dallas, TX
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester, Rochester, NY
| | - Nicole Fumo
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester, Rochester, NY
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, WI
| | - David M Gourlay
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Kinjalk M, Jain N, Neogi S, Ratan SK, Panda SS, Sehgal M, Arora V. Pediatric Age-adjusted Shock Index (SIPA): From Injury to Outcome in Blunt Abdominal Trauma. J Indian Assoc Pediatr Surg 2024; 29:33-38. [PMID: 38405261 PMCID: PMC10883172 DOI: 10.4103/jiaps.jiaps_156_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/16/2023] [Accepted: 08/27/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose The Shock Index Pediatric Age-Adjusted (SIPA) score is a useful tool for identifying pediatric trauma patients at a risk of poor outcomes and for triaging. We are studying the relationship between elevated SIPA score and specific outcomes in pediatric trauma patients. Materials and Methods A retrospective study was conducted in which case records of 58 pediatric patients with blunt abdominal trauma were evaluated and tabulated for their SIPA scores only at the time of their initial presentation and categorized into two groups - normal SIPA and elevated SIPA. The primary outcomes were need for blood transfusion, need for any intervention, and need for emergency surgery, and the secondary outcomes were need for computed tomography (CT) scan, need for a ventilator, intensive care unit (ICU) stay, length of hospital stay, and mortality. Statistical methods were applied to find a relationship between elevated SIPA score and the primary and secondary outcomes. Results An elevated SIPA score was noted in 27 (46%) patients. There was a significant relationship between elevated SIPA scores and patients needing blood transfusion (68.75%, n = 11) and length of hospital stay (10.48 ± 7.54 days). A significant relationship between elevated SIPA score and need for emergency surgery (54.54%, n = 6), need for a CT scan (56%, n = 14), and ICU stay (50%, n = 2) was not found. Conclusion We have seen in our study that elevated SIPA scores at presentation are significantly related to need for blood transfusion and length of hospital stay. In more than half of the patients, elevated SIPA was associated with need for emergency surgery and requirement of CT scan, but it was statistically not significant. Therefore, assessment of this parameter can help in identifying such poor outcomes.
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Affiliation(s)
- Meghna Kinjalk
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Nitin Jain
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Sujoy Neogi
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Simmi K. Ratan
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | | | - Mehak Sehgal
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Vanshika Arora
- Department of Pediatric Surgery, Maulana Azad Medical College, New Delhi, India
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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.
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Affiliation(s)
| | | | | | | | | | - Jack Senna
- Kansas City University School of Medicine, Kansas City, MO
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Glass NE, Salvi A, Wei R, Lin A, Malveau S, Cook JNB, Mann NC, Burd RS, Jenkins PC, Hansen M, Mohr NM, Stephens C, Fallat ME, Lerner EB, Carr BG, Wall SP, Newgard CD. Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers. JAMA Surg 2023; 158:1078-1087. [PMID: 37556154 PMCID: PMC10413216 DOI: 10.1001/jamasurg.2023.3344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/25/2023] [Indexed: 08/10/2023]
Abstract
Importance Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.
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Affiliation(s)
- Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Ran Wei
- School of Public Policy, University of California, Riverside
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, DC
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City
| | | | - Mary E. Fallat
- Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - E. Brooke Lerner
- Department of Emergency Medicine, University at Buffalo, Buffalo, New York
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephen P. Wall
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York
| | - Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
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Herren A, Palmer CS, Landolt MA, Lehner M, Neuhaus TJ, Simma L. Pediatric Trauma and Trauma Team Activation in a Swiss Pediatric Emergency Department: An Observational Cohort Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1377. [PMID: 37628376 PMCID: PMC10453385 DOI: 10.3390/children10081377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/02/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Trauma is one of the most common causes of death in childhood, but data on severely injured Swiss children are absent from existing national registries. Our aim was to analyze trauma activations and the profiles of critically injured children at a tertiary, non-academic Swiss pediatric emergency department (PED). In the absence of a national pediatric trauma database, this information may help to guide the design of infrastructure, processes within organizations, training, and policies. METHODS A retrospective analysis of pediatric trauma patients in a prospective resuscitation database over a 2-year period. Critically injured trauma patients under the age of 16 years were included. Patients were described with established triage and injury severity scales. Statistical evaluation included logistic regression analysis. RESULTS A total of 82 patients matched one or more of the study inclusion criteria. The most frequent age group was 12-15 years, and 27% were female. Trauma team activation (TTA) occurred with 49 patients (59.8%). Falls were the most frequent mechanism of injury, both overall and for major trauma. Road-traffic-related injuries had the highest relative risk of major trauma. In the multivariate analysis, patients receiving medicalized transport were more likely to trigger a TTA, but there was no association between TTA and age, gender, or Injury Severity Score (ISS). Nineteen patients (23.2%) sustained major trauma with an ISS > 15. Injuries of Abbreviated Injury Scale severity 3 or greater were most frequent to the head, followed by abdomen, chest, and extremities. The overall mortality rate in the cohort was 2.4%. Conclusions: Major trauma presentations only comprise a small proportion of the total patient load in the PED, and trauma team activation does not correlate with injury severity. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED. Our findings indicate that high priority should be given to training in the management of severely injured children in the PED. The leading major trauma mechanisms were preventable, which should prompt further efforts in injury prevention.
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Affiliation(s)
- Anouk Herren
- Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Department of Pediatrics, University’s Children Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
| | - Cameron S. Palmer
- Trauma Service, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Markus A. Landolt
- Department of Psychosomatics and Psychiatry and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Binzmuehlestrasse 14, CH-8050 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital of Zurich, University of Zurich, CH-8032 Zurich, Switzerland
| | - Markus Lehner
- Department of Pediatric Surgery, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Thomas J. Neuhaus
- Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
| | - Leopold Simma
- Children’s Research Center, University Children’s Hospital of Zurich, University of Zurich, CH-8032 Zurich, Switzerland
- Emergency Department, Children’s Hospital Lucerne, Spitalstrasse, CH-6000 Lucerne, Switzerland
- Emergency Department, University’s Children Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
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Reppucci ML, Cooper E, Stevens J, Meier M, Nolan MM, Moulton SL, Bensard DD, Acker SN. Comparison of Pediatric Trauma Scoring Tools That Incorporate Neurological Status for Trauma Team Activation. Pediatr Emerg Care 2023; 39:501-506. [PMID: 37276058 DOI: 10.1097/pec.0000000000002985] [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] [Indexed: 06/07/2023]
Abstract
BACKGROUND Two novel pediatric trauma scoring tools, SIPAB+ (defined as elevated SIPA with Glasgow Coma Scale ≤8) and rSIG (reverse Shock Index multiplied by Glasgow Coma Scale and defined as abnormal using cutoffs for early outcomes), which combine neurological status with Pediatric Age-Adjusted Shock Index (SIPA), have been shown to predict early trauma outcomes better than SIPA alone. We sought to determine if one more accurately identifies children in need of trauma team activation. METHODS Patients 1 to 18 years old from the 2014-2018 Pediatric Trauma Quality Improvement Program database were included. Sensitivity and specificity for SIPAB+ and rSIG were calculated for components of pediatric trauma team activation, based on criteria standard definitions. RESULTS There were 11,426 patients (1.9%) classified as SIPAB+ and 235,672 (39.0%) as having an abnormal rSIG. SIPAB+ was consistently more specific, with specificities exceeding 98%, but its sensitivity was poor (<30%) for all outcomes. In comparison, rSIG was a more sensitive tool, with sensitivities exceeding 60%, and specificity values exceeded 60% for all outcomes. CONCLUSIONS Trauma systems must determine their priorities to decide how best to incorporate SIPAB+ and rSIG into practice, although rSIG may be preferred as it balances both sensitivity and specificity. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Emily Cooper
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora
| | | | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora
| | - Margo M Nolan
- From the Pediatric Surgery, Children's Hospital Colorado, Aurora
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Cavanagh N, Blanchard IE, Weiss D, Tavares W. Looking back to inform the future: a review of published paramedicine research. BMC Health Serv Res 2023; 23:108. [PMID: 36732779 PMCID: PMC9893690 DOI: 10.1186/s12913-022-08893-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/28/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community. METHODS We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample. RESULTS The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice. CONCLUSIONS Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.
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Affiliation(s)
- N. Cavanagh
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - I. E. Blanchard
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - D. Weiss
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada
| | - W. Tavares
- grid.512795.dThe Wilson Centre, Department of Medicine, University of Toronto/University Health Network, Toronto, Ontario Canada ,grid.17063.330000 0001 2157 2938Department of Health and Society, University of Toronto, Toronto, Ontario Canada ,York Region Paramedic and Senior Services, Community Health Services Department, Regional Municipality of York, Newmarket, Ontario Canada
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Cohen N, Davis AL, Test G, Singer–Harel D, Pasternak Y, Beno S, Scolnik D. Evaluation of activation criteria in paediatric multi-trauma. Paediatr Child Health 2023; 28:17-23. [PMID: 36865755 PMCID: PMC9971577 DOI: 10.1093/pch/pxac085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/21/2022] [Indexed: 11/14/2022] Open
Abstract
Objective To explore the optimal set of trauma activation criteria predicting paediatric patients' need for acute care following multi-trauma, with particular attention to Glasgow Coma Scale (GCS) cut-off value. Methods A retrospective cohort study of paediatric multi-trauma patients aged 0 to 16 years, performed at a Level 1 paediatric trauma centre. Trauma activation criteria and GCS levels were examined with respect to patients' need for acute care, defined as: direct to operating room disposition, intensive care unit admission, need for acute interventions in the trauma room, or in-hospital death. Results We enrolled 436 patients (median age 8.0 years). The following predicted need for acute care: GCS <14 (adjusted odds ratio [aOR] 23.0, 95% confidence interval [CI]: 11.5 to 45.9, P < 0.001), hemodynamic instability: (aOR 3.7, 95% CI: 1.2-8.1, P = 0.01), open pneumothorax/flail chest (aOR: 20.0, 95% CI: 4.0 to 98.7, P < 0.001), spinal cord injury (aOR 15.4, 95% CI; 2.4 to 97.1, P = 0.003), blood transfusion at the referring hospital (aOR: 7.7, 95% CI: 1.3 to 44.2, P = 0.02) and GSW to the chest, abdomen, neck, or proximal extremities (aOR 11.0, 95% CI; 1.7 to 70.8, P = 0.01). Using these activation criteria would have decreased over- triage by 10.7%, from 49.1% to 37.2% and under-triage by 1.3%, from 4.7% to 3.5%, in our cohort of patients. Conclusions Using GCS<14, hemodynamic instability, open pneumothorax/flail chest, spinal cord injury, blood transfusion at the referring hospital, and GSW to the chest, abdomen, neck of proximal extremities, as T1 activation criteria could decrease over- and under-triage rates. Prospective studies are needed to validate the optimal set of activation criteria in paediatric patients.
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Affiliation(s)
- Neta Cohen
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Adrienne L Davis
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Gidon Test
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Dana Singer–Harel
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Yehonatan Pasternak
- Division of Clinical Immunology and Allergy, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Beno
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Scolnik
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
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10
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Adding age-adjusted shock index to the American College of Surgeons' trauma team activation criteria to predict severe injury in children. J Trauma Acute Care Surg 2023; 94:295-303. [PMID: 36694336 DOI: 10.1097/ta.0000000000003693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American College of Surgeons (ACS) requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation. Our goal was to evaluate the effect of adding age-adjusted shock index (SI) to the ACS-6 for the prediction of severe injury among pediatric trauma patients with the hypothesis that SI would significantly improve sensitivity with an acceptable decrease in specificity. METHODS We performed a secondary analysis of prospectively collected EMS and trauma registry data from two urban pediatric trauma centers. Age-adjusted SI thresholds were calculated as heart rate divided by systolic blood pressure using 2020 Pediatric Advanced Life Support SI vital sign ranges and previously published Shock Index, Pediatric Adjusted (SIPA) thresholds. The primary outcome was a composite of emergency operative (within 1 hour of arrival) or emergency procedural intervention (EOPI) or Injury Severity Score (ISS) greater than 15. Sensitivities, specificities, and 95% CIs were calculated for the ACS-6 alone and in combination with age-adjusted SI. RESULTS There were 8,078 patients included; 20% had an elevated age-adjusted SI and 17% met at least one ACS minimum criterion; 1% underwent EOPI; and 17% had ISS >15. Sensitivity and specificity of the ACS-6 for EOPI or ISS > 5 were 45% (95% confidence interval [CI], 41-50%) and 89% (95% CI, 81-96%). Inclusion of Pediatric Advanced Life Support-SI and SIPA resulted in sensitivities of 51% (95% CI, 47-56%) and 69% (95% CI, 65-72%), and specificities of 80% (95% CI, 71-89%) and 60% (95% CI, 53-68%), respectively. Similar trends were seen for each secondary outcome. CONCLUSION In this cohort of pediatric trauma registry patients, the addition of SIPA to the ACS-6 for trauma team activation resulted in significantly increased sensitivity for EOPI or ISS greater than 15 but poor specificity. Future investigation should explore using age-adjusted shock index in a two-tiered trauma activation system, or in combination with novel triage criteria, in a population-based cohort. LEVEL OF EVIDENCE Diagnostic Tests or Criteria; Level II.
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Ashby DW, Balakrishnan B, Gourlay DM, Meyer MT, Nimmer M, Drendel AL. Utilizing Near-Infrared Spectroscopy to Identify Pediatric Trauma Patients Needing Lifesaving Interventions: A Prospective Study. Pediatr Emerg Care 2023; 39:13-19. [PMID: 35580188 DOI: 10.1097/pec.0000000000002710] [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] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The aim of this study was to prospectively investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs). METHODS Prospective cohort study of children age 0 to 18 years who activated the trauma team response between August 15, 2017, and February 12, 2019, at a large, urban pediatric emergency department (ED).The relationship between the lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) was investigated. Categorical variables were analyzed by χ 2 test, and continuous variables were analyzed by Student t test. RESULTS A total of 148 pediatric trauma patients had somatic NIRS monitoring and met the inclusion criteria. Overall, 65.5% were male with a mean ± SD age of 10.9 ± 6.0 years. Injuries included 67.6% blunt trauma and 28.4% penetrating trauma with mortality of 3.4% (n = 5). Overall, the median lowest somatic NIRS value was 72% (interquartile range, 58%-88%; range, 15%-95%), and 43.9% of patients had a somatic NIRS value <70%. The median somatic NIRS duration recorded was 11 minutes (interquartile range, 7-17 minutes; range, 1-105 minutes). Overall, 36.5% of patients required a LSI including 53 who required a lifesaving procedure, 17 required blood products, and 17 required vasopressors. Among procedures, requiring a thoracostomy was significant.Pediatric trauma patients with a somatic NIRS value <70% had a significantly increased odds of requiring a LSI (odds ratio, 2.11; 95% confidence interval, 1.07-4.20). Somatic NIRS values <70% had a sensitivity and specificity of 56% and 63%, respectively. CONCLUSIONS Pediatric trauma patients with somatic NIRS values <70% within 30 minutes of ED arrival have an increased odds of requiring LSIs. Among LSIs, pediatric trauma patients requiring thoracostomy was significant. The role of NIRS in incrementally improving the identification of critically injured children in the ED and prehospital setting should be evaluated in larger prospective multicenter studies.
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Affiliation(s)
- David W Ashby
- From the Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | | | - David M Gourlay
- Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Michael T Meyer
- Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Mark Nimmer
- Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Amy L Drendel
- Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI
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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.
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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
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Castillo C, Steffens T, Livesay G, Sim L, Caffery L. IMPACT (Information Medically Pertinent in Acute Computed Tomography) requests: Delphi study to develop criteria standards for adequate clinical information in computed tomography requests in the Australian emergency department. J Med Radiat Sci 2022; 69:421-430. [PMID: 35835587 DOI: 10.1002/jmrs.607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 07/02/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Inadequate clinical information in medical imaging requests negatively affects the clinical relevance of imaging performed and the quality of resultant radiology reports. Currently, there are no published Australian guidelines on what constitutes adequate clinical information in computed tomography (CT) requests. This study aimed to determine specific items of clinical information radiologists require in CT requests for acute chest, abdomen and blunt trauma examinations, to support optimal reporting. METHODS A panel of 24 CT-reporting consultant radiologists participated in this e-Delphi consensus study. Panellists undertook multiple online survey rounds of open-ended, dichotomous and Likert scale questions, receiving feedback following each. Round 1 responses formulated lists for each CT examination. Round 2 set a threshold of 80% agreement after dichotomous scoring. Round 3 accepted items which averaged 4 or more on a 5-point Likert scale. Round 4 required panellists to rank items within the aggregated, accepted lists, based on panellists' perceived level of usefulness. RESULTS The large numbers of round 1 items (chest: 101, abdomen: 76, blunt trauma: 80) were rationalised and grouped into categories to facilitate efficiency during subsequent rounds. Twenty-three chest, 24 abdomen and 17 blunt trauma items met the 80% agreement threshold in round 2. Items below threshold were included in round 3; numbering 44, 19 and 23 for chest, abdomen and blunt trauma, respectively. Through the e-Delphi process, we formulated clinical information criteria standards for three CT types. CONCLUSIONS The developed standards will guide Australian referrers in providing adequate clinical information in CT requests, to support optimal reporting, diagnosis and treatment.
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Affiliation(s)
- Chelsea Castillo
- Centre for Online Health, Centre for Health Services Research, The University of Queensland, Brisbane, Australia.,Department of Diagnostic Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Tom Steffens
- Department of Diagnostic Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Georgia Livesay
- Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Lawrence Sim
- Centre for Online Health, Centre for Health Services Research, The University of Queensland, Brisbane, Australia.,Radiology Informatics Support Unit, Information & Technology Service, eHealth Queensland, Queensland Health, Brisbane, Australia
| | - Liam Caffery
- Centre for Online Health, Centre for Health Services Research, The University of Queensland, Brisbane, Australia
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Vetschera A, Beliveau V, Esswein K, Linzmeier K, Gozzi R, Hohlrieder M, Simma B. Preclinical Pediatric Care by Emergency Physicians: A Comparison of Trauma and Nontrauma Patients in a Population-Based Study in Austria. Pediatr Emerg Care 2022; 38:e1384-e1390. [PMID: 35696293 DOI: 10.1097/pec.0000000000002759] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fewer than 10% of emergency medical system (EMS) calls concern children and adolescents younger than 18 years. Studies have shown that the preclinical care of children differs from that of adults regarding assessment, interventions, and monitoring. The aims of this study were to describe the preclinical care and emergency transport of pediatric patients in Vorarlberg, Austria and to compare trauma and nontrauma cases. METHODS This is a population-based study, analyzing medical records of EMS calls to children and adolescents. We received all patient records of EMS calls to children and adolescents younger than 18 years (n = 4390 in total) from the 2 local EMS providers, the Red Cross Vorarlberg and the Austrian Mountain Rescue Service (Christophorus 8 and Gallus 1) covering a study period of 7 years, from 2013 to 2019. The record data were extracted by automation with an in-house program and subsequently anonymized. Statistical analyses were performed with SPSS Statistics. RESULTS During the study period, 7.9% of all EMS calls concerned children and adolescents younger than 18 years. For our study, 3761 records were analyzed and 1270 trauma cases (33.8%) were identified. The most common injuries were injuries of the extremities and traumatic brain injury. The frequency of National Advisory Committee of Aeronautics Scores of 4 or higher was 17.7%, similar for all age groups and for trauma as well as nontrauma patients. Mean Glasgow Coma Scale scores were higher in the trauma group than in the nontrauma group (14.2 vs 11.2). In 62.9% of all patients, 1 or more vital parameters were documented. A majority of these values was in the pathologic range for the respective age group. The rate of pulsoxymetry monitoring during transport was low (42.1% in trauma and 30.3% in nontrauma patients) and decreased significantly with patient age. Moreover, while the placing of intravenous lines and monitoring during transport were significantly more frequent in trauma patients, the administration of medication or oxygen was significantly more frequent in nontrauma patients. CONCLUSIONS The pediatric population lacks assessments and monitoring in preclinical care, especially the youngest children and nontrauma patients, although emergency severity scores are similar.
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Affiliation(s)
- Anna Vetschera
- From the Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch
| | - Vincent Beliveau
- Department of Neurology, Medical University of Innsbruck, Innsbruck
| | | | | | | | - Matthias Hohlrieder
- Department of Anesthesiology and Intensive Care Medicine, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Burkhard Simma
- From the Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch
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Newgard CD, Lin A, Goldhaber-Fiebert JD, Marin JR, Smith M, Cook JNB, Mohr NM, Zonfrillo MR, Puapong D, Papa L, Cloutier RL, Burd RS. Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers. JAMA Surg 2022; 157:e217419. [PMID: 35107579 PMCID: PMC8811708 DOI: 10.1001/jamasurg.2021.7419] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/28/2021] [Indexed: 02/04/2023]
Abstract
IMPORTANCE There is substantial variability among emergency departments (EDs) in their readiness to care for acutely ill and injured children, including US trauma centers. While high ED pediatric readiness is associated with improved in-hospital survival among children treated at trauma centers, the association between high ED readiness and long-term outcomes is unknown. OBJECTIVE To evaluate the association between ED pediatric readiness and 1-year survival among injured children presenting to 146 trauma centers. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, injured children younger than 18 years who were residents of 8 states with admission, transfer to, or injury-related death at one of 146 participating trauma centers were included. Children cared for in and outside their state of residence were included. Subgroups included those with an Injury Severity Score (ISS) of 16 or more; any Abbreviated Injury Scale (AIS) score of 3 or more; head AIS score of 3 or more; and need for early critical resources. Data were collected from January 2012 to December 2017, with follow-up to December 2018. Data were analyzed from January to July 2021. EXPOSURES ED pediatric readiness for the initial ED, measured using the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES Time to death within 365 days. RESULTS Of 88 071 included children, 30 654 (34.8%) were female; 2114 (2.4%) were Asian, 16 730 (10.0%) were Black, and 49 496 (56.2%) were White; and the median (IQR) age was 11 (5-15) years. A total of 1974 (2.2%) died within 1 year of the initial ED visit, including 1768 (2.0%) during hospitalization and 206 (0.2%) following discharge. Subgroups included 12 752 (14.5%) with an ISS of 16 or more, 28 402 (32.2%) with any AIS score of 3 or more, 13 348 (15.2%) with a head AIS of 3 or more, and 9048 (10.3%) requiring early critical resources. Compared with EDs in the lowest wPRS quartile (32-69), children cared for in the highest wPRS quartile (95-100) had lower hazard of death to 1 year (adjusted hazard ratio [aHR], 0.70; 95% CI, 0.56-0.88). Supplemental analyses removing early deaths had similar results (aHR, 0.75; 95% CI, 0.56-0.996). Findings were consistent across subgroups and multiple sensitivity analyses. CONCLUSIONS AND RELEVANCE Children treated in high-readiness trauma center EDs after injury had a lower risk of death that persisted to 1 year. High ED readiness is independently associated with long-term survival among injured children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer R. Marin
- Departments of Pediatrics, Emergency Medicine, and Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - McKenna Smith
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Nicholas M. Mohr
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - Mark R. Zonfrillo
- Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Devin Puapong
- Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children, Honolulu, Hawaii
- Department of Surgery, University of Hawai’i John A. Burns School of Medicine, Honolulu
| | - Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Robert L. Cloutier
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children’s National Hospital, Washington, DC
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16
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Ashby DW, Gourlay DM, Balakrishnan B, Meyer MT, Drendel AL. Utilizing Near-Infrared Spectroscopy (NIRS) to Identify Pediatric Trauma Patients Needing Lifesaving Interventions (LSIs): A Retrospective Study. Pediatr Emerg Care 2022; 38:e193-e199. [PMID: 32910035 DOI: 10.1097/pec.0000000000002211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs). METHODS Retrospective chart review of children age 0 to 18 years who activated the trauma team response between January 1, 2015 and August 14, 2017, at a large, urban pediatric emergency department. The lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) were abstracted from the chart. χ2 and descriptive statistics were used for analysis. RESULTS The charts of 84 pediatric trauma patients were reviewed. Overall, 80% were boys with a mean age of 10.4 years (SD, 6.2 years). Injuries included 56% blunt trauma and 36% penetrating trauma with mortality of 10.7% (n = 9). Overall, the median lowest NIRS value was 67% (interquartile range, 51-80%; range, 15%-95%) and 54.8% of the patients had a NIRS value less than 70%. The median somatic NIRS duration recorded was 12 minutes (interquartile range, 6-17 minutes; range, 1-59 minutes). Overall, 50% of patients required a LSI, including 39 who required a lifesaving procedure, 11 required blood products, and 14 required vasopressors. Pediatric trauma patients with NIRS less than 70% had a significantly increased odds of requiring a LSI (odds ratio, 2.67; 95% confidence interval, 1.10-6.47). NIRS less than 70% had a sensitivity and specificity of 67% and 57% respectively. CONCLUSIONS Pediatric trauma patients with somatic NIRS less than 70% within 30 minutes of emergency department arrival are associated with the need for LSIs. Continuous NIRS monitoring in the pediatric trauma population should be evaluated prospectively.
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Affiliation(s)
- David W Ashby
- From the Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - David M Gourlay
- Medical College of Wisconsin and Children's Hospital of Wisconsin, Wauwatosa, WI
| | - Binod Balakrishnan
- Medical College of Wisconsin and Children's Hospital of Wisconsin, Wauwatosa, WI
| | - Michael T Meyer
- Medical College of Wisconsin and Children's Hospital of Wisconsin, Wauwatosa, WI
| | - Amy L Drendel
- Medical College of Wisconsin and Children's Hospital of Wisconsin, Wauwatosa, WI
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17
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Newgard CD, Lin A, Olson LM, Cook JNB, Gausche-Hill M, Kuppermann N, Goldhaber-Fiebert JD, Malveau S, Smith M, Dai M, Nathens AB, Glass NE, Jenkins PC, McConnell KJ, Remick KE, Hewes H, Mann NC. Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers. JAMA Pediatr 2021; 175:947-956. [PMID: 34096991 PMCID: PMC8185631 DOI: 10.1001/jamapediatrics.2021.1319] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/25/2021] [Indexed: 01/20/2023]
Abstract
Importance The National Pediatric Readiness Project is a US initiative to improve emergency department (ED) readiness to care for acutely ill and injured children. However, it is unclear whether high ED pediatric readiness is associated with improved survival in US trauma centers. Objective To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centers. Design, Setting, and Participants A retrospective cohort study of 832 EDs in US trauma centers in 50 states and the District of Columbia was conducted using data from January 1, 2012, through December 31, 2017. Injured children younger than 18 years who were admitted, transferred, or with injury-related death in a participating trauma center were included in the analysis. Subgroups included children with an Injury Severity Score (ISS) of 16 or above, indicating overall seriously injured (accounting for all injuries); any Abbreviated Injury Scale (AIS) score of 3 or above, indicating at least 1 serious injury; a head AIS score of 3 or above, indicating serious brain injury; and need for early use of critical resources. Exposures Emergency department pediatric readiness for the initial ED visit, measured through the weighted Pediatric Readiness Score (range, 0-100) from the 2013 National Pediatric Readiness Project ED pediatric readiness assessment. Main Outcomes and Measures In-hospital mortality, with a secondary composite outcome of in-hospital mortality or complication. For the primary measurement tools used, the possible range of the AIS is 0 to 6, with 3 or higher indicating a serious injury; the possible range of the ISS is 0 to 75, with 16 or higher indicating serious overall injury. The weighted Pediatric Readiness Score examines and scores 6 domains; in this study, the lowest quartile included scores of 29 to 62 and the highest quartile included scores of 93 to 100. Results There were 372 004 injured children (239 273 [64.3%] boys; median age, 10 years [interquartile range, 4-15 years]), including 5700 (1.5%) who died in-hospital and 5018 (1.3%) who developed in-hospital complications. Subgroups included 50 440 children (13.6%) with an ISS of 16 or higher, 124 507 (33.5%) with any AIS score of 3 or higher, 57 368 (15.4%) with a head AIS score of 3 or higher, and 32 671 (8.8%) requiring early use of critical resources. Compared with EDs in the lowest weighted Pediatric Readiness Score quartile, children cared for in the highest ED quartile had lower in-hospital mortality (adjusted odds ratio [aOR], 0.58; 95% CI, 0.45-0.75), but not fewer complications (aOR for the composite outcome 0.88; 95% CI, 0.74-1.04). These findings were consistent across subgroups, strata, and multiple sensitivity analyses. If all children cared for in the lowest-readiness quartiles (1-3) were treated in an ED in the highest quartile of readiness, an additional 126 lives (95% CI, 97-154 lives) might be saved each year in these trauma centers. Conclusions and Relevance In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centers that care for children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Lenora M. Olson
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | | | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care, and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - McKenna Smith
- Department of Biostatistics, The University of Utah School of Medicine, Salt Lake City
| | - Mengtao Dai
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - K. John McConnell
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Katherine E. Remick
- Departments of Pediatrics and Surgery, Dell Medical School, The University of Texas at Austin
| | - Hilary Hewes
- National Emergency Medical Services for Children Data Analysis Resource Center, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - N. Clay Mann
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
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Need for surgeon presence: Continuing to Re-Think pediatric trauma triage strategies. Am J Surg 2020; 221:19-20. [PMID: 33187629 DOI: 10.1016/j.amjsurg.2020.10.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/24/2022]
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So you need a surgeon? Need for surgeon presence as an alternative metric to predict outcomes and assess triage in the pediatric trauma population. J Pediatr Surg 2020; 55:2124-2127. [PMID: 31761456 PMCID: PMC9587694 DOI: 10.1016/j.jpedsurg.2019.10.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/04/2019] [Accepted: 10/10/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Injury Severity Score (ISS) is the primary metric by which triage has been evaluated in trauma activations. We compared ISS to a previously described set of criteria defined as Need for Surgical Presence (NSP). We hypothesize that NSP may serve as a way to augment ISS in predicting mortality and assessing triage in pediatric trauma patients. METHODS A total of 19,139 pediatric trauma patients in the 2016 National Trauma Quality Improvement Program Database (excluding transfers) had complete data for mortality, mode of transport, age, injury type, ISS, and NSP factors. NSP was defined as having one or more of the following: intubation, transfusion, operation for hemorrhage control/craniotomy, vasopressors, interventional radiology, spinal cord Injury, tube thoracostomy, emergency thoracotomy, intracranial pressure monitor, or pericardiocentesis. RESULTS Overall mortality was 1.3% and 96% of all patients suffered blunt injury. A total of 2787 (14.6%) patients had an NSP indicator compared to 2036 (10.8%) with an ISS ≥16. NSP was noninferior to ISS in predicting mortality with the AUC of 0.91 (95% CI 0.89-0.92) and 0.90 (95% CI 0.88-0.92) respectively. CONCLUSION NSP predicts mortality in pediatric trauma patients as well as ISS, and may compliment ISS. NSP status can be assigned shortly after patient arrival. Proper assessment of over and undertriage allows for optimal resource utilization by the medical facility and ultimately benefits the hospital, physician and patient. STUDY TYPE Retrospective national dataset study. LEVEL OF EVIDENCE Level II.
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Gandhi G, Claiborne MK, Gross T, Sussman BL, Davenport K, Ostlie D, Bulloch B. Predictive value of the shock index (SI) compared to the age-adjusted pediatric shock index (SIPA) for identifying children that needed the highest-level trauma activation based on the presence of consensus criteria. J Pediatr Surg 2020; 55:1761-1765. [PMID: 31676079 DOI: 10.1016/j.jpedsurg.2019.09.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/14/2019] [Accepted: 09/01/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In previous studies, SIPA was shown to be better than the SI in identifying children who have an elevated ISS, required transfusion, or were at a high risk of death. No comparison has been made to the consensus-based criteria that identify patients requiring the highest-level trauma activation. The objective of this study was to determine if the SIPA was more accurate than the SI in identifying children with increased need for trauma team activation as defined by the criterion standard definition, and secondly the sensitivity and specificity of the SI and SIPA. METHODS Retrospective review of prospectively collected trauma based data. Children aged 1-17 years admitted to a pediatric level 1 trauma center between 1/1/16 and 12/31/17 and met the prehospital criteria for level 1 or 2 trauma activation were included. We evaluated the ability of SI > 0.9 at ED presentation and elevated SIPA to predict need for trauma activation based on consensus criteria. SIPA cutoffs were > 1.22 (age 4-6), >1.0 (age 7-12), and > 0.9 (age 13-17). RESULTS Among 3378 children, 1486 (44%) had an elevated SI and 590 (18%) had an elevated SIPA. There were 160 (5%) patients who met at least one consensus criterion. Broadly, sensitivity and specificity analyses reveal poor sensitivity for both SI and SIPA (59.4% versus 43.1% respectively) measures but a moderate specificity for SIPA (83.8%). Both SI and SIPA have a poor PPV (6.4% versus 11.7%) but high NPV (96.6% versus 96.7%). Overall, SIPA has higher accuracy than SI in predicting consensus criteria 82% versus 57%). CONCLUSION SIPA is more accurate than the SI in identifying children who meet a consensus criterion defining the need for highest-level trauma activation. The low PPV and sensitivity suggest that SIPA alone, while somewhat less likely to lead to overtriage than SI is not ideal for ruling in the need for level one resources as defined by the consensus criteria. Prognosis study, retrospective. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Geet Gandhi
- Phoenix Children's Hospital, Department of Emergency Medicine.
| | | | - Toni Gross
- Children's Hospital, New Orleans, Department of Emergency Medicine.
| | | | | | - Daniel Ostlie
- Phoenix Children's Hospital, Department of Trauma & Surgery.
| | - Blake Bulloch
- Phoenix Children's Hospital, Department of Emergency Medicine.
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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]
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Factors that predict the need for early surgeon presence in the setting of pediatric trauma. J Pediatr Surg 2020; 55:698-701. [PMID: 31153589 PMCID: PMC9580838 DOI: 10.1016/j.jpedsurg.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/09/2019] [Accepted: 05/11/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Evidence based variables predicting the need for surgeon presence (NSP) on arrival of an injured child are limited. We sought to identify prehospital factors that best correlate with NSP and highest level of activation in pediatric trauma. A secondary analysis was also performed to determine whether injury severity score (ISS) was predictive of NSP in pediatric trauma. METHODS This was a retrospective, single institution study of injured patients age ≤ 16 years delivered from scene to our Pediatric Level I trauma center between January 2016 and June 2017. 526 patients had complete data available for analysis. NSP was previously described as the presence of any of these factors: intubation, transfusion, emergent operation with the trauma team/craniotomy with the neurosurgery team, vasopressors, interventional radiology, spinal cord Injury, chest tube, emergency department thoracotomy, intracranial pressure monitor, pericardiocentesis, or death in the trauma bay. Multivariable analysis was performed with covariates of interest including scene and ED arrival vitals and interventions. RESULTS Independent predictors of NSP and highest level of activation were GCS of ≤12 (OR 22.3), penetrating trauma (OR 5.4), and hypotension (age adjusted) (OR 10.2). We also found that ISS ≥ 16 was a poor indicator of NSP with a sensitivity of only 61%. CONCLUSION A validated model based on these variables may be useful in predicting NSP and highest level of activation prior to arrival of pediatric trauma patients. NSP may augment assessment of over and undertriage in pediatric trauma patients as compared to the ISS/Cribari system alone. Level of evidence Level III, retrospective cohort study.
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Waydhas C, Trentzsch H, Hardcastle TC, Jensen KO. Survey on worldwide trauma team activation requirement. Eur J Trauma Emerg Surg 2020; 47:1569-1580. [PMID: 32123951 PMCID: PMC8476357 DOI: 10.1007/s00068-020-01334-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/15/2020] [Indexed: 11/24/2022]
Abstract
Purpose Trauma team activation (TTA) is thought to be essential for advanced and specialized care of very severely injured patients. However, non-specific TTA criteria may result in overtriage that consumes valuable resources or endanger patients in need of TTA secondary to undertriage. Consequently, criterion standard definitions to calculate the accuracy of the various TTA protocols are required for research and quality assurance purposes. Recently, several groups suggested a list of conditions when a trauma team is considered to be essential in the initial care in the emergency room. The objective of the survey was to post hoc identify trauma-related conditions that are thought to require a specialized trauma team that may be widely accepted, independent from the country’s income level. Methods A set of questions was developed, centered around the level of agreement with the proposed post hoc criteria to define adequate trauma team activation. The participants gave feedback before they answered the survey to improve the quality of the questions. The finalized survey was conducted using an online tool and a word form. The income per capita of a country was rated according to the World Bank Country and Lending groups. Results The return rate was 76% with a total of 37 countries participating. The agreement with the proposed criteria to define post hoc correct requirements for trauma team activation was more than 75% for 12 of the 20 criteria. The rate of disagreement was low and varied between zero and 13%. The level of agreement was independent from the country’s level of income. Conclusions The agreement on criteria to post hoc define correct requirements for trauma team activation appears high and it may be concluded that the proposed criteria could be useful for most countries, independent from their level of income. Nevertheless, more discussions on an international level appear to be warranted to achieve a full consensus to define a universal set of criteria that will allow for quality assessment of over- and undertriage of trauma team activation as well as for the validation of field triage criteria for the most severely injured patients worldwide. Electronic supplementary material The online version of this article (10.1007/s00068-020-01334-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Waydhas
- Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany. .,Medical Faculty of the University Duisburg-Essen, University Hospital, Hufelandstr. 55, 45147, Essen, Germany.
| | - Heiko Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum Der Universität München, Ludwig-Maximilians-Universität, Schillerstr. 53, 80336, Minich, Germany.,Committee On Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society, Berlin, Germany
| | - Timothy C Hardcastle
- Inkosi Albert Luthuli Central Hospital, Mayville and University of Kwa Zulu Natal, 800 Vusi Mzimela Rd, Congella, 4058, South Africa
| | - Kai Oliver Jensen
- Klinik für Traumatologie, UniversitätsSpital Zürich, Rämistrasse 100, 8091, Zurich, Switzerland
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Lerner EB, Badawy M, Cushman JT, Drendel AL, Fumo N, Jones CMC, Shah MN, Gourlay DM. Does Mechanism of Injury Predict Trauma Center Need for Children? PREHOSP EMERG CARE 2020; 25:95-102. [PMID: 32119577 DOI: 10.1080/10903127.2020.1737281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine if the Mechanism of Injury Criteria of the Field Triage Decision Scheme (FTDS) are accurate for identifying children who need the resources of a trauma center. METHODS EMS providers transporting any injured child ≤15 years, regardless of severity, to a pediatric trauma center in 3 midsized communities over 3 years were interviewed. Data collected through the interview included EMS observed physiologic condition, suspected anatomic injuries, and mechanism. Patients were then followed to determine if they needed the resources of a trauma center by reviewing their medical record after hospital discharge. Patients were considered to need a trauma center if they received an intervention included in a previously published consensus definition. Data were analyzed with descriptive statistics including positive likelihood ratios (+LR) and 95% confidence intervals (95%CI). RESULTS 9,483 provider interviews were conducted and linked to hospital outcome data. Of those, 230 (2.4%) met the consensus definition for needing a trauma center. 1,572 enrolled patients were excluded from further analysis because they met the Physiologic or Anatomic Criteria of the FTDS. Of the remaining 7,911 cases, 62 met the consensus definition for needing a trauma center (TC). Taken as a whole, the Mechanism of Injury Criteria of the FTDS identified 14 of the remaining 62 children who needed the resources of a trauma center for a 77% under-triage rate. The mechanisms sustained were 36% fall (16 needed TC), 28% motor vehicle crash (MVC) (20 needed TC), 7% struck by a vehicle (10 needed TC), <1% motorcycle crash (none needed TC), and 29% had a mechanism not included in the FTDS (16 needed TC). Of those who sustained a mechanisms not listed in the FTDS, the most common mechanisms were sport related injuries not including falls (24% of 2,283 cases with a mechanism not included) and assault (13%). Among those who fell from a height greater than 10 feet, 4 needed a TC (+LR 5.9; 95%CI 2.8-12.6). Among those in a MVC, 41 were reported to have been ejected and none needed a TC, while 31 had reported meeting the intrusion criteria and 0 needed a TC. There were 32 reported as having a death in the same vehicle, and 2 needed a TC (+LR 7.42; 95%CI: 1.90-29.0). CONCLUSION Over a quarter of the children who needed the resources of a trauma center were not identified using the Physiologic or Anatomic Criteria of the Field Triage Decision Scheme. The Mechanism of Injury Criteria did not apply to over a quarter of the mechanisms experienced by children transported by EMS for injury. Use of the Mechanism Criteria did not greatly enhance identification of children who need a trauma center. More work is needed to improve the tool used to assist EMS providers in the identification of children who need the resources of a trauma center.
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Gandhi G, Claiborne MK, Gross T, Sussman BL, Davenport K, Bulloch B. Comparison of Prehospital Calculated Age-Adjusted Pediatric Shock Index (SIPA) to Those Calculated in the ED for Identifying Trauma Patients That Needed the Highest-Level Activation Based on Consensus Criteria. PREHOSP EMERG CARE 2020; 24:778-782. [PMID: 31961754 DOI: 10.1080/10903127.2020.1718812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: The shock index (SI) is defined as the ratio of the heart rate to systolic blood pressure and a pediatric age-adjusted SI (SIPA) is more specific than the standard adult cutoff of 0.9 in identifying the sickest children presenting to a trauma center.Goal: To utilize prehospital vital signs to calculate the SIPA score and compare them to the SIPA calculated in the trauma bay to determine if they have the same validity in identifying critically ill children as determined by the consensus based standard criteria for trauma activation.Methods: Retrospective study using a cohort of patients transferred by EMS to a free standing, urban, level one, pediatric trauma center aged 1 to 16 years inclusive, and seen between January 1, 2016 and December 31, 2017. Vital signs collected during the patch call from the EMS agency were used to calculate the EMS SIPA. The first set of vital signs collected in the trauma bay was used to calculate the ED SIPA. Patients were dichotomized to an elevated or non-elevated ED SIPA and an elevated or non-elevated EMS SIPA.Results: Our cohort consisted of 2651 patients. 546 (20.6%) patients had an elevated EMS SIPA and 438 (16.5%) had an elevated ED SIPA. When compared to their non-elevated counterparts, EMS and ED SIPA were both able to identify patients who met consensus criteria in all areas except the need for IR intervention, and unstable spinal fracture/spinal cord injury. For these criteria, the ED SIPA was better than the EMS SIPA. Sensitivity and specificity analysis reveal poor sensitivity for both measures but a high specificity for ED and EMS SIPA. Both SI and SIPA have a poor PPV but high NPV.Conclusions: This study utilized prehospital vital signs to calculate the SIPA score and compare them to the SIPA calculated in the trauma bay. Both scores had similar test metrics when based on the consensus based standard trauma criteria and could be utilized in the triage traumatic injuries.
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Nordin A, Shi J, Wheeler K, Xiang H, Kenney B. Age-adjusted shock index: From injury to arrival. J Pediatr Surg 2019; 54:984-988. [PMID: 30952455 DOI: 10.1016/j.jpedsurg.2019.01.049] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 01/27/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Studies have demonstrated the superiority of the shock index, pediatric age-adjusted (SIPA) in predicting outcomes in pediatric blunt trauma patients. However, all have utilized SIPA calculated on emergency department (ED) arrival. We sought to evaluate the utility of SIPA at the trauma scene and describe changes in SIPA from the trauma scene to the ED. METHODS We used 2014-2016 Trauma Quality Improvement Program Data to identify blunt trauma patients 1-15 years old with an injury severity score (ISS) > 15. We calculated SIPA using vitals obtained at the trauma scene and on ED arrival. Outcome measures included ISS, transfusion within 24 h, intensive care unit (ICU), hospital length of stay (LOS), ventilator days, and mortality. RESULTS We identified 2917 patients, and 34.2% had a persistently elevated SI from the injury scene to ED arrival, whereas 17.9% had a persistently elevated SIPA. An elevated SIPA at the trauma scene was more predictive of greater ISS, LOS, and ventilator requirements. Furthermore, a SIPA that remained abnormal was associated with greater ISS, LOS, ICU admission, mechanical ventilation, and mortality. CONCLUSIONS Prehospital SIPA values predict worse outcomes in pediatric trauma patients, and their change over time may have greater predictive utility than a single value alone. LEVEL OF EVIDENCE II TYPE OF STUDY: Prognosis Study.
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Affiliation(s)
- Andrew Nordin
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; State University of New York University at Buffalo, Department of General Surgery, Buffalo, NY
| | - Junxin Shi
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Krista Wheeler
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Henry Xiang
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | - Brian Kenney
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH.
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Abstract
OBJECTIVES Hospital trauma activation criteria are intended to identify children who are likely to require aggressive resuscitation or specific surgical interventions that are time sensitive and require the resources of a trauma team at the bedside. Evidence to support criteria is limited, and no prior publication has provided historical or current perspectives on hospital practices toward informing best practice. This study aimed to describe the published variation in (1) highest level of hospital trauma team activation criteria for pediatric patients and (2) hospital trauma team membership and (3) compare these finding to the current ACS recommendations. METHODS Using an Ovid MEDLINE In-Process & Other Non-Indexed Citations search, any published description of hospital trauma team activation criteria for children that used information captured in the prehospital setting was identified. Only studies of children were included. If the study included both adults and children, it was included if the number of children assessed with the criteria was included. RESULTS Eighteen studies spanning 20 years and 13,184 children were included. Hospital trauma team activation and trauma team membership were variable. Nearly all (92%) of the trauma criteria used physiologic factors. Penetrating trauma (83%) was frequently included in the trauma team activation criteria. Mechanisms of injury (52%) were least likely to be included in the highest level of activation. No predictable pattern of criterion adoption was found. Only 2 of the published criteria and 1 of published trauma team membership are consistent with the current American College of Surgeons recommendations. CONCLUSIONS Published hospital trauma team activation criteria and trauma team membership for children were variable. Future prospective studies are needed to define the optimal hospital trauma team activation criteria and trauma team membership and assess its impact on improving outcomes for children.
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Studnek JR, Lerner EB, Shah MI, Browne LR, Brousseau DC, Cushman JT, Dayan PS, Drayna PC, Drendel AL, Gray MP, Kahn CA, Meyer MT, Shah MN, Stanley RM. Consensus-based Criterion Standard for the Identification of Pediatric Patients Who Need Emergency Medical Services Transport to a Hospital with Higher-level Pediatric Resources. Acad Emerg Med 2018; 25:1409-1414. [PMID: 30281884 DOI: 10.1111/acem.13625] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/24/2018] [Accepted: 09/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Emergency medical services (EMS) providers must be able to identify the most appropriate destination facility when treating children with potentially severe medical illnesses. Currently, no validated tool exists to assist EMS providers in identifying children who need transport to a hospital with higher-level pediatric care. For such a tool to be developed, a criterion standard needs to be defined that identifies children who received higher-level pediatric medical care. OBJECTIVE The objective was to develop a consensus-based criterion standard for children with a medical complaint who need a hospital with higher-level pediatric resources. METHODS Eleven local and national experts in EMS, emergency medicine (EM), and pediatric EM were recruited. Initial discussions identified themes for potential criteria. These themes were used to develop specific criteria that were included in a modified Delphi survey, which was electronically delivered. The criteria were refined iteratively based on participant responses. To be included, a criterion required at least 80% agreement among participants. If an item had less than 50% agreement, it was removed. A criterion with 50% to 79% agreement was modified based on participant suggestions and included on the next survey, along with any new suggested criteria. Voting continued until no new criteria were suggested and all criteria received at least 80% agreement. RESULTS All 11 recruited experts participated in all seven voting rounds. After the seventh vote, there was agreement on each item and no new criteria were suggested. The recommended criterion standard included 13 items that apply to patients 14 years old or younger. They included IV antibiotics for suspicion of sepsis or a seizure treated with two different classes of anticonvulsive medications within 2 hours, airway management, blood product administration, cardiopulmonary resuscitation, electrical therapy, administration of specific IV/IO drugs or respiratory assistance within 4 hours, interventional radiology or surgery within 6 hours, intensive care unit admission, specific comorbid conditions with two or more abnormal vital signs, and technology-assisted children seen for device malfunction. CONCLUSION We developed a 13-item consensus-based criterion standard definition for identifying children with medical complaints who need the resources of a hospital equipped to provide higher-level pediatric services. This criterion standard will allow us to create a tool to improve pediatric patient care by assisting EMS providers in identifying the most appropriate destination facility for ill children.
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Affiliation(s)
| | | | | | | | | | | | - Peter S. Dayan
- Columbia University College of Physicians and Surgeons New York NY
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Abstract
BACKGROUND Trauma team activation (TTA) represents a considerable expenditure of trauma centre resources. It is mainly triggered by field triage criteria. The overall quality of the criteria may be evaluated based on the rate of over- and undertriage. However, there is no gold standard that defines which adult patients truly require a trauma team. The objective of this study was to develop consensus-based criteria defining the necessity for a trauma team. METHODS A consensus group was formed by trauma specialists experienced in emergency and trauma care with a specific interest in field triage and having previously participated in guideline development. A literature search was conducted to identify criteria that have already been used or suggested. The initial list of criteria was discussed in two Delphi round and two consensus conferences. The entire process of discussion and voting was highly standardized and extensively documented, resulting in a final list of criteria. RESULTS Initially 95 criteria were identified. This was subsequently reduced to 20 final criteria to appropriately indicate the requirement for attendance of a trauma team. The criteria address aspects related to injury severity, admission to an intensive care unit, death within 24 h, need for specified invasive procedures, need for surgical and/or interventional radiological procedures, and abnormal vital signs within a defined time period. CONCLUSIONS The selected criteria may be applied as a tool for research and quality control concerning TTA. However, future studies are necessary to further evaluate for possible redundancy in criteria that may allow for further reduction in criteria.
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Abstract
BACKGROUND Despite the presence of a tiered in-hospital trauma triage system for the past decade, trauma centers still struggle with a definitive list of highest level activation criteria. In 2002, the American College of Surgeons (ACS) mandated 6 criteria for highest level activation. However, it is unknown if pediatric trauma centers follow these criteria. The purpose of this study is to identify and categorize the highest level pediatric trauma criteria used by pediatric trauma centers in the United States. METHODS In collaboration with the ACS, we reviewed activation criteria for highest level trauma activation for all ACS-verified level I pediatric trauma centers in the United States. Criteria were sorted by 2 reviewers into categories of indicators used for activation: patient demographic, physiologic, anatomic, intervention/resource usage, mechanism, and other. RESULTS A total of 51 unique criteria for highest level trauma activation were identified from 54 (96%) of 56 level I pediatric trauma centers. Each center used between 1 and 29 criteria. A total of 42.6% of pediatric trauma centers followed all 6 criteria recommended by ACS. The most commonly omitted criterion was emergency physician discretion. The most common criteria not included in the ACS recommendations, but included in the highest level activation criteria, were amputation proximal to wrist or ankle (63%), and spinal cord injury/paralysis (63%). CONCLUSIONS There is wide variation in the criteria used for highest level trauma activation among pediatric trauma centers. Further research investigating individual or grouped criteria to determine the most sensitive and specific criteria are necessary for appropriate triage and resource usage.
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Genovesi AL, Edgerton EA, Ely M, Hewes H, Olson LM. Getting More Performance Out of Performance Measures: The Journey and Impact of the EMS for Children Program. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Enabling informed policymaking for chronic kidney disease with a registry: Initiatory steps in Iran and the path forward. HEALTH POLICY AND TECHNOLOGY 2018. [DOI: 10.1016/j.hlpt.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Brown JB, Gestring ML, Leeper CM, Sperry JL, Peitzman AB, Billiar TR, Gaines BA. The value of the injury severity score in pediatric trauma: Time for a new definition of severe injury? J Trauma Acute Care Surg 2017; 82:995-1001. [PMID: 28328674 DOI: 10.1097/ta.0000000000001440] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The Injury Severity Score (ISS) is the most commonly used injury scoring system in trauma research and benchmarking. An ISS greater than 15 conventionally defines severe injury; however, no studies evaluate whether ISS performs similarly between adults and children. Our objective was to evaluate ISS and Abbreviated Injury Scale (AIS) to predict mortality and define optimal thresholds of severe injury in pediatric trauma. METHODS Patients from the Pennsylvania trauma registry 2000-2013 were included. Children were defined as younger than 16 years. Logistic regression predicted mortality from ISS for children and adults. The optimal ISS cutoff for mortality that maximized diagnostic characteristics was determined in children. Regression also evaluated the association between mortality and maximum AIS in each body region, controlling for age, mechanism, and nonaccidental trauma. Analysis was performed in single and multisystem injuries. Sensitivity analyses with alternative outcomes were performed. RESULTS Included were 352,127 adults and 50,579 children. Children had similar predicted mortality at ISS of 25 as adults at ISS of 15 (5%). The optimal ISS cutoff in children was ISS greater than 25 and had a positive predictive value of 19% and negative predictive value of 99% compared to a positive predictive value of 7% and negative predictive value of 99% for ISS greater than 15 to predict mortality. In single-system-injured children, mortality was associated with head (odds ratio, 4.80; 95% confidence interval, 2.61-8.84; p < 0.01) and chest AIS (odds ratio, 3.55; 95% confidence interval, 1.81-6.97; p < 0.01), but not abdomen, face, neck, spine, or extremity AIS (p > 0.05). For multisystem injury, all body region AIS scores were associated with mortality except extremities. Sensitivity analysis demonstrated ISS greater than 23 to predict need for full trauma activation, and ISS greater than 26 to predict impaired functional independence were optimal thresholds. CONCLUSION An ISS greater than 25 may be a more appropriate definition of severe injury in children. Pattern of injury is important, as only head and chest injury drive mortality in single-system-injured children. These findings should be considered in benchmarking and performance improvement efforts. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Affiliation(s)
- Joshua B Brown
- From the Division of Trauma and General Surgery, Department of Surgery (J.B.B., C.M.L., J.L.S., A.B.P., T.R.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Acute Care Surgery, Department of Surgery (M.L.G.), University of Rochester Medical Center, Rochester, New York; Golisano Children's Hospital (M.L.G.), University of Rochester, Rochester, New York; and Division of Pediatric General and Thoracic Surgery, Department of Surgery (C.M.L., B.A.G.), Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level. J Trauma Acute Care Surg 2017; 81:445-52. [PMID: 27116410 DOI: 10.1097/ta.0000000000001085] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Trauma activation level is determined by prehospital criteria. The American College of Surgeons (ACS) recommends trauma activation criteria; however, their accuracy may be limited. Prehospital lactate has shown promise in predicting trauma center resource requirements. Our objective was to investigate the added value of incorporating prehospital lactate in an algorithm to designate trauma activation level. METHODS Air medical trauma patients undergoing prehospital lactate measurement were included. Algorithms using ACS activation criteria (ACS) and ACS activation criteria plus prehospital lactate (ACS+LAC) to designate trauma activation level were compared. Test characteristics and net reclassification improvement (NRI), which evaluates reclassification of patients among risk categories with additional predictive variables, were calculated. Algorithms were compared to predict trauma center need defined as more than 1 unit of blood in the emergency department; spinal cord injury; advanced airway; thoracotomy or pericardiocentesis; ICP monitoring; emergent operative or interventional radiology procedure; or death. RESULTS There were 6,347 patients included. Twenty-eight percent had trauma center need. The ACS+LAC algorithm upgraded 256 patients and downgraded 548 patients compared to the ACS algorithm. The ACS+LAC algorithm versus ACS algorithm had an NRI of 0.058 (95% confidence interval [CI], 0.044-0.071; p < 0.01), with an event NRI of -0.5% and nonevent NRI of 6.2%. When weighted to favor changes in undertriage, the ACS+LAC still had a favorable overall reclassification (weighted NRI, 0.041; 95% CI, 0.028-0.054; p = 0.01). The ACS+LAC algorithm increased positive predictive value, negative predictive value, and accuracy. Over-triage was reduced 7.2%, while undertriage only increased 0.7%. The area under the curve was significantly higher for the ACS+LAC algorithm (0.79 vs. 0.76; p < 0.01). CONCLUSIONS The ACS+LAC algorithm reclassified patients to more appropriate levels of trauma activation compared to the ACS algorithm. This overall benefit is achieved by significant reduction in overtriage relative to very small increase in undertriage. In the context of trauma team activation, this trade-off may be acceptable, especially in the current health care environment. LEVEL OF EVIDENCE Therapeutic/care management study, level III; prognostic/epidemiologic study, level III.
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Acker SN, Bredbeck B, Partrick DA, Kulungowski AM, Barnett CC, Bensard DD. Shock index, pediatric age-adjusted (SIPA) is more accurate than age-adjusted hypotension for trauma team activation. Surgery 2017; 161:803-807. [DOI: 10.1016/j.surg.2016.08.050] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/25/2016] [Accepted: 08/16/2016] [Indexed: 10/20/2022]
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Escobar MA, Morris CJ. Using a multidisciplinary and evidence-based approach to decrease undertriage and overtriage of pediatric trauma patients. J Pediatr Surg 2016; 51:1518-25. [PMID: 27157260 DOI: 10.1016/j.jpedsurg.2016.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 04/08/2016] [Accepted: 04/11/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The American College of Surgeons Committee on Trauma (ACS-COT) view over- and undertriage rates based on trauma team activation (TTA) criteria as surrogate markers for quality trauma patient care. Undertriage occurs when classifying patients as not needing a TTA when they do. Over-triage occurs when a TTA is unnecessarily activated. ACS-COT recommends undertriage <5% and overtriage 25-35%. We sought to improve the under-triage and over-triage rates at our Level II Pediatric Trauma Center by updating our outdated trauma team activation criteria in an evidence-based fashion to better identify severely injured children and improving adherance to following established trauma team activation criteria. METHODS This study was designed prospectively as a Process Improvement Patient Safety (PIPS) project in two phases. Data was obtained from our trauma registry. Prior to the initiation of Phase I, the TTA was modified using the best available evidence at the time. A Base Station report was modified to include elements of the TTA to be checked when EMS called prior to arrival to guide in activation. Phase I of the study (April 1-June 30, 2011) involved improving adherence to activating a trauma according to our newly revised TTA criteria. Phase II of the study (July 1, 2011-June 30, 2012) moved the trauma team activation responsibility primarily to nursing (collaborating with MDs) and including activation criteria regarding transfers-in from outside hospitals. Triage rates were calculated using the Cribari method: undertriage=patients with an ISS >15 for which a major or modified was not activated, and overtriage=patients with an ISS <16 for which a major was activated. RESULTS 2011 Q1 YTD data was used as a baseline comparison. Baseline undertriage was 15% and overtriage was 75%. Phase I demonstrated 90% use of the redesigned Base Station report reflecting the new TTA criteria and was validated by RN/MD signatures. This resulted in an undertriage rate of 10% (12/118) and an overtriage rate of 20% (1/5). During Phase II, there was 100% use of the newly redesigned Base Station report. Phase IIa (concluding the data collection for 2011) demonstrated an undertriage rate of 8.4% (19/226) and an overtriage rate of 38% (5/13). Data during Phase IIb indicated an undertriage rate of 4.7% (12/251 pts) and overtriage rate of 54% (7/13). During baseline phase of the study, 50% of major patients went to the OR from the ER. During Phase I all major activations required admission to the PICU (4) or the OR (1). Finally, during Q2 2012 (the last quarter of Phase II), 25% of majors went to OR (2/8), 50% to ICU (4/8), 12.5% to Med-Surg (1/8), and 12.5% to home (1/8). CONCLUSIONS Standardization of process resulted in improved, sustainable under-/overtriage rates. Undertriage rates dropped from 15% to 5% undertriage, the ACS-recommended standard. Appropriate triage appears to have correlated with appropriate utilization of resources.
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