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Ngo LC, Carroll HM, Massimilian SS, Garapaty N, Palladino K, Samuels SK, Lao OB, Parreco JP, Levene T. Optimizing Triage Practice in Pediatric Trauma: Lessons From Under-triage and Over-triage Rates and Risk Factors. Am Surg 2024; 90:1892-1895. [PMID: 38532308 DOI: 10.1177/00031348241241693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
BACKGROUND Triage accuracy is essential for delivering effective trauma care, especially in the pediatric population where unique challenges exist. The purpose of this study was to investigate risk factors contributing to under-triage and over-triage in an urban pediatric trauma center. METHODS This retrospective cohort study included all trauma activations at an urban level 1 trauma center between January 1, 2021, and July 31, 2023 (patients <18 years old.) Patients who were under- or over-triaged were identified based on the level of trauma activation and injury severity score. RESULTS There were 1094 trauma activations included in this study. The rate of under-triage was 3.8% (n = 42) and over-triage was 13.6% (n = 149). Infants aged 0-1 years had the highest rate of under-triage (10.9%, n = 19, P < .001), while those aged 11-17 had the highest rate of over-triage (17.0%, n = 82, P = .003). Non-accidental trauma was the strongest risk factor for under-triage (OR 30.2 [6.4-142.8] P < .001). Penetrating mechanism was the strongest risk factor for over-triage (OR 12.2 [5.6-26.2] P < .001). DISCUSSION This study reveals the complexity of trauma triage in the pediatric population. We identified key predictive factors, such as age, comorbidities, and mechanism of injury, that can be used to refine triage practices and improve the care of pediatric trauma patients.
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Affiliation(s)
- Lisa C Ngo
- Memorial Regional Hospital, Hollywood, FL, USA
| | | | | | - Nikitha Garapaty
- Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | | | - Shenae K Samuels
- Memorial Healthcare System Office of Human Research, Hollywood, FL, USA
| | - Oliver B Lao
- Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | | | - Tamar Levene
- Joe DiMaggio Children's Hospital, Hollywood, FL, USA
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Ramgopal S. Using Outcome-Based Vital Sign Ranges can Enhance the Identification of Major Trauma in Children. J Pediatr Surg 2024; 59:1230-1231. [PMID: 38508970 DOI: 10.1016/j.jpedsurg.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Box 62 Chicago 60611, IL, USA.
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Khavandegar A, Salamati P, Zafarghandi M, Rahimi-Movaghar V, Sharif-Alhoseini M, Fakharian E, Saeed-Banadaky SH, Hoseinpour V, Sadeghian F, Nasr Isfahani M, Rahmanian V, Ghadiphasha A, Pourmasjedi S, Piri SM, Mirzamohamadi S, Hassan Zadeh Tabatabaei MS, Naghdi K, Baigi V. Comparison of nine trauma scoring systems in prediction of inhospital outcomes of pediatric trauma patients: a multicenter study. Sci Rep 2024; 14:7646. [PMID: 38561381 PMCID: PMC10985103 DOI: 10.1038/s41598-024-58373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024] Open
Abstract
Hereby, we aimed to comprehensively compare different scoring systems for pediatric trauma and their ability to predict in-hospital mortality and intensive care unit (ICU) admission. The current registry-based multicenter study encompassed a comprehensive dataset of 6709 pediatric trauma patients aged ≤ 18 years from July 2016 to September 2023. To ascertain the predictive efficacy of the scoring systems, the area under the receiver operating characteristic curve (AUC) was calculated. A total of 720 individuals (10.7%) required admission to the ICU. The mortality rate was 1.1% (n = 72). The most predictive scoring system for in-hospital mortality was the adjusted trauma and injury severity score (aTRISS) (AUC = 0.982), followed by trauma and injury severity score (TRISS) (AUC = 0.980), new trauma and injury severity score (NTRISS) (AUC = 0.972), Glasgow coma scale (GCS) (AUC = 0.9546), revised trauma score (RTS) (AUC = 0.944), pre-hospital index (PHI) (AUC = 0.936), injury severity score (ISS) (AUC = 0.901), new injury severity score (NISS) (AUC = 0.900), and abbreviated injury scale (AIS) (AUC = 0.734). Given the predictive performance of the scoring systems for ICU admission, NTRISS had the highest predictive performance (AUC = 0.837), followed by aTRISS (AUC = 0.836), TRISS (AUC = 0.823), ISS (AUC = 0.807), NISS (AUC = 0.805), GCS (AUC = 0.735), RTS (AUC = 0.698), PHI (AUC = 0.662), and AIS (AUC = 0.651). In the present study, we concluded the superiority of the TRISS and its two derived counterparts, aTRISS and NTRISS, compared to other scoring systems, to efficiently discerning individuals who possess a heightened susceptibility to unfavorable consequences. The significance of these findings underscores the necessity of incorporating these metrics into the realm of clinical practice.
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Affiliation(s)
- Armin Khavandegar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Salamati
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Sharif-Alhoseini
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Esmaeil Fakharian
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Seyed Houssein Saeed-Banadaky
- Trauma Research Center, Rahnemoon Hospital, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Vahid Hoseinpour
- Department of Emergency Medicine, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Farideh Sadeghian
- Center for Health-Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Mehdi Nasr Isfahani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Trauma Data Registration Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Rahmanian
- Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Amir Ghadiphasha
- Shahid Modarres Hospital, Saveh University of Medical Sciences, Saveh, Iran
| | - Sobhan Pourmasjedi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Mirzamohamadi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Khatereh Naghdi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vali Baigi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Science, Tehran, Iran.
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Ladha P, Curry CW, Badrinathan A, Imbroane MR, Bhamre RV, Como JJ, Tseng ES, Ho VP. Pediatric Trauma Care Disparities: Association of Race and Sex With High Acuity Trauma Hospital Admissions. J Surg Res 2024; 296:751-758. [PMID: 38377701 DOI: 10.1016/j.jss.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 02/22/2024]
Abstract
INTRODUCTION For adult trauma patients, the likelihood of receiving treatment at a hospital properly equipped for trauma care can vary by race and sex. This study examines whether a pediatric patient's race/ethnicity and sex are associated with treatment at a high acuity trauma hospital (HATH). MATERIALS AND METHODS Using the 2017 National Inpatient Sample, we identified pediatric trauma patients ( ≤16 y) using International Classification of Diseases-10 codes. Because trauma centers are not defined in National Inpatient Sample, we defined HATHs as hospitals which transferred 0% of pediatric neurotrauma. We used logistic regression to examine associations between race/ethnicity, sex, age, and treatment at a HATH, adjusted for factors including Injury Severity Score, mechanism of injury, and region. RESULTS Of 18,085 injured children (median Injury Severity Score 3 [IQR 1-8]), 67% were admitted to a HATH. Compared to White patients, Hispanic (odds ratio [OR] 0.85 [95% confidence interval [CI] 0.79-0.93]) and other race/ethnicity patients (OR 0.85 [95% CI 0.78-0.93]) had a significantly lower odds of treatment at a HATH. Children aged 2-11 (OR 1.36 [95% CI 1.27-1.46]) were more likely to be treated at a HATH compared to adolescents (age 12-16). After adjustment for other factors, sex was not associated with treatment at a HATH. CONCLUSIONS Our study demonstrated racial and ethnic disparities in access to HATHs for pediatric trauma patients. Hispanic and other race/ethnicity pediatric trauma patients have lower odds of treatment at HATHs. Further research is needed to study the root causes of these disparities to ensure that all children with injuries receive equitable and high-quality care.
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Affiliation(s)
- Prerna Ladha
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio.
| | - Caleb W Curry
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Marisa R Imbroane
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Rasika V Bhamre
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio
| | - John J Como
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Esther S Tseng
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
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Alsuwais S, Alqurashi N, Body R, Carley S. Interobserver reliability and diagnostic accuracy of prehospital triage for identifying traumatic brain injury in paediatric patients: a systematic review. Childs Nerv Syst 2024; 40:813-821. [PMID: 37851125 PMCID: PMC10891189 DOI: 10.1007/s00381-023-06144-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/31/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE The consistency and accuracy of paediatric TBI triage tools can be affected by different factors, such as patients' characteristics and the level of knowledge and skill of the caregiver. This systematic review included all the available data on the level of agreement between paramedics and ED physicians about the reliability of tools to identify paediatric TBI and the diagnostic accuracy of several such tools in prehospital settings when used by paramedics. METHODS MEDLINE (OVID), EMBASE (OVID), Cochrane Library (OVID), and CINAHL Plus (EBSCO) databases were searched from inception to 27 October 2022. Quality, bias, and applicability were assessed using COSMIN for interobserver reliability studies and QUADAS-2 tool for diagnostic accuracy studies. Narrative synthesis was employed because data were unsuitable for meta-analysis. RESULTS Initial searches identified 660 papers in total. Five met the inclusion criteria. Two studies showed moderate agreement between paramedics and ED physicians for GCS assessment. The PTS overtriage rate was 10% and the undertriage rate was 62%, while the triage tape had an overtriage rate of 18% and an undertriage rate of 68%. Pre-hospital GCS had 86.67% sensitivity and 71.43% specificity [95% CI]: 0.74-0.96 for neurosurgically significant TBI. CONCLUSION Low level of GCS agreement and poor diagnostic accuracy may cause further harm to the patient; thus, further studies are recommended to improve the prehospital management of children with head injuries.
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Affiliation(s)
- Sara Alsuwais
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.
- Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud bin Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Naif Alqurashi
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Simon Carley
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
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Gorski JK, Chaudhari PP, Spurrier RG, Goldstein SD, Zeineddin S, Martin-Gill C, Sepanski RJ, Stey AM, Ramgopal S. Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma. JAMA Netw Open 2024; 7:e2356472. [PMID: 38363566 PMCID: PMC10873773 DOI: 10.1001/jamanetworkopen.2023.56472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/26/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments. Objective To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children. Design, Setting, and Participants This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023. Exposure Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP). Main Outcome and Measures Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset. Results A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample. Conclusions and Relevance These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.
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Affiliation(s)
- Jillian K. Gorski
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Seth D. Goldstein
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Suhail Zeineddin
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert J. Sepanski
- Department of Quality and Safety, Children’s Hospital of The King’s Daughters, Norfolk, Virginia
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk
| | - Anne M. Stey
- Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Scaife JH, Bryce JR, Iantorno SE, Yang M, McCrum ML, Bucher BT. Secondary Undertriage of Pediatric Trauma Patients Across the United States Emergency Departments. J Surg Res 2024; 293:37-45. [PMID: 37703702 DOI: 10.1016/j.jss.2023.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/28/2023] [Accepted: 07/24/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION The American College of Surgeons has developed evidence-based guidelines to triage the care of severely injured children to Level 1 and 2 trauma centers. Undertriage is the treatment of patients at facilities not equipped to treat the patient's injuries appropriately. We sought to evaluate the association between patient and hospital characteristics and secondary undertriage in children after major trauma. METHODS We performed a retrospective cohort study using the 2019 Nationwide Emergency Department Sample. Patients aged less than 18 y were included if they presented to a Level 3 or nontrauma center (NTC) and were diagnosed with a traumatic injury with an injury severity score >15 based on International Classification of Diseases 10 codes. Our primary outcome was secondary undertriage, defined as inpatient admission to a Level 3 or NTC. We developed generalized linear models with inverse-probability survey weighting to determine the association between patient and hospital characteristics and the primary outcome. RESULTS Of 6572 weighted patients, 982 (15%) were undertriaged. Undertriage was significantly associated with older age (13 versus 7, P value < 0.001), metropolitan location (86% versus 68%, P < 0.001), and major abdominal injuries (19% versus 11%, P = 0.011). After multivariable adjustment, secondary undertriage was significantly associated with patients aged 6-10 y (adjusted odds ratio [aOR]: 2.47, P = 0.002) compared to patients aged 15-17 y, penetrating injury (aOR: 1.70, P = 0.011), major chest injury (aOR: 2.10, P = 0.014), and presentation at a teaching hospital (aOR: 5.66, P < 0.001). CONCLUSIONS After major trauma, a significant proportion of children are secondarily undertriaged at teaching NTCs. Level 1 and 2 trauma centers must partner with lower-level trauma centers to ensure children receive equitable care.
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Affiliation(s)
- Jack H Scaife
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Jacoby R Bryce
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stephanie E Iantorno
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Meng Yang
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Marta L McCrum
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Brian T Bucher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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Horne EF, Thornton SW, Leraas HJ, O'Brian R, Greenwald E, Tracy ET. Use of pediatric trauma simulations to facilitate exposure to pediatric trauma resuscitations during training. Surgery 2023; 174:1334-1339. [PMID: 37748976 DOI: 10.1016/j.surg.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/22/2023] [Accepted: 08/08/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Pediatric traumas are often high-acuity but are low-frequency compared to adult trauma activations. This is reflected in the relatively limited experience with these events during training. Although some principles of trauma resuscitation are similar between adults and children, there are also important differences in physiology, injury patterns, and presentation. Therefore, simulation can be used to supplement trainee exposure and enhance their ability to respond to these high-stakes events. METHODS We developed a multidisciplinary pediatric trauma resuscitation simulation curriculum to increase exposure to pediatric traumas at our institution. The intervention includes monthly sessions in the pediatric resuscitation bays, during which multidisciplinary teams complete 2 full pediatric trauma resuscitation simulations. This is supplemented with formal debriefing, simulation-specific teaching, and standardized trauma cognitive aids. The comprehensiveness of trauma evaluations and resuscitation efforts are evaluated using our institutional structured trauma resuscitation observation tool, and post-simulation surveys are used to assess the impact of the teaching interventions. RESULTS Nine simulation sessions were conducted with more than 100 participants, including surgical residents, emergency medicine residents, nursing staff, respiratory therapists, and medical students. Completeness of resuscitation efforts improved from 55% to 82% (P < .01) between initial and repeat simulations. Surveyed participants reported improvement in overall team performance on the Team Emergency Assessment Measure (P < .01). CONCLUSION Implementing a multidisciplinary pediatric trauma simulation curriculum with structured teaching interventions and standardized trauma scripts promotes teamwork and strengthens trainees' ability to conduct comprehensive evaluations required for high-acuity pediatric traumas.
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Affiliation(s)
| | | | - Harold J Leraas
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Rachel O'Brian
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Emily Greenwald
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Elisabeth T Tracy
- Division Pediatric General Surgery, Department of Surgery, Duke University, Durham, NC
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Thornton SW, Leraas HJ, Horne E, Cerullo M, Chang D, Greenwald E, Agarwal S, Haines KL, Tracy ET. A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study. J Surg Res 2023; 291:633-639. [PMID: 37542778 DOI: 10.1016/j.jss.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 07/01/2023] [Accepted: 07/06/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Most injured children receive trauma care outside of a pediatric trauma center. Differences in physiology, dosing, and injury pattern limit extrapolation of adult trauma principles to pediatrics. We compare US trauma center experience with pediatric and adult trauma resuscitation. MATERIALS AND METHODS We queried the 2019 Trauma Quality Improvement Program to describe the experience of US trauma centers with pediatric (<15 y) and adult trauma. We quantified blunt, penetrating, burn, and unspecified traumas and compared minor, moderate, severe, and critical traumas (ISS 1-8 Minor, ISS 9-14 Moderate, ISS 15-24 Severe, ISS 25+ Critical). We estimated center-level volumes for adults and children. Institutional identifiers were generated based on unique center specific factors including hospital teaching status, hospital type, verification level, pediatric verification level, state designation, state pediatric designation, and bed size. RESULTS A total of 755,420 adult and 76,449 pediatric patients were treated for traumatic injuries. There were 21 times as many critical or major injuries in adults compared to children, 17 times more moderate injuries, and 6 times more minor injuries. Children and adults presented with similar rates of blunt trauma, but penetrating injuries were more common in adults and burn injuries were more common in children. Comparing center-level data, adult trauma exceeded pediatric for every severity and mechanism. CONCLUSIONS There is relatively limited exposure to high-acuity pediatric trauma at US centers. Investigation into pediatric trauma resuscitation education and simulation may promote pediatric readiness and lead to improved outcomes.
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Affiliation(s)
- Steven W Thornton
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Harold J Leraas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Marcelo Cerullo
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Doreen Chang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Emily Greenwald
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Krista L Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Elisabeth T Tracy
- Division Pediatric General Surgery, Department of Surgery, Duke University, Durham, North Carolina
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Reppucci ML, Cooper E, Nolan MM, Lyttle BD, Gallagher LT, Jujare S, Stevens J, Moulton SL, Bensard DD, Acker SN. Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care. J Trauma Acute Care Surg 2023; 95:347-353. [PMID: 36899455 DOI: 10.1097/ta.0000000000003903] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
BACKGROUND Appropriate prehospital trauma triage ensures transport of children to facilities that provide specialized trauma care. There are currently no objective and generalizable scoring tool for emergency medical services to facilitate such decisions. An abnormal reverse shock index times Glasgow Coma Scale (rSIG), which is calculated using readily available parameters, has been shown to be associated with severely injured children. This study sought to determine if rSIG could be used in the prehospital setting to identify injured children who require the highest levels of care. METHODS Patients (1-18 years old) transferred from the scene to a level 1 pediatric trauma center from 2010 to 2020 with complete prehospital and emergency department vital signs, and Glasgow Coma Scale (GCS) scores were included. Reverse shock index times GCS was calculated as previously described ((systolic blood pressure/heart rate) × GCS), and the following cutoffs were used: ≤13.1, ≤16.5, and ≤20.1 for 1- to 6-, 7- to 12-, and 13- to 18-year-old patients, respectively. Trauma activation level and clinical outcomes upon arrival to the pediatric trauma center were collected. RESULTS There were 247 patients included in the analysis; 66.0% (163) had an abnormal prehospital rSIG. Patients with an abnormal rSIG had a higher rate of highest-level trauma activation compared with those with a normal rSIG (38.7% vs. 20.2%, p = 0.013). Patients with an abnormal prehospital rSIG also had higher rates of intubation (28.8% vs. 9.52%, p < 0.001), intracranial pressure monitor (9.20 vs. 1.19%, p = 0.032), need for blood (19.6% vs. 8.33%, p = 0.034), laparotomy (7.98% vs. 1.19%, p = 0.039), and intensive care unit admission (54.6% vs. 40.5%, p = 0.049). CONCLUSION Reverse shock index times GCS may assist emergency medical service providers in early identification and triage of severely injured children. An abnormal rSIG in the emergency department is associated with higher rates of intubation, need for blood transfusion, intracranial pressure monitoring, laparotomy, and intensive care unit admission. Use of this metric may help to speed the identification, care, and treatment of any injured child. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Marina L Reppucci
- From the Department of Surgery (M.L.R.), The Mount Sinai Hospital, New York, New York; Children's Hospital Center for Research in Outcomes for Children's Surgery (E.C.), Children's Hospital Colorado, Aurora, Colorado; Pediatric Surgery (M.M.N., B.D.L., L.T.G., S.J., S.L.M., D.D.B., S.N.A.), Children's Hospital Colorado; Division of Pediatric Surgery, Department of Surgery (B.D.L., L.T.G., S.L.M., D.D.B., S.N.A.), University of Colorado School of Medicine, Aurora, Colorado; Department of Surgery (J.S.), Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Pediatric Surgery, Denver Health (D.D.B.), Denver, Colorado
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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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12
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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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Flynn-O’Brien KT, Collings AT, Farazi M, Fallat ME, Minneci PC, Speck KE, Van Arendonk K, Deans KJ, Falcone RA, Foley DS, Fraser JD, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St. Peter SD, Sato TT. Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted time Series Analysis. J Surg Res 2023; 281:130-142. [PMID: 36155270 PMCID: PMC9424522 DOI: 10.1016/j.jss.2022.08.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/07/2022] [Accepted: 08/21/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION With the expected surge of adult patients with COVID-19, the Children's Hospital Association recommended a tiered approach to divert children to pediatric centers. Our objective was understanding changes in interfacility transfer to Pediatric Trauma Centers (PTCs) during the first 6 mo of the pandemic. METHODS Children aged < 18 y injured between January 1, 2016 and September 30, 2020, who met National Trauma Databank inclusion criteria from 9 PTCs were included. An interrupted time-series analysis was used to estimate an expected number of transferred patients compared to observed volume. The "COVID" cohort was compared to a historical cohort (historical average [HA]), using an average across 2016-2019. Site-based differences in transfer volume, demographics, injury characteristics, and hospital-based outcomes were compared between cohorts. RESULTS Twenty seven thousand thirty one/47,382 injured patients (57.05%) were transferred to a participating PTC during the study period. Of the COVID cohort, 65.4% (4620/7067) were transferred, compared to 55.7% (3281/5888) of the HA (P < 0.001). There was a decrease in 15-y-old to 17-y-old patients (10.43% COVID versus 12.64% HA, P = 0.003). More patients in the COVID cohort had injury severity scores ≤ 15 (93.25% COVID versus 87.63% HA, P < 0.001). More patients were discharged home after transfer (31.80% COVID versus 21.83% HA, P < 0.001). CONCLUSIONS Transferred trauma patients to Level I PTC increased during the COVID-19 pandemic. The proportion of transferred patients discharged from emergency departments increased. Pediatric trauma transfers may be a surrogate for referring emergency department capacity and resources and a measure of pediatric trauma triage capability.
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Affiliation(s)
- Katherine T. Flynn-O’Brien
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Children's Wisconsin, Milwaukee, Wisconsin,Corresponding author. Children's Wisconsin Corporate Center, 999 N. 92nd Street, Ste 320, Milwaukee WI 53266. Tel.: +1 414 266 6557
| | | | - Manzur Farazi
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Children's Wisconsin, Milwaukee, Wisconsin
| | - Mary E. Fallat
- Norton Children's Hospital, Louisville, Kentucky,Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - K. Elizabeth Speck
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, Michigan
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Children's Wisconsin, Milwaukee, Wisconsin
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Richard A. Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S. Foley
- Norton Children's Hospital, Louisville, Kentucky,Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jason D. Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Samir Gadepalli
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, Michigan
| | - Martin S. Keller
- Division of Pediatric Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Charles M. Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Troy A. Markel
- Department of Surgery, Indiana University, Indianapolis, Indiana
| | - Nathan Rubalcava
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, Michigan
| | | | - Thomas T. Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Children's Wisconsin, Milwaukee, Wisconsin
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14
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Ohana Sarna Cahan L, Tin D, Markovic V, Ciottone RG, Issa F, Kane AED, Hart A, Weiner DL, Ciottone GR. Pediatric Casualties in Terrorist Attacks: A Semi-Quantitative Analysis of Global Events. Prehosp Disaster Med 2022; 38:1-6. [PMID: 36503695 DOI: 10.1017/s1049023x22002291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Terrorism remains a major threat and concern in many countries around the world. Pediatric populations represent approximately 30% of the world population, and in the event of a terrorist attack, can either be primary targets, to include the possibility of abduction, or unintended victims. They are unique in their vulnerabilities and, therefore, require special consideration. METHODS This study is a semi-quantitative, epidemiological analysis of all terrorism-related pediatric fatalities and injuries sustained from 1970-2019. Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). Summaries of events including search terms associated with pediatric population were individually reviewed and those describing the deaths, injuries, or abductions were tallied. RESULTS Of the over 200,000 terror events, 2,302 events met inclusion criteria. This represented 1.14% of total events which involved death, injury, or abduction. Of 2,032 events, a total of 2,275 pediatric fatal injuries (FI) were recorded, as well as 2,280 pediatric non-fatal injuries (NFI). The most common weapons used in all attacks involving the pediatric population were explosives (1,539 [66.8%]), firearms (543 [23.5%]), other (169 [7.3%]), and melee (83 [3.6%]). A total of 275 of the 2,032 events were related to abductions, with 71 cases involving the abduction of 10 individuals or more. CONCLUSION Pediatric casualties in terrorist events represent a small proportion of overall victims. However, it should be understood that the pediatric population has unique vulnerabilities, and when directly impacted by terrorism, can have long-term physical and psychosocial sequelae, as well as a devastating emotional impact on the community.
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Affiliation(s)
- Lea Ohana Sarna Cahan
- BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MassachusettsUSA
- Department of Pediatrics Emergency Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Derrick Tin
- BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MassachusettsUSA
| | - Vesna Markovic
- Professor, Justice, Law and Public Safety Studies, Lewis University, Romeoville, IllinoisUSA
| | | | - Fadi Issa
- BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MassachusettsUSA
| | - Ashley E D Kane
- BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MassachusettsUSA
| | - Alexander Hart
- BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MassachusettsUSA
| | - Debra L Weiner
- BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MassachusettsUSA
- Pediatric Emergency Medicine, Boston Children's Hospital, Boston, MassachusettsUSA
| | - Gregory R Ciottone
- BIDMC Disaster Medicine Fellowship, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MassachusettsUSA
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15
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Liu TT, Cheng CT, Hsu CP, Chaou CH, Ng CJ, Jeng MJ, Chang YC. Validation of a five-level triage system in pediatric trauma and the effectiveness of triage nurse modification: A multi-center cohort analysis. Front Med (Lausanne) 2022; 9:947501. [PMID: 36388924 PMCID: PMC9664936 DOI: 10.3389/fmed.2022.947501] [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: 05/18/2022] [Accepted: 09/27/2022] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Triage is one of the most important tasks for nurses in a modern emergency department (ED) and it plays a critical role in pediatric trauma. An appropriate triage system can improve patient outcomes and decrease resource wasting. However, triage systems for pediatric trauma have not been validated worldwide. To ensure clinical reliability, nurses are allowed to override the acuity level at the end of the routine triage process. This study aimed to validate the Taiwan Triage and Acuity Scale (TTAS) for pediatric trauma and evaluate the effectiveness of triage nurse modification. METHODS This was a multicenter retrospective cohort study analyzing triage data of all pediatric trauma patients who visited six EDs across Taiwan from 2015 to 2019. Each patient was triaged by a well-trained nurse and assigned an acuity level. Triage nurses can modify their acuity based on their professional judgment. The primary outcome was the predictive performance of TTAS for pediatric trauma, including hospitalization, ED length of stay, emergency surgery, and costs. The secondary outcome was the accuracy of nurse modification and the contributing factors. Multivariate regression was used for data analysis. The Akaike information criterion and C-statistics were utilized to measure the prediction performance of TTAS. RESULTS In total, 45,364 pediatric patients were included in this study. Overall mortality, hospitalization, and emergency surgery rates were 0.17, 5.4, and 0.76%, respectively. In almost all cases (97.48%), the triage nurses agreed upon the original scale. All major outcomes showed a significant positive correlation with the upgrade of acuity levels in TTAS in pediatric trauma patients. After nurse modification, the Akaike information criterion decreased and C-statistics increased, indicating better prediction performance. The factors contributing to this modification were being under 6 years of age, heart rate, respiratory rate, and primary location of injuries. CONCLUSION The TTAS is a reliable triage tool for pediatric trauma patients. Modification by well-experienced triage nurses can enhance its prediction performance. Younger age, heart rate, respiratory rate, and primary location of injuries contributed to modifications of the triage nurse. Further external validation is required to determine its role in pediatric trauma worldwide.
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Affiliation(s)
- Tien-Tien Liu
- Department of Nursing, Chang Gung Memorial Hospital, Taoyuan, Taiwan,Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Chi-Tung Cheng
- Division of Trauma and Emergency Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Po Hsu
- Division of Trauma and Emergency Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Hsien Chaou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan,Chang Gung Medical Education Research Centre (CG-MERC), Taoyuan, Taiwan,Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chip-Jin Ng
- Chang Gung Medical Education Research Centre (CG-MERC), Taoyuan, Taiwan,Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan,National Working Group of Taiwan Triage and Acuity Scale (TTAS), Taipei, Taiwan
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan,*Correspondence: Mei-Jy Jeng
| | - Yu-Che Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan,Chang Gung Medical Education Research Centre (CG-MERC), Taoyuan, Taiwan,Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan,National Working Group of Taiwan Triage and Acuity Scale (TTAS), Taipei, Taiwan,Yu-Che Chang
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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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17
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Taylor A, Foster NW, Ricca RL, Choi PM. Pediatric Surgical Care During Humanitarian and Disaster Relief Missions. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00237-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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18
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Remick KE, Bartley KA, Gonzales L, MacRae KS, Edgerton EA. Consensus-driven model to establish paediatric emergency care measures for low-volume emergency departments. BMJ Open Qual 2022; 11:bmjoq-2021-001803. [PMID: 35803615 PMCID: PMC9272131 DOI: 10.1136/bmjoq-2021-001803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/19/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Katherine E Remick
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Krystle A Bartley
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Louis Gonzales
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Kate S MacRae
- Gonzaga University College of Arts and Sciences, Spokane, Washington, USA
| | - Elizabeth A Edgerton
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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Berne C, Evain J, Bouzat P, Mortamet G. Organization of trauma management in French level-1 pediatric trauma centers: A cross-sectional survey. Arch Pediatr 2022; 29:326-329. [DOI: 10.1016/j.arcped.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/15/2021] [Accepted: 02/20/2022] [Indexed: 10/18/2022]
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Colbachini PCM, Marson FAL, Peixoto AO, Sarti L, Fraga AMA. Air Rescue for Pediatric Trauma in a Metropolitan Region of Brazil: Profiles, Outcomes, and Overtriage Rates. Front Pediatr 2022; 10:890405. [PMID: 35722501 PMCID: PMC9201391 DOI: 10.3389/fped.2022.890405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Besides ensuring a quick response and transport of trauma victims, helicopter support also involves risks to patients and professionals and has higher operational costs. Studying prehospital triage criteria and their relationship with patient overtriage and outcomes is important, particularly in newly established services and in developing countries with limited health budgets. This could help improve the use of the helicopter rescue and provide better management of the costs and risks related to it. The objective of this study was to determine the epidemiologic and severity profiles of pediatric victims of trauma attended by helicopter in a Brazilian Metropolitan Area to evaluate the outcomes and overtriage rates related to pediatric air rescue in the region. We conducted an observational and retrospective study using 49 hospital and prehospital records from victims of trauma aged <18 years old (yo) assisted by helicopter and then transferred to a tertiary University Hospital. Of the 49 patients, 39 (79.6%) individuals were male, and the mean age was 11.3 yo. Vehicular collisions accounted for 15 (30.6%) of the traumas, and traumatic brain injuries occurred in 28 (57.1%) cases. A total of 29 (59.1%) individuals had severe trauma (Injury Severity Score; ISS >15), and 34 (69.4%) required admission to the intensive care unit. Overtriage varied from 18.4 to 40.8% depending on the criteria used for its definition, being more frequent in individuals aged between 1 and 5 yo. Death occurred in 10 (20.4%) patients. On prehospital evaluation, we classified 29/32 (90.6%) patients with severe trauma according to the Pediatric Trauma Score (PTS ≤8) and 18/25 (72%) according to the Revised Trauma Score (RTS ≤11). Of these, 7/29 (24.1%) and 6/18 (33.3%), respectively, presented ISS <15 at in-hospital evaluation. None of the patients with PTS >8 and 3/7 (42.8%) of those with RTS >11 presented ISS >15. In conclusion, air rescue of pediatric trauma victims was used mainly for critically ill individuals, resulting in rates of overtriage compatible with that found in the literature. PTS showed the lowest rates of overtriage within excellent rates of undertriage.
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Affiliation(s)
- Paulo C M Colbachini
- Postgraduate Program in Child and Adolescent Health, Department of Pediatrics, University of Campinas, Campinas, Brazil
| | - Fernando A L Marson
- Postgraduate Program in Child and Adolescent Health, Department of Pediatrics, University of Campinas, Campinas, Brazil.,Laboratory of Medical Genetics and Human Genetics, Postgraduate Program in Health Sciences, Health Sciences Department, São Francisco University, Bragança Paulista, Brazil
| | - Andressa O Peixoto
- Postgraduate Program in Child and Adolescent Health, Department of Pediatrics, University of Campinas, Campinas, Brazil
| | - Luisa Sarti
- Faculty of Medical Sciences, Clinical Hospital of University of Campinas, University of Campinas, Campinas, Brazil
| | - Andrea M A Fraga
- Postgraduate Program in Child and Adolescent Health, Department of Pediatrics, University of Campinas, Campinas, Brazil
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21
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Ageron FX, Porteaud J, Evain JN, Millet A, Greze J, Vallot C, Levrat A, Mortamet G, Bouzat P. Effect of under triage on early mortality after major pediatric trauma: a registry-based propensity score matching analysis. World J Emerg Surg 2021; 16:1. [PMID: 33413465 PMCID: PMC7791780 DOI: 10.1186/s13017-020-00345-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/10/2020] [Indexed: 11/29/2022] Open
Abstract
Background Little is known about the effect of under triage on early mortality in trauma in a pediatric population. Our objective is to describe the effect of under triage on 24-h mortality after major pediatric trauma in a regional trauma system. Methods This cohort study was conducted from January 2009 to December 2017. Data were obtained from the registry of the Northern French Alps Trauma System. The network guidelines triage pediatric trauma patients according to an algorithm shared with adult patients. Under triage was defined by the number of pediatric trauma patients that required specialized trauma care transported to a non-level I pediatric trauma center on the total number of injured patients with critical resource use. The effect of under triage on 24-h mortality was assessed with inverse probability treatment weighting (IPTW) and a propensity score (Ps) matching analysis. Results A total of 1143 pediatric patients were included (mean [SD], age 10 [5] years), mainly after a blunt trauma (1130 [99%]). Of the children, 402 (35%) had an ISS higher than 15 and 547 (48%) required specialized trauma care. Nineteen (1.7%) patients died within 24 h. Under triage rate was 33% based on the need of specialized trauma care. Under triage of children requiring specialized trauma care increased the risk of death in IPTW (risk difference 6.0 [95% CI 1.3–10.7]) and Ps matching analyses (risk difference 3.1 [95% CI 0.8–5.4]). Conclusions In a regional inclusive trauma system, under triage increased the risk of early death after pediatric major trauma.
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Affiliation(s)
- François-Xavier Ageron
- RENAU Northern French Alps Emergency Network, Public Health Department, Annecy Hospital, F-74000, Annecy, France
| | - Jordan Porteaud
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, F-38000, Grenoble, France
| | - Jean-Noël Evain
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, F-38000, Grenoble, France
| | - Anne Millet
- Department of Pediatric Care, Pediatric Intensive Care Unit, Grenoble University Hospital, F-38000, Grenoble, France
| | - Jules Greze
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, F-38000, Grenoble, France
| | - Cécile Vallot
- RENAU Northern French Alps Emergency Network, Public Health Department, Annecy Hospital, F-74000, Annecy, France
| | - Albrice Levrat
- Department of Intensive Care, Annecy Hospital, F-74000, Annecy, France
| | - Guillaume Mortamet
- Department of Pediatric Care, Pediatric Intensive Care Unit, Grenoble University Hospital, F-38000, Grenoble, France.,Grenoble Alps University, F-38000, Grenoble, France
| | - Pierre Bouzat
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, F-38000, Grenoble, France. .,Grenoble Alps University, F-38000, Grenoble, France. .,Grenoble Alpes Trauma Centre, Pôle d'Anesthésie-Réanimation, Hôpital Albert Michallon, BP 217, F-38043, Grenoble, France.
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