Association Between Hospital Arrival Time and Avoidable Transfer in Pediatric Trauma

BACKGROUND

Avoidable transfers (AT) in pediatric trauma can increase strain on healthcare resources and families. We sought to identify characteristics of patients and their injuries that are associated with AT.

METHODS

A multicenter retrospective cross-sectional study of the regional Trauma Registry was conducted from 1/1/10-12/31/21 of children <18 years-old who experienced an interfacility transfer. AT was defined as receiving hospital length of stay (LOS) < 48 hrs without procedure or intervention performed. Patient demographics, mechanism of injury, and arrival time were analyzed with descriptive statistics. A multivariable logistic regression was performed to analyze demographic and clinical factors associated with AT.

RESULTS

We included 5438 trauma transfers, of which 2187 (40.2%) were AT. Patients experiencing AT had a median [IQR] age of 5 years [1-12] and most were male (67%) and Hispanic/Latino (46.3%). The odds of experiencing AT decreased as age increased and were less likely in females and Non-Hispanic Black children. Injuries from falls (ground level (OR = 2.48; 95%CI = 1.89-3.28) and >10 ft (OR = 3.20; 95%CI = 2.35-4.39)), sports/recreational activities (OR = 2.36; 95%CI = 1.78-3.16), MVCs (OR = 1.44; 95%CI = 1.05-1.98), and firearms (OR = 1.74; 95%CI = 1.15-2.62) were associated with an increased odds of AT. Time of arrival at the receiving facility in early hours (00:00-07:59) (OR = 1.48; 95%CI = 1.24-1.76) and evening hours (17:00-23:59) (OR = 1.75; 95%CI = 1.47-2.07) were associated with an increased odds of AT.

CONCLUSION

Younger patients, injuries from falls, sports/recreational activities, MVCs, and firearms as well as arrival time outside of standard work hours are more likely to result in AT. Knowing these results, we can begin working with our referral centers to improve communication and strengthen institutional transfer criteria for pediatric trauma patients. Further investigation will then be needed to determine if the changes implemented have influenced care and lowered rates of avoidable transfer.

LEVEL OF EVIDENCE

Level III.

Outcome of interhospital pediatric foreign body transfers

BACKGROUND

Children with foreign bodies are often transferred from general emergency departments (EDs) to children's hospitals for optimal management. Our objective was to describe the outcomes of interhospital pediatric foreign body transfers and examine factors associated with potentially avoidable transfers (PATs) in this cohort.

METHODS

We conducted a retrospective cohort study of children aged <18 years transferred to our hospital for the primary complaint of foreign body from January 1, 2020, to September 30, 2022. Data collected included demographics, diagnostic studies and interventions performed, and disposition. A transfer was considered a PAT if the patient was either discharged from the pediatric emergency department (PED), or from inpatient care within 24 h, did not require procedural sedation and any procedural intervention by a pediatric sub-specialist (other than a pediatric ED physician). Logistic regression analysis was performed to evaluate factors associated with PATs.

RESULTS

A total of 213 patients were analyzed based on eligibility criteria. The majority of patients were male (51.2%), pre-school age (59.2%), symptomatic (55.8%), and transferred from academic EDs (61%). Coins were the most common foreign bodies (30%), with the gastrointestinal tract (63.8%) being the most common location. Half of the non-respiratory and non-gastrointestinal foreign bodies were successfully removed in the PED. Over half (57.3%) of the patients were discharged from PED. Operative intervention was required in 82 (38.5%) patients, most commonly for coins (50%). 41.8% of transfers were deemed PATs. Presence of foreign body in the esophagus or respiratory tract (OR: 0.071, 95% CI: 0.025-0.200), symptoms at presentation (OR: 0.265, 95% CI: 0.130-0.542), magnet ingestions (OR: 0.208, 95% CI: 0.049-0.886) and transfers from community EDs (OR: 0.415, 95% CI: 0.194-0.885) were less likely associated with PATs. Button battery-related transfers were more likely associated with an avoidable transfer (OR: 6.681, 95% CI: 1.15-39.91).

CONCLUSIONS

PATs are relatively common among children transferred to a children's hospital for foreign bodies. Factors associated with PATs have been identified and may represent targets for interventions to avoid low value pediatric foreign body transfers.

Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature

BACKGROUND

Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed.

METHODS

A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020.

RESULTS

Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs.

CONCLUSIONS

An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.

Emergency Department Pediatric Readiness and Potentially Avoidable Transfers

OBJECTIVE

To determine the association between potentially avoidable transfers (PATs) and emergency department (ED) pediatric readiness scores and the score's associated components.

STUDY DESIGN

This cross-sectional study linked the 2012 National Pediatric Readiness Project assessment with individual encounter data from California's statewide ED and inpatient databases during the years 2011-2013. A probabilistic linkage, followed by deterministic heuristics, linked pretransfer, and post-transfer encounters. Applying previously published definitions, a transferred child was considered a PAT if they were discharged within 1 day from the ED or inpatient care and had no specialized procedures. Analyses were stratified by injured and noninjured children. We compared PATs with necessary transfers using mixed-effects logistic regression models with random intercepts for hospital and adjustment for patient and hospital covariates.

RESULTS

After linkage, there were 6765 injured children (27% PATs) and 18 836 noninjured children (14% PATs) who presented to 283 hospitals. In unadjusted analyses, a 10-point increase in pediatric readiness was associated with lower odds of PATs in both injured (OR 0.93, 95% CI 0.90-0.96) and noninjured children (OR 0.90, 95% CI 0.88-0.93). In adjusted analyses, a similar association was detected in injured patients (aOR 0.92, 95% CI 0.86-0.98) and was not detected in noninjured patients (aOR 0.94, 95% CI 0.88-1.00). Components associated with decreased PATs included having a nurse pediatric emergency care coordinator and a quality improvement plan.

CONCLUSIONS

Hospital ED pediatric readiness is associated with lower odds of a PAT. Certain pediatric readiness components are modifiable risk factors that EDs could target to reduce PATs.

An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System

BACKGROUND

We sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC.

MATERIALS AND METHODS

The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge.

RESULTS

A total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT.

CONCLUSIONS

POT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

The authors looked at all of the pediatric patients with a head injury who were transferred from other hospitals to their own over 12 years and tried to identify factors that would allow patients to stay closer to home at their local hospitals and not be transferred. Many patients with isolated, nondisplaced skull fractures or negative CT imaging likely could have avoided transfer. While hospitals should be cautious, this may help families stay closer to home.