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Zwank MD, McGonigal MD, Adams NR, Akindumila OC, Omwanda GK. Improving CT scanner efficiency for trauma team activations in the emergency department. Am J Emerg Med 2024; 75:87-89. [PMID: 37925757 DOI: 10.1016/j.ajem.2023.10.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/19/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES A Trauma Team Activation (TTA) is initiated when a patient has sustained a life or limb-threatening injury thereby necessitating resources of a large care team. Previously, a CT scanner was cleared at the time of the prehospital TTA call. Wide variability in the time it took to stabilize patients often led to extended CT scanner idle time. A new policy was developed whereby the team leader would prompt the ED clerk to provide a '5-min heads-up' (5-min HU) notification to the CT scanner personnel as a patient was stabilized. At this point, the CT scanner was cleared. The purpose of this quality improvement project is to evaluate if the new policy saves CT scanner idle time. METHODS Research interns prospectively followed incoming TTAs in the ED of a large, urban, Level I Trauma Center in November 2022. The interns collected the following time points: TTA notification page, 5-min HU notification, and arrival to CT. Data was analyzed using a non-parametric comparison test (Mann-Whitney U). RESULTS A convenience sample of 46 TTAs was included. Trauma was blunt (85%; n = 39)) and penetrating (15%; n = 7). The median initial TTA announcement to CT arrival time was 24.0 min (IQR: 9.0 min). Previously, the scanner would have been held for this entire period. The median time from 5-min HU notification to CT arrival was 5.0 min (IQR: 4.0 min). The new policy saved a median of 19 min of CT scanner idle time per patient compared to the old policy (p < 0.0001). The total CT scanner time saved was 818 min (13.6 h). CONCLUSION These data support the implementation of a 5-min HU policy in the ED for patients arriving as TTAs. This maximizes the availability of CT scanners for other patients in the ED while TTA patients are being stabilized.
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Affiliation(s)
- Michael D Zwank
- Emergency Medicine Department, Regions Hospital, 640 Jackson Street MS11102F, Saint Paul, MN 55101, United States of America.
| | - Michael D McGonigal
- Department of Surgery, Regions Hospital, 640 Jackson Street MS11102F, Saint Paul, MN 55101, United States of America.
| | - Nellie R Adams
- Critical Care Research Center, Regions Hospital, Saint Paul, MN, United States of America.
| | - Opeyemi C Akindumila
- Critical Care Research Center, Regions Hospital, Saint Paul, MN, United States of America.
| | - Gloriah K Omwanda
- Critical Care Research Center, Regions Hospital, Saint Paul, MN, United States of America
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Menchetti I, Muzzo M, Malo C, Ackery A, Nemeth J, Rao J, Engels PT, Vogt K, Razek T, Beckett A, da Luz L. Who are the trauma team leaders across Canada? A national survey evaluating the profession in adult and pediatric level one trauma centres. CAN J EMERG MED 2023; 25:959-967. [PMID: 37853308 DOI: 10.1007/s43678-023-00607-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES Trauma Team Leaders (TTLs) are critical for coordinating and leading trauma resuscitations. This survey sought to characterize the demographics and professional practices of Canadian TTLs at level one trauma centres. As a secondary objective, this information will be utilized to inform the operational goals of the Trauma Association of Canada (TAC) TTL Committee. METHODS A detailed survey, developed by the TAC board of directors and TTL committee leads, was sent to 225 TTLs across Canada's level one trauma centres. TTLs were identified via contacting trauma directors at each level one centre, in addition to public registry searches. This survey captured demographics, professional background, resuscitation practices, trauma team composition, and TTL involvement in trauma responses. RESULTS The response rate was 41.7%. Mean respondent age was 42 (SD 7.4) and 71.0% were male. Most TTLs trained in emergency medicine (53.1%) or general surgery (25.5%); 63.8% underwent TTL training: either via a trauma surgery fellowship or TTL fellowship. All centres have a massive hemorrhage protocol implemented, and there is no large variation between the rates of use of cryoprecipitate and fibrinogen, nor the ratio of blood products transfused (2:1 vs 1:1). Most TTL respondents intend to participate in a TTL group associated with TAC (85.1%). CONCLUSION The results of this survey will contribute to the recognition of TTLs as a crucial role in the initial phase of care of severely injured trauma patients and serves as the first publication to document professional backgrounds and practices of Canadian TTLs at level one trauma centres. All the information gathered via this survey will be used by the TAC TTL Committee, which will focus on several initiatives such as the dissemination of best practice guidelines and creation of a TTL stream at the TAC Annual Conference.
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Affiliation(s)
- Isabella Menchetti
- Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada.
| | - Madison Muzzo
- Department of Neuroscience, Northeastern University, Boston, MA, USA
| | - Christian Malo
- Department of Emergency Medicine, CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Alun Ackery
- Department of Emergency Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Joe Nemeth
- Department of Emergency Medicine, McGill University, Montreal, QC, Canada
| | - Jagadish Rao
- Department of Surgery, University of Saskatchewan, Regina, SK, Canada
| | - Paul T Engels
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kelly Vogt
- Department of Surgery, London Health Sciences Centre, London, ON, Canada
| | - Tarek Razek
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Andrew Beckett
- Department of General Surgery, St Michael's Hospital, Toronto, ON, Canada
| | - Luis da Luz
- Department of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Baker H, Erdman MK, Christiano A, Strelzow JA. Team Approach: The Unstable Trauma Patient. JBJS Rev 2023; 11:01874474-202306000-00001. [PMID: 37276267 DOI: 10.2106/jbjs.rvw.22.00226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
» A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.» The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries» Effective and open dialog with consulting specialists is paramount for effective team-based care.» Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.
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Affiliation(s)
- Hayden Baker
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, Illinois
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Gao C, Marsic I, Sarcevic A, Gestrich-Thompson W, Burd RS. Real-time Context-Aware Multimodal Network for Activity and Activity-Stage Recognition from Team Communication in Dynamic Clinical Settings. PROCEEDINGS OF THE ACM ON INTERACTIVE, MOBILE, WEARABLE AND UBIQUITOUS TECHNOLOGIES 2023; 7:12. [PMID: 37719879 PMCID: PMC10501506 DOI: 10.1145/3580798] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In clinical settings, most automatic recognition systems use visual or sensory data to recognize activities. These systems cannot recognize activities that rely on verbal assessment, lack visual cues, or do not use medical devices. We examined speech-based activity and activity-stage recognition in a clinical domain, making the following contributions. (1) We collected a high-quality dataset representing common activities and activity stages during actual trauma resuscitation events-the initial evaluation and treatment of critically injured patients. (2) We introduced a novel multimodal network based on audio signal and a set of keywords that does not require a high-performing automatic speech recognition (ASR) engine. (3) We designed novel contextual modules to capture dynamic dependencies in team conversations about activities and stages during a complex workflow. (4) We introduced a data augmentation method, which simulates team communication by combining selected utterances and their audio clips, and showed that this method contributed to performance improvement in our data-limited scenario. In offline experiments, our proposed context-aware multimodal model achieved F1-scores of 73.2±0.8% and 78.1±1.1% for activity and activity-stage recognition, respectively. In online experiments, the performance declined about 10% for both recognition types when using utterance-level segmentation of the ASR output. The performance declined about 15% when we omitted the utterance-level segmentation. Our experiments showed the feasibility of speech-based activity and activity-stage recognition during dynamic clinical events.
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Wright AM, Ramage L, Barratt J, Grier G, Hughes A. A narrative review of damage control resuscitation for paediatric trauma patients in Iraq and Afghanistan from 2001 to 2016. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086231152661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Introduction Requirement for blood transfusion in the injured paediatric civilian population is rare. Therefore, a substantial evidence base underpinning damage control resuscitation (DCR) in paediatric patients is lacking. Published outcome data originating from Iraq and Afghanistan offer a unique opportunity to study large cohorts of children who received DCR. It is hoped that by collating the data, this review will inform pre-deployment medical training and support the development of paediatric specific DCR guidelines, which can be used in all trauma environments. Methodology A comprehensive search of the literature was conducted using online databases, grey literature searching and screening of reference lists. Papers discussing blood product, crystalloid or tranexamic acid (TXA) administration in paediatric patients injured in Iraq and Afghanistan from 2001to present were included. Results Eighteen papers were included – all were retrospective studies of data from military trauma databases. Most children that received massive transfusion were male (73.4%), injured in Afghanistan (69.9%) by explosives (60.4%) with a median age of 9 years. A definition of paediatric massive transfusion of 40 ml/kg of all blood products within 24 h was developed. Massive transfusion rates were high (15.7% of children). Whole blood administration occurred in 4% of patients requiring blood transfusions. Low crystalloid volumes in combination with balanced blood product ratios were associated with improved survival, along with the use of whole blood and TXA. Conclusion The review offers insight into the paediatric population likely to require DCR and the optimal DCR strategies to be used in their management.
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Affiliation(s)
- Annie Mae Wright
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, The Institute of Prehospital Care, London, UK
| | - Lisa Ramage
- Emergency Department, Addenbrookes Hospital, Magpas Air Ambulance, Queen Mary University of London, London, UK
| | - Jon Barratt
- Academic Department of Military Emergency Medicine, University Hospitals of the North Midlands NHS Trust, East Anglian Air Ambulance, Queen Mary University of London, London, UK
| | - Gareth Grier
- Royal London Hospital, Queen Mary University London, Centre for Excellence Project Lead, Essex and Herts Air Ambulance, London, UK
| | - Amy Hughes
- Bart's Health NHS Trust, Essex and Herts Air Ambulance, Queen Mary University of London, Essex, UK
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Maris M, Berben SAA, Verhoef W, van Grunsven P, Tan ECTH. The quality of pre-announcement communication and the accuracy of estimated arrival time in critically ill patients, a prospective observational study. BMC Emerg Med 2022; 22:44. [PMID: 35305570 PMCID: PMC8933928 DOI: 10.1186/s12873-022-00601-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Efficient communication between (helicopter) emergency medical services ((H)EMS) and healthcare professionals in the emergency department (ED) is essential to facilitate appropriate team mobilization and preparation for critically ill patients. A correct estimated time of arrival (ETA) is crucial for patient safety and time-management since all team members have to be present, but needless waiting must be avoided. The aim of this study is to investigate the quality of the pre-announcement and the accuracy of the ETA.
Methods
A prospective observational study was conducted in potentially critically ill/injured patients transported to the ED of a Level I trauma center by the (H)EMS. Research assistants observed time slots prior to arrival at the ED and during the initial assessment, using a stopwatch and an observation form. Information on the pre-announcement (including mechanisms of injury, vital signs, and the ETA) is also collected.
Results
One hundred and ninety-three critically ill/injured patients were included. Information in the pre-announcement was often incomplete; in particular vital signs (86%). Forty percent of the announced critically ill patients were non-critical at arrival in the ED. The observed time of arrival (OTA) for 66% of the patients was later than the provided ETA (median 5:15 min) and 19% of the patients arrived sooner (3:10 min). Team completeness prior to the arrival of the patient was achieved for 66% of the patients.
Conclusions
The quality of the pre-announcement is moderate, sometimes lacking essential information on vital signs. Forty percent of the critically ill patients turned out to be non-critical at the ED. Furthermore, the ETA was regularly inaccurate and team completeness was insufficient. However, none of the above was correlated to the rate of complications, mortality, LOS, ward of admission or discharge location.
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Campbell M, Zagel AL, Ortega H, Kreykes N, Tu A, Linabery AM, Plasencia L, Krause E, Bergmann KR. Quality Indicators for Children With Traumatic Brain Injury After Transition to an American College of Surgeons Level I Pediatric Trauma Center. Pediatr Emerg Care 2022; 38:e329-e336. [PMID: 33109937 DOI: 10.1097/pec.0000000000002276] [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: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare quality indicators, including frequency of acute surgical and emergent interventions, and resource utilization before and after American College of Surgeons (ACS) level I trauma verification among children with moderate or severe traumatic brain injury (TBI). METHODS This is a retrospective review of patients younger than 18 years treated for moderate or severe TBI, as determined by International Classification of Disease codes. Our institution obtained ACS level I trauma verification in 2013. Outcomes during the pre-ACS (June 2003-May 2008), interim (June 2008-May 2013), and post-ACS (June 2013-May 2018) periods were compared via nonparametric tests. Tests for linear trend were conducted using Cochran-Armitage tests for categorical data and by linear regression for continuous variables. RESULTS There were 677 children with moderate or severe TBIs (pre-ACS, 125; interim, 198; post-ACS, 354). Frequency of any surgical intervention increased significantly in the post-ACS period (12.2%) compared with interim (5.1%) and pre-ACS periods (5.6%, P = 0.007). More children in the post-ACS period required intracranial pressure monitoring (P = 0.017), external ventricular drain placement (P = 0.003), or endotracheal intubation (P = 0.001) compared with interim and pre-ACS periods. There was no significant change in time to operating room (P = 0.514), frequency of decompression (P = 0.096), or time to decompression (P = 0.788) between study periods. The median time to head CT decreased significantly in the post-ACS period (26 minutes; interquartile range [IQR], 9-60) compared with interim (36 minutes; IQR, 21-69) and pre-ACS periods (53 minutes; IQR, 36-89; P < 0.001). Frequency of repeat head computed tomography decreased significantly in the post-ACS period (30.2%) compared with interim (56.1%) and pre-ACS periods (64.0%, Ptrend = 0.044). CONCLUSIONS Transition to an ACS level I trauma verification was associated with improvements in quality indicators for children with moderate or severe TBI.
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Affiliation(s)
- Maryellen Campbell
- From the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | | | | | | | - Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Tashlizky Madar R, Goldberg A, Newman N, Waisman Y, Greenberg D, Adini B. A management model for admission and treatment of pediatric trauma cases. Isr J Health Policy Res 2021; 10:73. [PMID: 34903295 PMCID: PMC8670149 DOI: 10.1186/s13584-021-00506-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 11/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background Pediatric trauma, particularly major trauma cases, are often treated in less than optimal facilities by providers who lack training and experience in treating severely injured children. We aimed to develop a management model for admission and treatment of pediatric trauma using the Theory of Constraints (TOC).
Methods We conducted interviews with 17 highly experienced policy makers, senior nursing managers and medical managers in pediatrics and trauma. The interviews were analyzed by qualitative methods. The TOC was utilized to identify undesirable effects (UDEs) and core challenges, and to design a focused current reality tree (CRT). Subsequently, a management model for optimal admission and treatment of pediatric trauma was constructed. Results The CRT was illustrated according to 4 identified UDEs focusing on lack of: (1) clear definitions of case manager in pediatric trauma; (2) uniform criteria regarding the appropriate site for admitting pediatric trauma, (3) standard guidelines and protocols for treatment of trauma cases and for training of trauma medical teams; and (4) standard guidelines for evacuating pediatric trauma patients. The management model for treatment and admission of pediatric trauma is based on 3 major elements: human resources, hospital policy concerning the appropriate emergency department (ED) for pediatric trauma patients and clear definitions regarding children and trauma levels. Each of the elements contains components that should be clearly defined in order for a medical center to be designated for admitting and treating pediatric trauma patients. Conclusions Our analysis suggests that the optimal ED for pediatric trauma cases is one with available operating rooms, intensive care beds, an imaging unit, laboratories and equipment suitable for treating children as well as with staff trained to treat children with trauma. To achieve optimal outcomes, medical centers in Israel should be classified according to their trauma treatment capabilities and their ability to treat varied severities of pediatric trauma cases. Supplementary Information The online version contains supplementary material available at 10.1186/s13584-021-00506-5.
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Affiliation(s)
| | - Avishay Goldberg
- Department of Health Systems Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.,PREPARED Center for Emergency Response Research, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Nitza Newman
- Pediatric Surgery Department, Soroka University Medical Center, Beer Sheva, Israel
| | - Yehezkel Waisman
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,School of Continuing Medical Education, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Greenberg
- Pediatric Infectious Disease Unit, Pediatrics Department, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Bruria Adini
- Department of Emergency Management and Disaster Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Khan FA, Apple CG, Caldwell KJ, Larson SD, Islam S. Prehospital personnel discretion pediatric trauma team activations: Too much of a good thing? J Pediatr Surg 2021; 56:2052-2057. [PMID: 33814181 DOI: 10.1016/j.jpedsurg.2021.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/08/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Trauma team activation is essential to provide rapid assessment of injured patients, however excessive utilization can overburden systems. We aimed to identify predictors of over triage and evaluate impact of prehospital personal discretion trauma activations on the over triage rate. METHODS Retrospective comparative study of pediatric trauma patients (<18 years) evaluated after activation of the trauma team to those evaluated as a trauma consult treated between 2010 and 2013. Cohort matching of trauma activated and consult patients was done on the basis of patients' age and ISS. RESULTS 1363 patients including 359 trauma team activations were evaluated. Median age was 6 years, Injury Severity Score (ISS) 4, 116 (8.5%) required operative intervention and 20 (1.4%) died. Matched analysis using age and ISS showed trauma activated patients were more likely to have penetrating MOI (4.7% vs.1.7%; p = 0.03) and need ICU admission(32.9% vs.16.7%; p = 0.0001). State of Florida discrete criteria based trauma activated patients when compared to paramedic discretion activations had a higher ISS (9 vs.5; p = 0.014), need for ICU admission (36.5% vs.20.4%; p = 0.004), ICU LOS(2 vs.0 days; p = 0.02), hospital LOS(2 vs.2 days; p = 0.014) and higher likelihood of death(4.9% vs.0%;p = 0.0001). Moreover, paramedic discretion trauma activated patients were similar to trauma consult patients in terms of ISS score(p = 0.86), need for ICU admission(p = 0.86), operative intervention(p = 0.86), death(p = 0.86) and hospital LOS(p = 0.86), with a considerably higher cost of care(p = 0.0002). CONCLUSION Discrete criteria-based trauma team activations appear to more reliably identify patients likely to benefit from initial multidisciplinary management.
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Affiliation(s)
- Faraz A Khan
- Division of Pediatric Surgery, Department of Surgery, Loma Linda University School of Medicine., 11175 Campus Street, CP21111, Loma Linda, CA 923502, USA.
| | - Camille Gd Apple
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd. P.O. Box 10019, Gainesville, FL, USA
| | - Kenneth J Caldwell
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine., 1600 SW Archer Rd. P.O. Box 10019, Gainesville, FL, USA
| | - Shawn D Larson
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine., 1600 SW Archer Rd. P.O. Box 10019, Gainesville, FL, USA
| | - Saleem Islam
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine., 1600 SW Archer Rd. P.O. Box 10019, Gainesville, FL, USA
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Kelley MN, Mercurio L, Tsao HS, Toomey V, Carillo M, Brown L, Wing R. Excellence in Communication and Emergency Leadership (ExCEL): Pediatric Primary and Secondary Survey in Trauma Workshop for Residents. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11079. [PMID: 33501375 PMCID: PMC7821439 DOI: 10.15766/mep_2374-8265.11079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/06/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Unintentional traumatic injury remains the leading cause of pediatric death in the United States. There is wide variation in the assessment and management of pediatric trauma patients in emergency departments. Resident education on trauma evaluation and management is lacking. This workshop focused on developing resident familiarity with the primary and secondary trauma survey in pediatric patients. METHODS This hands-on workshop utilized patient-actors and low-fidelity simulators to instruct learners on the initial assessment of trauma patients during the primary and secondary trauma surveys. It was designed for residents across all levels of training who care for pediatric trauma patients (including pediatrics, medicine-pediatrics, emergency medicine, and family medicine) and adapted for different session durations and learner group sizes. RESULTS Eighteen residents participated in this workshop at two separate institutions. Participants strongly agreed that the workshop was relevant and effective in teaching the initial primary and secondary trauma survey assessment of pediatric trauma patients. Residents also reported high levels of confidence in performing a primary and secondary trauma survey after participation in the workshop. DISCUSSION This workshop provided residents with instruction and practice in performing the primary and secondary trauma survey for injured pediatric patients. Additional instruction is needed on assigning Glasgow Coma Scale and AVPU (alert, voice, pain, unresponsive) scores to injured patients. The structure and time line of this curriculum can be adapted to the needs of an individual institution's program and the number of workshop participants.
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Affiliation(s)
- Mariann Nocera Kelley
- Assistant Professor, Departments of Pediatrics and Emergency Medicine/Traumatology, Division of Pediatric Emergency Medicine, University of Connecticut School of Medicine and Connecticut Children's; Director of Simulation Education, University of Connecticut School of Medicine
| | - Laura Mercurio
- Fellow, Departments of Emergency Medicine and Pediatrics, Division of Pediatric Emergency Medicine, Warren Alpert Medical School of Brown University and Rhode Island Hospital/Hasbro Children's Hospital
| | - Hoi See Tsao
- Fellow, Departments of Emergency Medicine and Pediatrics, Division of Pediatric Emergency Medicine, Warren Alpert Medical School of Brown University and Rhode Island Hospital/Hasbro Children's Hospital
| | - Vanessa Toomey
- Clinical Fellow, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School and Boston Children's Hospital
| | - Marie Carillo
- Fellow, Department of Cardiology, Children's National Hospital
| | - Linda Brown
- Associate Professor, Departments of Emergency Medicine and Pediatrics, Division of Pediatric Emergency Medicine, Warren Alpert Medical School of Brown University and Rhode Island Hospital/Hasbro Children's Hospital; Vice Chair of Pediatric Emergency Medicine, Hasbro Children's Hospital; Director, Lifespan Medical Simulation Center
| | - Robyn Wing
- Assistant Professor, Departments of Emergency Medicine and Pediatrics, Division of Pediatric Emergency Medicine, Warren Alpert Medical School of Brown University and Rhode Island Hospital/Hasbro Children's Hospital; Director of Pediatric Simulation, Lifespan Medical Simulation Center
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Enayati M, Heaton H, Wang R, Marisamy G, Farahani NZ, Hellmich T, Pasupathy K, Kim B, Nestler D. Trauma Activation Responsiveness: An RFID-enabled trauma flowsheet. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:5718-5721. [PMID: 33019273 DOI: 10.1109/embc44109.2020.9175880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Manually documented trauma flow sheets contain critical information regarding trauma resuscitations in the emergency department (ED). The American College of Surgeons (ACS) has enforced certain thresholds on trauma surgeons' arrival time to the trauma bay. Due to the complex and fast-paced ED environment, this information can be easily overlooked or erroneously recorded, affecting compliance with ACS standards. This paper is a retrospective study conducted at a Level I trauma center equipped with an RFID system to investigate an automated solution to evaluate and improve the accuracy of measuring trauma surgeons' response time to the highest level (red) trauma activations.Clinical Relevance- Demonstration of timely response to trauma activations is required for ACS verification. As real-time location systems become more prevalent, they may improve a hospital's ability to report accurate response times for trauma team activations.
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How Does Mission Ground Time Impact on Population Coverage of Aeromedical Retrieval Systems? J Surg Res 2020; 258:362-369. [PMID: 33069390 DOI: 10.1016/j.jss.2020.08.080] [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] [Received: 06/28/2019] [Revised: 07/17/2020] [Accepted: 08/25/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Aeromedical retrieval is an essential component of contemporary emergency care systems. However, in many locations, ground emergency medical services are dispatched to the scene of an incident first to assess the patient and then call for a helicopter if needed. The time to definitive care therefore includes the helicopter's flight to the scene, flight to the trauma center, and nonflying time. Mission ground time (MGT) includes the time required to get the helicopter airborne, as well as time spent at the scene, packaging and loading the casualty into the aircraft. Estimates of MGT typically vary from 10 to 30 min. The impact of MGT duration on population coverage-the number of residents that could be taken to a trauma center within a set time-is not known. The aim of this study was to compare population coverage for different durations of MGT in a single state. METHODS Coverage was calculated using elliptical coverage areas ("isochrones") based on the location of helicopter bases and Level I and Level II trauma centers. The calculations were performed using Microsoft Excel, assuming a cruising speed of 133 knots (246 km/h), and mapped using arcGIS. The access time threshold was set at 60 min, and we evaluated MGTs of 10, 15, 20, 25, and 30 min. RESULTS MGT has a marked impact on population coverage. The effect is, furthermore, not linear. When considering the state's three Level I trauma centers, decreasing MGT from 30 to 10 min increased population coverage from 61.2% to 84.2%. When also considering Level II centers, decreasing MGT from 30 min to 10 min increased coverage by 20%. CONCLUSIONS Elliptical isochrones, with allowance for MGT, provide realistic estimates of population coverage. MGT significantly impacts the proportion of the population that can be taken to a Level I and/or Level II Trauma Center within a set time. The impact is not linear, reflecting the uneven distribution of the population. Consideration should be given to minimizing MGT to preserve the benefits of aeromedical retrieval.
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The Effect of a Multidisciplinary Trauma Team Leader Paradigm at a Tertiary Trauma Center: 10-Year Experience. Emerg Med Int 2020; 2020:8412179. [PMID: 32855826 PMCID: PMC7443032 DOI: 10.1155/2020/8412179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 04/23/2020] [Accepted: 05/23/2020] [Indexed: 11/18/2022] Open
Abstract
Background To illustrate the impact of the implementation of a multidisciplinary TTL program in 2005 on the mortality of trauma patients in a level 1 trauma center as well as admission rates and length of stay. Methods Retrospective observational study of all trauma patients included in the provincial trauma database at the Montreal General Hospital between 1998 and 2015. The primary outcome studied was in-hospital mortality. The secondary outcomes studied were hospital and intensive care unit (ICU) rates of admission and hospital and ICU length of stay. Results 24,107 patients were included. We observed a statistically significant reduction in mortality of 1.25% or a relative reduction of 16% (p value = 0.0058; rate ratio 0.844 (95% CI 0.747-0.952)). ICU admissions were also significantly reduced where we observed a statistically significant absolute reduction of 4.46% or a relative reduction of 14% (p value = 8.38 × 10-7; rate ratio 0.859 (95% CI 0.808-0.912)). The ICU length of stay was increased by 0.91 days or 19.03% (p value = 0.016 (95% CI 0.167-1.655)). There was no observed change in overall length of stay (13.97 days pre-TTL and 12.91 post-TTL (p value = 0.13; estimate -1.053 (95% CI -2.424-0.318))). Conclusions This article suggests that multidisciplinary TTL model may be beneficial in the care of trauma patients. Further subgroup analysis may help determine which patients could benefit more.
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Cuenca CM, Borgman MA, April MD, Fisher AD, Schauer SG. Validation of the age-adjusted shock index for pediatric casualties in Iraq and Afghanistan. Mil Med Res 2020; 7:33. [PMID: 32616047 PMCID: PMC7331217 DOI: 10.1186/s40779-020-00262-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pediatric casualties account for a notable proportion of encounters in the deployed setting based on the humanitarian medical care mission. Previously published data demonstrates that an age-adjust shock index may be a useful tool in predicting massive transfusion and death in children. We seek to determine if those previous findings are applicable to the deployed, combat trauma setting. METHODS We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties seeking to validate previously published data using the shock index, pediatric age-adjusted. We then used previously published thresholds to determine patients outcome for validation by age grouping, 1-3 years (1.2), 4-6 years (1.2), 7-12 years (1.0), 13-17 years (0.9). RESULTS From January 2007 through January 2016 there were 3439 pediatric casualties of which 3145 had a documented heart rate and systolic pressure. Of those 502 (16.0%) underwent massive transfusion and 226 (7.2%) died prior to hospital discharge. Receiver operating characteristic (ROC) thresholds were inconsistent across age groups ranging from 1.0 to 1.9 with generally limited area under the curve (AUC) values for both massive transfusion and death prediction characteristics. Using the previously defined thresholds for validation, we report sensitivity and specificity for the massive transfusion by age-group: 1-3 (0.73, 0.35), 4-6 (0.63, 0.60), 7-12 (0.80, 0.57), 13-17 (0.77, 0.62). For death, 1-3 (0.75, 0.34), 4-6 (0.66-0.59), 7-12 (0.64, 0.52), 13-17 (0.70, 0.57). However, negative predictive values (NPV) were generally high with all greater than 0.87. CONCLUSIONS Within the combat setting, the age-adjusted pediatric shock index had moderate sensitivity and relatively poor specificity for predicting massive transfusion and death. Better scoring systems are needed to predict resource needs prior to arrival, that perhaps include other physiologic metrics. We were unable to validate the previously published findings within the combat trauma population.
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Affiliation(s)
- Camaren M Cuenca
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX, 78234-7767, USA
| | - Matthew A Borgman
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA.,Uniformed Services University of the Heath Sciences, Bethesda, MD, USA
| | - Michael D April
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Andrew D Fisher
- Texas Army National Guard, Austin, TX, USA.,Department of Surgery, UNM School of Medicine, Albuquerque, NM, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX, 78234-7767, USA. .,Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA. .,Uniformed Services University of the Heath Sciences, Bethesda, MD, USA. .,59th Medical Wing, JBSA Lackland, San Antonio, TX, USA.
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Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids' Inpatient Database. J Pediatr Orthop 2020; 40:277-282. [PMID: 32501908 DOI: 10.1097/bpo.0000000000001452] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment. METHODS A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids' Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates. RESULTS A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012. CONCLUSIONS Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications. LEVEL OF EVIDENCE Level III-case series, database study.
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Kim OH, Go SJ, Kwon OS, Park CY, Yu B, Chang SW, Jung PY, Lee GJ. Part 2. Clinical Practice Guideline for Trauma Team Composition and Trauma Cardiopulmonary Resuscitation from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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The Evaluation of Trauma Care: The Comparison of 2 High-Level Pediatric Emergency Departments in the United States and Turkey. Pediatr Emerg Care 2020; 35:611-617. [PMID: 28419017 DOI: 10.1097/pec.0000000000001110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of the study is to compare the outcomes of pediatric trauma patients with motor vehicle crashes (MVCs) and motor vehicle versus pedestrian crashes (MPCs) at a level 1 pediatric trauma center in the United States and a pediatric trauma center in Turkey. METHODS The medical records of all pediatric MVC and MPC subjects presenting to the emergency departments (EDs) of a level 3 hospital in Turkey (Izmir Tepecik Training and Research Hospital [ITTRH]) and a level 1 pediatric trauma center in the United States (Children's Medical Center Dallas [CMCD]) over a 1-year period were reviewed. Data that were collected include patient demographics, prehospital report (mechanism of injury, mode of transportation), injury severity score (ISS), abbreviated injury scale score, Glasgow Coma Scale score, ED length of stay, ED interventions, ED and hospital disposition, and mortality. Patients with moderate (ISS, 5-15) and severe (ISS, >15) trauma scores were included in the study. RESULTS One hundred six patient charts from the ITTRH and 125 patient charts from the CMCD with moderate and severe ISS due to MVCs and MPCs were reviewed. Most of the patients were pedestrians (86%) in the ITTRH group and passengers (60%) in the CMCD group. The percentage of patients transferred by ambulance (ground or air) to the CMCD and the ITTRH was 97.9% and 85%, respectively. Fifteen percent of ITTRH patients and 2.1% of CMCD patients arrived by private vehicle. Emergency department arrival ISS and Glasgow Coma Scale were similar between the 2 hospitals (P > 0.05). The overall mortality rate in the study population was 8.8% (11/125) at the CMCD and 4.7% (5/106) at the ITTRH. (P = 0.223). Blood product utilization was significantly higher in the CMCD group compared with the ITTRH group (P = 0.005). The use of hypertonic saline/mannitol/hyperventilation in patients with significant head trauma and increased intracranial pressure was higher in the ITTRH group (P = 0.000). CONCLUSIONS This is the first study that compared pediatric trauma care and outcome at a level 1 pediatric trauma center in the United States and a pediatric hospital in Turkey. Our findings highlight the opportunities to improve pediatric trauma care in Turkey. Specifically, there is a need for national trauma registries, enhanced trauma education, and standardized trauma patient care protocols. In addition, efforts should be directed toward improving prehospital care through better integration within the health care system and physician participation in educating prehospital providers. Data and organized trauma care will be instrumental in system-wide improvement and developing appropriate injury-prevention strategies.
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Belhumeur V, Malo C, Nadeau A, Hegg-Deloye S, Gagné AJ, Émond M. Trauma team leaders in Canada: A national survey. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619847338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The availability, composition and activation criteria for trauma teams vary across different health care systems, but little is known about these features in the Canadian health system. The aim of this study is to provide a description of the current trauma team available in Level 1 and 2 centres across Canada. Methods In 2017, using a modified Dillman technique, a survey was sent to 210 health professionals across all Canadian trauma care facilities, including questions that focused on (1) the presence and the composition of a trauma team, (2) the established criteria to activate this team and (3) the initial patient care. Results Overall, 107 (57%) completed surveys were received. Only 22 (11.7%) were from Level 1 or 2 centre and considered for compilation. Seventeen respondents have a trauma team in their centre, and they all shared their criteria for activating their team (1–27 different indications). The suspected injuries, the judgment of the emergency physician, the systolic blood pressure, the Glasgow Coma Score and the respiratory rate were the most frequently mentioned items. In the presence of a pre-hospital care warning, the initial assessment of a severely injured patient is exclusively completed by a member of the trauma team for only 35.1% of the respondents. For 11.8% of respondents, trauma team coordinates airway management. For 64.7% of participants, the trauma team leader is the dedicated care provider to accompany patients until the final destination. Conclusions The results suggest a great variability across Canada, regarding the roles assumed by the trauma team but also regarding the activation criteria leading them to take action.
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Affiliation(s)
| | - Christian Malo
- Faculty of Medicine, Université Laval, Quebec City, Canada
- Emergency Department, CHU de Québec-Université Laval, Quebec City, Canada
| | - Alexandra Nadeau
- Faculty of Medicine, Université Laval, Quebec City, Canada
- Axe Santé des Populations et Pratiques Optimales en santé, Centre de Recherche du CHU de Québec-Université Laval, Quebec City, Canada
| | - Sandrine Hegg-Deloye
- Faculty of Medicine, Université Laval, Quebec City, Canada
- Axe Santé des Populations et Pratiques Optimales en santé, Centre de Recherche du CHU de Québec-Université Laval, Quebec City, Canada
| | - Anne-Julie Gagné
- Faculty of Medicine, Université Laval, Quebec City, Canada
- Axe Santé des Populations et Pratiques Optimales en santé, Centre de Recherche du CHU de Québec-Université Laval, Quebec City, Canada
| | - Marcel Émond
- Faculty of Medicine, Université Laval, Quebec City, Canada
- Emergency Department, CHU de Québec-Université Laval, Quebec City, Canada
- Axe Santé des Populations et Pratiques Optimales en santé, Centre de Recherche du CHU de Québec-Université Laval, Quebec City, Canada
- Centre de Recherche sur les Soins et Les Services de Première Ligne de l'Université Laval (CRSSPL-UL), Quebec City, Canada
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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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20
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Rubens JH, Ahmed OZ, Yenokyan G, Stewart D, Burd RS, Ryan LM. Mode of Transport and Trauma Activation Status in Admitted Pediatric Trauma Patients. J Surg Res 2019; 246:153-159. [PMID: 31586889 DOI: 10.1016/j.jss.2019.08.008] [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: 02/19/2019] [Revised: 06/13/2019] [Accepted: 08/15/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS). MATERIALS AND METHODS We performed a retrospective cohort study at two level I pediatric trauma centers. INCLUSION CRITERIA <15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics. RESULTS We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82). CONCLUSIONS Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.
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MESH Headings
- Child
- Child, Preschool
- Emergency Service, Hospital/organization & administration
- Emergency Service, Hospital/standards
- Emergency Service, Hospital/statistics & numerical data
- Facilities and Services Utilization/organization & administration
- Facilities and Services Utilization/standards
- Facilities and Services Utilization/statistics & numerical data
- Female
- Humans
- Injury Severity Score
- Length of Stay/statistics & numerical data
- Male
- Patient Admission/statistics & numerical data
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Registries/statistics & numerical data
- Retrospective Studies
- Transportation of Patients/statistics & numerical data
- Trauma Centers/organization & administration
- Trauma Centers/standards
- Trauma Centers/statistics & numerical data
- Triage/organization & administration
- Triage/standards
- Triage/statistics & numerical data
- United States
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/therapy
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/therapy
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Affiliation(s)
- Jessica H Rubens
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Omar Z Ahmed
- Department of Surgery, Children's National Health System, Washington, District of Columbia
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dylan Stewart
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Randall S Burd
- Department of Surgery, Children's National Health System, Washington, District of Columbia
| | - Leticia M Ryan
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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21
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Nti BK, Laniewicz M, Skaggs T, Cross K, Fallat ME, Rominger A. A novel streamlined trauma response team training improves imaging efficiency for pediatric blunt abdominal trauma patients. J Pediatr Surg 2019; 54:1854-1860. [PMID: 30736956 DOI: 10.1016/j.jpedsurg.2018.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE The morbidity and mortality of children with traumatic injuries are directly related to the time to definitive management of their injuries. Imaging studies are used in the trauma evaluation to determine the injury type and severity. The goal of this project is to determine if a formal streamlined trauma response improves efficiency in pediatric blunt trauma by evaluating time to acquisition of imaging studies and definitive management. METHODS This study is a chart review of patients <18 years who presented to a pediatric trauma center following blunt trauma requiring trauma team activation. 413 records were reviewed to determine if training changed the efficiency of CT acquisition and 652 were evaluated for FAST efficiency. The metrics used for comparison were time from ED arrival to CT image, FAST, and disposition. RESULTS Time from arrival to CT acquisition decreased from 37 (SD 23) to 28 (SD27) min (p < 0.05) after implementation. The proportion of FAST scans increased from 315 (63.5%) to 337 (80.8%) and the time to FAST decreased from 18 (SD15) to 8 (SD10) min (p < 0.05). The time to operating room (OR) decreased after implementation. CONCLUSION The implementation of a streamlined trauma team approach is associated with both decreased time to CT, FAST, OR, and an increased proportion of FAST scans in the pediatric trauma evaluation. This could result in the rapid identification of injuries, faster disposition from the ED, and potentially improve outcomes in bluntly injured children. TYPE OF STUDY Therapeutic LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Benjamin K Nti
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenus, FT 3, Indianapolis, IN 46202.
| | - Megan Laniewicz
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville School of Medicine, 571 S. Floyd St., Suite 802, Louisville, KY 40202.
| | | | - Keith Cross
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville School of Medicine, 571 S. Floyd St., Suite 802, Louisville, KY 40202.
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk, Jr. Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway, Suite 565, Louisville, KY 40202.
| | - Annie Rominger
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville School of Medicine, 571 S. Floyd St., Suite 802, Louisville, KY 40202.
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Pek JH, Ong YKG, Quek ECS, Feng XYJ, Allen JC, Chong SL. Evaluation of the criteria for trauma activation in the paediatric emergency department. Emerg Med J 2019; 36:529-534. [PMID: 31326954 DOI: 10.1136/emermed-2018-207857] [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: 06/08/2018] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma team activation criteria have a variable performance in the paediatric population. We aimed to identify predictors for high-level resource utilisation during trauma resuscitation in the ED. METHODS A retrospective study was conducted in the ED of a tertiary paediatric hospital. Patient data were collected from trauma surveillance registry and analysis was performed to identify significant predictors. We then assessed the sensitivity and specificity of proposed models with respect to observed patient outcomes. RESULTS Among 11 282 cases, the mean age was 6.1±4.9 (SD) years old. Fall was the most common mechanism of injury in 7364 (65.3%) patients. Eighty-eight (0.8%) patients required at least one high-level resource. Significant predictors for high-resource utilisation were overall GCS of <14 (relative risk (RR) 38.841, 95% CI 21.328 to 70.739, p<0.001), high-risk mechanisms of fall from height and motor vehicle collision (RR 7.863, 95% CI 4.687 to 13.192, p<0.001), as well as age-specific tachycardia (RR 1.796, 95% CI 1.145 to 2.817, p=0.0108). A model consisting of GCS and high-risk mechanism would under-triage 21 (0.2%) patients and over-triage 681 (6.0%) patients. When age-specific tachycardia was added, 8 (0.1%) less patients would be under-triaged but an additional 3251 (28.9%) patients would be over-triaged. CONCLUSION As utilisation of high-level resources in paediatric trauma was rare, it was difficult to find an appropriate balance between under-triage and over-triage. Between the two, minimising the proportion of under-triage is more important as patient safety is paramount in paediatric trauma care.
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Affiliation(s)
- Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - En Ci Samuel Quek
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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Durojaiye AB, Levin S, Toerper M, Kharrazi H, Lehmann HP, Gurses AP. Evaluation of multidisciplinary collaboration in pediatric trauma care using EHR data. J Am Med Inform Assoc 2019; 26:506-515. [PMID: 30889243 PMCID: PMC6515526 DOI: 10.1093/jamia/ocy184] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 09/30/2018] [Accepted: 12/17/2018] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES The study sought to identify collaborative electronic health record (EHR) usage patterns for pediatric trauma patients and determine how the usage patterns are related to patient outcomes. MATERIALS AND METHODS A process mining-based network analysis was applied to EHR metadata and trauma registry data for a cohort of pediatric trauma patients with minor injuries at a Level I pediatric trauma center. The EHR metadata were processed into an event log that was segmented based on gaps in the temporal continuity of events. A usage pattern was constructed for each encounter by creating edges among functional roles that were captured within the same event log segment. These patterns were classified into groups using graph kernel and unsupervised spectral clustering methods. Demographics, clinical and network characteristics, and emergency department (ED) length of stay (LOS) of the groups were compared. RESULTS Three distinct usage patterns that differed by network density were discovered: fully connected (clique), partially connected, and disconnected (isolated). Compared with the fully connected pattern, encounters with the partially connected pattern had an adjusted median ED LOS that was significantly longer (242.6 [95% confidence interval, 236.9-246.0] minutes vs 295.2 [95% confidence, 289.2-297.8] minutes), more frequently seen among day shift and weekday arrivals, and involved otolaryngology, ophthalmology services, and child life specialists. DISCUSSION The clique-like usage pattern was associated with decreased ED LOS for the study cohort, suggesting greater degree of collaboration resulted in shorter stay. CONCLUSIONS Further investigation to understand and address causal factors can lead to improvement in multidisciplinary collaboration.
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Affiliation(s)
- Ashimiyu B Durojaiye
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Operations Integration, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Hadi Kharrazi
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Harold P Lehmann
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ayse P Gurses
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Malone Center for Engineering in Healthcare, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
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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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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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Abstract
BACKGROUND In-hospital trauma team activation criteria are formulated to identify severely injured patients requiring specialized multidisciplinary care. Efficacy of trauma activation (TA) criteria is commonly measured by emergency department (ED) disposition, injury severity score, and mortality. Necessity of critical ED interventions is another measure that has been proposed to evaluate the appropriateness of TA criteria. METHODS Two-year retrospective cohort study of 1715 patients from our trauma registry at a Level 1 pediatric trauma center. We abstracted data on acute interventions, level and criterion of TA, ED disposition, and mortality. We report odds ratio (OR) with 95% confidence intervals (CIs), positive predictive value, and frequency of acute interventions. RESULTS Trauma activation was initiated for 947 (55%) of the 1715 patients. There were 426 ED interventions performed on 235 patients (14%); 67.8% were in level 1 activations; 17.6% in level 2, and 14.6% in level 3. Highest-level activations were highly associated with need for ED interventions (OR, 16.1; 95% CI, 11.5-22.4). The ORs for requiring an ED intervention were low for lower level activations (OR, 0.4; 95% CI, 0.3-0.5), trauma service consults (OR, 0.3; 95% CI, 0.2-0.4), and certain mechanism-based criteria. The ORs for ED intervention for isolated motor vehicle collision (0.2; 95% CI, 0.1-0.7), isolated all-terrain vehicle rollover (0.4; 95% CI, 0.1-1.7), and suspected spinal cord injury (0.5; 95% CI, 0.1-3.7) were significantly lower than 1. CONCLUSIONS Highest-level activation criteria correlate with high utilization of ED resources and interventions. Lower level activation criteria and trauma service consult criteria are not highly correlated with need for ED interventions. Downgrading isolated motor vehicle collision and all-terrain vehicle rollovers and suspected spinal cord injury to lower level activations could decrease the overtriage rate, and adding age-specific bradycardia as a physiologic criterion could improve our undertriage rate.
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Madar R, Adini B, Greenberg D, Waisman Y, Goldberg A. Perspectives of health professionals on the best care settings for pediatric trauma casualties: a qualitative study. Isr J Health Policy Res 2018; 7:12. [PMID: 29587869 PMCID: PMC5872513 DOI: 10.1186/s13584-018-0207-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Critically-injured children are frequently treated by providers who lack specialty pediatric training in facilities that have not been modified for the care of children. We set out to understand the attitudes and perspectives of policy makers, and senior nursing and medical managers in the Israeli healthcare system, concerning the provision of medical care to pediatric trauma casualties in emergency departments. METHODS We conducted semi-structured interviews with 17 health professionals from medical centers across Israel and the Ministry of Health. The interviews were analyzed by qualitative methods. RESULTS There was lack of clarity and uniformity concerning the definition of a pediatric trauma casualty. All of the participants attributed extreme importance to the professional level of the care team manager, and most suggested that this should be a pediatric emergency medicine specialist. They emphasized the importance of around-the-clock availability of pediatric medical teams to care for young trauma casualties, and the crucial need for caregivers to be equipped with a wide variety of professional skills for the adequate treatment of a broad spectrum of injuries. All participants described significant variability in pediatric-care training and experience among physicians and nurses working in emergency departments. Most participants believe that pediatric trauma casualties should be treated in designated pediatric emergency departments, in a limited number of medical centers across the country. CONCLUSIONS Our findings indicate that specialized pediatric EDs would constitute the best location for intake of children with major traumatic injuries. Pediatric emergency medicine specialists should manage trauma cases using pediatric surgeons as ad-hoc consultants. The term 'pediatric patient' should be defined to allow trauma patients to be referred to the most appropriate ED. Teams working at these EDs should undergo specialized pediatric emergency medicine training. Finally, to regulate the key aspects of trauma care, clear statutory guidelines should be formulated at national and local levels.
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Affiliation(s)
- Raya Madar
- Pediatric Surgery Department, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Bruria Adini
- Department of Disaster Management and Injury Prevention, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Greenberg
- Pediatric Infectious Disease Unit, Pediatrics Department, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yehezkel Waisman
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- School of Continuing Medical Education, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avishay Goldberg
- Department of Health Systems Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel
- PREPARED Center for Emergency Response Research, Ben-Gurion University of the Negev, Beer Sheba, Israel
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Zimmerman SA, Reed CS, Reed AN, Jones RJ, Chard A, Reed DN. Extending surgeon response times in tier 2 traumas does not adversely affect patient outcomes. J Surg Res 2018; 226:24-30. [PMID: 29661285 DOI: 10.1016/j.jss.2017.12.037] [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: 04/11/2017] [Revised: 12/18/2017] [Accepted: 12/28/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The presence of a trauma surgeon during patient resuscitations is required at most American College of Surgeons-verified trauma centers despite little evidence showing improved patient outcomes in the less-than-critically injured (Tier 2) trauma patients. This study was designed to identify the impact of extending required surgeon response times on outcomes in tier 2 trauma patients. METHODS An American College of Surgeons-verified level 2 trauma center extended the maximum allowed surgeon response time for tier 2 activations from 60 min to 120 min on November 1, 2011. Surgeon response time and patient outcomes of the retrospective control group (January 1, 2008-October 31, 2011) were then compared with the prospective test group (November 1, 2011-December 31, 2014). Primary outcomes included mortality and hospital length of stay (HLOS). Secondary outcomes were emergency department length of stay, and time from ED arrival to CT scan. A subset analysis of all patients evaluated by a surgeon within 60 min of arrival versus those evaluated by a surgeon after 60 min was also performed. RESULTS The control and test groups were composed of 757 and 792 patients, and their mean injury severity score was 9.0 and 6.0, respectively. Emergency department length of stay showed a statistically significant increase of 12 min, whereas HLOS was unchanged throughout the study. Mortality was not significantly different between the groups. Subset analysis revealed a median surgeon arrival time of 15 min in the <60-min group and 85 min in the >60-min group, whereas the injury severity score, HLOS, and mortality were not significantly different between these subsets. No correlation existed between these outcomes and surgeon arrival time. CONCLUSIONS Doubling required surgeon response time in tier 2 trauma patients does not produce negative outcomes in this patient group. Mandatory surgeon response times in similar patient groups can be re-evaluated to allow for greater flexibility of a limited surgeon workforce while still providing safe care.
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Affiliation(s)
| | - Christopher S Reed
- Department of Surgery, Indiana University School of Medicine, Fort Wayne, Indiana
| | | | - Ronald J Jones
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, Indiana
| | - Annette Chard
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, Indiana
| | - Donald N Reed
- Department of Surgery, Indiana University School of Medicine, Fort Wayne, Indiana
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Arabi YM, Al-Dorzi HM, Alamry A, Hijazi R, Alsolamy S, Al Salamah M, Tamim HM, Al-Qahtani S, Al-Dawood A, Marini AM, Al Ehnidi FH, Mundekkadan S, Matroud A, Mohamed MS, Taher S. The impact of a multifaceted intervention including sepsis electronic alert system and sepsis response team on the outcomes of patients with sepsis and septic shock. Ann Intensive Care 2017; 7:57. [PMID: 28560683 PMCID: PMC5449351 DOI: 10.1186/s13613-017-0280-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 05/17/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Compliance with the clinical practice guidelines of sepsis management has been low. The objective of our study was to describe the results of implementing a multifaceted intervention including an electronic alert (e-alert) with a sepsis response team (SRT) on the outcome of patients with sepsis and septic shock presenting to the emergency department. METHODS This was a pre-post two-phased implementation study that consisted of a pre-intervention phase (January 01, 2011-September 24, 2012), intervention phase I (multifaceted intervention including e-alert, from September 25, 2012-March 03, 2013) and intervention phase II when SRT was added (March 04, 2013-October 30, 2013) in a 900-bed tertiary-care academic hospital. We recorded baseline characteristics and processes of care in adult patients presenting with sepsis or septic shock. The primary outcome measures were hospital mortality. Secondary outcomes were the need for mechanical ventilation and length of stay in the intensive unit and in the hospital. RESULTS After implementing the multifaceted intervention including e-alert and SRT, cases were identified with less severe clinical and laboratory abnormalities and the processes of care improved. When adjusted to propensity score, the interventions were associated with reduction in hospital mortality [for intervention phase II compared to pre-intervention: adjusted odds ratio (aOR) 0.71, 95% CI 0.58-0.85, p = 0.003], reduction in the need for mechanical ventilation (aOR 0.45, 95% CI 0.37-0.55, p < 0.0001) and reduction in ICU LOS and hospital LOS for all patients as well as ICU LOS for survivors. CONCLUSIONS Implementing a multifaceted intervention including sepsis e-alert with SRT was associated with earlier identification of sepsis, increase in compliance with sepsis resuscitation bundle and reduction in the need for mechanical ventilation and reduction in hospital mortality and LOS.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, MC-1425, Respiratory Services, College of Medicine, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.
| | - Hasan M Al-Dorzi
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed Alamry
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Ra'ed Hijazi
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Sami Alsolamy
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Majid Al Salamah
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Hani M Tamim
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.,Department of Internal Medicine, American University of Beirut- Medical Center, Beirut, Lebanon
| | - Saad Al-Qahtani
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Al-Dawood
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdellatif M Marini
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Fatimah H Al Ehnidi
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Shihab Mundekkadan
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Amal Matroud
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohamed S Mohamed
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Saadi Taher
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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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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Hunt MM, Stevens AM, Hansen KW, Fenton SJ. The utility of a "trauma 1 OP" activation at a level 1 pediatric trauma center. J Pediatr Surg 2017; 52:322-326. [PMID: 27692626 DOI: 10.1016/j.jpedsurg.2016.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To expedite flow of injured children suspected to require operative intervention, a "trauma 1 OP" (T1OP) activation classification was created. The purpose of this study was to review this strategy at a level 1 pediatric trauma center. METHODS A retrospective review of T1OP activations between 2003 and 2015 was performed. Children suspected of requiring neurosurgical intervention were classified as trauma 1 OP neuro (T1OP(N)). Comparisons were made to trauma 1 (T1) patients who required emergent operative intervention, excluding orthopedic injuries. RESULTS Overall, 461 T1OP activations occurred (72% T1OP(N)) compared to 129 T1 activations requiring emergent surgery. Demographics were not significantly different between groups, although T1OP patients were slightly younger and more often experienced falls or were victims of abuse. Compared to T1 activations, T1OP activations had a significantly higher mortality rate (21% vs. 7%, p<0.001). Repeat head imaging was more common in the T1OP(N) group compared to imaged children in the T1 group (20% vs. 37%, p=0.05). T1OP(N) patients more often went directly to the OR (45% vs. 33%, p=0.02) and did so in a significantly faster period of time (32min vs. 53min, p<0.001). CONCLUSIONS Use of the T1OP activations appropriately triaged surgical patients, resulting in significantly faster transport times to the OR. LEVEL OF EVIDENCE II, prognosis study.
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Affiliation(s)
| | | | | | - Stephen J Fenton
- Division of Pediatric Surgery, University of Utah School of Medicine.
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Bach JA, Leskovan JJ, Scharschmidt T, Boulger C, Papadimos TJ, Russell S, Bahner DP, Stawicki SPA. The right team at the right time - Multidisciplinary approach to multi-trauma patient with orthopedic injuries. Int J Crit Illn Inj Sci 2017; 7:32-37. [PMID: 28382257 PMCID: PMC5364767 DOI: 10.4103/ijciis.ijciis_5_17] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Integrated, multidisciplinary team approach to the multiply injured patient can help optimize care, minimize morbidity, and reduce mortality. It also provides a framework for accelerated postinjury rehabilitation course. The characteristics and potential benefits of this approach, including team dynamics and interactions, are discussed in this brief review. Emphasis is placed on synergies provided by specialty teams working together in the framework of care coordination, timing of surgical and nonsurgical interventions, and injury/physiologic considerations. REPUBLISHED WITH PERMISSION FROM Bach JA, Leskovan JJ, Scharschmidt T, Boulger C, Papadimos TJ, Russell S, Bahner DP, Stawicki SPA. Multidisciplinary approach to multi-trauma patient with orthopedic injuries: the right team at the right time. OPUS 12 Scientist 2012;6(1):6-10.
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Affiliation(s)
- John A. Bach
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University College of Medicine, Columbus, OH, USA
| | - John J. Leskovan
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Thomas Scharschmidt
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Creagh Boulger
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Thomas J. Papadimos
- Department of Anesthesiology, Division of Critical Care, The Ohio State University College of Medicine, Columbus, OH, USA
- Multi-Center Trials Group, OPUS 12 Foundation Global, Bethlehem, PA, USA
| | - Sarah Russell
- Department of Anesthesiology, Division of Critical Care, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David P. Bahner
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Multi-Center Trials Group, OPUS 12 Foundation Global, Bethlehem, PA, USA
| | - Stanislaw P. A. Stawicki
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University College of Medicine, Columbus, OH, USA
- Multi-Center Trials Group, OPUS 12 Foundation Global, Bethlehem, PA, USA
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Abstract
BACKGROUND The role of the surveyor in trauma resuscitations is to identify life-threatening injuries and is meant to be conducted by a set protocol for every patient. Optimal performance of the trauma survey is known to be a challenge in pediatric trauma resuscitation. A postulated reason for this observation is that many trainees, such as pediatric residents, who perform the trauma survey have minimal experience and do not have formal advanced trauma life support training. The assessment of factors that may be obstacles in performing the trauma survey has not been studied robustly. OBJECTIVE The objective of this retrospective cohort study was to use video review of resuscitation of real-life traumatically injured children to (1) describe the characteristics of the trauma patient, the surveyor, and the trauma response team in its current state of function at a tertiary level I trauma center, (2) describe current performance of primary and secondary surveys, as measured by an assessment tool, and (3) determine whether there are specific characteristics associated with reduced quality, completeness, or timeliness of the assessment of an injured child. METHODS Retrospective review of emergency department (ED) trauma activations captured by video recording between June 2009 and January 2012. Video-recorded resuscitations were reviewed, and survey performance was scored using a novel assessment tool applying a scoring system (0, 1, or 2 points) for each essential element (airway, breathing, circulation, etc.) accounting for quality, sequence, and timing of assessments. Maximum score was 8 points for the primary survey and 22 points for the secondary survey. Time to completion of survey elements was recorded. Chart review identified surveyor characteristics (level of training and type of training program) and patient data fields (age, mechanism of injury, trauma level, Glasgow Coma Score, time of encounter, disposition, and number of procedures). Descriptive statistics and univariate analysis were performed. RESULTS Of 749 eligible trauma activations, 228 activations were enrolled in the study with complete data for 202 patients. Most activations met level II criteria and involved blunt trauma. Most patients had a Glasgow Coma Score of 15 and were non-ICU inpatient admissions. PGY-3 residents performed the most surveys (53% of surveys done by residents). Pediatric residents performed 46% of surveys; emergency medicine (EM) residents, 41%; and pediatric EM fellows, 6%. Median scores on primary and secondary surveys were 7 and 12, respectively; median time to completion was 82 seconds and 265 seconds, respectively. Only 22% of primary surveys and 0% of secondary surveys were performed completely. Pediatric EM fellows had the highest mean score on primary and secondary survey. Pediatric EM fellows took longest to perform primary survey and shortest to complete secondary survey. Mean scores on primary and secondary survey were not significantly different between pediatric and EM residents (6.7 vs 6.7; 12.5 vs 11.6). There was no association between survey scores and level or type of training. Emergency medicine residents spent less time on the trauma survey, but this difference did not reach statistical significance. CONCLUSIONS Primary and secondary surveys are frequently performed incompletely and inefficiently regardless of level of training or type of training program. There is no difference in measured performance among different types of residency programs. The impact of trauma resuscitation education on improved survey performance should be studied prospectively.
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Kim N. Organization and Roles of the Trauma Team. JOURNAL OF ACUTE CARE SURGERY 2016. [DOI: 10.17479/jacs.2016.6.2.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Namryeol Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Simultaneous multisystem surgery: An important capability for the civilian trauma hospital. Clin Neurol Neurosurg 2016; 148:13-6. [DOI: 10.1016/j.clineuro.2016.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/15/2016] [Accepted: 06/15/2016] [Indexed: 11/17/2022]
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Abstract
Over the past few years, several published reports have addressed the problem of drug-related morbidity in various practice settings. Studies evaluating drug-related hospitalization have estimated that approximately 5% to 10% of all hospital admissions are drug related. Unfortunately, many of these studies have excluded patients seeking medical attention in the emergency department (ED) but not requiring hospital admission. Drug-related visits to the emergency department are a significant problem and contribute to overall pressures on our current health care system. Despite the limited information published regarding drug-related ED visits, several studies describe the impact of this issue. The purpose of this article is to review the current literature pertaining to the incidence, classification, severity, preventability, and economic impact of drug-related visits to the emergency department.
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Affiliation(s)
- Peter J. Zed
- Clinical Service Unit Pharmaceutical Sciences, Vancouver General Hospital, Faculty of Pharmaceutical Sciences, Division of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,
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Trauma team size and task performance in adult trauma resuscitations. J Surg Res 2016; 204:176-82. [PMID: 27451884 DOI: 10.1016/j.jss.2016.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/19/2016] [Accepted: 05/03/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND The initial evaluation of a trauma patient involves multiple personnel from various disciplines. Whereas this approach can expedite care, an increasing number of personnel can also create chaos and hinder efficiency. We sought to determine the optimal number of persons associated with an expedient primary survey. METHODS Audio and/or video recordings of all consecutive adult trauma evaluations at a level 1 trauma center were reviewed for a 1-month period. A 20-task checklist was developed based on Advanced Trauma Life Support principles. The number of practitioners present (TeamN) and tasks completed at 2 and 5 min (Task2, Task5) were recorded. The association between TeamN, demographics, presence of attending surgeon, and team leader engagement and Task2/Task5 was measured the using chi square test and Spearman correlation. A multivariate regression model was developed. RESULTS A total of 170 cases were reviewed, 44 of which were top-tier activations. Average TeamN was 6 ± 2 persons. Task2 and Task5 were significantly positively correlated with TeamN (r = 0.34, P < 0.0001; r = 0.22, P = 0.004, respectively) and leader engagement (r = 0.27, P < 0.01; r = 0.16, P < 0.05, respectively). There was a significant positive correlation between TeamN and Task2 and Task5. Only TeamN had a significant, independent association with Task2 and Task5 (P = 0.005). We did not find a size that was negatively associated with task completion. Only assessment of breath sounds was negatively associated with increasing team size. CONCLUSIONS TeamN is significantly associated with efficiency of trauma evaluation. Studies evaluating reasons for this and the effect of maximal team size are needed to determine optimal trauma team staffing.
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Baudin F, Floccard B, Desgranges FP, Courtil-Teyssedre S, De Queiroz M, Richard N, Javouhey E. [Effectiveness of management of children with severe trauma in a pediatric trauma center and in an adult trauma center: A before-after study]. Arch Pediatr 2016; 23:367-72. [PMID: 26904971 DOI: 10.1016/j.arcped.2015.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/03/2015] [Accepted: 12/30/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare management of injured children in an adult trauma center (TC) with competencies in pediatric trauma care (2005-2007) and in a pediatric-only trauma center (2010-2012). STUDY DESIGN A before-after retrospective study. PATIENTS AND METHODS Fifty-nine children between 1 and 15 years of age admitted to the adult TC (2005-2007) were compared to 56 children admitted to the pediatric TC (2010-2012). Epidemiological data, severity scores, early outcome, and care duration in trauma resuscitation before whole-body CT were collected and compared between the two periods. RESULTS This study found no significant differences between the two periods in terms of care duration before the whole-body CT scan (28 min [18-40] vs 26.5 min [21-36], P=0.89) and early mortality (eight children [13.5%] vs ten children [17.8%], P=0.35). CONCLUSION With no differences in early management of injured children demonstrated, this study validates the organization within our pediatric trauma center. The effectiveness of management of children between 1 and 15 years of age with severe trauma seems to be similar in the two contexts.
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Affiliation(s)
- F Baudin
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, groupement hospitalier EST, 59, boulevard Pinel, 69677 Bron cedex, France.
| | - B Floccard
- Service de réanimation chirurgicale, hôpital Edouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - F-P Desgranges
- Service d'anesthésie-réanimation, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Bron, France
| | - S Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, groupement hospitalier EST, 59, boulevard Pinel, 69677 Bron cedex, France
| | - M De Queiroz
- Service d'anesthésie-réanimation, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Bron, France
| | - N Richard
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, groupement hospitalier EST, 59, boulevard Pinel, 69677 Bron cedex, France
| | - E Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, groupement hospitalier EST, 59, boulevard Pinel, 69677 Bron cedex, France; Université Claude-Bernard Lyon 1, 69008 Lyon, France
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Ko A, Harada MY, Murry JS, Nuño M, Barmparas G, Ma AA, Thomsen GM, Ley EJ. Heart rate in pediatric trauma: rethink your strategy. J Surg Res 2015; 201:334-9. [PMID: 27020816 DOI: 10.1016/j.jss.2015.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/23/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The optimal heart rate (HR) for children after trauma is based on values derived at rest for a given age. As the stages of shock are based in part on HR, a better understanding of how HR varies after trauma is necessary. Admission HRs of pediatric trauma patients were analyzed to determine which ranges were associated with lowest mortality. MATERIALS AND METHODS The National Trauma Data Bank was used to evaluate all injured patients ages 1-14 years admitted between 2007 and 2011. Patients were stratified into eight groups based on age. Clinical characteristics and outcomes were recorded, and regression analysis was used to determine mortality odds ratios (ORs) for HR ranges within each age group. RESULTS A total of 214,254 pediatric trauma patients met inclusion criteria. The average admission HR and systolic blood pressure were 104.7 and 120.4, respectively. Overall mortality was 0.8%. The HR range associated with lowest mortality varied across age groups and, in children ages 7-14, was narrower than accepted resting HR ranges. The lowest risk of mortality for patients ages 5-14 was captured at HR 80-99. CONCLUSIONS The HR associated with lowest mortality after pediatric trauma frequently differs from resting HR. Our data suggest that a 7y old with an HR of 115 bpm may be in stage III shock, whereas traditional HR ranges suggest that this is a normal rate for this child. Knowing when HR is critically high or low in the pediatric trauma population will better guide treatment.
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Affiliation(s)
- Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jason S Murry
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Nuño
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Annie A Ma
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gretchen M Thomsen
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
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Zundel S, Szavay P. Konservative vs. chirurgische Therapie des Bauchtraumas. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-015-3472-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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41
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A consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation. J Trauma Acute Care Surg 2015; 78:634-8. [PMID: 25710438 DOI: 10.1097/ta.0000000000000543] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bressan S, Franklin KL, Jowett HE, King SK, Oakley E, Palmer CS. Establishing a standard for assessing the appropriateness of trauma team activation: a retrospective evaluation of two outcome measures. Emerg Med J 2014; 32:716-21. [PMID: 25532103 DOI: 10.1136/emermed-2014-203998] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 11/27/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma team activation (TTA) is a well-recognised standard of care to provide rapid stabilisation of patients with time-critical, life-threatening injuries. TTA is associated with a substantial use of valuable hospital resources that may adversely impact upon the care of other patients if not carefully balanced. This study aimed to determine which of the two outcome measures would be a better standard for assessing the appropriateness of TTA at a paediatric centre: retrospective major trauma classification as defined within our state, and the use of emergency department high-level resources as recently published by Falcone et al (Falcone Interventions; FI). METHODS Trauma registry data and patients' charts between February 2011 and June 2013 were reviewed. Over-triage and under-triage rates for TTA, using both major trauma and FIs as outcome measures, were compared. RESULTS Totally, 280 patients received TTA, 243 met major trauma definition and 102 received one or more FIs. The rates of over-triage and under-triage were 39.7% (95% CI 35.0 to 44.6%) and 30.5% (95% CI 26.2 to 35.2%), when the major trauma definition was used as the outcome measure, and 67.5% (95% CI 62.2 to 72.5%) and 10.8% (95% CI 7.9 to 14.8%) when FI was used. Only 17.1% (95% CI 11.4% to 24.7%) of the under-triaged patients using the major trauma definition received one or more FIs. CONCLUSIONS Assessment of TTA appropriateness varied significantly based on the outcome measure used. FIs better reflected the use of acute-care TTA-related resources compared with the major trauma definition, and it should be used as the gold standard to prospectively assess and refine TTA criteria.
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Affiliation(s)
- Silvia Bressan
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia Murdoch Children's Research Institute, Victoria, Australia Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | | | - Helen E Jowett
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sebastian K King
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia Murdoch Children's Research Institute, Victoria, Australia Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Ed Oakley
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia Murdoch Children's Research Institute, Victoria, Australia Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Cameron S Palmer
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
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Browne LR, Keeney GE, Spahr CD, Lerner EB, Atabaki SM, Drayna P, Cooper A. Trauma Care for Children in the Field. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mechanism of injury alone is not justified as the sole indication for computed tomographic imaging in blunt pediatric trauma. J Trauma Acute Care Surg 2013; 75:995-1001. [DOI: 10.1097/ta.0b013e3182ab065b] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wohlgemut JM, Morrison JJ, Apodaca AN, Egan G, Sponseller PD, Driver CP, Jansen JO. Demographic and geographical characteristics of pediatric trauma in Scotland. J Pediatr Surg 2013; 48:1593-7. [PMID: 23895978 DOI: 10.1016/j.jpedsurg.2013.03.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/26/2013] [Accepted: 03/14/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trauma systems reduce mortality and improve functional outcomes. The aim of this study was to analyse the demographic and geospatial characteristics of pediatric trauma patients in Scotland, and determine the level of destination healthcare facility which injured children are taken to, to determine the need for, and general feasibility, of developing a pediatric trauma system for Scotland. METHODS Retrospective analysis of incidents involving children aged 1-14 attended to by the Scottish Ambulance Service between 1 November 2008 and 31 October 2010. A subgroup with physiological derangement was defined. Incident location postcode was used to determine incident location by health board region, rurality and social deprivation. Destination healthcare facility was classified into one of six categories. RESULTS Of 10,759 incidents, 72.3% occurred in urban areas and 5.8% in remote areas. Incident location was associated with socioeconomic deprivation. Of the patients, 11.6% were taken to a pediatric hospital with pediatric intensive care facilities, 21.8% to a pediatric hospital without pediatric intensive care service, and 50.2% to an adult large general hospital without pediatric surgical service. CONCLUSIONS The majority of incidents involving children with injuries occurred in urban areas. Half were taken to a hospital without pediatric surgical service. There was no difference between children with normal and deranged physiology.
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Affiliation(s)
- Jared M Wohlgemut
- School of Medicine and Dentistry, University of Aberdeen, Foresterhill, AB25 2ZD Aberdeen, UK
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Berg GM, Vasquez DG, Hale LS, Nyberg SM, Moran DA. Evaluation of Process Variations in Noncompliance in the Implementation of Evidence-Based Sepsis Care. J Healthc Qual 2013; 35:60-9. [DOI: 10.1111/j.1945-1474.2011.00168.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yeung L, Miraflor E, Garcia A, Victorino GP. Effect of surgery resident change of shift on trauma resuscitations and outcomes. JOURNAL OF SURGICAL EDUCATION 2013; 70:87-94. [PMID: 23337676 DOI: 10.1016/j.jsurg.2012.06.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 06/07/2012] [Accepted: 06/26/2012] [Indexed: 06/01/2023]
Abstract
INTRODUCTION The ability of surgery residents to provide continuity of care has come under scrutiny with work hour restrictions. The impact of the surgery resident sign-out period (6-8am and 6-8pm) on trauma outcomes remains unknown. We hypothesize that during shift change, resuscitation times are prolonged with worse outcomes. METHODS Records of patients treated at a university-based urban trauma center during 2008 and 2009 were reviewed. Patients were separated into a shift change group (6-8am and 6-8pm) and a control group of all other time periods and compared using ANOVA, chi square, and unpaired t-tests. RESULTS We reviewed the charts of 4361 consecutive trauma patients. There was no difference in gender, acuity, resuscitation times, Glasgow Coma Scale, revised trauma score, injury severity score (ISS), or probability of survival score between patients arriving during shift change compared to other times (p>0.2). There was no difference in total emergency department time for patients arriving during shift change (p = 0.07), even when stratified by ISS (ISS<15, p = 0.09; ISS>15, p = 0.2). Length of stay was increased for patients arriving during shift change compared to other times (5 vs 4 days, p<0.05). This was more pronounced for those with ISS>15 (16 vs 11 days, p = 0.03); however, there was no impact on intensive care unit length of stay, ventilator days, and mortality (p>0.3) regardless of ISS. CONCLUSIONS Trauma outcomes are generally unaffected by patient arrival during shift change when resident sign-outs occur. Although adaptations are being made to accommodate trauma patient arrival during these times, we need to continue paying close attention, especially to seriously injured patients, to ensure that there are no delays in care that may potentially affect patient outcomes.
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Affiliation(s)
- Louise Yeung
- Department of Surgery, University of California San Francisco East Bay, Oakland, California 94602, USA.
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A multicenter prospective analysis of pediatric trauma activation criteria routinely used in addition to the six criteria of the American College of Surgeons. J Trauma Acute Care Surg 2012; 73:377-84; discussion 384. [PMID: 22846943 DOI: 10.1097/ta.0b013e318259ca84] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The American College of Surgeons has defined six minimum activation criteria (ACS-6) for the highest level of trauma activations at trauma centers. The verification criteria also allow for the inclusion of additional criteria at the institution's discretion. The purpose of this prospective multicenter study was to evaluate the ACS-6 as well as commonly used activation criteria to evaluate overtriage and undertriage rates for pediatric trauma team activation. METHODS Data were prospectively collected at nine pediatric trauma centers to examine 29 commonly used activation criteria. Patients meeting any of these criteria were evaluated for the use of high-level trauma resuscitation resources according to an expert consensus list. Patients requiring a resource but not meeting any activation criteria were included to evaluate undertriage rates. RESULTS During the 1-year study, a total of 656 patients were enrolled with a mean age of 8 years, a median Injury Severity Score of 14, and mortality of 11%. Using all criteria, 55% of patients would have been overtriaged and 9% would have been undertriaged. If only the ACS-6 were used, 24% of patients would have been overtriaged and 16% would have been undertriaged. Among activation criteria with more than 10 patients, those most predictive of using a high-level resource were a gunshot wound to the abdomen (92%), blood given before arrival (83%), traumatic arrest (83%), tachycardia/poor perfusion (83%), and age-appropriate hypotension (77%). The addition of tachycardia/poor perfusion and pretrauma center resuscitation with greater than 40 mL/kg results in eight criteria with an overtriage of 39% and an undertriage of 10.5%. CONCLUSION The ACS-6 provides a reliable overtriage or undertriage rate for pediatric patients. The inclusion of two additional criteria can further improve these rates while maintianing a simplified triage list for children.
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Rosales-Mayor E, Miranda JJ, Lema C, López L, Paca-Palao A, Luna D, Huicho L. [Resources and capacity of emergency trauma care services in Peru]. CAD SAUDE PUBLICA 2012; 27:1837-46. [PMID: 21986611 DOI: 10.1590/s0102-311x2011000900017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 06/27/2011] [Indexed: 11/21/2022] Open
Abstract
The objectives of this study were to evaluate the resources and capacity of emergency trauma care services in three Peruvian cities using the WHO report Guidelines for Essential Trauma Care. This was a cross-sectional study in eight public and private healthcare facilities in Lima, Ayacucho, and Pucallpa. Semi-structured questionnaires were applied to the heads of emergency departments with managerial responsibility for resources and capabilities. Considering the profiles and volume of care in each emergency service, most respondents in all three cities classified their currently available resources as inadequate. Comparison of the health facilities showed a shortage in public services and in the provinces (Ayacucho and Pucallpa). There was a widespread perception that both human and physical resources were insufficient, especially in public healthcare facilities and in the provinces.
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Williams D, Foglia R, Megison S, Garcia N, Foglia M, Vinson L. Trauma activation: are we making the right call? A 3-year experience at a Level I pediatric trauma center. J Pediatr Surg 2011; 46:1985-91. [PMID: 22008339 DOI: 10.1016/j.jpedsurg.2011.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 05/31/2011] [Accepted: 06/01/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma is the leading cause of death in children, accounting for half of all deaths in patients between birth and 18 years of age, and is the cause of a significant number of hospital admissions. We reviewed our experience at a Level I pediatric trauma center with a 2-level trauma activation (TA) system for mobilization of personnel over a 3-year period. The aim was to assess severity of injury of the trauma patients, resource use, and outcome. METHODS After obtaining institutional review board approval, a retrospective analysis of all trauma patients between January 2006 and December 2008 was performed. Data analyzed included number of admissions, level of TA (STAT vs ALERT), mechanism of injury, intensive care unit (ICU) admission, injury severity score (ISS), need for operative intervention, and survival. RESULTS In 3 years, there were 4502 patients entered. Trauma activation was initiated in 1315 patients (29.2%), divided between 211 STATs (4.7%) and 1104 ALERTs (24.5%). Mean patient age was 5.9 ± 4.1 years, 65% of the patients were boys, and blunt trauma accounted for 92% of the admissions. An ICU admission was required in 736 (16.3%) of the entire group, whereas 502 (38.2%) patients in the TA group were admitted to the ICU(1). The 154 STAT (21%) and 348 ALERT (47%) patients accounted for 68% of all ICU admissions(1). An ISS listed as severe (16-24) or very severe (>24) was found in 468 (10.4%) and 232 (5.2%) patients, respectively. An ISS listed as 16 or higher was found in 144 (68.2%) of the STATs and 264 (23.9%) of the ALERTs(1). Operative intervention was required in 2118 patients (47%). The overall mortality rate was 1.9%, and this increased to 5.8% in the TA group(1). There were 48 deaths (22.7%) in the STAT group, 29 deaths (2.6%) in the ALERT group, and 9 deaths (0.28%) in patients with no TA(1). When emergency department deaths were excluded, the remaining 60 deaths resulted in a mortality rate of 1.3%. CONCLUSIONS Our Level I pediatric trauma center manages a large volume of patients with significant acuity and, evidenced by a TA in 29% of the patients, a severe or very severe ISS in 16% of the patients, 16% of the patients requiring ICU admission, and 47% requiring operative intervention. The TA patients had markedly higher rates of ICU admission, ISS, and mortality. Deaths in the study were lower by almost an order of magnitude comparing TA STATs with TA ALERTs and TA ALERT patients with patients without TA. The TA criteria are in many ways very helpful and is integral to a Level I trauma center. However, opportunities were identified for improvement because of areas of "overutilization" and discordance between TA and ISS.
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Affiliation(s)
- Derek Williams
- Pediatric Trauma Service, Division of Pediatric Surgery, Children's Medical Center Dallas, University of Texas Southwestern, Dallas, TX 75235, USA
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