PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study

BACKGROUND

The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma.

METHODS

For this prospective validation study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician's discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury).

FINDINGS

7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery.

INTERPRETATION

The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma.

FUNDING

The Eunice Kennedy Shriver National Institute of Child Health and Human Development.

A systematic review of large language models and their implications in medical education

INTRODUCTION

In the past year, the use of large language models (LLMs) has generated significant interest and excitement because of their potential to revolutionise various fields, including medical education for aspiring physicians. Although medical students undergo a demanding educational process to become competent health care professionals, the emergence of LLMs presents a promising solution to challenges like information overload, time constraints and pressure on clinical educators. However, integrating LLMs into medical education raises critical concerns and challenges for educators, professionals and students. This systematic review aims to explore LLM applications in medical education, specifically their impact on medical students' learning experiences.

METHODS

A systematic search was performed in PubMed, Web of Science and Embase for articles discussing the applications of LLMs in medical education using selected keywords related to LLMs and medical education, from the time of ChatGPT's debut until February 2024. Only articles available in full text or English were reviewed. The credibility of each study was critically appraised by two independent reviewers.

RESULTS

The systematic review identified 166 studies, of which 40 were found by review to be relevant to the study. Among the 40 relevant studies, key themes included LLM capabilities, benefits such as personalised learning and challenges regarding content accuracy. Importantly, 42.5% of these studies specifically evaluated LLMs in a novel way, including ChatGPT, in contexts such as medical exams and clinical/biomedical information, highlighting their potential in replicating human-level performance in medical knowledge. The remaining studies broadly discussed the prospective role of LLMs in medical education, reflecting a keen interest in their future potential despite current constraints.

CONCLUSIONS

The responsible implementation of LLMs in medical education offers a promising opportunity to enhance learning experiences. However, ensuring information accuracy, emphasising skill-building and maintaining ethical safeguards are crucial. Continuous critical evaluation and interdisciplinary collaboration are essential for the appropriate integration of LLMs in medical education.

Declaration on infection prevention and management in global surgery

Surgeons in their daily practice are at the forefront in preventing and managing infections. However, among surgeons, appropriate measures of infection prevention and management are often disregarded. The lack of awareness of infection and prevention measures has marginalized surgeons from this battle. Together, the Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) have jointly completed an international declaration, highlighting the threat posed by antimicrobial resistance globally and the need for preventing and managing infections appropriately across the surgical pathway. The authors representing these surgical societies call all surgeons around the world to participate in this global cause by pledging support for this declaration for maintaining the effectiveness of current and future antibiotics.

Revolutionizing Healthcare with ChatGPT: An Early Exploration of an AI Language Model's Impact on Medicine at Large and its Role in Pediatric Surgery

BACKGROUND

ChatGPT, a natural language processing model, has shown great promise in revolutionizing the field of medicine. This paper presents a comprehensive evaluation of the transformative potential of OpenAI's ChatGPT on healthcare and scientific research, with an exploration on its prospective capacity to impact the field of pediatric surgery.

METHODS

Through an extensive review of the literature, we illuminate ChatGPT's applications in clinical healthcare and medical research while presenting the ethical considerations surrounding its use.

RESULTS

Our review reveals the exciting work done so far evaluating the numerous potential uses of ChatGPT in clinical medicine and medical research, but it also shows that significant research and advancements in natural language processing models are still needed.

CONCLUSION

ChatGPT has immense promise in transforming how we provide healthcare and how we conduct research. Currently, further robust research on the safety, effectiveness, and ethical considerations of ChatGPT is greatly needed.

LEVEL OF STUDY

V.

Building an optimal pediatric trauma program

In this brief review, I suggest a framework for the ideal pediatric trauma program. I provide a trauma program construct devised by the American College of Surgeons. I expand on this design by offering some concepts around how trauma programs can maximize their effectiveness in care, education, and research. This review was a preamble for a minisymposium focused on pediatric hemorrhagic shock and resuscitation.

The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia

INTRODUCTION

Preservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions.

OPERATIVE TECHNIQUE

Two approaches using the Connect-EA are described - a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device.

OUTCOMES

Salvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy.

CONCLUSION

The Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.

Strategies for Safely Maintaining Surgical Volume During the COVID-19 Pandemic: A Mixed-Methods Study

Resuming elective surgeries that were canceled during the COVID-19 pandemic necessitated a change to preprocedure patient preparation at a pediatric tertiary care center in middle Tennessee. We conducted a prospective, observational, mixed-methods study to determine the effectiveness of a preprocedure COVID-19 testing team to prevent COVID-19-related cancellations among pediatric patients receiving planned anesthesia. The intervention involved family member and patient education and a change in health record reporting to include COVID-19 test results. A team tasked with follow-up reviewed test results, consulted with families, and coordinated the administration of rapid tests if necessary. We compared preimplementation and postimplementation cancellation rates in four procedural areas and found no significant difference in the cancellation or rescheduling rates (P = .89, 95% confidence interval = -4.29 to 3.09). The team-based intervention was associated with the preservation of low procedural cancellation rates by mitigating barriers to preprocedural testing.

Different Surgeon, Different Duration: Lack of Consensus on the Appropriate Duration of Antimicrobial Prophylaxis and Therapy in Surgical Practice

Background: The principles of antimicrobial stewardship promote the appropriate prescribing of agents with respect to efficacy, safety, duration, and cost. Antibiotic resistance often results from inappropriate use (e.g., indication, selection, duration). We evaluated practice variability in duration of antimicrobials in surgical infection treatment (Rx) or prophylaxis (Px). Hypothesis: There is lack of consensus regarding the duration of antibiotic Px and Rx for many common indications. Methods: A survey was distributed to the Surgical Infection Society (SIS) regarding the use of antimicrobial agents for a variety of scenarios. Standard descriptive statistics were used to compare survey responses. Heterogeneity among question responses were compared using the Shannon Index, expressed as natural units (nats). Results: Sixty-three SIS members responded, most of whom (67%) have held a leadership position within the SIS or contributed as an annual meeting moderator or discussant; 76% have been in practice for more than five years. Regarding peri-operative Px, more than 80% agreed that a single dose is adequate for most indications, with the exceptions of gangrenous cholecystitis (40% single dose, 38% pre-operative +24 hours) and inguinal hernia repair requiring a bowel resection (70% single dose). There was more variability regarding the use of antibiotic Px for various bedside procedures with respondents split between none needed (range, 27%-66%) versus a single dose (range, 31%-67%). Opinions regarding the duration of antimicrobial Rx for hospitalized patients who have undergone a source control operation or procedure varied widely based on indication. Only two of 20 indications achieved more than 60% consensus despite available class 1 evidence: seven days for ventilator-associated pneumonia (77%), and four plus one days for perforated appendicitis (62%). Conclusions: Except for peri-operative antibiotic Px, there is little consensus regarding antibiotic duration among surgical infection experts, despite class 1 evidence and several available guidelines. This highlights the need for further high-level research and better dissemination of guidelines.

Torso vascular trauma

Vascular injury within the chest or abdomen represents a unique challenge to the pediatric general surgeon, as these life- or limb-threatening injuries are rare and may require emergent treatment. Vascular injury may present as life-threatening hemorrhage, or with critical ischemia from intimal injury, dissection, or thrombosis. Maintaining the skillset and requisite knowledge to address these injuries is of utmost importance for pediatric surgeons that care for injured children, particularly for surgeons practicing in freestanding children's hospitals that frequently do not have adult vascular surgery coverage. The purpose of this review is to provide an overview of torso vascular trauma, with a specific emphasis in rapid recognition of torso vascular injury as well as both open and endovascular management options. Specific injuries addressed include blunt and penetrating mediastinal vascular injury, subclavian injury, abdominal aortic and visceral segment injury, inferior vena cava injury, and pelvic vascular injury. Operative exposure, vascular repair techniques, and damage control options including preperitoneal packing for pelvic hemorrhage are discussed. The role and limitations of endovascular treatment of each of these injuries is discussed, including endovascular stent graft placement, angioembolization for pelvic hemorrhage, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in children.

Pediatric peripheral vascular injuries and associated orthopedic considerations

Pediatric peripheral vascular trauma is a rare but highly morbid injury in children and is frequently associated with concomitant orthopedic injuries. These children require multidisciplinary care by pediatric, vascular, and orthopedic surgery. In this review, we describe elements of the complex care required for children with peripheral vascular trauma.

Surgical Infections and the Future of Research: Re-Defining the Research Agenda for the Surgical Infection Society

Background: Infections represent a major component of surgical practice. Risk mitigation, seeking eradication and optimal patient outcomes, require a concerted, multifocal effort to understand disease and microbiology, prevent infections, and treat them. The present study was undertaken to re-define the Surgical Infection Society (SIS) research agenda for the next decade. Hypothesis: We utilized the expertise of the SIS membership to identify research questions regarding surgical infections, hypothesizing that consensus among participants could be used to re-define the future research agenda. Methods: Members of the SIS were surveyed using a modified Delphi. The three rounds of the survey were targeted at: question generation; question ranking; and reaching consensus. Each of the 15 questions to emerge was evaluated according to level of consensus, feasibility, and data availability. Results: One hundred twenty-four participants contributed. Initially, 226 questions were generated that were condensed to 35 unique questions for consideration in the subsequent two rounds. The 35 questions encompassed several research themes, with antibiotic prophylaxis (n = 8), prevention of surgical site infections (SSIs; n = 6), and improved diagnostics (n = 5) being most common. Standard deviation of importance scores was inversely proportional to the question rank, indicating greater consensus among higher ranking questions. All 15 questions had a feasibility score of greater than three (five-point Likert scale), and the majority (12/15) had a mean data availability score of less than three. In the final round of the survey, the top three topics for further research surrounded non-antimicrobial treatments, optimal treatment duration for bacteremia, and treatment duration for necrotizing soft tissue infections. Conclusions: Using a modified Delphi process, 15 research questions addressing surgical infections were identified. Such questions can assist the SIS and the SIS Foundation for Research and Education in prioritizing and enabling research efforts, and development of a strategic research plan for the next decade.

Contemporary management of pediatric open skull fractures: a multicenter pediatric trauma center study

OBJECTIVE

The authors sought to evaluate the contemporary management of pediatric open skull fractures and assess the impact of variations in antibiotic and operative management on the incidence of infectious complications.

METHODS

The records of children who presented from 2009 to 2017 to 6 pediatric trauma centers with an open calvarial skull fracture were reviewed. Data collected included mechanism and anatomical site of injury; presence and depth of fracture depression; antibiotic choice, route, and duration; operative management; and infectious complications.

RESULTS

Of the fractures among the 138 patients included in the study, 48.6% were frontal and 80.4% were depressed; 58.7% of patients underwent fragment elevation. The average duration of intravenous antibiotics was 4.6 (range 0-21) days. Only 53 patients (38.4%) received a single intravenous antibiotic for fewer than 4 days. and 56 (40.6%) received oral antibiotics for an average of 7.3 (range 1-20) days. Wounds were managed exclusively in the emergency department in 28.3% of patients. Two children had infectious complications, including a late-presenting hardware infection and a superficial wound infection. There were no cases of meningitis or intracranial abscess. Neither antibiotic spectrum or duration nor bedside irrigation was associated with the development of infection.

CONCLUSIONS

The incidence of infectious complications in this population of children with open skull fractures was low and was not associated with the antibiotic strategy or site of wound care. Most minimally contaminated open skull fractures are probably best managed with a short duration of a single antibiotic, and emergency department closure is appropriate unless there is significant contamination or fragment elevation is necessary.

Parenteral nutrition prolongs hospital stay in children with nonoperative blunt pancreatic injury: A propensity score weighted analysis

BACKGROUND

Blunt pancreatic injury is frequently managed nonoperatively in children. Nutritional support practices - either enteral or parenteral - are heterogeneous and lack evidence-based guidelines. We hypothesized that use of parenteral nutrition (PN) in children with nonoperatively managed blunt pancreatic injury would 1) be associated with longer hospital stay and more frequent complications, and 2) differ in frequency by trauma center type.

METHODS

We conducted a retrospective cohort study using the National Trauma Data Bank (2007-2016). Children (≤18 years) with blunt pancreatic injury were included. Patients were excluded for duodenal injury, mortality <4 days from admission, or laparotomy. We compared children that received versus those that did not receive PN. Logistic regression was used to model patient characteristics, injury severity, and trauma center type as predictors for propensity to receive PN. Treatment groups were balanced using the inverse probability of treatment weights. Outcomes included hospital length of stay, intensive care unit days, incidence of complications and mortality.

RESULTS

554 children with blunt pancreatic injury were analyzed. PN use declined in adult centers from 2012 to 2016, but remained relatively stable in pediatric centers. Propensity-weighted analysis demonstrated longer median length of stay in patients receiving PN (14 versus 4 days, rate ratio 2.19 [95% CI: 1.97, 2.43]). Children receiving PN also had longer ICU stay (rate ratio 1.73 [95% CI: 1.30, 2.30]). There was no significant difference in incidence of complications or mortality.

CONCLUSIONS

Use of PN in children with blunt pancreatic injury that are managed nonoperatively differs between adult and pediatric trauma centers, and is associated with longer hospital stay. Early enteral feeding should be attempted first, with PN reserved for children with prolonged intolerance to enteral feeds.

LEVEL OF EVIDENCE

III, Retrospective cohort.

The Pediatric Critical Care Trauma Scientist Development: Building a Community of Scientists for the Fields of Pediatric Critical Care and Trauma Surgery

OBJECTIVES

To assess the National Institute of Child Health and Human Development's Pediatric Critical Care Trauma Scientist Development Program national K12 program.

DESIGN

Mixed-methods study.

SETTING

Pediatric Critical Care Trauma Scientist Development Program participants from 2005 to 2018.

SUBJECTS

Past participants in the Pediatric Critical Care Trauma Scientist Development Program, including those who received funding (scholars), those who did not receive funding (applicants), and those who participated as diversity fellows.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirty-four past scholars, participants, and fellows in the Pediatric Critical Care Trauma Scientist Development were interviewed, including 19 women (56%) and 15 men (44%) via Skype. Interviews were audio recorded and transcribed, with permission. Codes were developed, using qualitative methods, that included the following: Community Building and Mentorship, Career and Research Development, and Tensions and Growth Opportunities. Quantitative data about physician-scholar grant success were retrieved from the National Institutes of Health system to search for funded grants, RePORT, physician-scholar curriculum vitae, and university websites. Since inception of the program, 46 scholars have been appointed. Scholars are equally split between women and men. Four members of the total cohort (9%) are from under-represented minority groups in medicine. Among the total past 46 participants, 72% of those who completed the K12 achieved an National Institutes of Health K-award and 36% of those not on K-level funding achieved at least one Research Program Grant-level award. All scholars, except one, remain academically active, as noted by recent publications in the peer reviewed literature; scholars from 2005 to 2013 are progressing in their careers, with 60% promoted to associate or full professor.

CONCLUSIONS

The Pediatric Critical Care Trauma Scientist Development Program is reaching its programmatic goals of buildin g a community of scientists in pediatric critical care and trauma surgery as shown by the qualitative analysis. Key challenges include increasing the diversity of applicants, encouraging applicants who are not funded, increasing the rate of K- to R-conversion, and preserving National Institute of Child Health and Human Development Program priorities for national K12 programs and individual K-awards.

Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review

OBJECTIVE

Simulation-based training as an educational intervention for healthcare providers has increased in use over the past 2 decades. The simulation community has called for standardized reporting of methodologies and outcomes. The purpose of this review was to (1) summarize existing data on the use of simulation-based team training for acute trauma resuscitation, and (2) describe differences in training methodologies, outcomes reporting, and gaps in the literature to inform research priorities.

DESIGN

We performed a scoping review of Ovid Medline, Embase, Cochrane Library, CINAHL, Web of Science, ERIC, and Google Scholar for studies evaluating simulation-based team training for acute trauma resuscitation. Full-text review was performed by 2 reviewers and variables related to study design, training methodology, outcomes reported, and impact of training were abstracted.

RESULTS

Forty-seven out of 3,911 screened studies met criteria for inclusion. Only 2 studies were randomized. The most frequent design was a pre-post study (64%). Eleven studies did not report their simulated scenario design. Interventions occurred most frequently in a laboratory-based setting (45%). Simulation-based training was associated with greater knowledge (n = 5/6), higher nontechnical skills (n = 12/13), greater number of resuscitation tasks completed (n = 10/13), and faster time to resuscitation task completion (n = 11/11). No differences in patient outcomes were found (n = 3/3).

CONCLUSIONS

Simulation-based training for trauma resuscitation is associated with improved measures of teamwork, task performance and speed, knowledge, and provider satisfaction. Type of reported outcomes and training methodologies are variable. Standardized reporting of training methodology and outcomes is needed to address the impact of this intervention.

Symptomatic catheter-associated thrombosis in pediatric trauma patients: Choose your access wisely

BACKGROUND

Traumatic injury and the presence of a central venous catheter are 2 of the strongest risk factors for venous thromboembolism in children. The purpose of this study was to determine the incidence of symptomatic, catheter-associated thrombosis in critically injured children. We hypothesized that femoral venous catheters are associated with a greater rate of thrombotic complications when compared with all other central venous access points.

METHODS

We reviewed a retrospective cohort (2006-2016) of injured children (≤18 years) admitted to a pediatric intensive care unit with central access placed ≤7 days from admission. Symptomatic, catheter-associated thrombosis was determined by radiographic evidence. Poisson regression was used to compare the incidence of catheter-associated thrombosis per 1,000 catheter days between femoral and nonfemoral catheters. All comparisons were 2-tailed with α = 0.05.

RESULTS

We examined 209 pediatric trauma patients with central access (65% femoral, 19% subclavian, 11% arm vein, and 5% internal jugular). Femoral catheters were removed earlier (median [interquartile range] 4 [2-7] vs 8 [3-12] days, P < .001) and were larger in diameter (5 Fr [4-7] vs 4 Fr [4-4], P < .001) when compared with all other catheters. Catheter-associated thrombosis was more frequent in femoral versus nonfemoral catheters (18.4 vs 3.5 per 1,000 catheter days, P = .01).

CONCLUSION

Femoral venous catheters are associated with a greater incidence of symptomatic, catheter-associated thrombosis in pediatric trauma patients. When central venous access is indicated for injured children, the femoral site should be avoided. If a femoral venous catheter is necessary, use of a smaller catheter should be considered.

Interactive Education is Associated With Lower Incidence of Pedestrian-Related Injury in Children

BACKGROUND

Pedestrian-related injuries are a significant contributor to preventable mortality and disability in children. We hypothesized that interactive pedestrian safety education is associated with increased knowledge, safe crosswalk behaviors, and lower incidence of pedestrian-related injuries in elementary school-aged children.

METHODS

An interactive street-crossing simulation was implemented at target elementary schools in Los Angeles County beginning in 2009. Mixed-methods were used to evaluate the impact of this intervention. Multiple-choice examinations were used to test pedestrian safety knowledge, anonymous observations were used to assess street-crossing behaviors, and statewide traffic records were used to report pedestrian injuries in elementary school-aged (4-11 y) children in participating school districts. Pedestrian injury incidence was compared 1 y before and after the intervention, standardized to the incidence in the entire City of Los Angeles.

RESULTS

A total of 1424 and 1522 children completed the pretest and post-test, respectively. Correct answers increased for nine of ten questions (all P < 0.01). Children more frequently looked both ways before crossing the street after the intervention (10% versus 41%, P < 0.001). There were 6 reported pedestrian-related injuries in intervention school districts in the year before the intervention and 2 injuries in the year after the intervention, resulting in a significantly lower injury incidence (standardized rate ratio 0.28; 95% CI, 0.11-0.73).

CONCLUSION

Pedestrian safety education at Los Angeles elementary schools was associated with increased knowledge, safe street-crossing behavior, and lower incidence of pediatric pedestrian-related injury. Formal pedestrian safety education should be considered with injury prevention efforts in similar urban communities.

Pediatric trauma-associated acute respiratory distress syndrome: Incidence, risk factors, and outcomes

BACKGROUND/PURPOSE

Acute Respiratory Distress Syndrome (ARDS) results in significant morbidity and mortality in pediatric trauma victims. The objective of this study was to determine risk factors and outcomes specifically related to pediatric trauma-associated ARDS (PT-ARDS).

METHODS

A retrospective cohort (2007-2014) of children ≤18 years old from the American College of Surgeons National Trauma Data Bank (NTDB) was used to analyze incidence, risk factors, and outcomes related to PT-ARDS.

RESULTS

PT-ARDS was identified in 0.5% (2660/488,381) of the analysis cohort, with an associated mortality of 18.6% (494/2660). Mortality in patients with PT-ARDS most commonly occurred in the first week after injury. Risk factors associated with the development of PTARDS included nonaccidental trauma, near drowning, severe injury (AIS ≥ 3) to the head or chest, pneumonia, sepsis, thoracotomy, laparotomy, transfusion, and total parenteral nutrition use. After adjustment for age, injury complexity, injury mechanism, and physiologic variables, PT-ARDS was found to be independently associated with higher mortality (adjusted OR 1.33, 95% CI 1.18-1.51, p < 0.001).

CONCLUSIONS

PT-ARDS is a rare complication in pediatric trauma patients, but is associated with substantial mortality within 7 days of injury. Recognition and initiation of lung-protective measures early in the postinjury course may represent the best opportunity to change outcomes.

LEVEL OF EVIDENCE

Level 3 - Epidemiologic.

Variability in the evalution of pediatric blunt abdominal trauma

PURPOSE

To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT).

METHODS

Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed.

RESULTS

2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use.

CONCLUSIONS

Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma.

LEVEL OF EVIDENCE

Level II.

Pediatric firearm injuries in Los Angeles County: Younger children are more likely to be the victims of unintentional firearm injury

BACKGROUND

Firearm injuries are now the third leading cause of death in children. Understanding the circumstances surrounding pediatric firearm injuries will allow for targeted injury prevention efforts. We hypothesized that younger children are more likely to be victims of unintentional firearm injury.

METHODS

A multicenter, retrospective review of patients <18 years old who sustained firearm injuries in Los Angeles County from 2006 to 2015 was performed. Unintentional injuries were defined as accidental firearm discharge without violent intent. Intentional injuries were defined as firearm discharge with intent to injure (including suicide).

RESULTS

After review of 304 pediatric firearm injuries, 206 had sufficient narrative to determine intent with 10% of injuries classified as unintentional. Unintentional injuries were more common in younger children, more frequently caused by a firearm from within the home, and more likely to involve friend/family (all p < 0.05). Intentional injuries were associated with more injuries and accounted for all deaths in our study cohort.

CONCLUSIONS

In pediatric firearm injury, younger children are more susceptible to unintentional injuries, but intentional injuries are more common overall. Future interventions need to target both intentional violence in older children and unintentional firearm injury in young children if the frequency is to be reduced.

TYPE OF STUDY

Epidemiologic study.

LEVEL OF EVIDENCE

Level III.

Impact of Simulation-Based Training on Perceived Provider Confidence in Acute Multidisciplinary Pediatric Trauma Resuscitation

PURPOSE

Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients.

METHODS

An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children's hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation.

RESULTS

Survey response rate was 49% (n = 93/190) pre-simulation, 22% (n = 42/190) post-simulation, and 79% (n = 150/190) at 2-year follow-up. These providers reported more anxiety (p = 0.01) and less confidence (p = 0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p = 0.02) and greater confidence (p = 0.01), compared to untrained providers.

CONCLUSIONS

Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence.

LEVEL OF EVIDENCE

II, Prospective cohort.

Simulation-based training for trauma resuscitation among ACS TQIP-Pediatric centers: Understanding prevalence of use, associated center characteristics, training factors, and implementation barriers

BACKGROUND

Simulation-based training (SBT) for pediatric trauma resuscitation can improve team performance. The purpose of this study was to describe the nationwide trend in SBT use and barriers to SBT implementation.

METHODS

Trauma centers that participated in ACS TQIP Pediatric in 2016 (N = 125) were surveyed about SBT use. Center characteristics and reported implementation barriers were compared between centers using and not using SBT.

RESULTS

Survey response rate was 75% (94/125) with 78% (73/94) reporting SBT use. The frequency of pediatric SBT use increased from 2014 to 2016 (median 5.5 vs 6.5 annual sessions, p < 0.01). Funding barriers were negatively associated with number of annual SBT sessions (r ≤ -0.34, p < 0.05). Centers not using SBT reported lack of technical expertise (p = 0.01) and lack of data supporting SBT (p = 0.03) as significant barriers.

CONCLUSIONS

Simulation use increased from 2014 to 2016, but significant barriers to implementation exist. Strategies to share resources and decrease costs may improve usage.

LEVEL OF EVIDENCE

Level 3, epidemiological.

Pediatric dog bites: a population-based profile

BACKGROUND

Previous studies have identified risk factors for dog bites in children, but use data from individual trauma centers, with limited generalizability. This study identifies a population risk profile for pediatric dog bites using the National Trauma Data Bank. We hypothesized that the population at risk was younger boys, that such bites occur at home, are moderately severe, and are on the face or neck.

METHODS

For this retrospective cross-sectional study, a sample of 7912 children 17 years old and younger with International Classification of Diseases (ICD)-9 event code E906.0, for dog bites, were identified. Datasets from 2007 to 2014 were used. Data included patient's gender, age, ICD-9 primary and location E-codes, AIS body region and AIS severity.

RESULTS

Most children were 6-12 years old and female, but a similar number fell into the narrower range of 0-2 years old. Injuries in the younger group frequently occurred at home, on the face and head, and with minor severity. Age of the child predicts the location of incident (P<0.001), the severity of injury (P<0.001) and the body region of the injury (P<0.001). Body region of the injury predicted its severity (P<0.001).

DISCUSSION

Younger children are more likely to receive dog bites, and bites incurred are likely of greater severity. Children this young cannot yet be taught how to properly interact with a dog.

CONCLUSIONS

Dog bites are a significant source of morbidity for children. Based on the population risk factors profile generated, this study recommends targeting live dog education towards the parents of young children.

Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis

BACKGROUND/PURPOSE

The classic "trimodal" distribution of death has been described in adult patients, but the timing of mortality in injured children is not well understood. The purpose of this study was to define the temporal distribution of mortality in pediatric trauma patients.

METHODS

A retrospective cohort of patients with mortality from the National Trauma Data Bank (2007-2014) was analyzed. Categorical comparison of 'dead on arrival', 'death in the emergency department', and early (≤24h) or late (>24h) inpatient death was performed. Secondary analyses included mortality by pediatric age, predictors of early mortality, and late complication rates.

RESULTS

Children (N=5463 deaths) had earlier temporal distribution of death compared to adults (n=104,225 deaths), with 51% of children dead on arrival or in ED compared to 44% of adults (p<0.001). For patients surviving ED resuscitation, children and adolescents had a shorter median time to death than adults (1.2 d and 0.8 days versus 1.6 days, p<0.001). Older age, penetrating mechanism, bradycardia, hypotension, tube thoracostomy, and thoracotomy were associated with early mortality in children.

CONCLUSIONS

Injured children have higher incidence of early mortality compared to adults. This suggests that injury prevention efforts and strategies for improving early resuscitation have potential to improve mortality after pediatric injury.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Utilization patterns of extracorporeal membrane oxygenation in neonates in the United States 1997-2012

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) remains one of the most intensive therapies for newborns in the United States. However, there is limited information on resource utilization for neonates receiving ECMO.

METHODS

We conducted a retrospective data analysis of the Kids' Inpatient Database from 1997 to 2012. Bivariate and multivariate analysis was completed to identify predictors of LOS, hospital costs and mortality. Cardiac and non-cardiac diagnoses of neonates receiving ECMO were also included in the bivariate and multivariable analysis.

RESULTS

Of the 5151 ECMO cases, survival to discharge was 62%. 22% had a principal cardiac diagnosis. After adjusting for covariates, increased mortality was associated with treatment in the midwest compared to the northeast region (aOR=2.0, p<0.01) and decreased among neonates with a non-cardiac diagnosis (aOR=0.4, p<0.01). Living in midwest was associated with longer LOS by 13days and increased hospital costs by 63,000 dollars (p<0.01). When stratified by non-cardiac diagnoses, infants with a diagnosis of congenital diaphragmatic hernia was associated with increased mortality (2.3, p<0.01) and longer LOS (25, p<0.01) and increased costs (11,100, p<0.01).

CONCLUSION

Neonates who received ECMO in certain regions of the United States were associated with poorer survival outcomes as well as increased LOS and hospital costs.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

Level III.

The impact of acute coagulopathy on mortality in pediatric trauma patients

BACKGROUND

Traumatic coagulopathy (TC) occurs in 24% to 38% of adults and is associated with up to a six-fold increase in mortality. This study's purpose was to determine the incidence of pediatric TC and its impact on mortality.

METHODS

A retrospective review (2004-2009) of all trauma patients from our Level I trauma center was performed. Coagulopathy was defined as an international normalized ratio of 1.5 or higher or activated partial thromboplastin time of more than 36 seconds or platelets less than 100,000/mm. Clinical outcomes were compared between pediatric (younger than 16 years) and adult patients (≥16 years or older).

RESULTS

A total of 20,126 patients were identified (7.6% pediatric, 92.4% adult). Mean ± SD age was 8.7 ± 4.8 years for pediatric patients and 37.6 ± 16.7 years for adults. The incidence of admission coagulopathy was lower in children (5.8% vs. 8.4%; p < 0.001). Pediatric patients were less likely to develop coagulopathy (8.4% vs. 12.4%; p < 0.001) and developed coagulopathy later than adults (102.3 ± 123.2 hours vs. 59.2 ± 1,823.9 hours; p < 0.001). Traumatic brain injury (TBI) and non-TBI-related coagulopathy increased in stepwise fashion with age (up to 19.5% in elderly). Adult and pediatric TC was associated with increased mortality (pediatric: 14.4% vs. 0.5%; p = 0.02; adult: 18.3% vs. 1.8%; p < 0.001).

CONCLUSIONS

Pediatric trauma patients are less likely to present with coagulopathy, are less likely to develop coagulopathy during their admission, and tend to develop coagulopathy later than adults. If they develop coagulopathy, however, mortality increases in a stepwise fashion with age and is associated with a two- to four-fold increased risk of death.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Specific Etiologies Associated With the Multiple Organ Dysfunction Syndrome in Children: Part 1

OBJECTIVE

To describe a number of the conditions associated with multiple organ dysfunction syndrome presented as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015).

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by the relevant literature.

CONCLUSIONS

There is a wide range of medical conditions associated with multiple organ dysfunction syndrome in children. Traditionally, sepsis and trauma are the two conditions most commonly associated with multiple organ dysfunction syndrome both in children and adults. However, there are a number of other pathophysiologic processes that may result in multiple organ dysfunction syndrome. In this article, we discuss conditions such as cancer, congenital heart disease, and acute respiratory distress syndrome. In addition, the relationship between multiple organ dysfunction syndrome and clinical therapies such as hematopoietic stem cell transplantation and cardiopulmonary bypass is also considered. The purpose of this article is to describe the association of multiple organ dysfunction syndrome with a variety of conditions in an attempt to identify similarities, differences, and opportunities for therapeutic intervention.

Pediatric Trauma Assessment and Management Database: Leveraging Existing Data Systems to Predict Mortality and Functional Status after Pediatric Injury

BACKGROUND

Efforts to improve pediatric trauma outcomes need detailed data, optimally collected at lowest cost, to assess processes of care. We developed a novel database by merging 2 national data systems for 5 pediatric trauma centers to provide benchmarking metrics for mortality and non-mortality outcomes and to assess care provided throughout the care continuum.

STUDY DESIGN

Trauma registry and Virtual Pediatric Systems, LLC (VPS) from 5 pediatric trauma centers were merged for children younger than 18 years discharged in 2013 from a pediatric ICU after traumatic injury. For inpatient mortality, we compared risk-adjusted models for trauma registry only, VPS only, and a combination of trauma registry and VPS variables (trauma registry+VPS). To estimate risk-adjusted functional status, we created a prediction model de novo through purposeful covariate selection using dichotomized Pediatric Overall Performance Category scale.

RESULTS

Of 688 children included, 77.3% were discharged from the ICU with good performance or mild overall disability and 17.6% with moderate or severe overall disability or coma. Inpatient mortality was 5.1%. The combined dataset provided the best-performing risk-adjusted model for predicting mortality, as measured by the C-statistic, pseudo-R², and Akaike Information Criterion, when compared with the trauma registry-only model. The final Pediatric Overall Performance Category model demonstrated adequate discrimination (C-statistic = 0.896) and calibration (Hosmer-Lemeshow goodness-of-fit p = 0.65). The probability of poor outcomes varied significantly by site (p < 0.0001).

CONCLUSIONS

Merging 2 data systems allowed for improved risk-adjusted modeling for mortality and functional status. The merged database allowed for patient evaluation throughout the care continuum on a multi-institutional level. Merging existing data is feasible, innovative, and has potential to impact care with minimal new resources.

The Role of Adult Perceptions and Supervision Behavior in Preventing Child Injury

Supervision is an important factor in reducing injury risk. There are multiple factors that can affect the appropriate level of supervision including risk perception, anticipation of injury, and distracted behaviors. This study examined the perceived risks of child injury among parents and child caregivers and their supervision behavior among adults in an urban playground. Participant data from 25 individuals were collected through observations and anonymous self-reported surveys. More than half of the participants indicated practice of appropriate supervisory behavior, including attentiveness to their child's behavior and proximity to their child during play. Caregivers were more likely to report more careful levels of supervision. One-fourth of participants reported a change in the supervisory behavior during periods of distraction, specifically with phone use. Of the variables tested, there was a significant association between the variable 'talking to other adults' during supervision and 'prior injury' (P value = 0.04, 95% CI 0.03-0.91). Parents were more likely to report that they would leave their child unattended if they believed that the playground was a safe environment for play. There was a difference between self-reported behaviors and actual observed behavior, which is likely due to varying perspectives regarding child safety and injury prevention. In regards to injury risk, findings highlight the important role of appropriate supervisory behaviors and risk perceptions in preventing child injuries.

Factors associated with preparedness of the US healthcare system to respond to a pediatric surge during an infectious disease pandemic: Is our nation prepared?

OBJECTIVE

Recent incidents have demonstrated that the US health system is unprepared for infectious pandemics resulting in a pediatric surge. Development of efficient plans and a structured and coordinated regional response to pediatric pandemic surge remains an opportunity. To address this gap, we conducted a literature review to assess current efforts, propose a response plan structure, and recommend policy actions.

DESIGN

A literature review, utilizing MEDLINE and PubMed, through March 2017 identified articles regarding infectious disease pandemics affecting the US pediatric population. After review of current literature, a proposed response plan structure for a pediatric pandemic surge was designed.

RESULTS

Inclusion and exclusion criteria reduced an initial screening of 1,787 articles to 162 articles. Articles ranged in their discussion of pediatric pandemic surge. Review of the articles led to the proposal of organizing the results according to 4 S's; (1) Structure, (2) Staff, (3) Stuff (Resources), and (4) Space.

CONCLUSION

The review has supported the concern that the US health system is unprepared for a pediatric surge induced by infectious disease pandemics. Common themes suggest that response plans should reflect the 4Ss and national guidelines must be translated into regional response systems that account for local nuances.

Surgical Infection Society Curriculum Development Symposium: An Overview

Hospital-acquired infections, sepsis, and critically ill patients cost the healthcare system billions of dollars every year. Many factors contribute to these problems, and the remedies are multifactorial. Education is an important component in resolving many of the issues related to better combating the economic, social, and personal costs associated with surgical infections. The Surgical Infection Society (SIS) convened a symposium to begin a dialogue on how the SIS can facilitate a better understanding of how to educate the surgical infection professionals and trainees. The following report summarizes the presentations and commentary presented at the 2013 Annual Meeting.

Observed child restraint misuse in a large, urban community: Results from three years of inspection events

PROBLEM

Child restraints (CRs) are vital for optimizing child passenger safety and reducing the risk of pediatric injury and fatality in motor vehicle crashes. However, most CRs are installed improperly.

METHODS

This present study was an assessment of observed instances of CR misuse. Participants were recruited through advertisements for CR inspection events in Los Angeles County, California. Child Passenger Safety Technicians collected information about each child passenger, vehicle, and aspects of CR selection and installation.

RESULTS

Of 693 CRs installed upon arrival, only 3.8% were used with no instances of misuse. The most common misuses were inappropriate use of the top tether and failure to secure the seatbelt in locked mode.

CONCLUSIONS

The majority of observed CRs were installed with instances of misuse. CRs in newer vehicles were less likely to be installed in front of airbags and more likely to have the seatbelt routed inappropriately compared to those in older vehicles. Older children were more likely to be prematurely restrained in the front vehicle seat.

PRACTICAL APPLICATIONS

The majority of CRs are installed improperly. We identified specific instances of CR misuse that are common in a large, urban community and present recommendations to improve child passenger safety practices and education.

Mixed-Methods Pilot Study: Disaster Preparedness of Families With Children Followed in an Intestinal Rehabilitation Clinic

BACKGROUND

Children with special healthcare needs are a vulnerable population in disasters. Special-needs families tend to be less prepared for a disaster than the general public. The purpose of this pilot project was to examine the disaster preparedness levels of families in an intestinal rehabilitation (IR) clinic.

MATERIALS AND METHODS

We administered an anonymous survey to a convenience sample of IR clinic families and conducted 2 focus groups. Descriptive analyses were used for survey data; Atlas.ti was used to analyze focus group data.

RESULTS

Survey findings revealed that 69% of families lacked an emergency supply kit, and 93% did not have a clinician-completed emergency information form. On a scale of 1-10, the mean confidence in their family's disaster preparations was 4.9. The overarching theme from focus group discussions was challenges and/or barriers to disaster preparedness.

CONCLUSION

IR clinic families are generally unprepared for a disaster. These findings are highly relevant to our goal of developing a disaster survival toolkit for the IR families. Toolkits are being distributed in the IR clinic.

Assessing medical care availability for student athletes of a large urban high school district

BACKGROUND

The need for medical care for student athletes is mounting, as participation in high school athletics is continuing to rise. This study assessed medical care available to high school student athletes in a large, urban school district in California that has not been studied since 2002. By surveying athletic directors and coaches, we expected to find inadequate availability of medical care in the studied district and predicted that care would be more widely available for student athletes at larger high schools.

METHODS

We developed and validated a questionnaire assessing practice and game coverage, emergency preparedness, treatment, and injury prevention measures. The survey was administered to athletic directors and coaches at a school district athletic directors' meeting.

RESULTS

Forty-three (57%) of 75 distributed surveys were completed. We found that 70% of schools did not staff a healthcare provider for practices, 28% did not staff home games, and 30% did not staff away games, for any sports. We found no significant differences between school sizes with respect to physician referrals after a student was injured, provision of health education, or implementation of emergency action plans.

CONCLUSIONS

Although these data do not support our hypothesis of larger schools providing better medical care, it suggests that there are multiple areas of inadequate healthcare regardless of school size. We identified numerous gaps; thus, future work will examine the impact of these gaps.

Assessment of parental knowledge and attitudes toward pediatric sports-related concussions

Background:

Parents of young athletes play a major role in the identification and management of sports-related concussions. However, they are often unaware of the consequences of concussions and recommended management techniques.

Hypothesis:

This study quantitatively assessed parental understanding of concussions to identify specific populations in need of additional education. We predicted that parents with increased education and prior sports- and concussion-related experience would have more knowledge and safer attitudes toward concussions.

Study Design:

Cross-sectional survey.

Level of Evidence:

Level 5.

Methods:

Participants were parents of children brought to a pediatric hospital and 4 satellite clinics for evaluation of orthopaedic injuries. Participants completed a validated questionnaire that assessed knowledge of concussion symptoms, attitudes regarding diagnosis and return-to-play guidelines, and previous sports- and concussion-related experience.

Results:

Over 8 months, 214 parents completed surveys. Participants scored an average of 18.4 (possible, 0-25) on the Concussion Knowledge Index and 63.1 (possible, 15-75) on the Concussion Attitude Index. Attitudes were safest among white women, and knowledge increased with income and education levels. Previous sports experience did not affect knowledge or attitudes, but parents who reported experiencing an undiagnosed concussion had significantly better concussion knowledge than those who did not.

Conclusion:

Parents with low income and education levels may benefit from additional concussion-related education.

Clinical Relevance:

There exist many opportunities for improvement in parental knowledge and attitudes about pediatric sports-related concussions. Ongoing efforts to understand parental knowledge of concussions will inform the development of a strategic and tailored approach to the prevention and management of pediatric concussions.

Academic-Community Partnership to Develop a Novel Disaster Training Tool for School Nurses: Emergency Triage Drill Kit

As children spend approximately 28% of their day in school and disasters may strike at any time, it is important for school officials to conduct emergency preparedness activities. School nurses, teachers, and staff should be prepared to respond and provide support and first aid treatment. This article describes a collaborative effort within the Los Angeles Unified School District to enhance disaster preparedness. Specifically, the article outlines the program steps and tools developed to prepare staff in mass triage through an earthquake disaster training exercise.

Engagement and education: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Engagement and education of ICU clinicians in disaster preparedness is fragmented by time constraints and institutional barriers and frequently occurs during a disaster. We reviewed the existing literature from 2007 to April 2013 and expert opinions about clinician engagement and education for critical care during a pandemic or disaster and offer suggestions for integrating ICU clinicians into planning and response. The suggestions in this article are important for all of those involved in a pandemic or large-scale disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

A systematic literature review was performed and suggestions formulated according to the American College of Chest Physicians (CHEST) Consensus Statement development methodology. We assessed articles, documents, reports, and gray literature reported since 2007. Following expert-informed sorting and review of the literature, key priority areas and questions were developed. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Twenty-three suggestions were formulated based on literature-informed consensus opinion. These suggestions are grouped according to the following thematic elements: (1) situational awareness, (2) clinician roles and responsibilities, (3) education, and (4) community engagement. Together, these four elements are considered to form the basis for effective ICU clinician engagement for mass critical care.

CONCLUSIONS

The optimal engagement of the ICU clinical team in caring for large numbers of critically ill patients due to a pandemic or disaster will require a departure from the routine independent systems operating in hospitals. An effective response will require robust information systems; coordination among clinicians, hospitals, and governmental organizations; pre-event engagement of relevant stakeholders; and standardized core competencies for the education and training of critical care clinicians.