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Sullivan TM, Sippel GJ, Gestrich-Thompson WV, Jensen AR, Burd RS. Survival bias in pediatric hemorrhagic shock: Are we misrepresenting the data? J Trauma Acute Care Surg 2024; 96:785-792. [PMID: 37752639 DOI: 10.1097/ta.0000000000004119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. METHODS We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. RESULTS We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. CONCLUSION Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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MESH Headings
- Humans
- Shock, Hemorrhagic/therapy
- Shock, Hemorrhagic/mortality
- Shock, Hemorrhagic/etiology
- Shock, Hemorrhagic/diagnosis
- Child
- Female
- Male
- Retrospective Studies
- Adolescent
- Blood Transfusion/statistics & numerical data
- Child, Preschool
- Infant
- Bias
- Wounds, Penetrating/mortality
- Wounds, Penetrating/therapy
- Wounds, Penetrating/complications
- Wounds, Penetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/complications
- Resuscitation/methods
- Resuscitation/statistics & numerical data
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Affiliation(s)
- Travis M Sullivan
- From the Division of Trauma and Burn Surgery (T.M.S., G.J.S., W.V.G.-T., R.S.B.), Children's National Hospital, Washington, DC; Department of Surgery (A.R.J.), University of California San Francisco; and Division of Pediatric Surgery (A.R.J.), UCSF Benioff Children's Hospitals, San Francisco, CA
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Mehl SC, Vogel AM, Glasgow AE, Moody S, Kotagal M, Williams RF, Kayton ML, Alberto EC, Burd RS, Schroeppel TJ, Baerg JE, Munoz A, Rothstein WB, Boomer LA, Campion EM, Robinson C, Nygaard RM, Richardson CJ, Garcia DI, Streck CJ, Gaffley M, Petty JK, Greenwell C, Pandya S, Waters AM, Russell RT, Yorkgitis BK, Mull J, Pence J, Santore MT, MacArthur TA, Klinkner DB, Safford SD, Trevilian T, Cunningham M, Black C, Rea J, Spurrier RG, Jensen AR, Farr BJ, Mooney DP, Ketha B, Dassinger MS, Goldenberg-Sandau A, Roman JS, Jenkins TM, Falcone RA, Polites SF. Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children. J Trauma Acute Care Surg 2024:01586154-990000000-00661. [PMID: 38497936 DOI: 10.1097/ta.0000000000004301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE Prospective cohort study, Level II.
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Affiliation(s)
- Steven C Mehl
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Adam M Vogel
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Suzanne Moody
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meera Kotagal
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Mark L Kayton
- Department of Surgery, K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Hackensack-Meridian Health Network, Neptune, New Jersey
| | | | | | | | | | | | - William B Rothstein
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
| | - Laura A Boomer
- Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
| | | | | | | | | | - Denise I Garcia
- The Medical University of South Carolina, Charleston, South Carolina
| | | | - Michaela Gaffley
- Wake Forest University School of Medicine, Brenner Children's Hospital, Winston-Salem, North Carolina
| | - John K Petty
- Wake Forest University School of Medicine, Brenner Children's Hospital, Winston-Salem, North Carolina
| | | | | | | | | | - Brian K Yorkgitis
- College of Medicine, University of Florida - Jacksonville, Jacksonville, Florida
| | - Jennifer Mull
- College of Medicine, University of Florida - Jacksonville, Jacksonville, Florida
| | | | | | | | | | - Shawn D Safford
- University of Pittsburgh Medical Center, Harrisburg, Pennsylvania
| | - Tanya Trevilian
- Carilion Children's Hospital, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Megan Cunningham
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Christa Black
- ProMedica Toledo and Toledo Children's Hospital, Toledo, Ohio
| | - Jessica Rea
- Children's Hospital Los Angeles, Los Angeles, California
| | | | - Aaron R Jensen
- Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | | | - Bavana Ketha
- Arkansas Children's Hospital, Little Rock, Arkansas
| | | | | | | | - Todd M Jenkins
- Mayo Clinic, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Richard A Falcone
- Mayo Clinic, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
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Melhado C, Evans LL, Miskovic A, Subacius H, Nathens AB, Stein DM, Burd RS, Jensen AR. Benchmarking Pediatric Trauma Care in Mixed Trauma Centers: Adult Risk-Adjusted Mortality Is Not a Reliable Indicator of Pediatric Outcomes. J Am Coll Surg 2024; 238:243-251. [PMID: 38059567 DOI: 10.1097/xcs.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND Trauma center benchmarking has become standard practice for assessing quality. The American College of Surgeons adult trauma center verification standards do not specifically require participation in a pediatric-specific benchmarking program. Centers that treat adults and children may therefore rely solely on adult benchmarking metrics as a surrogate for pediatric quality. This study assessed discordance between adult and pediatric mortality within mixed trauma centers to determine the need to independently report pediatric-specific quality metrics. STUDY DESIGN A cohort of trauma centers (n = 493, including 347 adult-only, 44 pediatric-only, and 102 mixed) that participated in the American College of Surgeons TQIP in 2017 to 2018 was analyzed. Center-specific observed-to-expected mortality estimates were calculated using TQIP adult inclusion criteria for 449 centers treating adults (16 to 65 years) and using TQIP pediatric inclusion criteria for 146 centers treating children (0 to 15 years). We then correlated risk-adjusted mortality estimates for pediatric and adult patients within mixed centers and evaluated concordance of their outlier status between adults and children. RESULTS The cohort included 394,075 adults and 97,698 children. Unadjusted mortality was 6.1% in adults and 1.2% in children. Mortality estimates had only moderate correlation ( r = 0.41) between adult and pediatric cohorts within individual mixed centers. Mortality outlier status for adult and pediatric cohorts was discordant in 31% (32 of 102) of mixed centers (weighted Kappa statistic 0.06 [-0.11 to 0.22]), with 78% (23 of 32) of discordant centers having higher odds of mortality for children than for adults (6 centers with average adult mortality and high pediatric mortality and 17 centers with low adult mortality and average pediatric mortality, p < 0.01). CONCLUSIONS Adult mortality is not a reliable surrogate for pediatric mortality in mixed trauma centers. Incorporation of pediatric-specific benchmarks should be required for centers that admit children.
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Affiliation(s)
- Caroline Melhado
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
| | - Lauren L Evans
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
| | - Amy Miskovic
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
| | - Haris Subacius
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
| | - Avery B Nathens
- American College of Surgeons, Chicago, IL (Miskovic, Subacius, Nathens)
- Department of Surgery, University of Toronto, Toronto, ON (Nathens)
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Stein)
| | - Randall S Burd
- Division of Burn and Trauma Surgery, Children's National Medical Center, Washington, DC (Burd)
| | - Aaron R Jensen
- From the Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA (Melhado, Evans, Jensen)
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Melhado, Evans, Jensen)
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Sullivan TM, Sippel GJ, Gestrich-Thompson WV, Burd RS. Strategies to Obtain and Deliver Blood Products Into Critically Injured Children: A Survey of Pediatric Trauma Society Members. Pediatr Emerg Care 2024; 40:124-127. [PMID: 38286002 PMCID: PMC10842851 DOI: 10.1097/pec.0000000000003118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
OBJECTIVES Timely transfusion is associated with improved survival and a reduction in in-hospital morbidity. The benefits of early hemorrhagic shock recognition may be limited by barriers to accessing blood products and their timely administration. We examined how pediatric trauma programs obtain blood products, the types of rapid infusion models used, and the metrics tracked to improve transfusion process efficiency in their emergency department (ED). METHODS We developed and distributed a self-report survey to members of the Pediatric Trauma Society. The survey consisted of 6 initial questions, including the respondent's role and institution, whether a blood storage refrigerator was present in their ED, the rapid infuser model used to transfuse critically injured children in their ED, if their program tracked 4 transfusion process metrics, and if a video recording system was present in the trauma bay. Based on these responses, additional questions were prompted with an option for a free-text response. RESULTS We received 137 responses from 77 institutions. Most pediatric trauma programs have a blood storage refrigerator in the ED (n = 46, 59.7%) and use a Belmont rapid infuser to transfuse critically injured children (n = 45, 58.4%). The American College of Surgeons Level 1 designated trauma programs, or state-based equivalents, and "pediatric" trauma programs were more likely to have video recording systems for performance improvement review compared with lower designated trauma programs and "combined pediatric and adult" trauma programs, respectively. CONCLUSIONS Strategies to improve the timely acquisition and infusion of blood products to critically injured children are underreported. This study examined the current practices that pediatric trauma programs use to transfuse critically injured children and may provide a resource for trauma programs to cite for transfusion-related quality improvement.
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Affiliation(s)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Genevieve J. Sippel
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | | | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
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Mastrianni A, Hamlin L, Alberto EC, Sullivan TM, Ranganna A, Marsic I, Burd RS, Sarcevic A. Analysis of Task Attributes Associated with Crisis Checklist Compliance in Pediatric Trauma Resuscitation. AMIA Annu Symp Proc 2024; 2023:504-513. [PMID: 38222377 PMCID: PMC10785895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Although checklists can improve overall team performance during medical crises, non-compliant checklist use poses risks to patient safety. We examined how task attributes affected checklist compliance by studying the use of a digital checklist during trauma resuscitation. We first determined task attributes and checklist compliance behaviors for 3,131 resuscitation tasks. Using statistical analyses and qualitative video review, we then identified barriers to accurately tracking task status, finding that certain task attributes were associated with non-compliant checklist behaviors. For example, tasks with multiple steps were more likely to be incorrectly recorded as completed when the task was not performed to completion. We discuss challenges in capturing and tracking the status of tasks with attributes that contribute to non-compliant checklist use. We also contribute a framework for understanding how tasks with certain attributes can be designed on checklists to improve compliance.
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Affiliation(s)
- Angela Mastrianni
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Leah Hamlin
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Emily C Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Travis M Sullivan
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Adesh Ranganna
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ, USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
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Lundine JP, Huling JD, Adelson PD, Burd RS, Fuentes M, Haarbauer-Krupa J, Hagen K, Iske C, Koterba C, Kurowski BG, Petrucci S, Rose SC, Sadowsky CL, Westendorf J, Truelove A, Leonard JC. Using Billing Codes to Create a Pediatric Functional Status e-Score for Children Receiving Inpatient Rehabilitation. Arch Phys Med Rehabil 2023; 104:1882-1891. [PMID: 37075966 PMCID: PMC10579455 DOI: 10.1016/j.apmr.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/15/2023] [Accepted: 03/24/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Provide proof-of-concept for development of a Pediatric Functional Status eScore (PFSeS). Demonstrate that expert clinicians rank billing codes as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling. DESIGN Retrospective chart review, modified Delphi, and nominal group techniques. SETTING Large, urban, quaternary care children's hospital in the Midwestern United States. PARTICIPANTS Data from 1955 unique patients and 2029 hospital admissions (2000-2020); 12 expert consultants representing the continuum of rehabilitation care reviewed 2893 codes (procedural, diagnostic, pharmaceutical, durable medical equipment). MAIN OUTCOME MEASURES Consensus voting to determine whether codes were associated with functional status at discharge and, if so, what domains they informed (self-care, mobility, cognition/ communication). RESULTS The top 250 and 500 codes identified by statistical modeling were mostly composed of codes selected by the consultant panel (78%-80% of the top 250 and 71%-78% of the top 500). The results provide evidence that clinical experts' selection of functionally meaningful codes corresponds with codes selected by statistical modeling as most strongly associated with WeeFIM domain scores. The top 5 codes most strongly related to functional independence ratings from a domain-specific assessment indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS. CONCLUSIONS Development of a PFSeS that is predicated on billing data would improve researchers' ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to 3 important domains: self-care, mobility, and cognition/communication.
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Affiliation(s)
- Jennifer P Lundine
- Department of Speech & Hearing Science, The Ohio State University, Columbus, OH; Division of Clinical Therapies & Inpatient Rehabilitation Program, Nationwide Children's Hospital, Columbus, OH.
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - P David Adelson
- Rockefeller Neuroscience Institute and West Virginia, University Medicine Children's Neuroscience Center, Morgantown, WV
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Molly Fuentes
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | | | - Kaitlin Hagen
- International Center for Spinal Cord Injury, Kennedy Krieger Institute and Johns Hopkins School of Medicine, Baltimore, MD
| | - Cynthia Iske
- Inpatient Rehabilitation Program, Nationwide Children's Hospital, Columbus, OH
| | - Christine Koterba
- Division of Pediatric Psychology and Neuropsychology, Department of Pediatrics, The Ohio State University College of Medicine, and Nationwide Children's Hospital, Columbus, OH
| | - Brad G Kurowski
- Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Departments of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stephanie Petrucci
- Inpatient Rehabilitation Program, Nationwide Children's Hospital, Columbus, OH
| | - Sean C Rose
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
| | - Cristina L Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute and Johns Hopkins School of Medicine, Baltimore, MD
| | - Jennifer Westendorf
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Annie Truelove
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Julie C Leonard
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH; Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, and Nationwide Children's Hospital, Columbus, OH
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Glass NE, Salvi A, Wei R, Lin A, Malveau S, Cook JNB, Mann NC, Burd RS, Jenkins PC, Hansen M, Mohr NM, Stephens C, Fallat ME, Lerner EB, Carr BG, Wall SP, Newgard CD. Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers. JAMA Surg 2023; 158:1078-1087. [PMID: 37556154 PMCID: PMC10413216 DOI: 10.1001/jamasurg.2023.3344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/25/2023] [Indexed: 08/10/2023]
Abstract
Importance Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.
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Affiliation(s)
- Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Ran Wei
- School of Public Policy, University of California, Riverside
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, DC
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City
| | | | - Mary E. Fallat
- Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - E. Brooke Lerner
- Department of Emergency Medicine, University at Buffalo, Buffalo, New York
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephen P. Wall
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York
| | - Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
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8
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Melhado CG, Kao E, Hogan-Schlientz J, Crane D, Shui AM, Stephens CQ, Evans L, Burd RS, Jensen AR. Interrater reliability of chart-based assessment of functional impairment after pediatric injury using the functional status scale. J Trauma Acute Care Surg 2023; 95:391-396. [PMID: 37012628 DOI: 10.1097/ta.0000000000003912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Functional impairment has been proposed as an alternative outcome for quality improvement in pediatric trauma. The functional status scale (FSS) has been used in studies of injured children, but has only been validated with resource-intensive in-person assessment. Implementation with retrospective chart-based FSS assessment would offer a simplified and scalable alternative. The purpose of this study was to evaluate interrater reliability of retrospective FSS assessment and to identify factors associated with unreliable assessment. METHODS A retrospective cohort of admissions to a Level I pediatric trauma center between July 2020 and June 2021 was analyzed. Two physicians and two nurse registrars reviewed charts to obtain measures of six FSS domains (mental status, sensory functioning, communication, motor functioning, feeding, and respiratory status) at discharge. Functional impairment was categorized by total FSS scores as good (6,7), mild impairment (8,9), moderate impairment (10-15), severe impairment (16-21), or very severe impairment (>21). Interrater reliability was assessed using intraclass correlation (ICC). Predictors of rater disagreement were evaluated using multivariable logistic regression. RESULTS The cohort included 443 children with a mean age of 7.4 years (standard deviation, 5.4 years) and median Injury Severity Score of 9 (interquartile range, 5-12). The median time per chart to assess FSS was 2 minutes (interquartile range, 1-2). Thirty-seven patients (8%) had functional impairment at discharge. Interrater reliability was excellent for total FSS score (ICC = 0.87) and good for FSS impairment categorization (ICC = 0.80). Rater disagreement of functional impairment categorization occurred in 14% of cases overall. Higher level of functional impairment and use of therapies (occupational and speech language therapy) were independently associated with more frequent rater disagreement. CONCLUSION Chart-based FSS assessment is feasible and reliable, but may require more detailed review for patients with higher level of impairment that require allied health therapy. Validation of chart-based assessment is needed before widespread implementation. LEVEL OF EVIDENCE Prognostic/Epidemiological, Level III.
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Affiliation(s)
- Caroline G Melhado
- From the Division of Pediatric Surgery (C.G.M., E.K., C.Q.S., L.E., A.R.J.), UCSF Benioff Children's Hospitals; Department of Surgery (C.G.M., E.K., C.Q.S., L.E., A.R.J.), University of California San Francisco, San Francisco; Trauma Program (J.H.-S., D.C., A.R.J.), UCSF Benioff Children's Hospital Oakland, Oakland; Department of Epidemiology & Biostatistics (A.M.S.), University of California San Francisco, San Francisco, California; and Division of Trauma and Burn Surgery (R.S.B.), Children's National Hospital, Washington, District of Columbia
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Newgard CD, Babcock SR, Song X, Remick KE, Gausche-Hill M, Lin A, Malveau S, Mann NC, Nathens AB, Cook JNB, Jenkins PC, Burd RS, Hewes HA, Glass NE, Jensen AR, Fallat ME, Ames SG, Salvi A, McConnell KJ, Ford R, Auerbach M, Bailey J, Riddick TA, Xin H, Kuppermann N. Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated With Survival. Ann Surg 2023; 278:e580-e588. [PMID: 36538639 PMCID: PMC10149578 DOI: 10.1097/sla.0000000000005741] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. BACKGROUND ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. METHODS This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival. RESULTS There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present. CONCLUSIONS ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sean R. Babcock
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Xubo Song
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Katherine E. Remick
- Departments of Pediatrics and Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services, Harbor-UCLA Medical Center, Torrance, California
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, District of Columbia
| | - Hilary A. Hewes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Aaron R. Jensen
- Department of Surgery, University of California, San Francisco, Benioff Children’s Hospitals, San Francisco, California
| | - Mary E. Fallat
- Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky
| | - Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Apoorva Salvi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - K. John McConnell
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Rachel Ford
- Oregon Emergency Medical Services for Children Program, Oregon Health Authority, Portland, Oregon
| | - Marc Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jessica Bailey
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tyne A. Riddick
- Oregon Health & Science University-Portland State University, School of Public Health, Portland, Oregon
| | - Haichang Xin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California
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10
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Melhado CG, Sullivan TM, Stephens CQ, Burd RS, Jensen AR. Functional impairment associated with nonfatal pediatric firearm injuries. Surgery 2023; 174:692-697. [PMID: 37301611 DOI: 10.1016/j.surg.2023.04.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/08/2023] [Accepted: 04/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Firearm injury is now the leading cause of death for children in the United States. Functional morbidity among survivors also contributes to the public health burden of firearm injury but has not been quantified in children. This study aimed to assess functional impairment among survivors of pediatric firearm injury. METHODS We analyzed an 8-year (2014-2022) retrospective cohort of children (0-18 years) treated for firearm injuries at 2 urban level 1 pediatric trauma centers. The Functional Status Scale was used to assess functional impairment among survivors at discharge and at follow-up. Functional impairment was defined using multisystem (Functional Status Scale ≥8) and single-system (Functional Status Scale = 7) definitions. RESULTS The cohort included 282 children with a mean age of 11.1 (standard deviation 4.5) years. In-hospital mortality was 7% (n = 19). Functional impairment (Functional Status Scale ≥8) was present in 9% (n = 24) of children at discharge and in 7% (n = 13/192) at follow-up. Mild impairment in a single domain (Functional Status Scale = 7) was seen in 42% (n = 110) of the cohort at discharge. This impairment persisted to follow-up in most (67%, n = 59/88) of these children. CONCLUSION Functional impairment at discharge after firearm injury is common among children surviving transport in these trauma centers. These data highlight the added value of non-mortality metrics in assessing the health burden of pediatric firearm injuries. The collective impact of mortality and functional morbidity should be considered when advocating for resources to protect children.
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Affiliation(s)
- Caroline G Melhado
- Division of Pediatric Surgery, University of California-San Francisco Benioff Children's Hospitals, and Department of Surgery, University of California-San Francisco, CA
| | - Travis M Sullivan
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Caroline Q Stephens
- Division of Pediatric Surgery, University of California-San Francisco Benioff Children's Hospitals, and Department of Surgery, University of California-San Francisco, CA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Aaron R Jensen
- Division of Pediatric Surgery, University of California-San Francisco Benioff Children's Hospitals, and Department of Surgery, University of California-San Francisco, CA.
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11
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MacArthur TA, Vogel AM, Glasgow AE, Moody S, Kotagal M, Williams RF, Kayton ML, Alberto EC, Burd RS, Schroeppel TJ, Baerg JE, Munoz A, Rothstein WB, Boomer LA, Campion EM, Robinson C, Nygaard RM, Richardson CJ, Garcia DI, Streck CJ, Gaffley M, Petty JK, Ryan M, Pandya S, Russell RT, Yorkgitis BK, Mull J, Pence J, Santore MT, Klinkner DB, Safford SD, Trevilian T, Jensen AR, Mooney DP, Ketha B, Dassinger MS, Goldenberg-Sandau A, Falcone RA, Polites SF. Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis. J Trauma Acute Care Surg 2023; 95:78-86. [PMID: 37072882 DOI: 10.1097/ta.0000000000004013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Taleen A MacArthur
- Department of Surgery, Division of Pediatric Surgery (T.A.M., A.E.G., D.B.K., S.F.P.), Mayo Clinic, Rochester, Minnesota; Department of Pediatric Surgery (A.M.V.), Texas Children's Hospital, Houston, Texas; Division of Pediatric General and Thoracic Surgery (S.M., M.K., R.A.F.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Surgery (R.F.W.), Le Bonheur Children's Hospital, Memphis, Tennessee; Jersey Shore University Medical Center (M.L.K.), Hackensack-Meridian Health Network, Neptune, New Jersey; Department of Pediatric Surgery (E.C.A., R.S.B.), Children's National Hospital, Washington, DC; UCHealth Memorial Hospital (T.J.S.), Pediatric Surgery, Colorado Springs, Colorado; Division of Pediatric Surgery (J.E.B., A.M.), Loma Linda University, Loma Linda, California; Department of Surgery, Virginia Commonwealth University (W.B.R., L.A.B.), Children's Hospital of Richmond, Richmond, Virginia; Department of Surgery (E.M.C., C.R.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (R.M.N., C.J.R.), Hennepin Healthcare, Minneapolis, Minnesota; Department of Surgery (D.I.G., C.J.S.), The Medical University of South Carolina, Charleston, South Carolina; Department of Surgery (M.G., J.K.P.), Wake Forest Baptist Medical Center, Brenner Children's Hospital, Winston-Salem, North Carolina; Department of Surgery (M.R., S.P.), Children's Health Dallas, Dallas, Texas; Department of Pediatric Surgery, (R.T.R.), Children's of Alabama, Birmingham, Alabama; Department of Surgery (B.K.Y., J.M.), College of Medicine, University of Florida Jacksonville, Jacksonville, Florida; Department of Surgery (J.P.), Dayton Children's Hospital, Dayton, Ohio; Department of Surgery (M.T.S.), Children's Healthcare of Atlanta, Atlanta, Georgia; Department of Surgery (S.D.S., T.T.), Carilion Children's Hospital, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Department of Surgery (A.R.J.), Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatric Surgery (D.P.M.), Boston Children's Hospital, Boston, Massachusetts; Department of Surgery (B.K., M.S.D.), Arkansas Children's Hospital, Little Rock, Arkansas; and Department of Surgery (A.G.-S.), Cooper University Hospital, Camden, New Jersey
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12
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Sullivan TM, Sippel GJ, Matison EA, Gestrich-Thompson WV, DeWitt PE, Carlisle MA, Oluigbo D, Oluigbo C, Bennett TD, Burd RS. Development and validation of a Bayesian network predicting neurosurgical intervention after injury in children and adolescents. J Trauma Acute Care Surg 2023; 94:839-846. [PMID: 36917100 PMCID: PMC10205657 DOI: 10.1097/ta.0000000000003935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND Timely surgical decompression improves functional outcomes and survival among children with traumatic brain injury and increased intracranial pressure. Previous scoring systems for identifying the need for surgical decompression after traumatic brain injury in children and adults have had several barriers to use. These barriers include the inability to generate a score with missing data, a requirement for radiographic imaging that may not be immediately available, and limited accuracy. To address these limitations, we developed a Bayesian network to predict the probability of neurosurgical intervention among injured children and adolescents (aged 1-18 years) using physical examination findings and injury characteristics observable at hospital arrival. METHODS We obtained patient, injury, transportation, resuscitation, and procedure characteristics from the 2017 to 2019 Trauma Quality Improvement Project database. We trained and validated a Bayesian network to predict the probability of a neurosurgical intervention, defined as undergoing a craniotomy, craniectomy, or intracranial pressure monitor placement. We evaluated model performance using the area under the receiver operating characteristic and calibration curves. We evaluated the percentage of contribution of each input for predicting neurosurgical intervention using relative mutual information (RMI). RESULTS The final model included four predictor variables, including the Glasgow Coma Scale score (RMI, 31.9%), pupillary response (RMI, 11.6%), mechanism of injury (RMI, 5.8%), and presence of prehospital cardiopulmonary resuscitation (RMI, 0.8%). The model achieved an area under the receiver operating characteristic curve of 0.90 (95% confidence interval [CI], 0.89-0.91) and had a calibration slope of 0.77 (95% CI, 0.29-1.26) with a y intercept of 0.05 (95% CI, -0.14 to 0.25). CONCLUSION We developed a Bayesian network that predicts neurosurgical intervention for all injured children using four factors immediately available on arrival. Compared with a binary threshold model, this probabilistic model may allow clinicians to stratify management strategies based on risk. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Genevieve J. Sippel
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Elizabeth A. Matison
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | | | - Peter E. DeWitt
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | | | - Chima Oluigbo
- Department of Neurological Surgery, Children’s National Hospital, Washington, DC
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital of Colorado, Aurora, CO
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
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13
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Mastrianni A, Sarcevic A, Hu A, Almengor L, Tempel P, Gao S, Burd RS. Transitioning Cognitive Aids into Decision Support Platforms: Requirements and Design Guidelines. ACM Trans Comput Hum Interact 2023; 30:41. [PMID: 37694216 PMCID: PMC10489246 DOI: 10.1145/3582431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 12/16/2022] [Indexed: 09/12/2023]
Abstract
Digital cognitive aids have the potential to serve as clinical decision support platforms, triggering alerts about process delays and recommending interventions. In this mixed-methods study, we examined how a digital checklist for pediatric trauma resuscitation could trigger decision support alerts and recommendations. We identified two criteria that cognitive aids must satisfy to support these alerts: (1) context information must be entered in a timely, accurate, and standardized manner, and (2) task status must be accurately documented. Using co-design sessions and near-live simulations, we created two checklist features to satisfy these criteria: a form for entering the pre-hospital information and a progress slider for documenting the progression of a multi-step task. We evaluated these two features in the wild, contributing guidelines for designing these features on cognitive aids to support alerts and recommendations in time- and safety-critical scenarios.
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Affiliation(s)
- Angela Mastrianni
- College of Computing and Informatics, Drexel University, Philadelphia, USA
| | | | - Allison Hu
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, D.C., USA
| | - Lynn Almengor
- College of Computing and Informatics, Drexel University, Philadelphia, USA
| | - Peyton Tempel
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, D.C., USA
| | - Sarah Gao
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, D.C., USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, D.C., USA
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14
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Colson CD, Alberto EC, Milestone ZP, Batra N, Salvador T, Fooladi H, Cleary K, Izem R, Burd RS. EasyTBSA as a method for calculating total body surface area burned: a validation study. Emerg Med J 2023; 40:279-284. [PMID: 36639224 DOI: 10.1136/emermed-2022-212308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 11/25/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Current methods of burn estimation can lead to incorrect estimates of the total body surface area (TBSA) burned, especially among injured children. Inaccurate estimation of burn size can impact initial management, including unnecessary transfer to burn centres and fluid overload during resuscitation. To address these challenges, we developed a smartphone application (EasyTBSA) that calculates the TBSA of a burn using a body-part by body-part approach. The aims of this study were to assess the accuracy of the EasyTBSA application and compare its performance to three established methods of burn size estimation (Lund-Browder Chart, Rule of Nines and Rule of Palms). METHODS Twenty-four healthcare providers used each method to estimate burn sizes on moulaged manikins. The manikins represented different ages (infant, child and adult) with different TBSA burns (small <20%, medium 20%-49% and large >49%). We calculated the accuracy of each method as the difference between the user-estimated and actual TBSA. The true value of the complete body surface area of the manikins was obtained by three-dimensional scans. We used multivariable modelling to control for manikin size and method. RESULTS Among all age groups and burn sizes, the EasyTBSA application had the greatest accuracy for burn size estimation (-0.01%, SD 3.59%) followed by the Rule of Palms (3.92%, SD 10.71%), the Lund-Browder Chart (4.42%, SD 5.52%) and the Rule of Nines (5.05%, SD 6.87%). CONCLUSIONS The EasyTBSA application may improve the estimation of TBSA compared with existing methods.
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Affiliation(s)
- Cindy D Colson
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Emily C Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Zachary P Milestone
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Nikita Batra
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Tyler Salvador
- Bioengineering Operations, Children's National Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, DC, USA
| | - Hadi Fooladi
- Bioengineering Operations, Children's National Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, DC, USA
| | - Kevin Cleary
- Bioengineering Operations, Children's National Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, DC, USA
| | - Rima Izem
- Department of Pediatrics, Children's National Research Institute, Washington, DC, USA
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
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15
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Li K, Marsic I, Sarcevic A, Yang S, Sullivan TM, Tempel PE, Milestone ZP, O'Connell KJ, Burd RS. Discovering interpretable medical process models: A case study in trauma resuscitation. J Biomed Inform 2023; 140:104344. [PMID: 36940896 PMCID: PMC10111432 DOI: 10.1016/j.jbi.2023.104344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/20/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
Understanding the actual work (i.e., "work-as-done") rather than theorized work (i.e., "work-as-imagined") during complex medical processes is critical for developing approaches that improve patient outcomes. Although process mining has been used to discover process models from medical activity logs, it often omits critical steps or produces cluttered and unreadable models. In this paper, we introduce a TraceAlignment-based ProcessDiscovery method called TAD Miner to build interpretable process models for complex medical processes. TAD Miner creates simple linear process models using a threshold metric that optimizes the consensus sequence to represent the backbone process, and then identifies both concurrent activities and uncommon-but-critical activities to represent the side branches. TAD Miner also identifies the locations of repeated activities, an essential feature for representing medical treatment steps. We conducted a study using activity logs of 308 pediatric trauma resuscitations to develop and evaluate TAD Miner. TAD Miner was used to discover process models for five resuscitation goals, including establishing intravenous (IV) access, administering non-invasive oxygenation, performing back assessment, administering blood transfusion, and performing intubation. We quantitively evaluated the process models with several complexity and accuracy metrics, and performed qualitative evaluation with four medical experts to assess the accuracy and interpretability of the discovered models. Through these evaluations, we compared the performance of our method to that of two state-of-the-art process discovery algorithms: Inductive Miner and Split Miner. The process models discovered by TAD Miner had lower complexity and better interpretability than the state-of-the-art methods, and the fitness and precision of the models were comparable. We used the TAD process models to identify (1) the errors and (2)the best locations for the tentative steps in knowledge-driven expert models. The knowledge-driven models were revised based on the modifications suggested by the discovered models. The improved modeling using TAD Miner may enhance understanding of complex medical processes.
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Affiliation(s)
- Keyi Li
- Electrical and Computer Engineering Department, Rutgers University, 94 Brett Road, Piscataway, NJ 08854, USA.
| | - Ivan Marsic
- Electrical and Computer Engineering Department, Rutgers University, 94 Brett Road, Piscataway, NJ 08854, USA.
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University 3675 Market Street, Philadelphia, PA 19104, USA.
| | - Sen Yang
- Linkedin, 1000 W Maude Ave, Sunnyvale, CA 94085, USA.
| | - Travis M Sullivan
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Peyton E Tempel
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Zachary P Milestone
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Karen J O'Connell
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, USA.
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16
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Quintana M, Bornstein S, Zwemer C, Zebley JA, Amdur R, Trankiem CT, Burd RS, McKenna E, Williams M, Sarani B. A multicenter, citywide report on recurrent violent injury. Injury 2023:S0020-1383(23)00245-0. [PMID: 36925376 DOI: 10.1016/j.injury.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION The incidence of and risk factors for recurrent violent trauma are not well known. This information is needed to focus violence prevention efforts on at-risk cohorts. The purpose of this study was to determine the incidence of and risk factors for recurrence following violent injury in a large urban setting. We hypothesize that the overall incidence of recurrent violent injury is low but there are specific at-risk cohorts. METHODS A retrospective, citywide study of patients who sustained blunt assault or penetrating trauma from 2013 to 2019 was performed. Patients were tracked across all trauma centers using their name and date of birth. The primary outcome was incidence of recurrent violent injury, which was calculated by dividing the number of readmitted patients by the number who survived previous admissions due to penetrating trauma or blunt assault. Associations between readmission and injury severity score, abbreviated injury score, age, sex, hospital, mechanism of injury (MOI), and disposition were determined. Kaplan-Meier curves were plotted to determine the incidence of recurrent injury over time. A multivariable Cox proportional hazard model was used to examine the relationships between characteristics at first admission and time-to-readmission. RESULTS The recurrent injury rate was 836 patients (6.33%) out of 13,211 injured patients. Male, age 14-45 years old, discharge to jail or left against medical advice, and moderate/severe head injury were associated with re-injury. There was no association between recurrence and mechanism of injury or overall injury severity. Discharge to home was associated with a lower re-injury rate. CONCLUSION The low recurrent injury rate despite high injury prevalence suggests injury prevention efforts should target this demographic and their non-injured peers.
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Affiliation(s)
- Megan Quintana
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - Sydney Bornstein
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - Catherine Zwemer
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - James A Zebley
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - Richard Amdur
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - Christine T Trankiem
- Division of Trauma, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Randall S Burd
- Department of Pediatric Surgery, Children's National Medical Center, Washington, DC, USA
| | - Elise McKenna
- Department of Pediatric Surgery, Children's National Medical Center, Washington, DC, USA
| | - Mallory Williams
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Babak Sarani
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA.
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Townsend AN, Batra N, Lilenfeld L, Maurin E, Inverso H, Burd RS, Tully CB. Parent Traumatic Stress After Minor Pediatric Burn Injury. J Burn Care Res 2023; 44:329-334. [PMID: 35452502 DOI: 10.1093/jbcr/irac055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Indexed: 11/15/2022]
Abstract
Parents are at increased risk for psychological sequelae following their child's burn injury which has demonstrated negative impacts on the child. The current study sought to address gaps in the literature on risk factors for parental distress by examining the relationships among demographic variables, burn characteristics, and child functioning after burn injury, with parent post-traumatic stress symptoms (PTSS). Participants included parents of 660 pediatric burn patients from a regional burn clinic. Parents completed measures during their initial visit to the burn clinic. Additional demographic and burn data were retrospectively collected by medical chart review. Fifteen percent of parents reported at-risk levels of parent PTSS. Parent PTSS was independently associated with child burn characteristics of total body surface area (TBSA) affected by the burn, required hospitalization, number of nights hospitalized, and number of ambulatory burn appointments attended. Minority race was associated with higher parent PTSS than non-minority race status, with Asian parents endorsing the highest scores. Furthermore, when considered simultaneously, impaired child quality of life (QOL), a higher number of ambulatory burn appointments attended, and racial minority status were associated with higher parent PTSS. These findings highlight the need for routine parent trauma screening in pediatric burn clinics, while additionally identifying a feasible screening measure.
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Affiliation(s)
- Allie N Townsend
- Center for Translational Research, Children's National Hospital, Washington, DC 20010, USA.,The Chicago School of Professional Psychology, Washington, DC 20005, USA
| | - Nikita Batra
- Center for Translational Research, Children's National Hospital, Washington, DC 20010, USA
| | - Lisa Lilenfeld
- The Chicago School of Professional Psychology, Washington, DC 20005, USA
| | - Elana Maurin
- The Chicago School of Professional Psychology, Washington, DC 20005, USA
| | - Hailey Inverso
- Center for Translational Research, Children's National Hospital, Washington, DC 20010, USA
| | - Randall S Burd
- Center for Translational Research, Children's National Hospital, Washington, DC 20010, USA.,Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC 20020, USA
| | - Carrie B Tully
- Center for Translational Research, Children's National Hospital, Washington, DC 20010, USA
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18
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Alberto EC, Mastrianni A, Sullivan TM, McCarthy KH, Milestone ZP, Chung L, Cha N, Mapelli E, Sippel GJ, Marsic I, O'Connell KJ, Sarcevic A, Burd RS. Factors Affecting Peripheral Intravenous Catheter Placement During Pediatric Trauma Resuscitation. J Surg Res 2023; 283:241-248. [PMID: 36423472 PMCID: PMC9990681 DOI: 10.1016/j.jss.2022.10.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/16/2022] [Accepted: 10/18/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Intravenous access is required for resuscitation of injured patients but may be delayed in children because of challenges associated with peripheral intravenous (PIV) catheter placement. Early identification of factors predisposing patients to difficult PIV placement can assist in deciding strategies for timely intravenous access. METHODS We conducted a retrospective, video-based review of injured children and adolescents treated between April 2018 and May 2019. Patient demographic, physiological, injury, and resuscitation characteristics were obtained from the patient record, including age, race, weight, injury type, Injury Severity Score, initial systolic blood pressure, initial Glasgow Coma Score, intubation status, activation level, and presence of prearrival notification. Video review was used to determine the time to PIV placement, the number of attempts required, the purpose for additional access, and the reason for abandonment of PIV placement. Multivariable regressions were used to determine factors associated with successful placement. RESULTS During the study period, 154 consented patients underwent attempts at PIV placement in the trauma bay. Placement was successful in 139 (90.3%) patients. Older patients (OR [odds ratio]: 0.9, 95% confidence interval [CI]: 0.9, 0.9) and patients who required the highest level activation response (OR: 0.0, 95% CI: 0.0, 0.3) were less likely to have an attempt at PIV placement abandoned. Children with nonblunt injuries (OR: 11.6, 95% CI: 1.3, 119.2) and pre-existing access (OR: 39.6, 95% CI: 7.0, 350.6) were more likely to have an attempt at PIV placement abandoned. Among patients with successful PIV placement, the time required for establishing PIV access was faster as age increased (-0.5 s, 95% CI: -1.1, -0.0). CONCLUSIONS Younger age was associated with abandonment of PIV attempts and, when successful, increased time to placement. Strategies to improve successful PIV placement and alternate routes of access should be considered early to prevent treatment delays in younger children.
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Affiliation(s)
- Emily C Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Angela Mastrianni
- College of Computing and Informatics, Drexel University, Philadelphia, Pennsylvania
| | - Travis M Sullivan
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Kathleen H McCarthy
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Zachary P Milestone
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Lauren Chung
- College of Computing and Informatics, Drexel University, Philadelphia, Pennsylvania
| | - Nicholas Cha
- College of Computing and Informatics, Drexel University, Philadelphia, Pennsylvania
| | - Emily Mapelli
- College of Computing and Informatics, Drexel University, Philadelphia, Pennsylvania
| | - Genevieve J Sippel
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, New Jersey
| | - Karen J O'Connell
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, Pennsylvania
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia.
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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. Proc ACM Interact Mob Wearable Ubiquitous Technol 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] [What about the content of this article? (0)] [Affiliation(s)] [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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20
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Sullivan TM, Milestone ZP, Colson CD, Tempel PE, Gestrich-Thompson WV, Burd RS. Evaluation of Missing Prehospital Physiological Values in Injured Children and Adolescents. J Surg Res 2023; 283:305-312. [PMID: 36423480 PMCID: PMC9990680 DOI: 10.1016/j.jss.2022.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/11/2022] [Accepted: 10/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Prehospital vital signs and the Glasgow Coma Scale score are often missing in clinical practice and not recorded in trauma databases. Our study aimed to identify factors associated with missing prehospital physiological values, including systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, and Glasgow Coma Scale. METHODS We used our hospital trauma registry to obtain patient, injury, resuscitation, and transportation characteristics for injured children and adolescents (age <15 y). We evaluated the association of missing documentation of prehospital values with other patient, injury, transportation, and resuscitation characteristics using multivariable regression. We standardized vital sign values using age-adjusted z-scores. RESULTS The odds of a missing physiological value decreased with age (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.9, 0.9) and were higher when prehospital cardiopulmonary resuscitation was required (OR = 3.3, 95% CI = 1.9, 5.7). Among the physiological values considered, we observed the highest odds of missingness of systolic blood pressure, respiratory rate, and oxygen saturation. The odds of observing normal emergency department physiological values were lower when prehospital physiological values were missing (OR = 0.9, 95% CI = 0.9, 1.0; P = 0.04). CONCLUSIONS Missing prehospital physiological values were associated with younger age and cardiopulmonary resuscitation among the injured children treated at our hospital. Measurement and documentation of physiological variables of patients with these characteristics should be targeted.
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Affiliation(s)
- Travis M Sullivan
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Zachary P Milestone
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Cindy D Colson
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Peyton E Tempel
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | | | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia.
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21
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Sullivan TM, Milestone ZP, Tempel PE, Gao S, Burd RS. Development and validation of a Bayesian belief network predicting the probability of blood transfusion after pediatric injury. J Trauma Acute Care Surg 2023; 94:304-311. [PMID: 35696359 PMCID: PMC9748028 DOI: 10.1097/ta.0000000000003709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Early recognition and intervention of hemorrhage are associated with decreased morbidity in children. Triage models have been developed to aid in the recognition of hemorrhagic shock after injury but require complete data and have limited accuracy. To address these limitations, we developed a Bayesian belief network, a machine learning model that represents the joint probability distribution for a set of observed or unobserved independent variables, to predict blood transfusion after injury in children and adolescents. METHODS We abstracted patient, injury, and resuscitation characteristics of injured children and adolescents (age 1 to 18 years) from the 2017 to 2019 Trauma Quality Improvement Project database. We trained a Bayesian belief network to predict blood transfusion within 4 hours after arrival to the hospital following injury using data from 2017 and recalibrated the model using data from 2018. We validated our model on a subset of patients from the 2019 Trauma Quality Improvement Project. We evaluated model performance using the area under the receiver operating characteristic curve and calibration curves and compared performance with pediatric age-adjusted shock index (SIPA) and reverse shock index with Glasgow Coma Scale (rSIG) using sensitivity, specificity, accuracy, and Matthew's correlation coefficient (MCC). RESULTS The final model included 14 predictor variables and had excellent discrimination and calibration. The model achieved an area under the receiver operating characteristic curve of 0.92 using emergency department data. When used as a binary predictor at an optimal threshold probability, the model had similar sensitivity, specificity, accuracy, and MCC compared with SIPA when only age, systolic blood pressure, and heart rate were observed. With the addition of the Glasgow Coma Scale score, the model has a higher accuracy and MCC than SIPA and rSIG. CONCLUSION A Bayesian belief network predicted blood transfusion after injury in children and adolescents better than SIPA and rSIG. This probabilistic model may allow clinicians to stratify hemorrhagic control interventions based upon risk. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Zachary P. Milestone
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Peyton E. Tempel
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Sarah Gao
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
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22
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Newgard CD, Lin A, Malveau S, Cook JNB, Smith M, Kuppermann N, Remick KE, Gausche-Hill M, Goldhaber-Fiebert J, Burd RS, Hewes HA, Salvi A, Xin H, Ames SG, Jenkins PC, Marin J, Hansen M, Glass NE, Nathens AB, McConnell KJ, Dai M, Carr B, Ford R, Yanez D, Babcock SR, Lang B, Mann NC. Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care. JAMA Netw Open 2023; 6:e2250941. [PMID: 36637819 PMCID: PMC9857584 DOI: 10.1001/jamanetworkopen.2022.50941] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
IMPORTANCE Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. OBJECTIVE To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. EXPOSURE ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. RESULTS There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. CONCLUSIONS AND RELEVANCE These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.
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Affiliation(s)
- Craig D. Newgard
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Susan Malveau
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Jennifer N. B. Cook
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - McKenna Smith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Katherine E. Remick
- Department of Pediatric, Dell Medical School, University of Texas at Austin, Austin
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services, Harbor-UCLA Medical Center, Torrance, California
| | - Jeremy Goldhaber-Fiebert
- Centers for Health Policy, Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children’s National Hospital, Washington, DC
| | - Hilary A. Hewes
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Apoorva Salvi
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Haichang Xin
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Stefanie G. Ames
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Jennifer Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew Hansen
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Nina E. Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Avery B. Nathens
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - K. John McConnell
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Mengtao Dai
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Brendan Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachel Ford
- Oregon Emergency Medical Services for Children Program, Oregon Health Authority, Portland
| | - Davis Yanez
- Department of Anesthesia, Yale School of Medicine, New Haven, Connecticut
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Sean R. Babcock
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland
| | - Benjamin Lang
- Department of Pediatric, Dell Medical School, University of Texas at Austin, Austin
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
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23
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Russell RT, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper CM, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference research priorities. J Trauma Acute Care Surg 2023; 94:S11-S18. [PMID: 36203242 PMCID: PMC9805504 DOI: 10.1097/ta.0000000000003802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traumatic injury is the leading cause of death in children and adolescents. Hemorrhagic shock remains a common and preventable cause of death in the pediatric trauma patients. A paucity of high-quality evidence is available to guide specific aspects of hemorrhage control in this population. We sought to identify high-priority research topics for the care of pediatric trauma patients in hemorrhagic shock. METHODS A panel of 16 consensus multidisciplinary committee members from the Pediatric Traumatic Hemorrhagic Shock Consensus Conference developed research priorities for addressing knowledge gaps in the care of injured children and adolescents in hemorrhagic shock. These ideas were informed by a systematic review of topics in this area and a discussion of these areas in the consensus conference. Research priorities were synthesized along themes and prioritized by anonymous voting. RESULTS Eleven research priorities that warrant additional investigation were identified by the consensus committee. Areas of proposed study included well-designed clinical trials and evaluations, including increasing the speed and accuracy of identifying and treating hemorrhagic shock, defining the role of whole blood and tranexamic acid use, and assessment of the utility and appropriate use of viscoelastic techniques during early resuscitation. The committee recommended the need to standardize essential definitions, data elements, and data collection to facilitate research in this area. CONCLUSION Research gaps remain in many areas related to the care of hemorrhagic shock after pediatric injury. Addressing these gaps is needed to develop improved evidence-based recommendations for the care of pediatric trauma patients in hemorrhagic shock.
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Affiliation(s)
- Robert T. Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL
| | - Melania M. Bembea
- Division of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew A. Borgman
- Department of Pediatrics, Brooke Army Medical Center, Uniformed Services University
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Barbara A. Gaines
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children’s Hospital, Pittsburgh, PA
| | - Mubeen Jafri
- Division of Pediatric Surgery, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR
| | - Cassandra D. Josephson
- Department of Oncology, Sydney Kimmel Cancer Center, Johns Hopkins University School of Medicine, Baltimore MD, and Cancer and Blood Disorders Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Christine M. Leeper
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julie C. Leonard
- Department of Pediatrics, Division of Emergency Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Kathleen K. Nicol
- Department of Pathology and Laboratory Medicine, The Ohio State University College of Medicine Nationwide Children’s Hospital, Columbus, OH
| | - Daniel K. Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Paul A. Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam M. Vogel
- Divisions of Pediatric Surgery and Critical Care, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Trisha E. Wong
- Division of Pediatric Hematology and Oncology and Department of Pathology, Oregon Health and Science University, Portland, OR
| | - Philip C. Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center. Pittsburgh, PA
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24
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Sullivan TM, Gestrich-Thompson WV, Milestone ZP, Burd RS. Time is tissue: Barriers to timely transfusion after pediatric injury. J Trauma Acute Care Surg 2023; 94:S22-S28. [PMID: 35916621 PMCID: PMC9805480 DOI: 10.1097/ta.0000000000003752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Strategies to improve outcomes among children and adolescents in hemorrhagic shock have primarily focused on component resuscitation, pharmaceutical coagulation adjuncts, and hemorrhage control techniques. Many of these strategies have been associated with better outcomes in children, but the barriers to their use and the impact of timely use on morbidity and mortality have received little attention. Because transfusion is uncommon in injured children, few studies have identified and described barriers to the processes of using these interventions in bleeding patients, processes that move from the decision to transfuse, to obtaining the necessary blood products and adjuncts, and to delivering them to the patient. In this review, we identify and describe the steps needed to ensure timely blood transfusion and propose practices to minimize barriers in this process. Given the potential impact of time on hemorrhage associated outcomes, ensuring timely intervention may have a similar or greater impact than the interventions themselves.
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Affiliation(s)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | | | - Zachary P. Milestone
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
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25
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Russell RT, Esparaz JR, Beckwith MA, Abraham PJ, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper C, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference recommendations. J Trauma Acute Care Surg 2023; 94:S2-S10. [PMID: 36245074 PMCID: PMC9805499 DOI: 10.1097/ta.0000000000003805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Hemorrhagic shock in pediatric trauma patients remains a challenging yet preventable cause of death. There is little high-quality evidence available to guide specific aspects of hemorrhage control and specific resuscitation practices in this population. We sought to generate clinical recommendations, expert consensus, and good practice statements to aid providers in care for these difficult patients.The Pediatric Traumatic Hemorrhagic Shock Consensus Conference process included systematic reviews related to six subtopics and one consensus meeting. A panel of 16 consensus multidisciplinary committee members evaluated the literature related to 6 specific topics: (1) blood products and fluid resuscitation for hemostatic resuscitation, (2) utilization of prehospital blood products, (3) use of hemostatic adjuncts, (4) tourniquet use, (5) prehospital airway and blood pressure management, and (6) conventional coagulation tests or thromboelastography-guided resuscitation. A total of 21 recommendations are detailed in this article: 2 clinical recommendations, 14 expert consensus statements, and 5 good practice statements. The statement, the panel's voting outcome, and the rationale for each statement intend to give pediatric trauma providers the latest evidence and guidance to care for pediatric trauma patients experiencing hemorrhagic shock. With a broad multidisciplinary representation, the Pediatric Traumatic Hemorrhagic Shock Consensus Conference systematically evaluated the literature and developed clinical recommendations, expert consensus, and good practice statements concerning topics in traumatically injured pediatric patients with hemorrhagic shock.
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Affiliation(s)
- Robert T. Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL
| | - Joseph R. Esparaz
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL
| | - Michael A. Beckwith
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, Ann Arbor, MIS
| | - Peter J. Abraham
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Melania M. Bembea
- Division of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew A. Borgman
- Department of Pediatrics, Brooke Army Medical Center, Uniformed Services University
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Barbara A. Gaines
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children’s Hospital, Pittsburgh, PA
| | - Mubeen Jafri
- Division of Pediatric Surgery, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR
| | - Cassandra D. Josephson
- Departments of Pathology and Laboratory Medicine and Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Christine Leeper
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julie C. Leonard
- Department of Pediatrics, Division of Emergency Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Kathleen K. Nicol
- Department of Pathology and Laboratory Medicine, The Ohio State University College of Medicine Nationwide Children’s Hospital, Columbus, OH
| | - Daniel K. Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Paul A. Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam M. Vogel
- Divisions of Pediatric Surgery and Critical Care, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Trisha E. Wong
- Division of Pediatric Hematology and Oncology and Department of Pathology, Oregon Health & Science University, Portland, OR
| | - Philip C. Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center. Pittsburgh, PA
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Ward SL, VanBuren JM, Richards R, Holubkov R, Alvey JS, Jensen AR, Pollack MM, Burd RS. Evaluating the association between obesity and discharge functional status after pediatric injury. J Pediatr Surg 2022; 57:598-605. [PMID: 35090717 PMCID: PMC9808528 DOI: 10.1016/j.jpedsurg.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/17/2021] [Accepted: 01/05/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Children with obesity frequently have functional impairment after critical illness. Although obesity increases morbidity risk after trauma, the association with functional outcomes in children is unknown. OBJECTIVE To evaluate the association of weight with functional impairment at hospital discharge in children with serious injuries. METHODS This secondary analysis of a multicenter prospective study included children <15 years old with a serious injury. Four weight groups, underweight, healthy weight, overweight, and obesity/severe obesity were defined by body mass index z-scores. The functional status scale (FSS) measured impairment across six functional domains before injury and at hospital discharge. New domain morbidity was defined as a change ≥2 points. The association between weight and functional impairment was determined using logistic regression adjusting for demographics, physiological measures, injury details, presence of a severe head injury, and physical abuse. RESULTS Although most patients discharged with good/unchanged functional status, new domain morbidity occurred in 74 patients (17%). New FSS domain morbidity occurred in 13% of underweight, 14% of healthy weight, 15% of overweight, and 26% of obese/severe obese patients. Compared to healthy weight patients, those with obesity had more frequent new domain morbidity (p = 0.01), while the other weight groups had similar morbidity. However, after adjustment for confounders, weight was not associated with new functional morbidity at discharge. CONCLUSION Patients with obesity have greater frequency of new domain morbidity after a serious injury; however, after accounting for injury characteristics, weight group is not independently associated with new functional morbidity at hospital discharge after injury in children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shan L Ward
- Department of Pediatrics, UCSF Benioff Children's Hospitals Oakland, Oakland, CA, United States; Department of Pediatrics, UCSF Benioff Children's Hospitals San Francisco, San Francisco, CA, United States.
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Aaron R Jensen
- Department of Surgery, University of California San Francisco and Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, CA, United States
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington DC, United States
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC, United States; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) Assessment of Health-Related Quality of Life and Functional Outcomes after Pediatric Trauma Project Investigators
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27
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Lukish J, Levitt M, Burd RS, Kane T, Sandler T. More evidence against appendectomy at the time of a Ladd procedure. J Pediatr Surg 2022; 57:751. [PMID: 35738918 DOI: 10.1016/j.jpedsurg.2022.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Jeff Lukish
- Division of Pediatric Surgery, Children's National Hospital, Washington D.C; Department of Surgery, The George Washington University, Washington D.C; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Marc Levitt
- Division of Pediatric Surgery, Children's National Hospital, Washington D.C; Department of Surgery, The George Washington University, Washington D.C; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Randall S Burd
- Division of Pediatric Surgery, Children's National Hospital, Washington D.C; Department of Surgery, The George Washington University, Washington D.C; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Tim Kane
- Division of Pediatric Surgery, Children's National Hospital, Washington D.C; Department of Surgery, The George Washington University, Washington D.C; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Tony Sandler
- Division of Pediatric Surgery, Children's National Hospital, Washington D.C; Department of Surgery, The George Washington University, Washington D.C; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
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Pinto NP, Maddux AB, Dervan LA, Woodruff AG, Jarvis JM, Nett S, Killien EY, Graham RJ, Choong K, Luckett PM, Heneghan JA, Biagas K, Carlton EF, Hartman ME, Yagiela L, Michelson KN, Manning JC, Long DA, Lee JH, Slomine BS, Beers SR, Hall T, Morrow BM, Meert K, del Pilar Arias Lopez M, Knoester H, Houtrow A, Olson L, Steele L, Schlapbach LJ, Burd RS, Grosskreuz R, Butt W, Fink EL, Watson RS. A Core Outcome Measurement Set for Pediatric Critical Care. Pediatr Crit Care Med 2022; 23:893-907. [PMID: 36040097 PMCID: PMC9633391 DOI: 10.1097/pcc.0000000000003055] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To identify a PICU Core Outcome Measurement Set (PICU COMS), a set of measures that can be used to evaluate the PICU Core Outcome Set (PICU COS) domains in PICU patients and their families. DESIGN A modified Delphi consensus process. SETTING Four webinars attended by PICU physicians and nurses, pediatric surgeons, rehabilitation physicians, and scientists with expertise in PICU clinical care or research ( n = 35). Attendees were from eight countries and convened from the Pediatric Acute Lung Injury and Sepsis Investigators Pediatric Outcomes STudies after PICU Investigators and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network PICU COS Investigators. SUBJECTS Measures to assess outcome domains of the PICU COS are as follows: cognitive, emotional, overall (including health-related quality of life), physical, and family health. Measures evaluating social health were also considered. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Measures were classified as general or additional based on generalizability across PICU populations, feasibility, and relevance to specific COS domains. Measures with high consensus, defined as 80% agreement for inclusion, were selected for the PICU COMS. Among 140 candidate measures, 24 were delineated as general (broadly applicable) and, of these, 10 achieved consensus for inclusion in the COMS (7 patient-oriented and 3 family-oriented). Six of the seven patient measures were applicable to the broadest range of patients, diagnoses, and developmental abilities. All were validated in pediatric populations and have normative pediatric data. Twenty additional measures focusing on specific populations or in-depth evaluation of a COS subdomain also met consensus for inclusion as COMS additional measures. CONCLUSIONS The PICU COMS delineates measures to evaluate domains in the PICU COS and facilitates comparability across future research studies to characterize PICU survivorship and enable interventional studies to target long-term outcomes after critical illness.
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Affiliation(s)
- Neethi P. Pinto
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine and Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Leslie A. Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s, Seattle, WA, USA
| | - Alan G. Woodruff
- Department of Anesthesiology, Section of Pediatric Critical Care Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jessica M. Jarvis
- Department of Physical Medicine and Rehabilitation, Division of Pediatric Rehabilitation Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sholeen Nett
- Department of Pediatrics, Section of Critical Care Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s, Seattle, WA, USA
| | - Robert J. Graham
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Karen Choong
- Departments of Pediatrics, Critical Care, Health Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Peter M. Luckett
- Department of Pediatrics, UT Southwestern Medical Center and Division of Pediatric Critical Care Medicine, Children’s Health, Dallas, TX, USA
| | - Julia A. Heneghan
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, USA
| | - Katherine Biagas
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, The Renaissance School of Medicine at Stony Brook University and the Stony Brook Children’s Hospital, Stony Brook, NY, USA
| | - Erin F. Carlton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan; Susan B. Meister Child Health Evaluation and Research Center; Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Mary E. Hartman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Lauren Yagiela
- Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University, Mount Pleasant, MI, USA
| | - Kelly N. Michelson
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph C. Manning
- Centre for Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK; Nottingham Children’s Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Debbie A. Long
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia
| | - Jan Hau Lee
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Beth S. Slomine
- Department of Neuropsychology, Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Trevor Hall
- Department of Pediatrics, Division of Pediatric Psychology, Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health & Science University, Portland, OR, USA
| | - Brenda M. Morrow
- Department of Paediatrics and Child Health; University of Cape Town; Cape Town; South Africa
| | - Kathleen Meert
- Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University, Mount Pleasant, MI, USA
| | - Maria del Pilar Arias Lopez
- Department of Pediatric Critical Care, Hospital de Niños Ricardo Gutierrez. SATI-Q Program. Argentine Society of Intensive Care, Buenos Aires. Argentina
| | - Hennie Knoester
- Pediatric Intensive Care Unit, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Amy Houtrow
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lenora Olson
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Lisa Steele
- Nationwide Children’s Hospital, Columbus, OH, USA
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, Children`s Research Center, University Children`s Hospital Zurich, Zurich, Switzerland; and Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, DC, USA
| | | | - Warwick Butt
- Intensive Care Unit, Royal Children’s Hospital Melbourne, Australia
| | - Ericka L. Fink
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s, Seattle, WA, USA
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Tully CB, Amatya K, Batra N, Inverso H, Burd RS. Parent resilience after young child minor burn injury. Fam Syst Health 2022; 40:322-331. [PMID: 35549488 DOI: 10.1037/fsh0000703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Pediatric burn injuries are common injuries that are traumatic for the child and their families. Although many families report high amounts of distress soon after injury, most are resilient and do not continue to experience prolonged psychosocial problems. The aim was to identify factors associated with parent resilience after pediatric burn injury. METHOD Fifty-seven parents of young children (< 5 years old) enrolled in a longitudinal assessment study. Baseline evaluations were conducted within 1 week of injury and included a medical chart review and parent self-report measures of resilience, social support, family functioning, and coping. Follow-up measurement of parent traumatic stress was measured 3 months after injury. We examined baseline resilience, positive emotionality, social support, family functioning, and problem-solving coping behaviors for relationships to traumatic stress. RESULTS Parent resilience at baseline was associated with lower rates of parent traumatic stress symptoms at follow-up. Lower rates of traumatic stress were more common in parents of older children with more trait-level resilience, more social support, and more planning problem-solving behaviors at baseline. CONCLUSIONS Baseline resilience characteristics are associated with less traumatic stress for parents several months after the injury. Findings can be used to develop screening strategies and interventions that address planning and problem-solving and emphasize social support. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Maddux AB, VanBuren JM, Jensen AR, Holubkov R, Alvey JS, McQuillen P, Mourani PM, Meert KL, Burd RS. Post-discharge rehabilitation and functional recovery after pediatric injury. Injury 2022; 53:2795-2803. [PMID: 35680434 PMCID: PMC9808527 DOI: 10.1016/j.injury.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Variability in rehabilitation disposition has been proposed as a trauma center quality metric. Benchmarking rehabilitation disposition is limited by a lack of objective measures of functional impairment at discharge. The primary aim of this study was to determine the relative contribution of patient characteristics and hospitalization factors associated with inpatient and outpatient rehabilitation after discharge. The secondary aims were to evaluate the sensitivity of the Functional Status Scale (FSS) score for identifying functional impairments at hospital discharge and track post-discharge recovery. PATIENTS AND METHODS We report a planned secondary analysis of a prospective observational study of seriously injured children (<15 years old) enrolled at seven pediatric trauma centers. Functional Status Scale (FSS) score was measured for pre-injury, hospital discharge, and 6-month follow-up timepoints. Multinomial logistic regression identified factors associated with three dispositions: home without rehabilitation services, home with outpatient rehabilitation, and inpatient rehabilitation. Relative weight analysis was used to identify the impact of individual factors associated with inpatient or outpatient rehabilitation disposition. RESULTS We analyzed 427 children with serious injuries. Functional impairment at discharge was present in 103 (24.1%) children, including 43/337 (12.8%) discharged without services, 12/38 (31.6%) discharged with outpatient rehabilitation, and 44/47 (93.6%) discharged to inpatient rehabilitation. In multivariable modeling, variables most contributing to prediction of inpatient rehabilitation were severe initial Glasgow coma scale (GCS), injured body region, and functional impairment at discharge. Severe initial GCS, private insurance, and extremity injury were independently associated with disposition with outpatient rehabilitation. Patients discharged without services or with outpatient rehabilitation most frequently had motor impairments that improved during the next 6 months. Patients discharged to inpatient rehabilitation had impairments in all domains, with many improving within 6 months. A higher proportion of patients discharged to inpatient rehabilitation had residual impairments at follow-up. CONCLUSION Injury characteristics and discharge impairment were associated with discharge to inpatient rehabilitation. The FSS score identified impairments needing inpatient rehabilitation and characterized improvements after discharge. Less severe impairments needing outpatient rehabilitation were not identified by the FSS score.
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Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Ave, MS 8414, Aurora, CO, 80045, United States,Corresponding author at: Pediatric Critical Care, University of Colorado School of Medicine, Children’s Hospital Colorado, Education 2 South, 13121 East 17th Avenue, MS 8414, Aurora, CO 80045. (A.B. Maddux)
| | - John M. VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Aaron R. Jensen
- Department of Surgery, University of California San Francisco and UCSF Benioff Children’s Hospital, 1411 East 31st St, Oakland, CA, 94602, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Jessica S. Alvey
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, United States
| | - Patrick McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, 1550 Fourth St, San Francisco, CA, 94158, United States
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Ave, MS 8414, Aurora, CO, 80045, United States,Department of Pediatrics, Section of Critical Care, Arkansas Children’s, 13 Children’s Way, Slot 842, Little Rock, AR, 72202, United States
| | - Kathleen L Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, 3901 Beaubien, Detroit, MI, 48201, United States
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, 111 Michigan Avenue NW, Washington, DC 20010, United States
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Newgard CD, Lin A, Goldhaber-Fiebert JD, Marin JR, Smith M, Cook JNB, Mohr NM, Zonfrillo MR, Puapong D, Papa L, Cloutier RL, Burd RS. Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers. JAMA Surg 2022; 157:e217419. [PMID: 35107579 PMCID: PMC8811708 DOI: 10.1001/jamasurg.2021.7419] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/28/2021] [Indexed: 02/04/2023]
Abstract
IMPORTANCE There is substantial variability among emergency departments (EDs) in their readiness to care for acutely ill and injured children, including US trauma centers. While high ED pediatric readiness is associated with improved in-hospital survival among children treated at trauma centers, the association between high ED readiness and long-term outcomes is unknown. OBJECTIVE To evaluate the association between ED pediatric readiness and 1-year survival among injured children presenting to 146 trauma centers. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, injured children younger than 18 years who were residents of 8 states with admission, transfer to, or injury-related death at one of 146 participating trauma centers were included. Children cared for in and outside their state of residence were included. Subgroups included those with an Injury Severity Score (ISS) of 16 or more; any Abbreviated Injury Scale (AIS) score of 3 or more; head AIS score of 3 or more; and need for early critical resources. Data were collected from January 2012 to December 2017, with follow-up to December 2018. Data were analyzed from January to July 2021. EXPOSURES ED pediatric readiness for the initial ED, measured using the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES Time to death within 365 days. RESULTS Of 88 071 included children, 30 654 (34.8%) were female; 2114 (2.4%) were Asian, 16 730 (10.0%) were Black, and 49 496 (56.2%) were White; and the median (IQR) age was 11 (5-15) years. A total of 1974 (2.2%) died within 1 year of the initial ED visit, including 1768 (2.0%) during hospitalization and 206 (0.2%) following discharge. Subgroups included 12 752 (14.5%) with an ISS of 16 or more, 28 402 (32.2%) with any AIS score of 3 or more, 13 348 (15.2%) with a head AIS of 3 or more, and 9048 (10.3%) requiring early critical resources. Compared with EDs in the lowest wPRS quartile (32-69), children cared for in the highest wPRS quartile (95-100) had lower hazard of death to 1 year (adjusted hazard ratio [aHR], 0.70; 95% CI, 0.56-0.88). Supplemental analyses removing early deaths had similar results (aHR, 0.75; 95% CI, 0.56-0.996). Findings were consistent across subgroups and multiple sensitivity analyses. CONCLUSIONS AND RELEVANCE Children treated in high-readiness trauma center EDs after injury had a lower risk of death that persisted to 1 year. High ED readiness is independently associated with long-term survival among injured children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Jeremy D. Goldhaber-Fiebert
- Centers for Health Policy, Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer R. Marin
- Departments of Pediatrics, Emergency Medicine, and Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - McKenna Smith
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City
| | - Jennifer N. B. Cook
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Nicholas M. Mohr
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - Mark R. Zonfrillo
- Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Devin Puapong
- Department of Pediatric Surgery, Kapiolani Medical Center for Women and Children, Honolulu, Hawaii
- Department of Surgery, University of Hawai’i John A. Burns School of Medicine, Honolulu
| | - Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Robert L. Cloutier
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children’s National Hospital, Washington, DC
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Evans LL, Jensen AR, Meert KL, VanBuren JM, Richards R, Alvey JS, Carcillo JA, McQuillen PS, Mourani PM, Nance ML, Holubkov R, Pollack MM, Burd RS. All body region injuries are not equal: Differences in pediatric discharge functional status based on Abbreviated Injury Scale (AIS) body regions and severity scores. J Pediatr Surg 2022; 57:739-746. [PMID: 35090715 DOI: 10.1016/j.jpedsurg.2021.09.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Functional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity. METHODS Children with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores. RESULTS The study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS< 9) compared to those with a higher GCS score (43% versus 9%; p < 0.01). Patients with AIS 3 extremity and severe head injuries had a higher proportion of abnormal FSS at discharge than AIS 3 abdomen or non-severe head injuries. CONCLUSIONS AIS severity does not account for variability in discharge functional impairment within or between body regions. Benchmarking based on functional status assessment requires clinical factors in addition to AIS severity for appropriate risk adjustment. LEVEL OF EVIDENCE 1 (Prognostic and Epidemiological).
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Affiliation(s)
- Lauren L Evans
- Department of Surgery, Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, 4th Floor OPC2, Oakland CA 94609, United States
| | - Aaron R Jensen
- Department of Surgery, Division of Pediatric Surgery, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, 4th Floor OPC2, Oakland CA 94609, United States.
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI 48201, United States
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
| | - Peter M Mourani
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - Michael L Nance
- Division of Pediatric Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington DC 20010, United States
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC 20010, United States
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Colson CD, Alberto EA, Milestone ZP, Batra N, Salvadore T, Fooladi H, Cleary K, Izem R, Burd RS. 56 Evaluation of a Smartphone Application as a Method for Calculating Total Body Surface Area Burned. J Burn Care Res 2022. [PMCID: PMC8946009 DOI: 10.1093/jbcr/irac012.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Introduction Current methods of burn estimation can lead to incorrect estimates of the total body surface area burned, especially among injured children. Inaccurate estimation of burn size can impact initial management, including unnecessary transfer to burn centers and fluid overload during resuscitation. To address these challenges, we developed a smartphone application that calculates the total body surface area of a burn using a body-part by body-part approach. The aims of this study were to assess the accuracy of the smartphone application and compare its performance to three established methods of burn size estimation (Lund-Browder Chart, Rule of Nines, Rule of Palms). Methods Twenty-four healthcare providers used each method to estimate burn sizes on moulaged manikins. The manikins represented different ages (infant, child, adult) with different total body surface area burns (small < 20%, medium 20-49%, large >49%). We calculated the accuracy of each method as the difference between the user-estimated and actual total body surface area. We used multivariable modeling to control for manikin size and method. Results Among all age groups and burn sizes, the smartphone application had the greatest accuracy for burn size estimation (-0.01%, SD 3.59%) followed by the Rule of Palms (3.92%, SD 10.71%), the Lund-Browder Chart (4.42%, SD 5.52%), and the Rule of Nines (5.05%, SD 6.87%). Conclusions The smartphone application may improve the estimation of total body surface area burned compared to existing methods. ![]()
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Affiliation(s)
- Cindy D Colson
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
| | - Emily A Alberto
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
| | - Zachary P Milestone
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
| | - Nikita Batra
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
| | - Tyler Salvadore
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
| | - Hadi Fooladi
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
| | - Kevin Cleary
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
| | - Rima Izem
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
| | - Randall S Burd
- Children's National Hospital, Bowie, Maryland; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Washington, District of Columbia; Children's National Hospital, Wa
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Zhang Y, Marsic I, Burd RS. Real-time medical phase recognition using long-term video understanding and progress gate method. Med Image Anal 2021; 74:102224. [PMID: 34543914 PMCID: PMC8560574 DOI: 10.1016/j.media.2021.102224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 01/10/2023]
Abstract
We introduce a real-time system for recognizing five phases of the trauma resuscitation process, the initial management of injured patients in the emergency department. We used depth videos as input to preserve the privacy of the patients and providers. The depth videos were recorded using a Kinect-v2 mounted on the sidewall of the room. Our dataset consisted of 183 depth videos of trauma resuscitations. The model was trained on 150 cases with more than 30 minutes each and tested on the remaining 33 cases. We introduced a reduced long-term operation (RLO) method for extracting features from long segments of video and combined it with the regular model having short-term information only. The model with RLO outperformed the regular short-term model by 5% using the accuracy score. We also introduced a progress gate (PG) method to distinguish visually similar phases using video progress. The final system achieved 91% accuracy and significantly outperformed previous systems for phase recognition in this setting.
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Affiliation(s)
- Yanyi Zhang
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ 08854, USA.
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ 08854, USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC 20010, USA
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O'Connell KJ, Carter EA, Fritzeen JL, Waterhouse LJ, Burd RS. Effect of Family Presence on Advanced Trauma Life Support Task Performance During Pediatric Trauma Team Evaluation. Pediatr Emerg Care 2021; 37:e905-e909. [PMID: 28486265 DOI: 10.1097/pec.0000000000001164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
IMPORTANCE In many hospitals, family members are separated from their children during the early phases of trauma care. Including family members during this phase of trauma care varies by institution and is limited by concerns for adverse effects on clinical care. OBJECTIVE The aim of this study is to evaluate the effect of family presence (FP) on advanced trauma life support primary and secondary survey task performance by pediatric trauma teams. We hypothesized that trauma care with FP would be noninferior to care when families were absent. DESIGN We performed a retrospective video review of consecutive pediatric trauma evaluations. Family presence status was determined by availability of the family. SETTING The study was conducted at an American College of Surgeons-designated level I pediatric trauma center that serves the Washington, DC, metropolitan area. PARTICIPANTS Participants included patients younger than 16 years of age who met trauma activation criteria and were evaluated by the trauma team in our emergency department. OUTCOME MEASURES We compared task performance between patients with and without FP. RESULTS Video recordings of 135 trauma evaluations were reviewed. Family was present for 88 (65%) evaluations. Patients with FP were younger (mean age, 6.4 years [SD = 4.1] vs 9.0 years [SD = 4.9]; P < 0.001) and more likely to have sustained blunt injuries (95% vs 85%, P = 0.03). Noninferiority of frequency and timeliness of completion of all primary survey tasks were confirmed for evaluations with FP. Noninferiority of frequencies of secondary survey task completion was confirmed for most tasks except for examination of the neck, pelvis, and upper extremities. Family members did not directly interfere with patient care in any case. CONCLUSIONS Performance of most advanced trauma life support tasks during pediatric trauma evaluation was not worsened by FP. Our data provide additional evidence supporting FP during the acute management of injured children.
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Affiliation(s)
| | - Elizabeth A Carter
- Trauma and Burn Surgery, Children's National Health System, Washington, DC
| | | | | | - Randall S Burd
- Trauma and Burn Surgery, Children's National Health System, Washington, DC
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36
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Jensen AR, Evans LL, Meert KL, VanBuren JM, Richards R, Alvey JS, Holubkov R, Pollack MM, Burd RS. Functional status impairment at six-month follow-up is independently associated with child physical abuse mechanism. Child Abuse Negl 2021; 122:105333. [PMID: 34583299 DOI: 10.1016/j.chiabu.2021.105333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Children with abusive injuries have worse mortality, length-of-stay, complications, and healthcare costs compared to those sustaining an accidental injury. Long-term functional impairment is common in children with abusive head trauma but has not been examined in a cohort with heterogeneous body region injuries. OBJECTIVE To assess for an independent association between child physical abuse and functional impairment at discharge and six-month follow-up. PARTICIPANTS AND SETTING Seriously injured children (<15 years) treated at seven pediatric trauma centers. METHODS Functional status was compared between child physical abuse and accidental injury groups at discharge and six-month follow-up. Functional impairment was defined at discharge ("new domain morbidity") as a change from pre-injury ≥2 points in any of the six domains of the Functional Status Scale (FSS), and impairment at six-month follow-up as an abnormal total FSS score. RESULTS Children with abusive injuries accounted for 10.5% (n = 45) of the cohort. New domain morbidity was present in 17.8% (n = 8) of child physical abuse patients at discharge, with 10% (n = 3) of children having an abnormal FSS at six-months. There were no differences in new domain morbidity at hospital discharge between children injured by abuse and or accidental injury. However, children injured by physical abuse were 4.09 (2.15, 7.78) times more likely to have functional impairment at six months. CONCLUSIONS Child physical abuse is an independent risk factor for functional impairment at six-month follow-up. Functional status measurement for this high-risk group of children should be routinely measured and incorporated into trauma center quality assessments.
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Affiliation(s)
- Aaron R Jensen
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, and Department of Surgery, University of California San Francisco, San Francisco, CA 94611, USA.
| | - Lauren L Evans
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, and Department of Surgery, University of California San Francisco, San Francisco, CA 94611, USA.
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, 48201, USA.
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84108, USA.
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC 20010, USA.
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC 20010, USA.
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37
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Patterson KN, Onwuka A, Horvath KZ, Fabia R, Giles S, Marx D, Aguayo P, Ziegfeld S, Garcia A, Stewart FD, Fritzeen J, Burd RS, Vitale L, Klein J, Thakkar RK. Length of Stay per Total Body Surface Area Burn Relative to Mechanism: A Pediatric Injury Quality Improvement Collaborative (PIQIC) Study. J Burn Care Res 2021; 43:863-867. [PMID: 34788832 DOI: 10.1093/jbcr/irab212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Studies on length of stay (LOS) per total body surface area (TBSA) burn in pediatric patients are often limited to single institutions and are grouped in ranges of TBSA burn which lacks specific detail to counsel patients and families. A LOS to TBSA burn ratio of 1 has been widely accepted but not validated with multi-institution data. The objective of this study is to describe the current relationship of LOS per TBSA burn and LOS per TBSA burn relative to burn mechanism with the use of multi-institutional data. Data from the Pediatric Injury Quality Improvement Collaborative (PIQIC) were obtained for patients across five pediatric burn centers from July 2018-September 2020. LOS per TBSA burn ratios were calculated. Descriptive statistics and generalized linear regression which modeled characteristics associated with LOS per TBSA ratio are described. Among the 1267 pediatric burn patients, the most common mechanism was scald (64%), followed by contact (17%) and flame (13%). The average LOS/TBSA burn ratio across all cases was 1.2 (SD 2.1). In adjusted models, scald burns and chemical burns had similar LOS/TBSA burn ratios of 0.8 and 0.9, respectively, while all other burns had a significantly higher LOS/TBSA burn ratio (p<0.0001). LOS/TBSA burn ratios were similar across races, although Hispanics had a slightly higher ratio at 1.4 days. These data establish a multi-institution LOS per TBSA ratio across PIQIC centers and demonstrate significant variation in the LOS per TBSA burn relative to the burn mechanism sustained.
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Affiliation(s)
- Kelli N Patterson
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH
| | - Kyle Z Horvath
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH
| | - Renata Fabia
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH.,Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH
| | - Sheila Giles
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH
| | - Daniel Marx
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO
| | - Susan Ziegfeld
- Department of Pediatric Surgery, Johns Hopkins Children's Center, 1800 Orleans Street, Baltimore, MD
| | - Alejandro Garcia
- Department of Pediatric Surgery, Johns Hopkins Children's Center, 1800 Orleans Street, Baltimore, MD
| | - F Dylan Stewart
- Department of Pediatric Surgery, Johns Hopkins Children's Center, 1800 Orleans Street, Baltimore, MD
| | - Jennifer Fritzeen
- Division Trauma and Burn Surgery, Center for Surgical Care, Children's National Medical Center, 111 Michigan Ave, Washington, DC
| | - Randall S Burd
- Division Trauma and Burn Surgery, Center for Surgical Care, Children's National Medical Center, 111 Michigan Ave, Washington, DC
| | - Lisa Vitale
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, 3901 Beaubien Blvd, Detroit MI
| | - Justin Klein
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, 3901 Beaubien Blvd, Detroit MI
| | - Rajan K Thakkar
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH.,Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH
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38
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Evans LL, Melhado C, Miskovic A, Subacius H, Stein DM, Burd RS, Nathens AB, Jensen AR. Benchmarking Pediatric Trauma Care in Mixed Trauma Centers: Center-Specific Risk-Adjusted Mortality Is Frequently Discordant Between Pediatric and Adult Cohorts. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ahmed OZ, Clay CE, Spiliopoulos K, Taylormoore J, Karwoski BA, Burd RS. Periocular Facial Scald Burns in Children: Is Ophthalmology Consultation Necessary? Pediatr Emerg Care 2021; 37:e713-e715. [PMID: 32675709 DOI: 10.1097/pec.0000000000002129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Criteria that predict the need for ocular injury treatment in children who suffer periocular facial scald burns are not known. The purpose of this study was to evaluate the incidence and management of ocular injuries among children sustaining facial scald burns and to determine predictors of injuries requiring additional treatment. METHODS Children treated at a burn center with periocular facial scald burns were analyzed. Patient and injury profiles were compared between those evaluated and not evaluated by an ophthalmologist. Factors associated with an ocular injury requiring treatment were determined, and treatment differences before and after ophthalmology consultation were evaluated. RESULTS Seventy-three children with facial scald burns were identified, none with a full-thickness injury. Thirteen children had ocular findings on examination including corneal abrasion, conjunctivitis, scleral burn, and chemosis of the conjunctiva. Twenty-three patients received erythromycin ointment, only 8 of whom had a documented ocular injury. Children seen by an ophthalmologist (n = 24) more often had a positive finding on examination (37.5% vs 8.2%, P = 0.007) and received treatment (66.7% vs 14.3%, P < 0.001). Only 4 patients had modification in their treatment plan after consultation, 3 of whom were started on treatment despite not having a positive finding on examination. CONCLUSIONS Ocular injury after periocular facial scald burns is an infrequent finding. Among children with partial-thickness periocular facial scald burns, initial evaluation and treatment without ophthalmology consultation are appropriate. Ophthalmic antibiotic ointment is an appropriate initial treatment in most symptomatic patients, with ophthalmologic consultation being limited to children without symptomatic improvement.
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40
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Alberto EC, McCarthy KH, Hamilton CA, Shalkevich J, Milestone ZP, Izem R, Fritzeen JL, Marsic I, Sarcevic A, O'Connell KJ, Burd RS. Personal Protective Equipment Adherence of Pediatric Resuscitation Team Members During the COVID-19 Pandemic. Ann Emerg Med 2021; 78:619-627. [PMID: 34353649 PMCID: PMC8164378 DOI: 10.1016/j.annemergmed.2021.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/11/2021] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE During the COVID-19 pandemic, health care workers have had the highest risk of infection among essential workers. Although personal protective equipment (PPE) use is associated with lower infection rates, appropriate use of PPE has been variable among health care workers, even in settings with COVID-19 patients. We aimed to evaluate the patterns of PPE adherence during emergency department resuscitations that included aerosol-generating procedures. METHODS We conducted a retrospective, video-based review of pediatric resuscitations involving one or more aerosol-generating procedures during the first 3 months of the COVID-19 pandemic in the United States (March to June 2020). Recommended adherence (complete, inadequate, absent) with 5 PPE items (headwear, eyewear, masks, gowns, gloves) and the duration of potential exposure were evaluated for individuals in the room after aerosol-generating procedure initiation. RESULTS Among the 345 health care workers observed during 19 resuscitations, 306 (88.7%) were nonadherent (inadequate or absent adherence) with the recommended use of at least 1 PPE type at some time during the resuscitation, 23 (6.7%) of whom had no PPE. One hundred and forty health care workers (40.6%) altered or removed at least 1 type of PPE during the event. The aggregate time in the resuscitation room for health care workers across all events was 118.7 hours. During this time, providers had either absent or inadequate eyewear for 46.4 hours (39.1%) and absent or inadequate masks for 35.2 hours (29.7%). CONCLUSION Full adherence with recommended PPE use was limited in a setting at increased risk for SARS-CoV-2 virus aerosolization. In addition to ensuring appropriate donning, approaches are needed for ensuring ongoing adherence with PPE recommendations during exposure.
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Affiliation(s)
- Emily C Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Kathleen H McCarthy
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Colleen A Hamilton
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Jacob Shalkevich
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Zachary P Milestone
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Rima Izem
- Division of Biostatistics and Study Methods, Children's National Research Institute, Washington, DC; Department of Pediatrics and the Department of Epidemiology, George Washington University, Washington, DC
| | - Jennifer L Fritzeen
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ
| | | | - Karen J O'Connell
- Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC.
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Millar MM, Olson LM, VanBuren JM, Richards R, Pollack MM, Holubkov R, Berg RA, Carcillo JA, McQuillen PS, Meert KL, Mourani PM, Burd RS. Incentive delivery timing and follow-up survey completion in a prospective cohort study of injured children: a randomized experiment comparing prepaid and postpaid incentives. BMC Med Res Methodol 2021; 21:233. [PMID: 34706653 PMCID: PMC8549144 DOI: 10.1186/s12874-021-01421-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background Retaining participants over time is a frequent challenge in research studies evaluating long-term health outcomes. This study’s objective was to compare the impact of prepaid and postpaid incentives on response to a six-month follow-up survey. Methods We conducted an experiment to compare response between participants randomized to receive either prepaid or postpaid cash card incentives within a multisite study of children under 15 years in age who were hospitalized for a serious, severe, or critical injury. Participants were parents or guardians of enrolled children. The primary outcome was survey response. We also examined whether demographic characteristics were associated with response and if incentive timing influenced the relationship between demographic characteristics and response. We evaluated whether incentive timing was associated with the number of calls needed for contact. Results The study enrolled 427 children, and parents of 420 children were included in this analysis. Follow-up survey response did not differ according to the assigned treatment arm, with the percentage of parents responding to the survey being 68.1% for the prepaid incentive and 66.7% with the postpaid incentive. Likelihood of response varied by demographics. Spanish-speaking parents and parents with lower income and lower educational attainment were less likely to respond. Parents of Hispanic/Latino children and children with Medicaid insurance were also less likely to respond. We found no relationship between the assigned incentive treatment and the demographics of respondents compared to non-respondents. Conclusions Prepaid and postpaid incentives can obtain similar participation in longitudinal pediatric critical care outcomes research. Incentives alone do not ensure retention of all demographic subgroups. Strategies for improving representation of hard-to-reach populations are needed to address health disparities and ensure the generalizability of studies using these results. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01421-8.
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Affiliation(s)
- Morgan M Millar
- Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Lenora M Olson
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201 and, Central Michigan University, Mt. Pleasant, MI, USA.,Central Michigan University, Mt. Pleasant, MI, USA
| | - Peter M Mourani
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC, 20010, USA
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Alberto EC, Zheng Y, Milestone ZP, Cheng M, Ahmed OZ, Olafson S, Fritzeen JL, Sharron MP, Burd RS, Jacquot C. Patterns of paediatric massive blood transfusion protocol use in trauma and non-trauma patients. Transfus Med 2021; 31:439-446. [PMID: 34704638 DOI: 10.1111/tme.12829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/19/2021] [Accepted: 10/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Massive blood transfusion is infrequently required by children but can be a lifesaving intervention for haemorrhage or coagulopathy. Product volumes and ratios administered during the initiation of paediatric massive blood transfusion protocol (MBTP) are highly variable and the optimal component ratio is unknown. METHODS/MATERIALS We performed a single-centre retrospective chart review of patients (<20 years) who received MBTP activation from August 2012 through January 2018. Logistic regression was used to determine the association between MBTP use characteristics (including blood product type and volume transfused, extracorporeal membrane oxygenation [ECMO] support, and cardiac arrest occurrence) and 24-h mortality. "Low" product ratio was defined as a ratio of plasma or platelets to red blood cells (RBCs) of <1:2 and "high" as ≥1:2. RESULTS Ninety-eight MBTPs were activated for 89 patients (range 1-4 per patient). The most common underlying diagnoses were congenital heart disease (CHD, n = 28, 31.5%), followed by cardiopulmonary disease, and trauma. CHD patients required the greatest volume of RBCs (226.3 ml/kg, 95%CI [160.0, 292.7], p = 0.002) and platelets (46.7 ml/kg, 95%CI [33.2, 60.2], p < 0.001). A "low" product ratio was more common for the MBTP, with its incidence similar among the underlying diagnoses. CONCLUSION An MBTP developed for trauma patients can be applied to non-trauma patients but standard MBTP components may not be optimal for all children. These findings show that underlying patient diagnoses may be a factor when designing an MBTP for a heterogeneous paediatric population.
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Affiliation(s)
- Emily C Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Yinan Zheng
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Zachary P Milestone
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Megan Cheng
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Omar Z Ahmed
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Samantha Olafson
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Jennifer L Fritzeen
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Matthew P Sharron
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Cyril Jacquot
- Departments of Laboratory Medicine and Hematology, Children's National Hospital, Washington, District of Columbia, USA
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Burd RS, Jensen AR, VanBuren JM, Alvey JS, Richards R, Holubkov R, Pollack MM. Long-Term Outcomes after Pediatric Injury: Results of the Assessment of Functional Outcomes and Health-Related Quality of Life after Pediatric Trauma Study. J Am Coll Surg 2021; 233:666-675.e2. [PMID: 34592405 DOI: 10.1016/j.jamcollsurg.2021.08.693] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/19/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Disability and impaired health-related quality of life can persist for months among injured children. Previous studies of long-term outcomes have focused mainly on children with specific injury types rather than those with multiple injured body regions. This study's objective was to determine the long-term functional status and health-related quality of life after serious pediatric injury, and to evaluate the associations of these outcomes with features available at hospital discharge. STUDY DESIGN We conducted a prospective observational study at 7 Level I pediatric trauma centers of children treated for at least 1 serious (Abbreviated Injury Scale severity 3 or higher) injury. Patients were sampled to increase the representation of less frequently injured body regions and multiple injured body regions. Six-month functional status was measured using the Functional Status Scale (FSS) and health-related quality of life using the Pediatric Quality of Life Inventory. RESULTS Among 323 injured children with complete discharge and follow-up assessments, 6-month FSS score was abnormal in 33 patients (10.2%)-16 with persistent impairments and 17 previously normal at discharge. Increasing levels of impaired discharge FSS score were associated with impaired FSS and lower Pediatric Quality of Life Inventory scores at 6-month follow-up. Additional factors on multivariable analysis associated with 6-month FSS impairment included older age, penetrating injury type, severe head injuries, and spine injuries, and included older age for lower 6-month Pediatric Quality of Life Inventory scores. CONCLUSIONS Older age and discharge functional status are associated with long-term impairment of functional status and health-related quality of life. Although most seriously injured children return to normal, ongoing disability and reduced health-related quality of life remained 6 months after injury. Our findings support long-term assessments as standard practice for evaluating the health impacts of serious pediatric injury.
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Affiliation(s)
- Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center.
| | | | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Jessica S Alvey
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington DC
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Alberto EC, McKenna E, Amberson MJ, Tashiro J, Donnelly K, Thenappan AA, Tempel PE, Ranganna AS, Keller S, Marsic I, Sarcevic A, O’Connell KJ, Burd RS. Metrics of shock in pediatric trauma patients: A systematic search and review. Injury 2021; 52:3166-3172. [PMID: 34238538 PMCID: PMC8560576 DOI: 10.1016/j.injury.2021.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Shock-index (SI) and systolic blood pressure (SBP) are metrics for identifying children and adults with hemodynamic instability following injury. The purpose of this systematic review was to assess the quality of these metrics as predictors of outcomes following pediatric injury. MATERIALS AND METHODS We conducted a literature search in Pubmed, SCOPUS, and CINAHL to identify studies describing the association between shock metrics on the morbidity and mortality of injured children and adolescents. We used the data presented in the studies to calculate the sensitivity and specificity for each metric. This study was registered with Prospero, protocol CRD42020162971. RESULTS Fifteen articles met the inclusion criteria. seven studies evaluated SI or SIPA score, an age-corrected version of SI, as predictors of outcomes following pediatric trauma, with one study comparing SIPA score and SBP and one study comparing SI and SBP. The remaining eight studies evaluated SBP as the primary indicator of shock. The median sensitivity for predicting mortality and need for blood transfusion was highest for SI, followed by SIPA, and then SBP. The median specificity for predicting these outcomes was highest for SBP, followed by SIPA, and then SI. CONCLUSIONS Common conclusions were that high SIPA scores were more specific than SI and more sensitive than SBP. SIPA score had better discrimination for severely injured children compared to SI and SBP. An elevated SIPA was associated with a greater need for blood transfusion and higher in-hospital mortality. SIPA is specific enough to exclude most patients who do not require a blood transfusion.
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Affiliation(s)
- Emily C. Alberto
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Elise McKenna
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Michael J. Amberson
- Department of Pediatrics, Children’s National Hospital, Washington D.C., United States
| | - Jun Tashiro
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Katie Donnelly
- Division of Emergency Medicine, Children’s National Hospital, Washington D.C., United States
| | - Arunachalam A. Thenappan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Peyton E. Tempel
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Adesh S. Ranganna
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States
| | - Susan Keller
- Department of Nursing Science Professional Practice and Quality, Children’s National Hospital, Washington D.C., United States
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ, United States
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, United States
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Washington D.C., United States
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington D.C., United States,Corresponding author at: Division of Trauma and Burn Surgery, Children’s National Hospital, 111 Michigan Ave NW, Washington D.C. 20010, United States. (R.S. Burd)
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Burd RS, Jensen AR, VanBuren JM, Richards R, Holubkov R, Pollack MM, Berg RA, Carcillo JA, Carpenter TC, Dean JM, Gaines B, Hall MW, McQuillen PS, Meert KL, Mourani PM, Nance ML, Yates AR. Factors Associated With Functional Impairment After Pediatric Injury. JAMA Surg 2021; 156:e212058. [PMID: 34076684 DOI: 10.1001/jamasurg.2021.2058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown. Objective To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers. Design, Setting, and Participants This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020. Exposure At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5). Main Outcomes and Measures New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites. Results This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge. Conclusions and Relevance In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.
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Affiliation(s)
- Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC
| | - Aaron R Jensen
- University of California San Francisco Benioff Children's Hospital Oakland, Oakland
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Robert A Berg
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Barbara Gaines
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit.,Central Michigan University, Mt Pleasant
| | - Peter M Mourani
- Arkansas Children's Research Institute, Arkansas Children's Hospital, Little Rock
| | - Michael L Nance
- Division of Pediatric Trauma, Department of Surgery, College of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
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Siems A, Banks R, Holubkov R, Meert KL, Bauerfeld C, Beyda D, Berg RA, Bulut Y, Burd RS, Carcillo J, Dean JM, Gradidge E, Hall MW, McQuillen PS, Mourani PM, Newth CJL, Notterman DA, Priestley MA, Sapru A, Wessel DL, Yates AR, Zuppa AF, Pollack MM. Structured Chart Review: Assessment of a Structured Chart Review Methodology. Hosp Pediatr 2021; 10:61-69. [PMID: 31879317 DOI: 10.1542/hpeds.2019-0225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Chart reviews are frequently used for research, care assessments, and quality improvement activities despite an absence of data on reliability and validity. We aim to describe a structured chart review methodology and to establish its validity and reliability. METHODS A generalizable structured chart review methodology was designed to evaluate causes of morbidity or mortality and to identify potential therapeutic advances. The review process consisted of a 2-tiered approach with a primary review completed by a site physician and a short secondary review completed by a central physician. A total of 327 randomly selected cases of known mortality or new morbidities were reviewed. Validity was assessed by using postreview surveys with a Likert scale. Reliability was assessed by percent agreement and interrater reliability. RESULTS The primary reviewers agreed or strongly agreed in 94.9% of reviews that the information to form a conclusion about pathophysiological processes and therapeutic advances could be adequately found. They agreed or strongly agreed in 93.2% of the reviews that conclusions were easy to make, and confidence in the process was 94.2%. Secondary reviewers made modifications to 36.6% of cases. Duplicate reviews (n = 41) revealed excellent percent agreement for the causes (80.5%-100%) and therapeutic advances (68.3%-100%). κ statistics were strong for the pathophysiological categories but weaker for the therapeutic categories. CONCLUSIONS A structured chart review by knowledgeable primary reviewers, followed by a brief secondary review, can be valid and reliable.
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Affiliation(s)
- Ashley Siems
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Russell Banks
- School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Kathleen L Meert
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - Christian Bauerfeld
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - David Beyda
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yonca Bulut
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - Randall S Burd
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Joseph Carcillo
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - J Michael Dean
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Eleanor Gradidge
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- University of California, San Francisco and University of California, San Francisco Benioff Children's Hospital, San Francisco, California
| | - Peter M Mourani
- University of Colorado and Children's Hospital of Colorado, Denver, Colorado
| | - Christopher J L Newth
- Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California; and
| | | | | | - Anil Sapru
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - David L Wessel
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | | | - Athena F Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Murray M Pollack
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia;
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Batra N, Colson CD, Alberto EC, Burd RS. Using Social Media for the Prevention of Pediatric Burn Injuries: Pilot Design and Usability Study. JMIR Form Res 2021; 5:e23242. [PMID: 34264194 PMCID: PMC8323015 DOI: 10.2196/23242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/12/2020] [Accepted: 05/17/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Most pediatric burn injuries are preventable. Social media is an effective method for delivering large-scale messaging and may be useful for injury prevention in this domain. OBJECTIVE This study evaluates the feasibility of creating a social media campaign for pediatric burn injury prevention. METHODS Ad spots containing a headline, short introduction, and video were created and posted on Facebook and Instagram over 4 months. Ad spots were targeted to parents and caregivers of children in our region with the highest number of burn injuries. We assessed the impact of each ad set using ThruPlays, reach, and video plays. RESULTS We created 55 ad spots, with an average length of 24.1 (range 10-44) seconds. We reached 26,496 people during the campaign. The total ThruPlays of the 55 ad spots were 14,460 at US $0.19 per ThruPlay. Ad spots related to home safety had a significantly higher daily ThruPlay rate than those related to fire safety (6.5 vs 0.5 per day; P<.001). CONCLUSIONS Social media is a feasible modality for delivering public health messages focused on preventing pediatric burn injuries. Engagement with these ads is influenced by ad presentation and the focus of the underlying injury prevention message.
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Affiliation(s)
- Nikita Batra
- Children's National Hospital, Washington, DC, United States
| | - Cindy D Colson
- Children's National Hospital, Washington, DC, United States
| | | | - Randall S Burd
- Children's National Hospital, Washington, DC, United States
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Mastrianni A, Sarcevic A, Chung LS, Zakeri I, Alberto EC, Milestone ZP, Burd RS, Marsic I. Designing Interactive Alerts to Improve Recognition of Critical Events in Medical Emergencies. DIS (Des Interact Syst Conf) 2021; 2021:864-878. [PMID: 35330919 PMCID: PMC8941664 DOI: 10.1145/3461778.3462051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Vital sign values during medical emergencies can help clinicians recognize and treat patients with life-threatening injuries. Identifying abnormal vital signs, however, is frequently delayed and the values may not be documented at all. In this mixed-methods study, we designed and evaluated a two-phased visual alert approach for a digital checklist in trauma resuscitation that informs users about undocumented vital signs. Using an interrupted time series analysis, we compared documentation in the periods before (two years) and after (four months) the introduction of the alerts. We found that introducing alerts led to an increase in documentation throughout the post-intervention period, with clinicians documenting vital signs earlier. Interviews with users and video review of cases showed that alerts were ineffective when clinicians engaged less with the checklist or set the checklist down to perform another activity. From these findings, we discuss approaches to designing alerts for dynamic team-based settings.
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Batra N, Zheng Y, Alberto EC, Ahmed OZ, Cheng M, Shupp JW, Burd RS. Pediatric Treadmill Friction Burns to the Hand: Outcomes of an Initial Nonoperative Approach. J Burn Care Res 2021; 42:434-438. [PMID: 33022715 DOI: 10.1093/jbcr/iraa178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Treadmill burns that occur from friction mechanism are a common cause of hand burns in children. These burns are deeper and more likely to require surgical intervention compared to hand burns from other mechanisms. The purpose of this study was to identify the factors associated with healing time using an initial nonoperative approach. A retrospective chart review was performed examining children (<15 years) who were treated for treadmill burns to the hand between 2012 and 2019. Patient age, burn depth, total body surface area of the hand injury, and time to healing were recorded. Topical wound management strategies (silver sheet, silver cream, non-silver sheet, and non-silver cream) and associated treatment durations were determined. For patients with burns to bilateral hands, the features, treatment, and outcomes of each hand were assessed separately. Cox regression analysis was used to evaluate the association between time to healing and patient characteristics and treatment type. Seventy-seven patients with 86 hand burns (median age 3 years, range 1-11) had a median total body surface area per hand burn of 0.8% (range 0.1-1.5%). Full-thickness burns (n = 47, 54.7%) were associated with longer time to healing compared to partial-thickness burns (HR 0.28, CI 0.15-0.54, P < .001). Silver sheet treatment was also associated with more rapid time to healing compared to treatment with a silver cream (HR 2.64, CI 1.01-6.89, P = .047). Most pediatric treadmill burns can be managed successfully with a nonoperative approach. More research is needed to confirm the superiority of treatment with silver sheets compared to treatment with silver creams.
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Affiliation(s)
- Nikita Batra
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Yinan Zheng
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Emily C Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Omar Z Ahmed
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Megan Cheng
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
| | - Jeffrey W Shupp
- Burn Center, MedStar Washington Hospital Center, Department of Surgery, Georgetown University School of Medicine, District of Columbia
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, District of Columbia
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Alberto EC, Jagannath S, McCusker ME, Keller S, Marsic I, Sarcevic A, O’Connell KJ, Burd RS. Classification strategies for non-routine events occurring in high-risk patient care settings: A scoping review. J Eval Clin Pract 2021; 27:464-471. [PMID: 33249690 PMCID: PMC7961264 DOI: 10.1111/jep.13456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Non-routine events (NREs) are atypical or unusual occurrences in a pre-defined process. Although some NREs in high-risk clinical settings have no adverse effects on patient care, others can potentially cause serious patient harm. A unified strategy for identifying and describing NREs in these domains will facilitate the comparison of results between studies. METHODS We conducted a literature search in PubMed, CINAHL, and EMBASE to identify studies related to NREs in high-risk domains and evaluated the methods used for event observation and description. We applied The Joint Commission on Accreditation of Healthcare Organization (JCAHO) taxonomy (cause, impact, domain, type, prevention, and mitigation) to the descriptions of NREs from the literature. RESULTS We selected 25 articles that met inclusion criteria for review. Real-time documentation of NREs was more common than a retrospective video review. Thirteen studies used domain experts as observers and seven studies validated observations with interrater reliability. Using the JCAHO taxonomy, "cause" was the most frequently applied classification method, followed by "impact," "type," "domain," and "prevention and mitigation." CONCLUSIONS NREs are frequent in high-risk medical settings. Strengths identified in several studies included the use of multiple observers with domain expertise and validation of the event ascertainment approach using interrater reliability. By applying the JCAHO taxonomy to the current literature, we provide an example of a structured approach that can be used for future analyses of NREs.
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Affiliation(s)
- Emily C. Alberto
- Division of Trauma and Burns, Children’s National Hospital, Washington, DC, USA
| | - Swathi Jagannath
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Maureen E. McCusker
- Office of Institutional Research and Decision Support, Virginia Commonwealth University, Richmond, VA, USA
| | - Susan Keller
- Department of Nursing Science Professional Practice and Quality, Children’s National Hospital, Washington, DC, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Washington, DC, USA
| | - Randall S. Burd
- Division of Trauma and Burns, Children’s National Hospital, Washington, DC, USA
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