Documentation of Trauma-Informed Care Elements for Young People Hospitalized After Assault Trauma

INTRODUCTION

Violent traumatic injury, including firearm violence, can adversely impact individual and community health. Trauma-informed care (TIC) can promote resilience and prevent future violence in patients who have experienced trauma. However, few protocols exist to facilitate implementation of TIC for patients who survive traumatic injury. The purpose of the study is to characterize documentation of TIC practices and identify opportunities for intervention in a single academic quaternary care center.

METHODS

This study is a retrospective chart review analyzing the documentation of trauma-informed elements in the electronic medical record of a random sample of youth patients (ages 12-23) admitted for assault trauma to the pediatric (n = 50) and adult trauma (n = 200) services between 2016 and mid-2021. Descriptive statistics were used to summarize patient demographics, hospitalization characteristics, and documentation of trauma-informed elements. Chi-square analyses were performed to compare pediatric and adult trauma services.

RESULTS

Among pediatric and adult assault trauma patients, 36.0% and 80.5% were hospitalized for firearm injury, respectively. More patients admitted to the pediatric trauma service (96%) had at least one trauma-informed element documented than patients admitted to the adult service (82.5%). Social workers were the most likely clinicians to document a trauma-informed element. Pain assessment and social support were most frequently documented. Safety assessments for suicidal ideation, retaliatory violence, and access to a firearm were rarely documented.

CONCLUSIONS

Results highlight opportunities to develop trauma-informed interventions for youth admitted for assault trauma. Standardized TIC documentation could be used to assess risk of violent reinjury and mitigate sequelae of trauma.

A Study of Households with Children and Firearms in Baltimore, Maryland

Firearm injuries are the leading cause of death among children and adolescents in the US. Safe storage of firearms in the home is one of the most effective ways of preventing firearm injuries in children. This feasibility study was conducted in both the pediatric and general Emergency Departments of a large urban academic medical center in a community with high rates of firearm injuries in children. The objective was to pilot a survey seeking to describe sociodemographic characteristics, firearm specific risk factors, and firearm storage practices of households with children in the community. One hundred participants completed a survey containing items regarding participant demographics, household features, firearm ownership, firearm characteristics, and storage practices. Descriptive statistics were used to define sociodemographic characteristics of the enrolled population, comparing those with firearms to those without, and to describe firearms and storage practices of firearm owners in households with children. Of 100 participants, 30 lived in households with firearms and children. Most firearms in homes with children were stored locked and unloaded most of the time; however, 30% of participants with firearms and children in the home reported not consistently storing a firearm locked and unloaded. The most common reason given for not storing a firearm in the safest manner possible was that storing a firearm locked and unloaded would make it difficult to access quickly. Engaging families with children in discussions around firearm prevention during Emergency Department visits is feasible and may have implications for future efforts to promote safe firearm storage practices.

Pediatric Residents' Outpatient Firearm Screening and Safety Counseling Practices (Or Lack Thereof): A Retrospective Chart Review

The American Academy of Pediatrics recommends that children and adolescents be universally screened for access to firearms and exposure to violence. The purpose of this study was to characterize how often pediatric residents at one institution document screening for firearm access and violence risk factors and provide risk reduction counseling in the primary care setting. A retrospective chart review was conducted at two primary care clinics in Baltimore, Maryland, for patient ages 10 to 25 years who were seen by resident physicians for well care between October 2019 and December 2020. We reviewed 169 patients' charts meeting the inclusion criteria. Forty (24%) patients had a documented history of exposure to violence or history of suicidal ideation. Based on resident documentation, one (<1%) patient was screened for firearm access or exposure to firearm violence and 10 (6%) were provided risk reduction counseling or any type of firearm safety counseling. Pediatric resident physicians at our institution rarely screen for firearm access or provide violence prevention counseling in the primary care setting. Targeted interventions and quality improvement projects are needed to address screening barriers and design novel interventions to overcome these barriers.

Disparities in Patient Safety Voluntary Event Reporting: A Scoping Review

Voluntary event reporting (VER) systems underestimate the incidence of safety events and often capture only serious events. A limited amount of data is collected through these systems, and they may be inadequate to characterize disparities in reported safety events. We conducted a scoping review of the literature to summarize the state of the evidence as it relates to differences in safety events and safety event reporting by age, gender, and race. Using a broad-based query, a systematic search for published, peer-reviewed literature that discusses patient safety event reporting and differences by age, gender, race, and socioeconomic status was conducted. Based on modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 283 studies underwent title and abstract review, yielding 56 studies for full text review. After full text review, 23 studies were carefully reviewed individually, grouped thematically, and summarized to highlight the most pertinent findings. The studies reviewed yielded important insights, particularly with regard to race, gender, and the ways events are identified. Patients from minoritized groups may be less likely to have events reported and more likely to suffer serious events. Some studies found differences in rates of reporting safety events for female vs. male providers. The rate of VER is consistently lower than the rate of events identified through identified using automated detection. The current literature describing VER data shows disparities by race, language, age, and gender for patients and providers. Further research and systematic change are needed to specifically study these disparities to guide health care institutions on ways to mitigate bias and deliver more equitable care.

Epidemiology and clinical characteristics of drowning patients presenting to a pediatric emergency department from 2018 to 2020

BACKGROUND

Drowning is a common mechanism of injury in the pediatric population that often requires hospitalization. The primary objective of this study was to describe the epidemiology and clinical characteristics of pediatric drowning patients evaluated in a pediatric emergency department (PED), including the clinical interventions and outcomes of this patient population.

METHODS

A retrospective cohort study was conducted of pediatric patients evaluated in a mid-Atlantic urban pediatric emergency department from January 2017 to December 2020 after a drowning event.

RESULTS

Eighty patients ages 0-18 were identified, representing 57 79 unintentional events and 1 intentional self-injury event. The majority of patients (50%) were 1-4 years of age. The majority (65%) of patients 4 years of age or younger were White, whereas racial/ethnic minority patients accounted for the majority (73%) of patients 5 years of age or older. Most drowning events (74%) occurred in a pool, on Friday through Saturday (66%) and during the summer (73%). Oxygen was used in 54% of admitted patients and only in 9% of discharged patients. Cardiopulmonary resuscitation (CPR) was performed in 74% of admitted patients and 33% of discharged patients.

CONCLUSIONS

Drowning can be an intentional or unintentional source of injury in pediatric patients. Among the patients who presented to the emergency department for drowning, more than half received CPR and/or were admitted, suggesting high acuity and severity of these events. In this study population, outdoor pools, summer season and weekends are potential high yield targets for drowning prevention efforts.

Assessing the effect of COVID-19 stay-at -home orders on firearm injury in Maryland

This study sought to characterize frequency and demographic characteristics of firearm injury and penetrating trauma in Maryland over the first year of the pandemic, by comparing these characteristics to those of the three years prior to stay-at-home order issuance. Patients were identified in the Maryland Health Services Cost Review Commission database using ICD-10 codes for firearm injury by all intents and assaults by penetrating trauma. Cases from July 1, 2017 to March 31, 2020 ("pre-stay-at-home") were compared to those from April 1, 2020 to March 31, 2021 ("post-stay-at-home") using descriptive statistics. There was no significant change overall in frequency or demographics of firearm injury or penetrating trauma in the year after stay-at-home orders were issued. Youth between ages 15 and 24, overwhelmingly male, comprise a disproportionately high percentage of firearm injuries and assaults, and most penetrating trauma occurs in urban environments where Black non-Hispanic youth and children of low socioeconomic status are at high risk. Our study also found unintentional firearm injury among adults was significantly increased during the pandemic. While increased unintentional firearm injury among adults was the major significant change found in our study, the persistence of firearm injury, particularly in youth, racial and ethnic minority groups, and those in urban environments, should be deeply concerning. Stay-at-home policies did not keep youth safer from firearm injury. With continued high rates of firearm injury and the national debate over how to prevent these incidents, increased education and comprehensive strategies for prevention are needed.

The 5 A's of firearm safety counseling: Validating a clinical counseling methodology for firearms in a simulation-based randomized controlled trial

The 5 A's of Firearm Safety Counseling is a novel framework by which clinicians can approach firearm injury prevention counseling. To evaluate this methodology as a tool for clinicians, a single-center, simulation-based randomized controlled trial was performed with clinical trainees in psychiatry, medicine, and pediatrics in an urban quaternary care center. Participants received didactic education on firearm injury epidemiology and evidence-based policies and training on a specific counseling framework, the 5 A's of Firearm Safety Counseling which they then implemented in a simulation setting with standardized patients. Of the 29 participants who were randomized, 28 completed the trial. Most participants were psychiatry trainees (residents or subspecialty fellows). While over 60% of participants were uncomfortable or extremely uncomfortable counseling on firearm injury prior to the interventions, only 4% reported being uncomfortable after receiving education and participating in simulated encounters. There was no significant difference between the quality and content of the counseling provided before and after the didactic-only session. There was a significant difference between the quality and content of the counseling provided before and after the specific training on the 5 A's for Firearm Safety Counseling strategy. The 5 A's for Firearm Safety Counseling is a promising educational tool to improve quality, content, and comfort delivering patient-centered counseling on firearm injury prevention in a simulation-based setting. These findings suggest that further validation in a clinical setting is warranted given there is an urgent need for feasible and effective firearm injury prevention strategies among clinicians.

Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals

PURPOSE

Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals.

METHOD

In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list.

RESULTS

This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury.

CONCLUSIONS

Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

Firearm Suicide Among Veterans of the U.S. Military: A Systematic Review

INTRODUCTION

In the United States, firearm suicide represents a major cause of preventable, premature death among veterans. The purpose of this systematic review was to characterize the body of literature on veteran firearm suicide and identify areas for future research, which may facilitate the development of firearm suicide interventions in Veterans Health Administration (VHA) and non-Veterans Health Administration clinical settings.

MATERIALS AND METHODS

All randomized controlled trials, quasi-experimental, naturalistic, observational, and case study designs published between January 1, 1990 and February 21, 2019 were included in our review. Following title and abstract review, 65 papers were included in our full-text review and 37 studies were included in our analysis. We based our approach on a modification of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were grouped into broad, nonmutually exclusive categories: (1) heterogeneity of datasets and veteran status determination for inclusion, (2) service histories, (3) firearm ownership, storage, behaviors, and risk perceptions, (4) patient and clinician attitudes toward firearm restriction interventions, (5) firearm suicide risk factors by study population, and (6) assessments of clinical firearm interventions.

RESULTS

This body of literature consists predominately of cross-sectional studies with mixed definitions and validation of veteran status, which revealed high concordance of increased risk of firearm suicide compared with nonveterans. Veterans have higher rates of firearm ownership than the general population, primarily citing personal protection as the reason for gun ownership. Veterans often exhibit risky firearm usage and storage behaviors but tend to favor measures that limit access to firearms by at-risk individuals. Despite this, there remains persistent hesitation among clinicians to screen and counsel veterans on firearm safety.

CONCLUSIONS

This systematic review highlights an urgent need to produce higher quality evidence and new data with standard definitions that are critical to inform clinical practice and enhance public health measures to reduce firearm suicide among veterans.

Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU

BACKGROUND

Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision support algorithm to standardize the use of EACs from ventilated PICU patients.

METHODS

We monitored EAC use using a statistical process control chart. We compared the rate of EACs using Poisson regression and a quasi-experimental interrupted time series model and assessed clinical outcomes 1 year before and after introduction of the algorithm.

RESULTS

In the preintervention year, there were 557 EACs over 5092 ventilator days; after introduction of the algorithm, there were 234 EACs over 3654 ventilator days (an incident rate of 10.9 vs 6.5 per 100 ventilator days). There was a 41% decrease in the monthly rate of EACs (incidence rate ratio [IRR]: 0.59; 95% confidence interval [CI] 0.51-0.67; P < .001). The interrupted time series model revealed a preexisting 2% decline in the monthly culture rate (IRR: 0.98; 95% CI 0.97-1.0; P = .01), immediate 44% drop (IRR: 0.56; 95% CI 0.45-0.70; P = .02), and stable rate in the postintervention year (IRR: 1.03; 95% CI 0.99-1.07; P = .09). In-hospital mortality, hospital length of stay, 7-day readmissions, and All Patients Refined Diagnosis Related Group severity and mortality scores were stable. The estimated direct cost savings was $26 000 per year.

CONCLUSIONS

A clinical decision support algorithm standardizing EAC obtainment from ventilated PICU patients was associated with a sustained decline in the rate of EACs, without changes in mortality, readmissions, or length of stay.

Stay-at-home orders and firearms in the United States during the COVID-19 pandemic

Firearms are a leading cause of death and injury in the United States, and this trend has continued during the COVID-19 pandemic. We sought to identify whether states designated gun retailers as essential businesses in their stay-at-home orders and characterize other references that could affect firearm acquisition during the COVID-19 pandemic. In this cross-sectional policy review, we assessed stay-at-home orders issued in March or April 2020. Orders were reviewed in their entirety, and any reference to firearms, firearm retailers, shooting ranges, or other relevant elements was documented. Forty-three states and the District of Columbia issued stay-at-home orders. Most considered federal firearm licensees to be among essential businesses or made provisions for them to remain open during widespread business closures. Others referenced the US Department of Homeland Security's Cybersecurity and Infrastructure Security Agency (CISA) advisory memorandum on essential critical infrastructure workers which named workers supporting firearm manufacturing and retail among essential workers. Therefore, stay-at-home orders issued in most states included provisions for firearms retailers to remain open, at least in some capacity. Only four states and the District of Columbia did not include federal firearms licensees among essential businesses or include provisions for them to be open. Meanwhile, an all-time high in firearm background checks indicates firearm sales have markedly increased. Given the associations between firearm access and injury risk, the effects of continued firearm access facilitated by these orders should be the focus of future research.

Assessment of Physician Self-reported Knowledge and Use of Maryland's Extreme Risk Protection Order Law

IMPORTANCE

On October 1, 2018, Maryland's extreme risk protection order (ERPO) law took effect. This was the first ERPO law in the United States to authorize clinicians to initiate a civil court process to temporarily prohibit people behaving dangerously and at risk of engaging in violence from purchasing and possessing firearms. This is the first publication reporting results from a survey of physicians about ERPOs.

OBJECTIVES

To assess Maryland physicians' knowledge, past use, and likely future use of ERPOs, and to identify barriers to physicians' use of ERPOs and strategies to address those barriers.

DESIGN, SETTING, AND PARTICIPANTS

This survey study conducted at The Johns Hopkins Hospital in Baltimore, Maryland, surveyed physicians, including emergency medicine physicians, pediatricians, and psychiatrists, using a 15-question online instrument between June 15, 2019, and July 1, 2019. Data analysis was performed in July 2019.

EXPOSURE

Maryland's ERPO law.

MAIN OUTCOMES AND MEASURES

Knowledge, use, and likely use of ERPOs, barriers to use, and strategies to address those barriers.

RESULTS

Ninety-two of 353 physicians invited (26.1%) completed the survey; 1 respondent reported having filed an ERPO petition. Sixty-six respondents (71.7%) described themselves as not at all familiar with ERPOs. After reading a brief description of the ERPO law, 85 respondents (92.4%) indicated that they encounter patients whom they would consider for an ERPO at least a few times per year. Fifty-five respondents (59.8%) reported that they would be very or somewhat likely to file an ERPO petition when they identify a qualifying patient. Respondents identified time as the main barrier to using ERPOs (not enough time to complete paperwork, 57 respondents [62.6%]; not enough time to attend hearing at courthouse, 64 respondents [70.3%]), followed by concern that filing an ERPO would negatively affect their relationship with the patient (36 respondents [39.6%]). Having a coordinator to manage the process (80 respondents [87.0%]), training (79 respondents [85.9%]), participating in court hearings remotely (68 respondents [73.9%]), and having access to legal counsel (59 respondents [64.1%]) were all selected by large majorities of respondents as strategies to address barriers to ERPO use.

CONCLUSIONS AND RELEVANCE

Awareness of ERPOs among physicians in the sample was low. Physicians are treating patients who would qualify for an ERPO, and respondents in the sample indicated a willingness to use ERPOs. Training, providing access to legal counsel, designating a clinician to process petitions, and allowing clinicians to participate remotely in court hearings were strategies respondents identified to address barriers to ERPO use. These survey findings identify concrete solutions for addressing barriers to physician use of ERPOs.

1956. Reduction in Endotracheal Aspirate Cultures after Implementation of a Diagnostic Stewardship Intervention in a Pediatric Intensive Care Unit

Background

Clinicians obtain endotracheal aspirate (ETA) cultures from mechanically ventilated patients in the pediatric intensive care unit (PICU) for the evaluation of ventilator-associated infection (i.e., tracheitis or pneumonia). Positive cultures prompt clinicians to treat with antibiotics even though ETA cultures cannot distinguish bacterial colonization from infection. We undertook a quality improvement initiative to standardize the use of endotracheal cultures in the evaluation of ventilator-associated infections among hospitalized children.

Methods

A multidisciplinary team developed a clinical decision support algorithm to guide when to obtain ETA cultures from patients admitted to the PICU and ventilated for >1 day. We disseminated the algorithm to all bedside providers in the PICU in April 2018 and compared the rate of cultures one year before and after the intervention using Poisson regression and a quasi-experimental interrupted time-series models. Charge savings were estimated based on $220 average charge for one ETA culture.

Results

In the pre-intervention period, there was an average of 46 ETA cultures per month, a total of 557 cultures over 5,092 ventilator-days; after introduction of the algorithm, there were 19 cultures obtained per month, a total of 231 cultures over 3,554 ventilator-days (incident rate 10.9 vs. 6.5 per 100 ventilator-days, Figure 1). There was a 43% decrease in the monthly rate of cultures (IRR 0.57, 95% CI 0.50–0.67, P < 0.001). The ITSA revealed a pre-existing 2% decline in the monthly culture rate (IRR 0.98, 95% CI 0.97–1.00, P = 0.01), an immediate 44% drop (IRR 0.56, 95% CI 0.45–0.69, P = 0.02) and a stable rate in the post-intervention period (IRR 1.03, 95% CI 0.99–1.07, P = 0.09). The intervention led to an estimated $6000 in monthly charge savings.

Conclusion

Introduction of a clinical decision support algorithm to standardize the obtainment of ETA cultures from ventilated children was associated with a significant decline in the rate of ETA cultures. Additional investigation will assess the impact on balancing measures and secondary outcomes including mortality, duration of ventilation, duration of admission, readmissions, and antibiotic prescribing.

Disclosures

All Authors: No reported Disclosures.

Two discrete promoters regulate the alternatively spliced human interferon regulatory factor-5 isoforms. Multiple isoforms with distinct cell type-specific expression, localization, regulation, and function

Interferon regulatory factor-5 (IRF-5) is a mediator of virus-induced immune activation and type I interferon (IFN) gene regulation. In human primary plasmacytoid dendritic cells (PDC), IRF-5 is transcribed into four distinct alternatively spliced isoforms (V1, V2, V3, and V4), whereas in human primary peripheral blood mononuclear cells two additional new isoforms (V5 and V6) were identified. The IRF-5 V1, V2, and V3 transcripts have different noncoding first exons and distinct insertion/deletion patterns in exon 6. Here we showed that V1 and V3 have distinct transcription start sites and are regulated by two discrete promoters. The V1 promoter (P-V1) is constitutively active, contains an IRF-E consensus-binding site, and is further stimulated in virus-infected cells by IRF family members. In contrast, endogenous V3 transcripts were up-regulated by type I IFNs, and the V3 promoter (P-V3) contains an IFN-stimulated responsive element-binding site that confers responsiveness to IFN through binding of the ISGF3 complex. In addition to V5 and V6, we have identified three more alternatively spliced IRF-5 isoforms (V7, V8, and V9); V5 and V6 were expressed in peripheral blood mononuclear cells from healthy donors and in immortalized B and T cell malignancies, whereas expression of V7, V8, and V9 transcripts were detected only in human cancers. The results of this study demonstrated the existence of multiple IRF-5 spliced isoforms with distinct cell type-specific expression, cellular localization, differential regulation, and dissimilar functions in virus-mediated type I IFN gene induction.