A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic.

BACKGROUND: Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic. METHODS: This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020. RESULTS: The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019. CONCLUSIONS: The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

The American Academy of Pediatrics firearm safety infographic improves firearm safety guidance: A qualitative study.

PURPOSE: Approximately 800 children annually suffer unintentional firearm injuries and deaths from unsecured firearms in the United States. These injuries are preventable, and may be avoided by providing parents with firearm safety guidance (FSG). The purpose of this study was to evaluate the experience of pediatric providers in delivering FSG following incorporation of the American Academy of Pediatrics (AAP) infographic. METHODS: Qualitative study completed July 2019-December 2019. Community pediatricians in Houston, Texas were provided the AAP firearm safety infographic and encouraged to provide FSG routinely during well-child visits with firearm-owning parents. Efficacy, feasibility of use and barriers to FSG were assessed via focus groups. Content analysis was utilized to identify emergent themes from provider experiences. RESULTS: Forty-four pediatricians across eight clinics delivered FSG using the AAP infographic. Of these, thirty-four participated in focus groups discussing their experience. Only 34% of those in the focus groups had routinely provided FSG prior to the study. The AAP infographic was a useful tool because of its visibility, valuable information, and assistance with broaching the topic of firearm safety with parents. Three themes were identified from qualitative analysis: methods of successful delivery of FSG (62%), patient responses to FSG (25%), and barriers to delivery of FSG (13%). Parents were generally receptive to the guidance. CONCLUSIONS: The AAP firearm safety infographic, which is free and publicly available, can be a valuable and satisfactory tool for delivery of firearm safety guidance by pediatric providers, including surgeons. Further study is needed to assess whether the guidance changes parental storage behaviors. LEVEL OF EVIDENCE: Level VI.

Implementation of a firearm safety guidance training program for pediatric providers.

PURPOSE: Pediatric unintentional firearm injuries are potentially preventable with firearm safety guidance (FSG). In baseline assessment, we learned that providers feel uncomfortable delivering FSG due to lack of training, but are inclined to learn. Here we present the development and concept testing of an FSG training program. METHODS: Using Kern's 6 rules of curriculum development, a training template was developed: 1. Program development, 2. Review by multidisciplinary expert team, 3. Concept testing, and 4. Modifications. Foundations included: raising awareness, increasing provider knowledge of safe storage methods, introducing a visual aide (American Academy of Pediatrics [AAP] infographic), and providing examples of guidance delivery. In-person training was provided and modifications made until there was uniform provider satisfaction. Program effectiveness and satisfaction were evaluated through surveys and focus groups. Descriptive statistics and univariate analyses were utilized. RESULTS: Over one year, in-person training was provided to 44 pediatric providers (residents and practicing pediatricians) at 8 clinics. Modifications included: addition of a Spanish-version visual aide, instruction on safety device use, simulation scenarios, making the handout more child-friendly, and development of a home safety video to include firearm safety with other topics. Following training, routine FSG by pediatricians increased from 34% to 71% (p = 0.001). Focus groups revealed provider satisfaction with the AAP infographic and increased comfort of FSG delivery. CONCLUSION: Following development and quality improvement, our FSG training model received positive feedback and increased provider delivery by pediatric providers. This model could be used for development of FSG training programs in other settings.

Physician-driven or self-directed safe firearm storage guidance: Which one is best?

BACKGROUND/PURPOSE: Access to firearms is a preventable cause of unintentional injury and suicide in children. Pediatric physicians provide injury prevention guidance, but firearm safety may not routinely be included. The purpose of this pilot study was to evaluate the effectiveness of firearm safety guidance (FSG) provided by a physician. METHODS: Prospective, randomized-controlled, trial assessing physician-delivered FSG at two pediatric clinics in Houston, Texas. Firearm-owning parents were randomized to physician guidance (PG) versus control (CG) groups. The CG received a handout with firearm safety facts and a free cable lock. The PG additionally received FSG by a physician. Pre- and post-intervention surveys were conducted. Results were analyzed using descriptive statistics and Chi square analysis. RESULTS: Thirty-two families participated; most (70%) were satisfied with the guidance. Pre-intervention safe firearm storage was high in both groups, and the intervention did not lead to improved habits in either group [PG: Pre 93% vs. Post 89%, p = 0.7 and CG: Pre 82% vs. 78%, p = 0.7].There was no difference in use of the free cable lock among groups (44% vs. 22%, p = 0.9). The PG demonstrated improved knowledge of the state child access protection law (PG: Pre 60% vs. Post 100% vs. CG: Pre 29% vs. Post 67%; p = 0.02). CONCLUSIONS: For firearm-owning parents, physician-delivered safe storage guidance may not be more effective than self-directed guidance provided by a handout. A larger trial is underway to confirm the findings of this pilot study.

Pediatric Providers' Knowledge, Attitudes, Practice, and Barriers to Firearms Safety Counseling.

OBJECTIVES: Firearms-related injuries and deaths are a leading cause of death in children and young adults ages 5 to 24 years. This study evaluated the counseling practices and barriers to providing safe firearms storage education by pediatricians and advance practice providers. METHODS: An online survey was sent to 296 pediatric outpatient providers in Houston, Texas. Pediatric providers were asked about demographics, knowledge, attitudes, and current practices regarding firearms safety counseling. Descriptive and comparative analyses were performed. RESULTS: Survey respondents (N = 76) were 86% women and 87% physicians. Most (86%) agree that they should discuss firearms safety with parents, whereas only 32% report routine counseling. The most frequent barrier to providing education was insufficient time (63%), followed by unfamiliarity with guns (26%). CONCLUSIONS: Pediatric providers are interested in firearms safety counseling, but few incorporate it into their practice. Addressing barriers of time and comfort level around firearms are potential first steps to curbing a leading cause of injury death among children. Further research is needed to develop counseling methods that are time efficient and culturally competent for the pediatric office.

Comparison of the effectiveness of hands-on versus online education in child passenger safety.

BACKGROUND: Community paediatricians' knowledge of appropriate child safety seat (CSS) use in vehicles may be inadequate. We compared the effectiveness of hands-on and online education in improving and retaining child passenger safety (CPS) knowledge and skills among paediatric trainees. METHODS: Paediatric trainees were randomised to receive hands-on skills training versus a 1-hour online module in CPS. CSS knowledge and installation skills were assessed using a validated 10-item/point questionnaire and an assessment tool respectively at baseline and after 6 months. Preintervention and postintervention knowledge improvement and CSS installation skills between groups were assessed using paired t-tests and effect size (d). RESULTS: Forty-eight students agreed to participate and were randomised. Thirty-nine completed training (hands-on: 23 and online: 15). At entry, no significant differences in learners' demographics and prior CPS education existed. Baseline CPS knowledge scores did not differ significantly between groups (p=0.26). Postintervention, both groups demonstrated a significant increase in knowledge scores (hands-on=3.1 (95% CI 2.4 to 3.7), p<0.0001; online=2.6 (95% CI 1.9 to 3.3), p<0.0001), though the pre-post gain in knowledge scores were not significantly different between groups (p=0.35). At follow-up, both groups demonstrated a significant increase in knowledge scores (hands-on=1.8 (95% CI 1.2 to 2.4), p<0.0001; online=1.1 (95% CI 0.7 to 1.6), p<0.0001) with the hands-on group scores significantly better than the online group (p<0.02). The long-term gain in knowledge scores was not significantly different between groups (p=0.12).Baseline CSS installation skill scores did not significantly differ between groups for forward-facing seats (p=0.16) and rear-facing seats (p=0.51). At follow-up, mean CSS installation skill scores significantly increased for the hands-on group (forward-facing seat: 0.8 (95% CI 0.16 to 1.44), p<0.02; rear-facing seat: 1.2 (95% CI 0.6 to 1.7), p<0.001) but not for the online group (forward-facing seat: 0.9 (95% CI -0.08 to 1.9), p=0.07); rear-facing seat: -0.2 (95% CI -1.1 to 0.7), p=0.6). CONCLUSIONS: Among paediatric trainees, hands-on and online CPS education are both effective in improving long-term CPS knowledge. Long-term installation skills for forward-facing and rear-facing CSS persist for hands-on education but are inconclusive for online education.