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BACKGROUND: In 2004, our level 1 regional pediatric trauma center created a protocol to activate ECMO for children with suspected hypothermic cardiac arrest based on inclusion criteria: serum potassium ≤9, submersion <90 min, and core body temperature <30 °C. In 2017, Pasquier et al. developed a model to help predict the survival of adults after hypothermic cardiac arrest (HOPE score) that has not been validated in children. We sought to apply this score to our pediatric patient population to determine if it can optimize our patient selection. METHODS: This was a retrospective review of all patients cannulated onto VA ECMO for hypothermic cardiac arrest between 2004 and 2022. We used abstracted data points to calculate the HOPE score for our patient population, both with and without presumed asphyxia. RESULTS: Over 19 years, 18 patients were cannulated for suspected hypothermic arrest, with three survivors (17 %). The HOPE score survival prediction ranged from 1 to 86 % with presumed asphyxia and 6-98 % without presumed asphyxia. Survivor HOPE scores ranged from 9 to 86 % with presumed asphyxia and 42-98 % without presumed asphyxia. Non-survivors' scores ranged 1-29 % with asphyxia and 6-57 % without asphyxia. A cutoff of >5 % predicted survival with asphyxia for ECMO could have decreased our cannulations by half without missing survivors. CONCLUSION: ECMO can be a lifesaving measure for specific children after hypothermic arrest. However, identifying the patients that will benefit from this resource-intensive intervention remains difficult. HOPE score utilization may decrease the rate of futile cannulation in children, but multi-centered research is needed in the pediatric population.
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Objective: We estimate annual hospital expenditures to achieve high emergency department (ED) pediatric readiness (HPR), that is, weighted Pediatric Readiness Score (wPRS) ≥ 88 (0-100 scale) across EDs with different pediatric volumes of children, overall and after accounting for current levels of readiness. Methods: We calculated the annual hospital costs of HPR based on two components: (1) ED pediatric equipment and supplies and (2) labor costs required for a Pediatric Emergency Care Coordinator (PECC) to perform pediatric readiness tasks. Data sources to generate labor cost estimates included: 2021 national salary information from U.S. Bureau of Labor Statistics, detailed patient and readiness data from 983 EDs in 11 states, the 2021 National Pediatric Readiness Project assessment; a national PECC survey; and a regional PECC survey. Data sources for equipment and supply costs included: purchasing costs from seven healthcare organizations and equipment usage per ED pediatric volume. We excluded costs of day-to-day ED operations (ie, direct clinical care and routine ED supplies). Results: The total annual hospital costs for HPR ranged from $77,712 (95% CI 54,719-100,694) for low volume EDs to $279,134 (95% CI 196,487-362,179) for very high volume EDs; equipment costs accounted for 0.9-5.0% of expenses. The total annual cost-per-patient ranged from $3/child (95% CI 2-4/child) to $222/child (95% CI 156-288/child). After accounting for current readiness levels, the cost to reach HPR ranged from $23,775 among low volume EDs to $145,521 among high volume EDs, with costs per patient of $4/child to $48/child. Conclusions: Annual hospital costs for HPR are modest, particularly when considered per child.
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BACKGROUND: Emergency department (ED) pediatric readiness has been associated with lower mortality for injured children but has historically been suboptimal in non-pediatric trauma centers. Over the past decade, the National Pediatric Readiness Project (NPRP) has invested resources in improving ED pediatric readiness. This study aimed to quantify current trauma center pediatric readiness and identify associations with center-level characteristics to target further efforts to guide improvement. METHODS: The study cohort included all centers that responded to the 2021 NPRP national assessment and contributed data to the National Trauma Databank (NTDB) the same calendar year. Center characteristics and pediatric (0-15y) volume from the NTDB were linked to weighted pediatric readiness scores (wPRS) obtained from the NPRP assessment. Univariate and multivariable analyses were used to determine associations between wPRS and trauma center type as well as center-level facility characteristics. RESULTS: The wPRS was reported for 77% (749/973) of centers that contributed to the NTDB. ED Pediatric Readiness was highest in ACS level one pediatric trauma centers (PTCs), but wPRS in the highest quartile was seen among all adult and pediatric trauma center types. Independent predictors of high wPRS included ACS level one PTC verification, pediatric trauma volume, and the presence of a PICU. Higher-level adult trauma centers and pediatric trauma centers were more likely to have pediatric-specific physician requirements, pediatric emergency care coordinators, and pediatric quality improvement initiatives. CONCLUSION: ED pediatric readiness in trauma centers remains variable and is predictably lower in centers that lack inpatient resources. There is, however, no aspect of ED pediatric readiness that is constrained to high-level pediatric facilities, and a highest quartile wPRS was achieved in all types of adult centers in our study. Ongoing efforts to improve pediatric readiness for initial stabilization at non-pediatric centers are needed, particularly in centers that routinely transfer children out. LEVEL OF EVIDENCE: Epidemiologic, Level III.
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OBJECTIVE: To use updated 2021 weighted Pediatric Readiness Score (wPRS) data to identify a threshold level of trauma center emergency department (ED) pediatric readiness. SUMMARY BACKGROUND DATA: Most children in the US receive initial trauma care at non-pediatric centers. The National Pediatric Readiness Project (NPRP) aims to ensure that all EDs are prepared to provide quality care for children. Trauma centers reporting the highest quartile of wPRS on the 2013 national assessment have been shown to have lower mortality. Significant efforts have been invested to improve pediatric readiness in the past decade. STUDY DESIGN: A retrospective cohort of trauma centers that completed the NPRP 2021 national assessment and contributed to the National Trauma Data Bank (NTDB) in 2019-21 was analyzed. Center-specific observed-to-expected mortality estimates for children (0-15y) were calculated using Pediatric TQIP models. Deterministic linkage was used for transferred patients to account for wPRS at the initial receiving center. Center-specific mortality odds ratios were then compared across quartiles of wPRS. RESULTS: 66,588 children from 630 centers with a median [IQR] wPRS of 79 [66-93] were analyzed. The average observed-to-expected odds of mortality (1.02 [0.97-1.06]) for centers in the highest quartile (wPRS≥93) was lower than any of the lowest three wPRS quartiles (1.19 [1.14-1.23](Q1), 1.29 [1.24-1.33](Q2), and 1.28 [1.19-1.36](Q3), all P <0.05). The presence of a pediatric-specific quality improvement plan was the domain with the strongest independent association with mortality (standardized beta -0.095 [-0.146--0.044]). CONCLUSION: Trauma centers should address gaps in pediatric readiness to include a pediatric-specific quality improvement plan and aim to achieve wPRS ≥93.
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Importance: The National Pediatric Readiness Project assessment provides a comprehensive evaluation of the readiness of US emergency departments (EDs) to care for children. Increased pediatric readiness has been shown to improve survival for children with critical illness and injury. Objectives: To complete a third assessment of pediatric readiness of US EDs during the COVID-19 pandemic, to examine changes in pediatric readiness from 2013 to 2021, and to evaluate factors associated with current pediatric readiness. Design, Setting, and Participants: In this survey study, a 92-question web-based open assessment of ED leadership in US hospitals (excluding EDs not open 24 h/d and 7 d/wk) was sent via email. Data were collected from May to August 2021. Main Outcomes and Measures: Weighted pediatric readiness score (WPRS) (range, 0-100, with higher scores indicating higher readiness); adjusted WPRS (ie, normalized to 100 points), calculated excluding points received for presence of a pediatric emergency care coordinator (PECC) and quality improvement (QI) plan. Results: Of the 5150 assessments sent to ED leadership, 3647 (70.8%) responded, representing 14.1 million annual pediatric ED visits. A total of 3557 responses (97.5%) contained all scored items and were included in the analysis. The majority of EDs (2895 [81.4%]) treated fewer than 10 children per day. The median (IQR) WPRS was 69.5 (59.0-84.0). Comparing common data elements from the 2013 and 2021 NPRP assessments demonstrated a reduction in median WPRS (72.1 vs 70.5), yet improvements across all domains of readiness were noted except in the administration and coordination domain (ie, PECCs), which significantly decreased. The presence of both PECCs was associated with a higher adjusted median (IQR) WPRS (90.5 [81.4-96.4]) compared with no PECC (74.2 [66.2-82.5]) across all pediatric volume categories (P < .001). Other factors associated with higher pediatric readiness included a full pediatric QI plan vs no plan (adjusted median [IQR] WPRS: 89.8 [76.9-96.7] vs 65.1 [57.7-72.8]; P < .001) and staffing with board-certified emergency medicine and/or pediatric emergency medicine physicians vs none (median [IQR] WPRS: 71.5 [61.0-85.1] vs 62.0 [54.3-76.0; P < .001). Conclusions and Relevance: These data demonstrate improvements in key domains of pediatric readiness despite losses in the health care workforce, including PECCs, during the COVID-19 pandemic, and suggest organizational changes in EDs to maintain pediatric readiness.
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COVID-19 , Pandemias , Niño , Humanos , COVID-19/epidemiología , Encuestas y Cuestionarios , Servicio de Urgencia en Hospital , Mejoramiento de la CalidadRESUMEN
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 796â¯937 children, including 90â¯963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33â¯516 [36.8%] female; 1820 [2.0%] deaths) and 705â¯974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329â¯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 545â¯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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Servicio de Urgencia en Hospital , Centros Traumatológicos , Niño , Humanos , Femenino , Preescolar , Recién Nacido , Lactante , Masculino , Estudios Retrospectivos , Tratamiento de Urgencia , Mortalidad HospitalariaRESUMEN
BACKGROUND/PURPOSE: Thromboelastography's (TEG's) use in pediatric trauma patients is not widely studied. Identifying clotting cascade defects can direct decision making regarding blood product transfusion. METHODS: We performed a single-center retrospective review of all level 1 pediatric trauma patients. Data collected included demographics, diagnoses, Injury Severity Score, intensive care unit length of stay (ICU LOS), mortality, TEG values, and blood products received. We identified TEG values associated with mortality, ICU LOS, and need for blood product transfusion. RESULTS: A total of 237 trauma 1 patients were identified. After exclusions, 148 patients were included for analysis. Most patients were below TEG transfusion cut points. Patients with elevated reaction time, K value, and fibrinolysis at 30 minutes had increased odds of mortality with odds ratios of 1.71 (95% confidence interval [CI], 1.22-2.40), 1.94 (95% CI, 1.23-3.05), and 1.15 (95% CI, 1.03-1.28), respectively. For ICU LOS, elevated reaction time, K value, and fibrinolysis at 30 minutes, α angle, and maximum amplitude demonstrated hazard ratios of 0.76 (95% CI, 0.65-0.88), 0.82 (95% CI, 0.64-1.0), 0.95 (95% CI, 0.88-0.99), 1.05 (95% CI, 1.02-1.08), and 1.04 (95% CI, 1.01-1.06), respectively. There was no association between TEG and blood product transfusion. CONCLUSIONS: Coagulopathic patients based on TEG had higher mortality. All TEG values, as they moved toward transfusion-trigger cut points, were associated with increased mortality.
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Trastornos de la Coagulación Sanguínea , Heridas y Lesiones , Humanos , Niño , Tromboelastografía , Trastornos de la Coagulación Sanguínea/etiología , Trastornos de la Coagulación Sanguínea/diagnóstico , Transfusión Sanguínea , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Heridas y Lesiones/terapiaRESUMEN
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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Servicio de Urgencia en Hospital , Centros Traumatológicos , Estados Unidos , Niño , Humanos , Estudios Retrospectivos , Encuestas y Cuestionarios , HospitalesRESUMEN
OBJECTIVE: Whether ambulance transport patterns are optimized to match children to high-readiness emergency departments (EDs) and the resulting effect on survival are unknown. We quantified the number of children transported by 9-1-1 emergency medical services (EMS) to high-readiness EDs, additional children within 30 minutes of a high-readiness ED, and the estimated effect on survival. METHODS: This was a cross-sectional study using data from the National EMS Information System for 5,461 EMS agencies in 28 states from 1/1/2012 through 12/31/2019, matched to the 2013 National Pediatric Readiness Project assessment of ED pediatric readiness. We performed a geospatial analysis of children 0 to 17 years requiring 9-1-1 EMS transport to acute care hospitals, including day-, time-, and traffic-adjusted estimates for driving times to all EDs within 30 minutes of the scene. We categorized receiving hospitals by quartile of ED pediatric readiness using the weighted Pediatric Readiness Score (wPRS, range 0-100) and defined a high-risk subgroup of children as a proxy for admission. We used published estimates for the survival benefit of high readiness EDs to estimate the number of lives saved. RESULTS: There were 808,536 children transported by EMS, of whom 253,541 (31.4%) were high-risk. Among the 2,261 receiving hospitals, the median wPRS was 70 (IQR 57-85, range 26-100) and the median number of receiving hospitals within 30 minutes was 4 per child (IQR 2-11, range 1 to 53). Among all children, 411,685 (50.9%) were taken to EDs in the highest quartile of pediatric readiness, and 180,547 (22.3%) children transported to lower readiness EDs were within 30 minutes of a high readiness ED. Findings were similar among high-risk children. Based on high-risk children, we estimated that 3,050 pediatric lives were saved by transport to high-readiness EDs and an additional 1,719 lives could have been saved by shifting transports to high readiness EDs within 30 minutes. CONCLUSIONS: Approximately half of children transported by EMS were taken to high-readiness EDs and an additional one quarter could have been transported to such an ED, with measurable effect on survival.
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Servicios Médicos de Urgencia , Niño , Humanos , Ambulancias , Estudios Transversales , Servicio de Urgencia en Hospital , Recolección de DatosRESUMEN
OBJECTIVES: After evaluation and treatment of minor traumatic cervical spine injury (CSI), many children are discharged home in a rigid cervical orthosis (RCO). This study investigated their adherence to RCO treatment recommendations. The feasibility of telehealth cervical spine clearance was also explored. METHODS: This was a prospective observational study of children 3 to 18 years old with mild CSI evaluated at a level I pediatric trauma center from December 1, 2019, through July 31, 2021. Before emergency department discharge, patients received RCO use instructions and recommendation for follow-up with in-person neurosurgery clinic visit, neurosurgery telehealth visit, or in-person primary care provider visit. The family was responsible for arranging follow-up. Primary outcomes included compliance with follow-up and collar use. RESULTS: Ninety-eight children (mean age, 11.3 ± 4.1 years) were included. Overall, follow-up contact was available for 51 patients (52%). At 1-week follow-up with 36 children, 64% were collar compliant, 13 had no pain (38% remained in RCO), 14 had mild pain without limitations, 8 had pain with some limitations, and 1 had significant pain. At 2-week follow-up with 31 children, 9 (29%) were collar compliant, 23 had no pain, 7 had mild pain without limitations, and 1 with significant persistent pain was found to have an odontoid fracture requiring C1-2 fusion. Patients/families often discontinued the use of the collar without follow-up (47%). Approximately half utilized a recommended clinical follow-up option for clearance, most often in neurosurgery clinic or using a neurosurgery telehealth visit. The mean time to follow-up was 11.34 ± 4.9 days (range, 3-25 days), and mean collar compliance lasted 9.8 ± 5.7 days (range, 1-25 days). No child experienced any short-term complications related to RCO use. CONCLUSIONS: In this pilot study, a substantial portion of children with mild CSIs discharged from the emergency department with an RCO did not adhere to compliance or follow-up recommendations. Persistent pain requires further evaluation.
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Traumatismos del Cuello , Alta del Paciente , Humanos , Niño , Adolescente , Preescolar , Proyectos Piloto , Cuidados Posteriores , Servicio de Urgencia en Hospital , Traumatismos del Cuello/terapia , Vértebras Cervicales/lesiones , DolorRESUMEN
High emergency department (ED) pediatric readiness is associated with improved survival in children, but the cost is unknown. We evaluated the costs of emergency care for children across quartiles of ED pediatric readiness. This was a retrospective cohort study of children aged 0-17 years receiving emergency services in 747 EDs in 9 states from January 1, 2012, through December 31, 2017. We measured ED pediatric readiness using the weighted Pediatric Readiness Score (range: 0-100). The primary outcome was the total cost of acute care (ED and inpatient) in 2022 dollars, adjusted for ED case mix and hospital characteristics. A total of 15 138 599 children received emergency services, including 27.6% with injuries and 72.4% with acute medical illness. The average adjusted per-patient cost by quartile of ED pediatric readiness ranged from $991 (quartile 1) to $1064 (quartile 4) for injured children and $1104-$1217 for medical children. The resulting cost differences were $72 (95% CI: -$6 to $151) and $113 (95% CI: $20-$206), respectively. Receiving emergency care in high-readiness EDs was not associated with marked increases in the cost of delivering services.
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Study Objectives: The objective of this study was to determine if there is a proximity effect of high-acuity, pediatric-capable emergency departments (EDs) on the weighted pediatric readiness score of neighboring general EDs and whether this effect is attributable to specific components of the National Pediatric Readiness Guidelines. Methods: Pediatric readiness was assessed using the weighted pediatric readiness score of EDs based on the 2013 National Pediatric Readiness Project assessment. High-acuity, pediatric-capable EDs were defined as those with a separate pediatric ED and inpatient pediatric services, including the following: pediatric ICU, pediatric ward, and neonatal ICU. Neighboring general EDs are within a 30-minute drive time of a high-acuity, pediatric-capable ED. Analysis was stratified by annual ED pediatric volume: low (<1800), medium (1800-4999), medium-high (5000-9999), and high (>10,000). We analyzed components of the readiness guidelines, including quality improvement/safety initiatives, pediatric emergency care coordinators, and availability of pediatric-specific equipment. Groups were compared using chi-squared or Wilcoxon rank-sum test with P values <0.05 considered significant. Results: Of the 4149 surveyed hospitals, 3933 general EDs (not high-acuity, pediatric-capable EDs) were identified, of which 1009 were located within a 30-minute drive to a high-acuity, pediatric-capable ED. Neighboring general EDs had a statistically significantly higher median weighted pediatric readiness score across pediatric volumes (weighted pediatric readiness score 76.3 vs 65.3; P < 0.001). Neighboring general EDs were more likely to have a pediatric emergency care coordinator, a notification policy for abnormal pediatric vital signs, and >90% of pediatric-specific equipment. Conclusions: We found neighboring general EDs have a higher level of pediatric readiness as measured by the median weighted pediatric readiness score. High-acuity, pediatric-capable EDs may influence the pediatric readiness of neighboring general Eds, but further investigation is needed to clarify target areas for outreach by state and national partners to improve overall pediatric readiness.
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BACKGROUND: Sledding is not a risk-free winter sport. According to the US Consumer Product Safety Commission, there were an estimated 13,954 sledding accidents requiring medical care in 2010. However, specific information concerning pediatric injuries related to sledding is not well defined. OBJECTIVES: This study aimed to identify the most common types of injuries associated with sledding accidents and demographic factors related to risk of injury in pediatric patients, and to compare injuries associated with 2 different age groups and sexes. METHODS: This is a retrospective descriptive study of pediatric patients (<18 years of age) presenting to a regional level I pediatric trauma center secondary to a sledding injury between 2006 and 2016. Demographic information including sex, age, mechanism of injury, and injury severity score was captured and analyzed using descriptive statistics. RESULTS: There were 209 patients identified for 10 years. There were no mortalities. There were 85 patients with primary head injury, of which 82 (96.5%) were hospitalized and 33 (38.8%) required an intensive care unit (ICU) stay. Seventy-five patients primarily suffered from extremity injuries, of which 56 (74.6%) had lower extremity fractures requiring operative intervention. There was no difference in ICU or length of stay between younger children (0-11 years) and adolescents (12-18 years) or between male and female patients. CONCLUSIONS: Childhood sledding can result in a variety of significant injuries requiring surgical intervention and hospitalization. Children pulled on sleds behind motorized vehicles are at higher risk for more severe injuries resulting in a higher rate of ICU admission.
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Traumatismos en Atletas , Deportes de Nieve , Accidentes , Adolescente , Niño , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Estudios Retrospectivos , Deportes de Nieve/lesiones , Centros TraumatológicosRESUMEN
BACKGROUND: The antifibrinolytic drug tranexamic acid (TXA) improves survival in adults with traumatic hemorrhage; however, the drug has not been evaluated in a trial in injured children. We evaluated the feasibility of a large-scale trial evaluating the effects of TXA in children with severe hemorrhagic injuries. METHODS: Severely injured children (0 up to 18th birthday) were randomized into a double-blind randomized trial of 1) TXA 15 mg/kg bolus dose, followed by 2 mg/kg/hr infusion over 8 hours, 2) TXA 30 mg/kg bolus dose, followed by 4 mg/kg/hr infusion over 8 hours, or 3) normal saline placebo bolus and infusion. The trial was conducted at 4 pediatric Level I trauma centers in the United States between June 2018 and March 2020. We enrolled patients under federal exception from informed consent (EFIC) procedures when parents were unable to provide informed consent. Feasibility outcomes included the rate of enrollment, adherence to intervention arms, and ability to measure the primary clinical outcome. Clinical outcomes included global functioning (primary), working memory, total amount of blood products transfused, intracranial hemorrhage progression, and adverse events. The target enrollment rate was at least 1.25 patients per site per month. RESULTS: A total of 31 patients were randomized with a mean age of 10.7 years (standard deviation [SD] 5.0 years) and 22 (71%) patients were male. The mean time from injury to randomization was 2.4 hours (SD 0.6 hours). Sixteen (52%) patients had isolated brain injuries and 15 (48%) patients had isolated torso injuries. The enrollment rate using EFIC was 1.34 patients per site per month. All eligible enrolled patients received study intervention (9 patients TXA 15 mg/kg bolus dose, 10 patients TXA 30 mg/kg bolus dose, and 12 patients placebo) and had the primary outcome measured. No statistically significant differences in any of the clinical outcomes were identified. CONCLUSION: Based on enrollment rate, protocol adherence, and measurement of the primary outcome in this pilot trial, we confirmed the feasibility of conducting a large-scale, randomized trial evaluating the efficacy of TXA in severely injured children with hemorrhagic brain and/or torso injuries using EFIC.
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Objectives: Treating pediatric patients often invokes discomfort and anxiety among emergency medical service (EMS) personnel. As part of the process to improve pediatric care in the prehospital system, the Health Resources and Services Administration (HRSA) Emergency Services for Children (EMSC) Program implemented two prehospital performance measures -access to a designated pediatric care coordinator (PECC) and skill evaluation using pediatric equipment-along with a multi-year plan to aid states in achieving the measures. Baseline data from a survey conducted in 2017 showed that less than 25% of EMS agencies had access to PECC and 47% performed skills evaluation using pediatric equipment at least twice a year. To evaluate change over time, the survey was again conducted in 2020, and agencies that participated in both years are compared. Methods: A web-based survey was sent to EMS agency administrators in 58 states and territories from January to March 2020. Descriptive statistics, odds ratios, and 95% confidence intervals were conducted. Results: The response rate was 56%. A total of 5,221 agencies participated in both survey periods representing over 250,000 providers. The percentage of agencies reporting the presence of a PECC increased from 24% to 34% (p= <0.001). However, some agencies reported that they no longer had a PECC, while others reported having a PECC for the first time. Fifty percent (50%) of agencies conduct pediatric psychomotor skills evaluation at least twice/year, a 2% increase over time (p = 0.041); however, a third (34%) evaluate skills using pediatric equipment less than once a year. The presence of a PECC continues to be the variable associated with the highest odds (AOR 2.15, 95% CI 1.91-2.43) of conducting at least semiannual skills evaluation.Conclusions: There is an increase in the presence of pediatric care coordination and the frequency of pediatric psychomotor skills evaluation among national EMS agencies over time. Continued efforts to increase and sustain PECC presence should be an ongoing focus to improve pediatric readiness in the prehospital system.
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Servicios Médicos de Urgencia , Niño , Humanos , Encuestas y CuestionariosRESUMEN
Survey response is higher when the request comes from a familiar entity compared to an unknown sender. Little is known about how sender influences response to surveys of organizations. We assessed whether familiarity of the sender influences response outcomes in a survey of emergency medical services agencies. Emergency medical services agencies in one U.S. state were randomly assigned to receive survey emails from either a familiar or unfamiliar sender. Both deployment approaches were subsequently used nationwide, with each state selecting one of the two contact methods. Experimental results showed that requests from the familiar sender achieved higher survey response (54.3%) compared to requests from the unfamiliar sender (36.9%; OR: 2.03; 95% CI: 1.23, 3.33). Similar results were observed in the subsequent nationwide survey; in states where the familiar sender deployed the survey, 62.0% of agencies responded, compared to 51.0% when the survey was sent by the unfamiliar sender (OR: 1.57; 95% CI: 1.47, 1.67). The response difference resulted in nearly 60 additional hours of staff time needed to perform telephone follow-up to nonrespondents. When surveying healthcare organizations, surveyors should recognize that it is more challenging to obtain responses without a pre-established relationship with the organizations.
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Servicios Médicos de Urgencia , Humanos , Encuestas y CuestionariosRESUMEN
OBJECTIVES: The purpose of our study was to describe children with life-threatening bleeding. DESIGN: We conducted a prospective observational study of children with life-threatening bleeding events. SETTING: Twenty-four childrens hospitals in the United States, Canada, and Italy participated. SUBJECTS: Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included. INTERVENTIONS: Children were compared according bleeding etiology: trauma, operative, or medical. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours. CONCLUSIONS: Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.
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Transfusión Sanguínea/estadística & datos numéricos , Servicios Médicos de Urgencia , Hemorragia/terapia , Adolescente , Antifibrinolíticos/uso terapéutico , Transfusión de Componentes Sanguíneos/estadística & datos numéricos , Canadá , Niño , Preescolar , Femenino , Hemorragia/mortalidad , Humanos , Lactante , Recién Nacido , Italia , Masculino , Estudios Prospectivos , Estados UnidosRESUMEN
OBJECTIVE: We evaluated the acceptability of the Pediatric Quality of Life Inventory (PedsQL) and other outcomes as the primary outcomes for a pediatric hemorrhagic trauma trial (TIC-TOC) among clinicians. METHODS: We conducted a mixed-methods study that included an electronic questionnaire followed by teleconference discussions. Participants confirmed or rejected the PedsQL as the primary outcome for the TIC-TOC trial and evaluated and proposed alternative primary outcomes. Responses were compiled and a list of themes and representative quotes was generated. RESULTS: 73 of 91 (80%) participants completed the questionnaire. 61 (84%) participants agreed that the PedsQL is an appropriate primary outcome for children with hemorrhagic brain injuries. 32 (44%) participants agreed that the PedsQL is an acceptable primary outcome for children with hemorrhagic torso injuries, 27 (38%) participants were neutral, and 13 (18%) participants disagreed. Several themes were identified from responses, including that the PedsQL is an important and patient-centered outcome but may be affected by other factors, and that intracranial hemorrhage progression assessed by brain imaging (among patients with brain injuries) or blood product transfusion requirements (among patients with torso injuries) may be more objective outcomes than the PedsQL. CONCLUSIONS: The PedsQL was a well-accepted proposed primary outcome for children with hemorrhagic brain injuries. Traumatic intracranial hemorrhage progression was favored by a subset of clinicians. A plurality of participants also considered the PedsQL an acceptable outcome for children with hemorrhagic torso injuries. Blood product transfusion requirement was favored by fewer participants.
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Hemorragias Intracraneales/psicología , Evaluación de Resultado en la Atención de Salud/métodos , Calidad de Vida , Encuestas y Cuestionarios/normas , Niño , Medicina de Emergencia/estadística & datos numéricos , Femenino , Humanos , Hemorragias Intracraneales/complicaciones , Masculino , Investigación Cualitativa , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Child abuse and neglect (CAN) has an estimated annual incidence of 1.46% among those ≤3 years old. Prehospital providers (PHPs) report difficulties identifying CAN and the frequency in which PHPs document CAN during prehospital encounters of young children is not known. OBJECTIVE: To report the percentage of CAN documentation by PHPs during encounters among children ≤3 years in a national dataset and describe the characteristics of this population. METHODS: This is an analysis of concurrent cases in the 2017-18 National Emergency Medical Services Information System database. We identified children ≤3 years old with ICD-10-CM codes specific for CAN including codes for physical and sexual abuse as well as neglect. We examined patient demographics including race, gender, Emergency Medical Services (EMS) primary and secondary impression, associated symptoms, anatomic location of chief complaint, and cause of injury. Our primary outcome is the percentage of CAN reported as an EMS primary or secondary impression; secondary outcomes include proportion of children with each subtype of abuse, the description of patients by demographic information, anatomic location of injury, and associated symptoms. RESULTS: There were 498,555 for children ≤3 years old, of which 522 had an impression of CAN (0.10%). Within our cohort, 43% were <1 year of age, 51% were male. The most common anatomic location of injury was general/global (29.7%), followed by head (23.5%) and extremity (14%). The most common symptoms reported by PHPs are those associated with injury including codes for injury, burn, fracture, cutaneous findings, hemorrhage, or pain (n = 244, 63%). Pain is the most commonly reported symptom (n = 110, 21%). Few encounters specified vomiting, seizure, or disordered breathing as symptoms (1%, 1%, and 5.4%, respectively). Interestingly, 28.2% (27/124) of cases in our cohort were related to sexual abuse. CONCLUSIONS: The percentage of PHP documentation of CAN among children ≤3 years of age is very low. Among those with an EMS primary impression of CAN, documentation is primarily associated with findings of injury whereas documentation of nonspecific symptoms such as vomiting and seizure is infrequent. These findings suggest that recognition of abuse primarily occurs in young patients with overt signs of trauma.
Asunto(s)
Maltrato a los Niños , Servicios Médicos de Urgencia , Niño , Maltrato a los Niños/diagnóstico , Preescolar , Bases de Datos Factuales , Documentación , Humanos , Masculino , Estudios RetrospectivosRESUMEN
Introduction Our institution uses video review as a quality improvement tool. Starting in March 2018, we specifically focused on meeting certain time goals during trauma resuscitation aimed at decreasing time to final disposition. The purpose of this study was to evaluate the effect of establishing strict time goals on total time spent in the trauma bay by pediatric trauma patients. Materials and methods A retrospective review of all level I trauma activations at a level I pediatric trauma center between November 2017 and December 2018 was performed via manual review of the recorded trauma activations. Data on key time points such as time from arrival to transfer to gurney, to completion of primary survey, to chest x-ray, to Emergency Medical Services (EMS) report, to CT scan, and to disposition (CT or admission/operating room [OR] if no CT scan was performed) were analyzed and compared between the cohort of patients prior to implementation of the time goals with that after. The cohort of patients who presented between March 2018 and May 2018 were excluded to allow for time for the intervention to take effect. Results There were 13 level I trauma activations before implementation of the time goals and 41 after. There was a significant decrease in time to transfer to gurney (1.8 minutes vs. 1.0 minutes; p=0.02), to CT scan (18.8 minutes vs. 14.2 minutes; p=0.01), and to disposition (18.3 minutes vs. 14.9 minutes; p=0.047). There was no decrease in time to completion of primary survey, EMS report, or chest x-ray. Conclusions Utilizing video review in pediatric trauma as a quality improvement initiative with a focus on meeting specific time goals for key elements of the activation led to decreased total time in our trauma bay with critically ill patients.