Evaluating Health Literacy in Families of Injured Children: A Prospective Observational Cohort Study at a Level One Pediatric Trauma Center.

BACKGROUND: Low health literacy (HL) has been associated with poor health outcomes in children. Optimal recovery after pediatric injury requires caregiver participation in complicated rehabilitative and medical aftercare. We aimed to quantify HL among guardians of injured children and identify factors associated with low HL of guardians. METHODS: A prospective observational cohort study was conducted to evaluate the HL using the Newest Vital Sign™ of guardians of injured children (≤18 years) admitted to a level 1 pediatric trauma center. Patient and guardian characteristics were compared across levels of HL using univariate statistics. We conducted multivariable logistic regression to identify factors independently-associated with low HL. RESULTS: A sample of 95 guardian-child dyads were enrolled. The majority of guardians had low HL (n = 52, 55%), followed by moderate HL (n = 36, 38%) and high HL (n = 7, 7%). Many families received public benefits (n = 47, 49%) and 12 guardians (13%) had both housing and employment insecurity. Guardians with low HL were significantly more likely to have insecure housing and not have completed any college. CONCLUSION: The majority of injured children had a primary guardian with low HL. Pediatric trauma centers should consider screening for low HL to ensure that families have adequate post-discharge support. LEVEL OF EVIDENCE: Level 3.

Leveraging Existing Datasets to Advance Family Caregiving Research: Opportunities to Measure What Matters.

More than 17.7 million people in the U.S. care for older adults. Analyzing population datasets can increase our understanding of the needs of family caregivers of older adults. We reviewed 14 U.S. population-based datasets (2003-2023) including older adults' and caregivers' data to assess inclusion and measurement of 8 caregiving science domains, with a focus on whether measures were validated and/or unique variables were used. Challenges exist related to survey design, sampling, and measurement. Findings highlight the need for consistent data collection by researchers, state, tribal, local, and federal programs, for improved utility of population-based datasets for caregiving and aging research.

Mortality risk following end-of-life caregiving: A population-based analysis of hospice users and their families.

Experiencing the death of a family member and providing end-of-life caregiving can be stressful on families - this is well-documented in both the caregiving and bereavement literatures. Adopting a linked-lived theoretical perspective, exposure to the death and dying of one family member could be conceptualized as a significant life stressor that produces short and long-term health consequences for surviving family members. This study uses familial-linked administrative records from the Utah Population Database to assess how variations in family hospice experiences affect mortality risk for surviving spouses and children. A cohort of hospice decedents living in Utah between 1998 and 2016 linked to their spouses and adult children (n = 37,271 pairs) provides an ideal study population because 1) hospice typically involves family members in the planning and delivery of end-of-life care, and 2) hospice admission represents a conscious awareness and acknowledgment that the decedent is entering an end-of-life experience. Thus, hospice duration (measured as the time between admission and death) is a precise measure of the family's exposure to an end-of-life stressor. Linking medical records, vital statistics, and other administrative microdata to describe decedent-kin pairs, event-history models assessed how hospice duration and characteristics of the family, including familial network size and coresidence with the decedent, were associated with long-term mortality risk of surviving daughters, sons, wives (widows), and husbands (widowers). Longer hospice duration increased mortality risk for daughters and husbands, but not sons or wives. Having other family members in the state was protective, and living in the same household as the decedent prior to death was a risk factor for sons. We conclude that relationship type and sex likely modify the how of end-of-life stressors (i.e., potential caregiving demands and bereavement experiences) affect health because of normative gender roles. Furthermore, exposure to dementia deaths may be particularly stressful, especially for women.

Efforts to improve outcomes among neonates with complex intestinal atresia: a single-center low-income country experience.

PURPOSE: Intestinal obstruction caused by intestinal atresia is a surgical emergency in newborns. Outcomes for the jejunal ileal atresia (JIA), the most common subtype of atresia in low-income countries (LIC), are poor. We sought to assess the impact of utilizing the Bishop-Koop (BK) approach to JIA in improving outcomes. METHODS: A retrospective cohort study was performed on children with complex JIA (Type 2-4) treated at our national referral hospital from 1/2018 to 12/2022. BK was regularly used starting 1/1/2021, and outcomes between 1/2021 and 12/2022 were compared to those between 1/2018 and 12/2020. Statistical significance was set at p < 0.05. RESULTS: A total of 122 neonates presented with JIA in 1/2018-12/2022, 83 of whom were treated for complex JIA. A significant decrease (p = 0.03) was noted in patient mortality in 2021 and 2022 (n = 33, 45.5% mortality) compared to 2018-2020 (n = 35, 71.4% mortality). This translated to a risk reduction of 0.64 (95% CI 0.41-0.98) with the increased use of BK. CONCLUSION: Increased use of BK anastomoses with early enteral nutrition and decreased use of primary anastomosis improves outcomes for neonates with severe JIA in LIC settings. Implementing this surgical approach in LICs may help address the disparities in outcomes for children with JIA.

Dying with dementia in nursing homes: A population-based study of decedents and their families.

BACKGROUND: Families play a critical role in end-of-life (EOL) care for nursing home (NH) residents with dementia. Despite the important role of family, little is known about the availability and characteristics of families of persons with dementia who die in NHs. METHODS: This is a retrospective cohort study of 18,339 individuals 65 years and older with dementia who died in a Utah NH between 1998 and 2016, linked to their first-degree family (FDF) members (n = 52,566; spouses = 11.3%; children = 58.3%; siblings = 30.3%). Descriptive statistics, chi-square tests, and t-tests were used to describe the study cohort and their FDF members and to compare sociodemographic and death characteristics of NH decedents with (n = 14,398; 78.5%) and without FDF (n = 3941; 21.5%). RESULTS: Compared with NH decedents with FDF, NH decedents with dementia without FDF members were more likely to be older (mean age 86.5 vs 85.5), female (70.5% vs 59.3%), non-White/Hispanic (9.9% vs 3.2%), divorced/separated/widowed (84.4% vs 61.1%), less educated (<12th grade; 42.2% vs 33.7%), have Medicare and Medicaid (20.8% vs 12.5%), and die in a rural/frontier NH (25.0% vs 23.4%). NH decedents who did not have FDF were also more likely to die from cancer (4.2% vs 3.9%), chronic obstructive pulmonary disease (COPD; 3.9% vs 2.5%), and dementia (40.5% vs 38.4%) and were less likely to have 2+ inpatient hospitalizations at EOL (13.9% vs 16.2%), compared with NH decedents with FDF. CONCLUSIONS: Findings highlight differences in social determinants of health (e.g., sex, race, marital status, education, insurance, rurality) between NH decedents with dementia who do and do not have FDF-factors that may influence equity in EOL care. Understanding the role of family availability and familial characteristics on EOL care outcomes for NH residents with dementia is an important next step to informing NH dementia care interventions and health policies.

Developing 60-Day Readmission Risk Score among Home Healthcare Patients with Heart Failure.

Heart failure (HF) readmissions are common, costly, and often preventable. Despite the implementation of HF programs across clinical settings, rehospitalization is still common. Efforts to identify risk factors for 60-day rehospitalization among HF patients exist, but risk scoring has not been utilized in home healthcare. The purpose of this study was to develop a 60-day rehospitalization risk score for home care patients with HF. This study is a secondary data analysis of a retrospective cross-sectional dataset that was composed of data using the Outcome Assessment Information Set (OASIS)-C version for patients with HF. We computed the Charlson Comorbidity Index (CCI) to use as a confounder. The risk score was computed from the final logistic regression model regression coefficients. The median age was 78 years old, 45.4% were male, and 81.0% were White. We identified 10 significant risk factors including CCI score. The risk score achieved a c-statistic of 0.70 in this patient sample. This risk score could prove useful in clinical practice for guiding attention and decision-making for personalized care of patients with unrecognized or under-treated health needs.

Pediatric Emergency Surgery Course in Uganda: Long-Term Follow-Up and Insights From Further Dissemination.

INTRODUCTION: Approximately 170 pediatric surgeons are needed for the 24 million children in Uganda. There are only seven. Consequently, general surgeons manage many pediatric surgical conditions. In response, stakeholders created the Pediatric Emergency Surgery Course (PESC) for rural providers, given three times in 2018-2019. We sought to understand the course's long-term impact, current pediatric surgery needs, and determine measures for improvement. METHODS: In October 2021, we distributed the same test given in 2018-2019. Student's t-test was used to compare former participants' scores to previous scores. The course was delivered again in May 2022 to new participants. We performed a quantitative needs assessment and also conducted a focus group with these participants. Finally, we interviewed Surgeon in Chiefs at previous sites. RESULTS: Twenty three of the prior 45 course participants re-took the PESC course assessment. Alumni scored on average 71.9% ± 18% correct. This was higher from prior precourse test scores of 55.4% ± 22.4%, and almost identical to the 2018-2019 postcourse scores 71.9% ± 14%. Fifteen course participants completed the needs assessment. Participants had low confidence managing pediatric surgical disease (median Likert scale ≤ 3.0), 12 of 15 participants endorsed lack of equipment, and eight of 15 desired more educational resources. Qualitative feedback was positive: participants valued the pragmatic lessons and networking with in-country specialists. Further training was suggested, and Chiefs noted the need for more trained staff like anesthesiologists. CONCLUSIONS: Participants favorably reviewed PESC and retained knowledge over three years later. Given participants' interest in more training, further investment in locally derived educational efforts must be prioritized.

Factors associated with trauma recidivism in young children.

BACKGROUND: Trauma recidivism is associated with future trauma-associated morbidity and mortality. Previous evidence suggests that socioeconomic factors predict trauma recidivism in older children (10-18 years); however, risk factors in US children ≤10 have not been studied. We sought to determine the factors associated with trauma recidivism in young children ≤10. METHODS: We conducted a retrospective cohort study of pediatric trauma patients ≤10 years who presented to a single ACS-verified level I Pediatric Trauma Center from 7/1/2017 - 6/30/2021. All patients were evaluated for prior injury during trauma registry entry. Characteristics at the index injury were collected via chart review. Patients were geocoded to assess social vulnerability index (SVI). Logistic regression examined factors associated with recidivism. Best subset selection was used to compare multivariable models and identify the most predictive and parsimonious model. Statistical significance was set at p < 0.05. RESULTS: Of the 3,518 patients who presented in the study period, 169 (4.8%) experienced a prior injury. 76% (n = 128) had one prior injury presentation, 18% (n = 31) had 2 prior presentations, and 5.9% (n = 10) had ≥3. Falls were the most common mechanism in recidivists (63% vs. 52%, p = 0.009). Child physical abuse occurred in 6.5% of patients and 0.9% experienced penetrating injury. The majority (83%, n = 137) were discharged home from the ED. There was no significant difference in the frequency of penetrating injury and child physical abuse between recidivists and non-recidivists. Following logistic regression, the most parsimonious model demonstrated that recidivism was associated with comorbidities, age, falls, injury location, non-transfer, and racialization. No significant associations were found with SVI and insurance status. CONCLUSIONS: Medical comorbidities, young age, injury location, and falls were primarily associated with trauma recidivism. Support for parents of young children and those with special healthcare needs through injury prevention programs could reduce trauma recidivism in this population.Level of Evidence: III, Prognostic & Epidemiological.

Impact of Bowel Coverage and Resuscitation Protocol on Gastroschisis Mortality in Low-Income Countries: Experience and Lessons From Uganda.

BACKGROUND: Gastroschisis causes near complete mortality in low-income countries (LICs). This study seeks to understand the impact of bedside bowel reduction and silo placement, and protocolized resuscitation on gastroschisis outcomes in LICs. METHODS: We conducted a retrospective cohort study of gastroschisis patients at a tertiary referral center in Kampala, Uganda. Multiple approaches for bedside application of bowel coverage devices and delayed closure were used: sutured urine bags (2017-2018), improvised silos using wound protectors (2020-2021), and spring-loaded silos (2022). Total parental nutrition (TPN) was not available; however, with the use of improvised silos, a protocol was implemented to include protocolized resuscitation and early enteral feeding. Risk ratios (RR) for mortality were calculated in comparison to historic controls from 2014. RESULTS: 368 patients were included: 42 historic controls, 7 primary closures, 81 sutured urine bags, 133 improvised silos and 105 spring-loaded silos. No differences were found in sex (p = 0.31), days to presentation (p = 0.84), and distance traveled to the tertiary hospital (p = 0.16). Following the introduction of bowel coverage methods, the proportion of infants that survived to discharge increased from 2% to 16-29%. In comparison to historic controls, the risk of mortality significantly decreased: sutured urine bags 0.65 (95%CI: 0.52-0.80), improvised silo 0.76 (0.66-0.87), and spring-loaded silo 0.65 (0.56-0.76). CONCLUSION: Bedside application of bowel coverage and protocolization decreases the risk of death for infants with gastroschisis, even in the absence of TPN. Further efforts to expand supply of low-cost silos in LICs would significantly decrease the mortality associated with gastroschisis in this setting. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: III (Retrospective Comparative Study).

The Pediatric Emergency Surgery Course: Impact on Provider Practice in Rural Uganda.

PURPOSE: The Pediatric Emergency Surgery Course (PESC) trains rural Ugandan providers to recognize and manage critical pediatric surgical conditions. 45 providers took PESC between 2018 and 2019. We sought to assess the impact of the course at three regional hospitals: Fort Portal, Kabale, and Kiwoko. METHODS: We conducted a retrospective cohort study. Diagnosis, procedure, and patient outcome data were collected twelve months before and after PESC from admission and theater logbooks. We also assessed referrals from these institutions to Uganda's two pediatric surgery hubs: Mulago and Mbarara Hospitals. Wilcoxon rank-sum and Pearson's chi-squared tests compared pre- and post-PESC measures. Interrupted time-series-analysis assessed referral volume before and after PESC. RESULTS: 1534 admissions and 2148 cases were documented across the three regional hospitals. Kiwoko made 539 referrals, while pediatric surgery hubs received 116 referrals. There was a statistically significant immediate increase in the number of referrals from Fort Portal, from 0.5 patients/month pre-PESC to 0.8 post-PESC (95 % CI 0.03-1.51). Moving averages of the combined number of pyloromyotomy, intussusception reductions, and hernia repairs at the rural hospitals also increased post-course. Neonatal time to referral and referred patient age were significantly lower after PESC delivery. CONCLUSION: Our data suggest that PESC increased referrals to tertiary centers and operative volume of selected cases at rural hospitals and shortened time to presentation at sites receiving referrals. PESC is a locally-driven, validated, clinical education intervention that improves timely care of pediatric surgical emergencies and merits further support and dissemination. TYPE OF STUDY: Retrospective Cohort Study. LEVEL OF EVIDENCE: III.

Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family.

Background: Little is known about nursing home (NH) residents' family characteristics despite the important role families play at end-of-life (EOL). Objective: To describe the size and composition of first-degree families (FDFs) of Utah NH residents who died 1998-2016 (n = 43,405). Methods: Using the Utah Population Caregiving Database, we linked NH decedents to their FDF (n = 124,419; spouses = 10.8%; children = 55.3%; siblings = 32.3%) and compared sociodemographic and death characteristics of those with and without FDF members (n = 9424). Results: Compared to NH decedents with FDF (78.3%), those without (21.7%) were more likely to be female (64.7% vs. 57.1%), non-White/Hispanic (11.2% vs. 4.2%), less educated (<9th grade; 41.1% vs. 32.4%), and die in a rural/frontier NH (25.3% vs. 24.0%, all p < 0.001). Despite similar levels of disease burden (Charlson Comorbidity score 3 + 37.7% vs. 38.0%), those without FDF were more likely to die from cancer (14.2% vs. 12.4%), Chronic Obstructive Pulmonary Disease (COPD) (6.0% vs. 4.0%), and dementia (17.1% vs. 16.6%, all p < 0.001), and were less likely to have 2+ hospitalizations at EOL (20.5% vs. 22.4%, p < 0.001). Conclusions: Among NH decedents, those with and without FDF have different sociodemographic and death characteristics-factors that may impact care at EOL. Understanding the nature of FDF relationship type on NH resident EOL care trajectories and outcomes is an important next step in clarifying the role of families of persons living and dying in NHs.

Setting an agenda for a national pediatric trauma system: Operationalization of the Pediatric Trauma State Assessment Score.

ABSTRACT: Pediatric trauma system development is essential to public health infrastructure and pediatric health systems. Currently, trauma systems are managed at the state level, with significant variation in consideration of pediatric needs. A recently developed Pediatric Trauma System Assessment Score (PTSAS) demonstrated that states with lower PTSAS have increased pediatric mortality from trauma. Critical gaps are identified within 6 PTSAS domains: Legislation & Funding, Access to Care, Injury Prevention and Recognition, Disaster, Quality Improvement & Trauma Registry, and Pediatric Readiness. For each gap, a recommendation is provided regarding the necessary steps to address these challenges. Existing national organizations, including governmental, professional, and advocacy, highlight the potential partnerships that could be fostered to support efforts to address existing gaps. The organizations created under the U.S. Administration are described to highlight the ongoing efforts to support the development of pediatric emergency health systems.It is no longer sufficient to describe the disparities in pediatric trauma outcomes without taking action to ensure the health system is equipped to manage injured children. By capitalizing on organizations that intersect with trauma and emergency systems to address known gaps, we can reduce the impact of injury on all children across the United States.

Factors associated with mobile medical clinic use: a retrospective cohort study.

BACKGROUND: Mobile medical clinics have been used for decades to provide primary and preventive care to underserved populations. While several studies have examined their return on investment and impact on chronic disease management outcomes in the Mid-Atlantic and East Coast regions of the United States, little is known about the characteristics and clinical outcomes of adults who receive care aboard mobile clinics on the West Coast region. Guided by the Anderson Behavioral Model, this study describes the predisposing, enabling, and need factors associated with mobile medical clinic use among mobile medical clinic patients in Southern California and examines the relationship between mobile clinic utilization and presence and control of diabetes and hypertension. METHODS: We conducted a retrospective cohort study of 411 adults who received care in four mobile clinic locations in Southern California from January 1, 2018, to December 31, 2019. Data were collected from patient charts on predisposing (e.g., sex, race, age), enabling (e.g., insurance and housing status), and need (e.g., chronic illness) factors based on Andersen's Behavioral Model. Zero-truncated negative binomial regression was used to examine the association of chronic illness (hypertension and diabetes) with number of clinic visits, accounting for potential confounding factors. RESULTS: Over the course of the 2-year study period, 411 patients made 1790 visits to the mobile medical clinic. The majority of patients were female (68%), Hispanic (78%), married (47%), with a mean age of 50 (SD = 11). Forty-four percent had hypertension and 29% had diabetes. Frequency of mobile clinic utilization was significantly associated with chronic illness. Patients with hypertension and diabetes had 1.22 and 1.61 times the rate of mobile medical clinic visit than those without those conditions, respectively (IRR = 1.61, 95% CI, 1.36-1.92; 1.22, 95% CI, 1.02-1.45). CONCLUSIONS: Mobile clinics serve as an important system of health care delivery, especially for adults with uncontrolled diabetes and hypertension.

Disparities and determinants of place of death: Insights from the Utah Population Database.

To better understand determinants and potential disparities in end of life, we model decedents' place of death with explanatory variables describing familial, social, and economic resources. A retrospective cohort of 204,041 decedents and their family members are drawn from the Utah Population Database family caregiving dataset. Using multinomial regression, we model place of death, categorized as at home, in a hospital, in another location, or unknown. The model includes family relationship variables, sex, race and ethnicity, and a socioeconomic status score, with control variables for age at death and death year. We identified the effect of a family network of multiple caregivers, with 3+ daughters decreasing odds of a hospital death by 17 percent (OR: 0.83 [0.79, 0.87], p < 0.001). Place of death also varies significantly by race and ethnicity, with most nonwhite groups more likely to die in a hospital. These determinants may contribute to disparities in end of life.

Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers.

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.

Functional impairment associated with nonfatal pediatric firearm injuries.

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.

Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life-A Narrative Review.

BACKGROUND: Many potentially treatable non-congenital and non-traumatic surgical conditions can occur during the first 8000 days of life and an estimated 85% of children in low- and middle-income countries (LMICs) will develop one before 15 years old. This review summarizes the common routine surgical emergencies in children from LMICs and their effects on morbidity and mortality. METHODS: A narrative review was undertaken to assess the epidemiology, treatment, and outcomes of common surgical emergencies that present within the first 8000 days (or 21.9 years) of life in LMICs. Available data on pediatric surgical emergency care in LMICs were aggregated. RESULTS: Outside of trauma, acute appendicitis, ileal perforation secondary to typhoid fever, and intestinal obstruction from intussusception and hernias continue to be the most common abdominal emergencies among children in LMICs. Musculoskeletal infections also contribute significantly to the surgical burden in children. These "neglected" conditions disproportionally affect children in LMICs and are due to delays in seeking care leading to late presentation and preventable complications. Pediatric surgical emergencies also necessitate heavy resource utilization in LMICs, where healthcare systems are already under strain. CONCLUSIONS: Delays in care and resource limitations in LMIC healthcare systems are key contributors to the complicated and emergent presentation of pediatric surgical disease. Timely access to surgery can not only prevent long-term impairments but also preserve the impact of public health interventions and decrease costs in the overall healthcare system.

Interrater reliability of chart-based assessment of functional impairment after pediatric injury using the functional status scale.

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.

Pediatric Trauma Care Standardization: A Statewide Survey of Trauma Providers and Program Managers.

INTRODUCTION: Rural-urban disparities in pediatric trauma outcomes are well documented. However, few studies examine how differences in setting and resources impact rural providers' approach to trauma. We sought to understand the provider experience in managing injured children across our state and assess the potential for standardization of care. METHODS: A statewide cross-sectional survey was distributed to trauma providers and program managers through the American College of Surgeons, the Oregon Medical Board lists, and the State Trauma Advisory Board. Topics included pediatric management processes, challenges, and transfer or admission procedures. Rural-urban commuting codes were used to categorize responses. RESULTS: Of the 350 individuals who sent the survey, 68 responded (response rate 19%), representing 67% of trauma-verified hospitals and 72% of Oregon counties. Fifty-six respondents (82%) care for injured children, with 58% practicing rurally and 22% at critical access hospitals. Rural providers experienced lower trauma volumes (<1 patient/month, 63% versus 0%, P < 0.001), more difficulties obtaining pediatric-appropriate material resources (44% versus 30%), and challenges caring for infants/toddlers (25% versus 17%). Despite 77% of rural providers stating that <10% of patients had multisystem injuries, they described using full-body CT often (41% versus 10%, P = 0.007). Transfer interruptions were common (93%), with 44% having cancelled a transfer. The majority supported admission/transfer (85%) and imaging (82%) protocols. CONCLUSIONS: Rural providers experience lower pediatric trauma volumes, greater material-resource issues, and discomfort with traumatically injured small children. Lack of care standardization may lead to reliance on full-body CT, and potentially complex/avoidable transfers. Adoption of standardized protocols could facilitate a state-wide collaborative approach to pediatric trauma management.