Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study.

BACKGROUND: The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends. METHODS: We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics. RESULTS: We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05). CONCLUSIONS: During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Pediatric Firearm Injury Emergency Department Visits From 2017 to 2022: A Multicenter Study.

BACKGROUND AND OBJECTIVE: Pediatric firearm injuries increased during the coronavirus disease 2019 pandemic, but recent trends in firearm injury emergency department (ED) visits are not well described. We aimed to assess how pediatric firearm injury ED visits during the pandemic differed from expected prepandemic trends. METHODS: We retrospectively studied firearm injury ED visits by children <18 years old at 9 US hospitals participating in the Pediatric Emergency Care Applied Research Network Registry before (January 2017 to February 2020) and during (March 2020 to November 2022) the pandemic. Multivariable Poisson regression models estimated expected visit rates from prepandemic data. We calculated rate ratios (RRs) of observed to expected visits per 30 days, overall, and by sociodemographic characteristics. RESULTS: We identified 1904 firearm injury ED visits (52.3% 15-17 years old, 80.0% male, 63.5% non-Hispanic Black), with 694 prepandemic visits and 1210 visits during the pandemic. Death in the ED/hospital increased from 3.1% prepandemic to 6.1% during the pandemic (P = .007). Firearm injury visits per 30 days increased from 18.0 prepandemic to 36.1 during the pandemic (RR 2.09, 95% CI 1.63-2.91). Increases beyond expected rates were seen for 10- to 14-year-olds (RR 2.61, 95% CI 1.69-5.71), females (RR 2.46, 95% CI 1.55-6.00), males (RR 2.00, 95% CI 1.53-2.86), Hispanic children (RR 2.30, 95% CI 1.30-9.91), and Black non-Hispanic children (RR 1.88, 95% CI 1.34-3.10). CONCLUSIONS: Firearm injury ED visits for children increased beyond expected prepandemic trends, with greater increases among certain population subgroups. These findings may inform firearm injury prevention efforts.

Increases in adolescent firearm injuries were associated with school closures during COVID-19.

BACKGROUND: Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic. METHODS: Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes. RESULTS: There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city. CONCLUSION: AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

Variability in firearm injury among major pediatric trauma centers across the USA.

Objectives: In 2020, firearm injuries surpassed automobile collisions as the leading cause of death in US children. Annual automobile fatalities have decreased during 40 years through a multipronged approach. To develop similarly targeted public health interventions to reduce firearm fatalities, there is a critical need to first characterize firearm injuries and their outcomes at a granular level. We sought to compare firearm injuries, outcomes, and types of shooters at trauma centers in four pediatric health systems across the USA. Methods: We retrospectively extracted data from each institution's trauma registry, paper and electronic health records. Study included all patients less than 19 years of age with a firearm injury between 2003 and 2018. Variables collected included demographics, intent, resources used, and emergency department and hospital disposition. Descriptive statistics were reported using medians and IQRs for continuous data and counts with percentages for categorical data. χ2 test or Fisher's exact test was conducted for categorical comparisons. Results: Our cohort (n=1008, median age 14 years) was predominantly black and male. During the study period, there was an overall increase in firearm injuries, driven primarily by increases in the South (S) site (ß=0.11 (SE 0.02), p=<0.001) in the setting of stable rates in the West and decreasing rates in the Northeast and Mid-Atlantic sites (ß=-0.15 (SE 0.04), p=0.002; ß=-0.19 (SE0.04), p=0.001). Child age, race, insurance type, resource use, injury type, and shooter type all varied by regional site. Conclusion: The incidence of firearm-related injuries seen at four sites during 15 years varied by site and region. The overall increase in firearm injuries was predominantly driven by the S site, where injuries were more often unintentional. This highlights the need for region-specific data to allow for the development of targeted interventions to impact the burden of injury.Level of Evidence: II, retrospective study.

Timing of Mental Health Service Use After a Pediatric Firearm Injury.

OBJECTIVES: To examine how timing of the first outpatient mental health (MH) visit after a pediatric firearm injury varies by sociodemographic and clinical characteristics. METHODS: We retrospectively studied children aged 5 to 17 years with a nonfatal firearm injury from 2010 to 2018 using the IBM Watson MarketScan Medicaid database. Logistic regression estimated the odds of MH service use in the 6 months after injury, adjusted for sociodemographic and clinical characteristics. Cox proportional hazard models, stratified by previous MH service use, evaluated variation in timing of the first outpatient MH visit by sociodemographic and clinical characteristics. RESULTS: After a firearm injury, 958 of 2613 (36.7%) children used MH services within 6 months; of these, 378 of 958 (39.5%) had no previous MH service use. The adjusted odds of MH service use after injury were higher among children with previous MH service use (adjusted odds ratio, 10.41; 95% confidence interval [CI], 8.45-12.82) and among non-Hispanic white compared with non-Hispanic Black children (adjusted odds ratio, 1.29; 95% CI, 1.02-1.63). The first outpatient MH visit after injury occurred sooner among children with previous MH service use (adjusted hazard ratio, 6.32; 95% CI, 5.45-7.32). For children without previous MH service use, the first MH outpatient visit occurred sooner among children with an MH diagnosis made during the injury encounter (adjusted hazard ratio, 2.72; 95% CI, 2.04-3.65). CONCLUSIONS: More than 3 in 5 children do not receive MH services after firearm injury. Previous engagement with MH services and new detection of MH diagnoses during firearm injury encounters may facilitate timelier connection to MH services after injury.

Trends in Adolescent Firearm-Related Injury: A Time Series Analysis.

BACKGROUND: Firearm-related injury (FRI) became the leading cause of death among children/adolescents in 2019. PURPOSE: This study sought to determine changes over time in the population of adolescents affected by FRI in Atlanta, Georgia, such that high risk cohorts could be identified. RESEARCH DESIGN: City-wide retrospective cohort review. STUDY SAMPLE: Adolescent victims (age 11-21 years of age) of FRI, defined by ICD9/10 codes, in Atlanta, Georgia. DATA ANALYSIS: Descriptive, multivariate and time series analysis. RESULTS: There were 1,453 adolescent FRI victims in this time period, predominantly Black (86%) and male (86.6%). Unintentional injury was higher among ages 11-14 years (43.1%) compared to 15-17 years (10.2%) and 18-21 years (9.3%) (P < .01). FRI affecting females increased at a rate of 8.1 injuries/year (P < .01), and unintentional injuries increased at by 7.6/year (P < .01). Mortality declined from 16% in 2016 to 7.7% in 2021. CONCLUSION: Our data provides evidence for firearm policy reform. Interventions should target prevention of intentional injury among AQ4 females and seek to reverse the trend in unintentional injuries.

Two-Year Utilization and Expenditures for Children After a Firearm Injury.

INTRODUCTION: Firearm injuries are a leading cause of morbidity among children, but data on healthcare utilization and expenditures after injury are limited. This study sought to analyze healthcare encounters and expenditures for 2 years after a nonfatal firearm injury. METHODS: A retrospective cohort study was conducted between 2020 and 2022 of children aged 0-18 years with International Classification of Diseases, Ninth Revision/ICD-10 diagnosis codes for firearm injury from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included the difference in healthcare encounters and expenditures, including mental health. Descriptive statistics characterized patient demographics and healthcare utilization. Changes in health expenditures were evaluated with Wilcoxon sign rank tests. RESULTS: Among 911 children, there were 12,757 total healthcare encounters in the year before the index firearm injury, 15,548 1 encounters in the year after (p<0.001), and 10,228 total encounters in the second year (p<0.001). Concomitantly, there was an overall increase of $14.4 million in health expenditures ($11,415 per patient) 1 year after (p<0.001) and a $0.8 million decrease 2 years after the firearm injury (p=0.001). The children with low previous expenditures (majority of sample) had sustained increases throughout the second year after injury. There was a 31% and 37% absolute decrease in mental health utilization and expenditures, respectively, among children 2 years after the firearm injury. CONCLUSIONS: Children who experience nonfatal firearm injury have an increased number of healthcare encounters and healthcare expenditures in the year after firearm injury, which is not sustained for a second year. Mental health utilization and expenditures remain decreased up to 2 years after a firearm injury. More longitudinal research on the morbidity associated with nonfatal firearm injuries is needed.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies.

OBJECTIVE: To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC). BACKGROUND: A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury. METHODS: We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms. RESULTS: We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76). CONCLUSIONS: Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury.

OBJECTIVE: Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury. METHODS: This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury (excluding nonpowder) in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included: (1) difference in health care encounters for 1 year before and 1 year after injury, (2) difference in health care expenditures, and (3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests. RESULTS: Among 1,821 children, there were 22,398 health care encounters before the injury and 28,069 after. Concomitantly, there was an overall increase of $16.5 million in health expenditures ($9,084 per patient). There was a 50% increase in children qualifying for complex chronic condition status after firearm injury. CONCLUSIONS: Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.

Retracted Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury.

Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury. This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included 1) difference in health care encounters for 1 year before and 1 year after injury, 2) difference in health care expenditures, and 3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests. Among 3,296 children, there were 47,660 health care encounters before the injury and 61,660 after. Concomitantly, there was an overall increase of $18.5 million in health expenditures ($5,612 per patient). There was a 40% increase in children qualifying for complex chronic condition status after firearm injury. Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.

Characteristics of Diagnosed Concussions in Children Aged 0 to 4 Years Presenting to a Large Pediatric Healthcare Network.

OBJECTIVE: The aim of the study was to comprehensively describe the natural history of concussion in early childhood between 0 and 4 years. METHODS: Retrospective cohort study of 329 patients aged 0 to 4 years, with an International Classification of Diseases, Ninth Revision, concussion diagnosis in the Children's Hospital of Philadelphia healthcare network from October 1, 2013, to September 30, 2015. Clinical data were abstracted from the Children's Hospital of Philadelphia electronic health record, which captured all clinical care visits and injury characteristics. RESULTS: Nearly 9 (86.6%) of 10 patients sought care in the emergency department or urgent care setting, most commonly on the day of injury (56.2%) and as a result of a fall (64.4%). More than two-thirds (64.4%) of patients or their parent/caregiver reported somatic symptoms (ie, vomiting or headache), whereas close to half (49.2%) reported sleep issues. One of 5 patients identified emotional symptoms (21.9%) or visio-vestibular dysfunction (20.4%). Many patients also experienced symptoms not included in standard assessment tools including personality changes (34.0%) and change in appetite (12.8%). CONCLUSIONS: These results provide insight into the clinical characteristics of concussion in early childhood up to 4 years of age. Because assessment in this group relies heavily on parent/caregiver symptom reporting, rather than patient self-report, these results will aid clinicians with the challenge of diagnosing concussions in this population. These findings highlight the need to develop additional tools to adequately and systematically assess common signs and symptoms of concussion in early childhood that may not be included in standard assessment scales routinely used in older adolescents and adults.

The Relationship Between Parents' Reported Storage of Firearms and Their Children's Perceived Access to Firearms: A Safety Disconnect.

Locked-up and unloaded firearm storage is a tenet of injury prevention campaigns to decrease children's access to firearms. This study cohort describes the reported presence of, storage mechanisms for, and children's perceived access to firearms. Parent-child dyads (n = 297) were recruited from pediatric emergency departments in Atlanta, GA. Gun owners were 25% of cohort; 53% reported storing some firearms insecurely. Gun owners were more likely to believe their child could access a firearm versus non-gun owners (11% vs 3%). Children of gun owners versus non-gun owners indicated increased ability to acquire a gun (14% vs 4%). Fifty-nine percent of children could not identify a real versus toy gun in a picture. This study highlights a plurality of parents storing firearms insecurely with a significant portion of children reporting gun access and demonstrating inability to recognize actual guns. This disconnect points to the importance of public health interventions to decrease access to firearms in this vulnerable population.

Pediatric falls ages 0-4: understanding demographics, mechanisms, and injury severities.

BACKGROUND: Pediatric unintentional falls are the leading cause of injury-related emergency visits for children < 5 years old. The purpose of this study was to identify population characteristics, injury mechanisms, and injury severities and patterns among children < 5 years to better inform age-appropriate falls prevention strategies. METHODS: This retrospective database study used trauma registry data from the lead pediatric trauma system in Georgia. Data were analyzed for all patients < 5 years with an international classification of disease, 9th revision, clinical modification (ICD-9 CM) external cause of injury code (E-code) for unintentional falls between 1/1/2013 and 12/31/2015. Age (months) was compared across categories of demographic variables, injury mechanisms, and emergency department (ED) disposition using Kruskal-Wallis ANOVA and the Mann Whitney U test. The relationships between demographic variables, mechanism of injury (MOI), and Injury Severity Score (ISS) were evaluated using multinomial logistic regression. RESULTS: Inclusion criteria were met by 1086 patients (median age = 28 months; 59.7% male; 53.8% White; 49.1% <  1 m fall height). Younger children, < 1-year-old, primarily fell from caregiver's arms, bed, or furniture, while older children sustained more falls from furniture and playgrounds. Children who fell from playground equipment were older (median = 49 months, p < 0.01) than those who fell from the bed (median = 10 months), stairs (median = 18 months), or furniture (median = 19 months). Children < 1 year had the highest proportion of head injuries including skull fracture (63.1%) and intracranial hemorrhage (65.5%), 2-year-old children had the highest proportion of femur fractures (32.9%), and 4-year-old children had the highest proportion of humerus fractures (41.0%). Medicaid patients were younger (median = 24.5 months, p < 0.01) than private payer (median = 34 months). Black patients were younger (median = 20.5 months, p < 0.001) than White patients (median = 29 months). Results from multinomial logistic regression models suggest that as age increases, odds of a severe ISS (16-25) decreased (OR = 0.95, CI = 0.93-0.97). CONCLUSIONS: Pediatric unintentional falls are a significant burden of injury for children < 5 years. Future work will use these risk and injury profiles to inform current safety recommendations and develop evidence-based interventions for parents/caregivers and pediatric providers.

Pediatric injury prevention programs: Identifying markers for success and sustainability.

BACKGROUND: Injury is the leading cause of death in children. Although many pediatric hospitals and trauma centers provide injury prevention (IP) programming, there is no national standard. This study aims to identify characteristics of a sustainable and successful IP program by querying programs affiliated with the Injury Free Coalition for Kids (IFCK). METHODS: The IFCK sites were sent a 30-question survey via e-mail. Questions focused on demographics, scope of IP activities, self-efficacy, and outcome measures including finances, academic productivity, and legislative advocacy. Counts and frequencies were calculated and compared using χ tests. RESULTS: The survey was completed by 38 (90.4%) of 42 sites. The majority were associated with a freestanding children's hospital (57.9%) and Level I pediatric trauma center (86.8%). Most programs (79%) had at least one dedicated full-time equivalent (FTE) staff. Research was most common on child passenger safety and teen driving. Nearly 30% of programs offered educational curricula to health care providers; these sites were more likely to have FTE support (p = 0.036). Steady sources of funding were identified for 60.5% of programs, with 47.8% citing their hospital as the primary source; 73% of respondents were confident in their program's capacity to sustain activities; these were more likely to be larger programs (p = 0.001) with steady sources of funding (p < 0.001). Despite 73.7% of sites having academic affiliations, 60.5% had 5 or fewer publications over the previous 5 years. In the prior 2 years, 55.3% of programs impacted legislative or policy changes. Funding, size of program, and FTE had no statistical correlation with research productivity or number of legislative/policy contributions. CONCLUSIONS: This study characterizes the variation among pediatric IP programs within IFCK sites, while highlighting the association between financial and FTE support from programs' institutions with sustainable IP programming. These results can assist programs in identifying differences in relation to their peers.