Simulation-Based Design of ED Operations with Care Streams to Optimize Care Delivery and Reduce Length of Stay in the Emergency Department.

Faced with the opportunity to significantly deviate from classic operations, a new emergency department (ED) and novel strategy for patient care delivery were simultaneously initiated with the aid of model-based simulation. To answer the design and implementation questions, a traditional strategy for construction of discrete-eventmodel simulation was employed to define ED operations for a newly constructed facility in terms of workflow, variables, resources, structure, process logic and associated assumptions. Benefits were achieved before, during and after implementation of an unprecedented operations strategy-i.e., the organization of the ED care delivery around four care streams: Critical, Diagnostic, Therapeutic and Fast Track. Prior to opening, it shed light on the range of context variables where benefits might be anticipated, and it facilitated staff understanding and judgements of performance. Two years after opening, the operations data is compared to the simulation with encouraging results that shed light on where to continue pursuit of improvement.

Traumatic brain injuries and computed tomography use in pediatric sports participants.

BACKGROUND: Childhood sports-related head trauma is common, frequently leading to emergency department (ED) visits. We describe the spectrum of these injuries and trends in computed tomography (CT) use in the Pediatric Emergency Care Applied Research Network. METHODS: This was a secondary analysis of a large prospective cohort of children with head trauma in 25 Pediatric Emergency Care Applied Research Network EDs between 2004 and 2006. We described and compared children 5 to 18 years old by CT rate, traumatic brain injury (TBI) on CT, and clinically important TBI (ciTBI). We used multi-variable logistic regression to compare CT rates, adjusting for clinical severity. Outcomes included frequency of CT, TBIs on CT, and ciTBIs (defined by [a] death, [b] neurosurgery, [c] intubation>24 hours, or [d] hospitalization for ≥2 nights). FINDINGS: A total of 3289 (14%) of 23082 children had sports-related head trauma. Two percent had Glasgow Coma Scale scores less than 14. 53% received ED CTs, 4% had TBIs on CT, and 1% had ciTBIs. Equestrians had increased adjusted odds (1.8; 95% confidence interval [CI], 1.0-3.0]) of CTs; the rate of TBI on CT was 4% (95% CI, 3%-5%). Compared with team sports, snow (adjusted odds ratio, 4.1; 95% CI 1.5-11.4) and nonmotorized wheeled (adjusted odds ratio, 12.8; 95% CI, 5.5-32.4) sports had increased adjusted odds of ciTBIs. CONCLUSIONS: Children with sports-related head trauma commonly undergo CT. Only 4% of those imaged had TBIs on CT. Clinically important TBIs occurred in 1%, with significant variation by sport. There is an opportunity for injury prevention efforts in high-risk sports and opportunities to reduce CT use in general by use of evidence-based prediction rules. What is known about this subject: Pediatric sports-related head injuries are a common and increasingly frequent ED presentation, as is the use of CT in their evaluation. Little is known about TBIs resulting from different types of sports activities in children. What this study adds to existing knowledge: This study broadens the understanding of the epidemiology of Pediatric TBIs resulting from different sports activities through a prospective assessment of frequency and severity of ciTBIs and ED CT use in a large cohort of head-injured children in a network of pediatric EDs.

Changes in Bronchiolitis Characteristics During the COVID-19 Pandemic: A Description of Pediatric Emergency Department Visits in a Community Hospital, 2019-2021.

A retrospective, cross-sectional study of children with bronchiolitis aged 1 to 24 months during an ED visit between 2019 and 2021 was performed. Chi-square or Kruskal-Wallis was used to compare groups. The gamma coefficient was used to measure the association of variables through time. Bronchiolitis cases decreased by 75% from 2019 to 2020 and rose back to prepandemic levels by 2021. Radiographs (gamma -0.443), steroids (gamma -0.298), and bronchodilators (gamma -0.414) decreased during the study period (P < .001). Laboratory studies (gamma 0.032), viral testing (gamma 0.097), antibiotic use (gamma -0.069), and respiratory support (gamma 0.166) were unchanged. The decrease in steroids and bronchodilators was related to a clinical pathway that discouraged their use. Respiratory support remained unchanged. The COVID-19 pandemic (2019-2021) seems to have had little effect on the severity or resource utilization associated with bronchiolitis but may have unraveled a potential bronchiolitis phenotype that may have been more prominent during the pandemic.

Effect of the COVID-19 Pandemic on the Pediatric Emergency Department Flow.

OBJECTIVE: The aim of this study was to determine how the early stages of the coronavirus disease 2019 (COVID-19) pandemic affected the use of the pediatric emergency department (PED). METHODS: Cross-sectional study of PED visits during January through April, 2016-2020. Data included: total PED visits, emergency severity index (ESI), disposition, chief complaint, age (months), time from first provider to disposition (PTD), and PED length of stay (PED-LOS). P-value <0.01 was statistically significant. RESULTS: In total, 67,499 visits were reported. There was a significant decrease in PED visits of 24-71% from March to April 2020. Chief complaints for fever and cough were highest in March 2020; while April 2020 had a shorter mean PED-LOS (from 158 to 123 min), an increase of admissions (from 8% to 14%), a decrease in ESI 4 (10%), and an increase in ESI 3 (8%) (P < 0.001). There was no difference in mean monthly PTD time. CONCLUSIONS: Patient flow in the PED was negatively affected by a decrease in PED visits and increase in admission rate that may be related to higher acuity. By understanding the interaction between hospital processes on PEDs and patient factors during a pandemic, we are able to anticipate and better allocate future resources.

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.

BACKGROUND: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. METHODS: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). FINDINGS: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. INTERPRETATION: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. FUNDING: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Comparison of Prediction Rules and Clinician Suspicion for Identifying Children With Clinically Important Brain Injuries After Blunt Head Trauma.

OBJECTIVE: Children with minor head trauma frequently present to emergency departments (EDs). Identifying those with traumatic brain injuries (TBIs) can be difficult, and it is unknown whether clinical prediction rules outperform clinician suspicion. Our primary objective was to compare the test characteristics of the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules to clinician suspicion for identifying children with clinically important TBIs (ciTBIs) after minor blunt head trauma. Our secondary objective was to determine the reasons for obtaining computed tomography (CT) scans when clinical suspicion of ciTBI was low. METHODS: This was a planned secondary analysis of a previously conducted observational cohort study conducted in PECARN to derive and validate clinical prediction rules for ciTBI among children with minor blunt head trauma in 25 PECARN EDs. Clinicians recorded their suspicion of ciTBI before CT as <1, 1-5, 6-10, 11-50, or >50%. We defined ciTBI as 1) death from TBI, 2) neurosurgery, 3) intubation for more than 24 hours for TBI, or 4) hospital admission of 2 nights or more associated with TBI on CT. To avoid overfitting of the prediction rules, we performed comparisons of the prediction rules and clinician suspicion on the validation group only. On the validation group, we compared the test accuracies of clinician suspicion > 1% versus having at least one predictor in the PECARN TBI age-specific prediction rules for identifying children with ciTBIs (one rule for children <2 years [preverbal], the other rule for children >2 years [verbal]). RESULTS: In the parent study, we enrolled 8,627 children to validate the prediction rules, after enrolling 33,785 children to derive the prediction rules. In the validation group, clinician suspicion of ciTBI was recorded in 8,496/8,627 (98.5%) patients, and 87 (1.0%) had ciTBIs. CT scans were obtained in 2,857 (33.6%) patients in the validation group for whom clinician suspicion of ciTBI was recorded, including 2,099/7,688 (27.3%) of those with clinician suspicion of ciTBI of <1% and 758/808 (93.8%) of those with clinician suspicion >1%. The PECARN prediction rules were significantly more sensitive than clinician suspicion >1% of ciTBI for preverbal (100% [95% confidence interval {CI} = 86.3% to 100%] vs. 60.0% [95% CI = 38.7% to 78.9%]) and verbal children (96.8% [95% CI = 88.8% to 99.6%] vs. 64.5% [95% CI = 51.3% to 76.3%]). Prediction rule specificity, however, was lower than clinician suspicion >1% for preverbal children (53.6% [95% CI = 51.5% to 55.7%] vs. 92.4% [95% CI = 91.2% to 93.5%]) and verbal children (58.2% [95% CI = 56.9% to 59.4%] vs. 90.6% [95% CI = 89.8% to 91.3%]). Of the 7,688 patients in the validation group with clinician suspicion recorded as <1%, CTs were nevertheless obtained in 2,099 (27.3%). Three of 16 (18.8%) patients undergoing neurosurgery had clinician suspicion of ciTBI <1%. CONCLUSIONS: The PECARN TBI prediction rules had substantially greater sensitivity, but lower specificity, than clinician suspicion of ciTBI for children with minor blunt head trauma. Because CT ordering did not follow clinician suspicion of <1%, these prediction rules can augment clinician judgment and help obviate CT ordering for children at very low risk of ciTBI.

Isolated linear skull fractures in children with blunt head trauma.

BACKGROUND AND OBJECTIVE: Children and adolescents with minor blunt head trauma and isolated skull fractures are often admitted to the hospital. The objective of this study was to describe the injury circumstances and frequency of clinically important neurologic complications among children with minor blunt head trauma and isolated linear skull fractures. METHODS: This study was a planned secondary analysis of a large prospective cohort study in children <18 years old with blunt head trauma. Data were collected in 25 emergency departments. We analyzed patients with Glasgow Coma Scale scores of 14 or 15 and isolated linear skull fractures. We ascertained acute neurologic outcomes through clinical information collected during admission or via telephone or mail at least 1 week after the emergency department visit. RESULTS: In the parent study, we enrolled 43,904 children (11,035 [25%] <2 years old). Of those with imaging studies, 350 had isolated linear skull fractures. Falls were the most common injury mechanism, accounting for 70% (81% for ages <2 years old). Of 201 hospitalized children, 42 had computed tomography or MRI repeated; 5 had new findings but none required neurosurgical intervention. Of 149 patients discharged from the hospital, 20 had repeated imaging, and none had new findings. CONCLUSIONS: Children with minor blunt head trauma and isolated linear skull fractures are at very low risk of evolving other traumatic findings noted in subsequent imaging studies or requiring neurosurgical intervention. Hospital admission for neurologically normal children with isolated linear skull fractures after minor blunt head trauma for monitoring is typically unnecessary.

Modeling both the mechanical and hypoxic features of traumatic brain injury in vitro in rats.

In traumatic brain injury, the brain is subjected to mechanical shear and varying degrees of hypoxia/ischemia. To compare effects of stretch injury, hypoxia, and the combination of both insults on neurons, mixed neuronal and astrocytic cultures were established from day 17 fetal rat brains. On days 17-19 in vitro, cultures were subjected to stretch injury or hypoxia of varying degrees, alone and in combination. Cultures were assayed for lactate dehydrogenase release and Trypan Blue uptake. Hypoxia or Stretch injury alone induced a graded response (P<0.05) on both assays. Stretch+Hypoxia (4 or 6 h) resulted in significantly greater injury as compared with controls (P<0.05), and as compared with either isolated Stretch or Hypoxia (1, 2, 4 or 6 h) alone (P<0.05).

Isolated loss of consciousness in children with minor blunt head trauma.

IMPORTANCE: A history of loss of consciousness (LOC) is frequently a driving factor for computed tomography use in the emergency department evaluation of children with blunt head trauma. Computed tomography carries a nonnegligible risk for lethal radiation-induced malignancy. The Pediatric Emergency Care Applied Research Network (PECARN) derived 2 age-specific prediction rules with 6 variables for clinically important traumatic brain injury (ciTBI), which included LOC as one of the risk factors. OBJECTIVE: To determine the risk for ciTBIs in children with isolated LOC. DESIGN, SETTING, AND PARTICIPANTS: This was a planned secondary analysis of a large prospective multicenter cohort study. The study included 42 ,412 children aged 0 to 18 years with blunt head trauma and Glasgow Coma Scale scores of 14 and 15 evaluated in 25 emergency departments from 2004-2006. EXPOSURE: A history of LOC after minor blunt head trauma. MAIN OUTCOMES AND MEASURES: The main outcome measures were ciTBIs (resulting in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥2 nights) and a comparison of the rates of ciTBIs in children with no LOC, any LOC, and isolated LOC (ie, with no other PECARN ciTBI predictors). RESULTS: A total of 42 412 children were enrolled in the parent study, with 40 693 remaining in the current analysis after exclusions. Of these, LOC occurred in 15.4% (6286 children). The prevalence of ciTBI with any history of LOC was 2.5% and for no history of LOC was 0.5% (difference, 2.0%; 95% CI, 1.7-2.5). The ciTBI rate in children with isolated LOC, with no other PECARN predictors, was 0.5% (95% CI, 0.2-0.8; 13 of 2780). When comparing children who have isolated LOC with those who have LOC and other PECARN predictors, the risk ratio for ciTBI in children younger than 2 years was 0.13 (95% CI, 0.005-0.72) and for children 2 years or older was 0.10 (95% CI, 0.06-0.19). CONCLUSIONS AND RELEVANCE: Children with minor blunt head trauma presenting to the emergency department with isolated LOC are at very low risk for ciTBI and do not routinely require computed tomographic evaluation.

Presentations and outcomes of children with intraventricular hemorrhages after blunt head trauma.

OBJECTIVE: To describe the clinical presentations and outcomes of children with intraventricular hemorrhages (IVHs) after blunt head trauma (BHT). DESIGN: Subanalysis of a large, prospective, observational cohort study performed from June 1, 2004, through September 31, 2006. SETTING: Twenty-five emergency departments participating in the Pediatric Emergency Care Applied Research Network. Patients Children presenting with IVH after BHT. Exposure Blunt head trauma. MAIN OUTCOME MEASURES: Clinical presentations and outcomes, including the Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scores at hospital discharge. RESULTS: Of 15 907 patients evaluated with computed tomography, 1156 (7.3%) had intracranial injuries. Forty-three of the 1156 (3.7%; 95% CI, 2.7%-5.0%) had nonisolated IVHs (ie, with intracranial injuries on computed tomography), and 10 of 1156 (0.9%; 95% CI, 0.4%-1.6%) had isolated IVHs. Only 4 of 43 (9.3%) of those with nonisolated IVHs had Glasgow Coma Scale (GCS) scores of 14 to 15, and all 10 (100.0%) with isolated IVHs had GCS scores of 15. No patients with isolated IVHs required neurosurgery or died. One patient had moderate overall disability (by the POPC score), and no patient had moderate or severe disability at discharge (by the PCPC score). Of the 43 patients with nonisolated IVHs, however, 16 (37.2%) died and 18 (41.9%) required neurosurgery. In 27 patients (62.8%), injuries ranged from moderate overall disability to brain death by the POPC score. CONCLUSIONS: Children with nonisolated IVHs after BHT typically present with GCS scores of less than 14, frequently require neurosurgery, and have high mortality rates. In contrast, those with isolated IVHs typically present with normal mental status and are at low risk for acute adverse events and poor outcomes.

The impact of excitotoxic blockade on the evolution of injury following combined mechanical and hypoxic insults in primary rat neuronal culture.

Traumatic brain injury (TBI) involves alterations in neuronal physiology, often complicated by secondary hypoxic or hypotensive events. Excitotoxicity is an important process induced in both TBI and hypoxic or ischemic insults to the brain. We investigated two hypotheses: (1) excitotoxicity is more prominent following combined mechanical and hypoxic injury than either alone; (2) both AMPA and NMDA receptor activation mediate combined mechanical and hypoxic injury. Media in primary mixed neuronal cultures were replaced with conditioned media containing MK801 (NMDA antagonist) and/or NBQX (AMPA/kainate antagonist). Cultures were then subjected to mechanical injury. Afterward, media were exchanged for hypoxic media containing the antagonist, and plates were placed in hypoxia chambers for 7 h. At 24 h following hypoxia, LDH release, trypan blue uptake, and morphologic changes were assessed. Blockade had no effect after mechanical injury. After hypoxia, MK801 and combined MK801/NBQX decreased LDH and trypan blue to control levels. NBQX alone after hypoxia had less impact. After combined mechanical injury and hypoxia, both MK801 and NBQX partially reduced LDH and trypan blue. Combining the antagonists led to reduction to control values for both endpoints. We conclude that excitotoxic processes are more prominent after combined than isolated injuries in neurons and that increased cell death is mediated by both NMDA and AMPA receptor activation following combined injuries.

Use of artificial intelligence to identify cardiovascular compromise in a model of hemorrhagic shock.

OBJECTIVE: To determine whether a prototype artificial intelligence system can identify volume of hemorrhage in a porcine model of controlled hemorrhagic shock. DESIGN: Prospective in vivo animal model of hemorrhagic shock. SETTING: Research foundation animal surgical suite; computer laboratories of collaborating industry partner. SUBJECTS: Nineteen, juvenile, 25- to 35-kg, male and female swine. INTERVENTIONS: Anesthetized animals were instrumented for arterial and systemic venous pressure monitoring and blood sampling, and a splenectomy was performed. Following a 1-hr stabilization period, animals were hemorrhaged in aliquots to 10, 20, 30, 35, 40, 45, and 50% of total blood volume with a 10-min recovery between each aliquot. Data were downloaded directly from a commercial monitoring system into a proprietary PC-based software package for analysis. MEASUREMENTS AND MAIN RESULTS: Arterial and venous blood gas values, glucose, and cardiac output were collected at specified intervals. Electrocardiogram, electroencephalogram, mixed venous oxygen saturation, temperature (core and blood), mean arterial pressure, pulmonary artery pressure, central venous pressure, pulse oximetry, and end-tidal CO(2) were continuously monitored and downloaded. Seventeen of 19 animals (89%) died as a direct result of hemorrhage. Stored data streams were analyzed by the prototype artificial intelligence system. For this project, the artificial intelligence system identified and compared three electrocardiographic features (R-R interval, QRS amplitude, and R-S interval) from each of nine unknown samples of the QRS complex. We found that the artificial intelligence system, trained on only three electrocardiographic features, identified hemorrhage volume with an average accuracy of 91% (95% confidence interval, 84-96%). CONCLUSIONS: These experiments demonstrate that an artificial intelligence system, based solely on the analysis of QRS amplitude, R-R interval, and R-S interval of an electrocardiogram, is able to accurately identify hemorrhage volume in a porcine model of lethal hemorrhagic shock. We suggest that this technology may represent a noninvasive means of assessing the physiologic state during and immediately following hemorrhage. Point of care application of this technology may improve outcomes with earlier diagnosis and better titration of therapy of shock.

Hypoxic preconditioning protects against ischemic brain injury.

Animals exposed to brief periods of moderate hypoxia (8% to 10% oxygen for 3 hours) are protected against cerebral and cardiac ischemia between 1 and 2 days later. This hypoxia preconditioning requires new RNA and protein synthesis. The mechanism of this hypoxia-induced tolerance correlates with the induction of the hypoxia-inducible factor (HIF), a transcription factor heterodimeric complex composed of inducible HIF-1alpha and constitutive HIF-1beta proteins that bind to the hypoxia response elements in a number of HIF target genes. Our recent studies show that HIF-1alpha correlates with hypoxia induced tolerance in neonatal rat brain. HIF target genes, also induced following hypoxia-induced tolerance, include vascular endothelial growth factor, erythropoietin, glucose transporters, glycolytic enzymes, and many other genes. Some or all of these genes may contribute to hypoxia-induced protection against ischemia. HIF induction of the glycolytic enzymes accounts in part for the Pasteur effect in brain and other tissues. Hypoxia-induced tolerance is not likely to be equivalent to treatment with a single HIF target gene protein since other transcription factors including Egr-1 (NGFI-A) have been implicated in hypoxia regulation of gene expression. Understanding the mechanisms and genes involved in hypoxic tolerance may provide new therapeutic targets to treat ischemic injury and enhance recovery.