Evaluation of Missing Prehospital Physiological Values in Injured Children and Adolescents.

INTRODUCTION: Prehospital vital signs and the Glasgow Coma Scale score are often missing in clinical practice and not recorded in trauma databases. Our study aimed to identify factors associated with missing prehospital physiological values, including systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, and Glasgow Coma Scale. METHODS: We used our hospital trauma registry to obtain patient, injury, resuscitation, and transportation characteristics for injured children and adolescents (age <15 y). We evaluated the association of missing documentation of prehospital values with other patient, injury, transportation, and resuscitation characteristics using multivariable regression. We standardized vital sign values using age-adjusted z-scores. RESULTS: The odds of a missing physiological value decreased with age (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.9, 0.9) and were higher when prehospital cardiopulmonary resuscitation was required (OR = 3.3, 95% CI = 1.9, 5.7). Among the physiological values considered, we observed the highest odds of missingness of systolic blood pressure, respiratory rate, and oxygen saturation. The odds of observing normal emergency department physiological values were lower when prehospital physiological values were missing (OR = 0.9, 95% CI = 0.9, 1.0; P = 0.04). CONCLUSIONS: Missing prehospital physiological values were associated with younger age and cardiopulmonary resuscitation among the injured children treated at our hospital. Measurement and documentation of physiological variables of patients with these characteristics should be targeted.

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport.

OBJECTIVES: Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol. METHODS: We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS: We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight. CONCLUSIONS: EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

EasyTBSA as a method for calculating total body surface area burned: a validation study.

BACKGROUND: Current methods of burn estimation can lead to incorrect estimates of the total body surface area (TBSA) burned, especially among injured children. Inaccurate estimation of burn size can impact initial management, including unnecessary transfer to burn centres and fluid overload during resuscitation. To address these challenges, we developed a smartphone application (EasyTBSA) that calculates the TBSA of a burn using a body-part by body-part approach. The aims of this study were to assess the accuracy of the EasyTBSA application and compare its performance to three established methods of burn size estimation (Lund-Browder Chart, Rule of Nines and Rule of Palms). METHODS: Twenty-four healthcare providers used each method to estimate burn sizes on moulaged manikins. The manikins represented different ages (infant, child and adult) with different TBSA burns (small <20%, medium 20%-49% and large >49%). We calculated the accuracy of each method as the difference between the user-estimated and actual TBSA. The true value of the complete body surface area of the manikins was obtained by three-dimensional scans. We used multivariable modelling to control for manikin size and method. RESULTS: Among all age groups and burn sizes, the EasyTBSA application had the greatest accuracy for burn size estimation (-0.01%, SD 3.59%) followed by the Rule of Palms (3.92%, SD 10.71%), the Lund-Browder Chart (4.42%, SD 5.52%) and the Rule of Nines (5.05%, SD 6.87%). CONCLUSIONS: The EasyTBSA application may improve the estimation of TBSA compared with existing methods.

The Development and Implementation of a Transfer Follow-up Program at a Level I Pediatric Trauma Center.

BACKGROUND: Inconsistent trauma patient referral feedback limits trauma system growth and may perpetuate suboptimal care. Trauma and burn patients are transferred to our Level I pediatric trauma center from hospitals in the surrounding metropolitan area. In the past, we had no consistent method to address performance improvement opportunities or provide information on patient outcomes to the referring facilities. The purpose of this study is to describe the implementation and evaluation of a formal electronic transfer follow-up program. METHODS: This was a before-and-after quality improvement study of pediatric trauma patients comparing prefeedback program implementation (2018) to postfeedback program implementation (2019). A new transfer patient feedback program was designed to address low rates of feedback provided to referring hospitals. Our center worked with a software developer to create a program that stored outside hospital contacts, automated follow-up letters, and tracked the number of letters sent, and opened, to enhance communication between trauma center and referring facilities. RESULTS: A total of 383 preprogram (2018) patients and 369 postprogram (2019) patients were evaluated. Since program implementation, an average of 70% follow-up per referral and an average return rate of 45% have been maintained. CONCLUSION: As we continue to use the system and make changes, we fully expect to exceed our goal in providing essential feedback on the care of pediatric trauma and burn patients to our referring facilities.

Using Social Media for the Prevention of Pediatric Burn Injuries: Pilot Design and Usability Study.

BACKGROUND: Most pediatric burn injuries are preventable. Social media is an effective method for delivering large-scale messaging and may be useful for injury prevention in this domain. OBJECTIVE: This study evaluates the feasibility of creating a social media campaign for pediatric burn injury prevention. METHODS: Ad spots containing a headline, short introduction, and video were created and posted on Facebook and Instagram over 4 months. Ad spots were targeted to parents and caregivers of children in our region with the highest number of burn injuries. We assessed the impact of each ad set using ThruPlays, reach, and video plays. RESULTS: We created 55 ad spots, with an average length of 24.1 (range 10-44) seconds. We reached 26,496 people during the campaign. The total ThruPlays of the 55 ad spots were 14,460 at US $0.19 per ThruPlay. Ad spots related to home safety had a significantly higher daily ThruPlay rate than those related to fire safety (6.5 vs 0.5 per day; P<.001). CONCLUSIONS: Social media is a feasible modality for delivering public health messages focused on preventing pediatric burn injuries. Engagement with these ads is influenced by ad presentation and the focus of the underlying injury prevention message.