Nurses' Perceptions of Barriers and Facilitators Affecting the Shaken Baby Syndrome Education Initiative: An Exploratory Study of a Massachusetts Public Policy.

The objective of this study was to assess nurses' perceptions of barriers to and facilitators of implementation of the shaken baby syndrome (SBS)/abusive head trauma (AHT) public policy. A legislative Act providing for the prevention of SBS/AHT was passed in Massachusetts in November 2006. A stipulation of this Act was the provision of a program to educate parents/guardians of newborns about SBS/AHT prevention. A quantitative, cross-sectional research design with a qualitative component was used for this study. Nurses in 13 Massachusetts birthing hospitals were surveyed using a Web-based questionnaire (hosted by Qualtrics, Provo, Utah). Hospital nurses' responses (N = ∼ 922; 155 responded) revealed barriers to and facilitators of SBS/AHT guideline implementation. The disadvantage of Web-based surveys as they relate to the challenges of enlisting cooperation and a lack of direct access to the nurses may have attributed to the low response rate (17%) for this study. The outcomes of logistic regression analyses and themes from the qualitative analysis revealed a lack of SBS/AHT brochures and an inability to provide SBS/AHT education for non-English-speaking parents/guardians as barriers to SBS/AHT education. An atmosphere of supportive leadership facilitated implementation of the SBS/AHT education guidelines by nurses. It is imperative that nurse leadership support be sustained so that nurses have SBS/AHT education resources, an understanding of the SBS/AHT education guidelines, and feedback about the impact of their SBS/AHT education interventions.

Unintentional Window Falls in Children and Adolescents.

OBJECTIVE: Unintentional window falls represent a preventable source of injury and death in children. Despite major campaigns in some larger cities, there continue to be unintentional falls from windows throughout the United States. We aimed to identify risk factors and trends in unintentional window falls in the pediatric population in a national and regional sample. METHODS: A retrospective analysis of annual emergency department (ED) visits from the National Electronic Injury Surveillance System using product codes specific to windows, as well as patient encounters for unintentional window falls from January 2007 to August 2017 using site-specific trauma registries from 10 tertiary care children's hospitals in New England. National and state-specific census population estimates were used to compute rates per 100,000 population. RESULTS: There were 38,840 ED visits and 496 regional patients who unintentionally fell from a window across the study period between 0 and 17 years old. The majority of falls occurred in children under the age of 6 and were related to falls from a second story or below. A decreased trend in national ED visits was seen, but no change in rates over time for regional trauma center encounters. A high number of falls was found to occur in smaller cities surrounding metropolitan areas and from single family residences. CONCLUSIONS: Falls from windows represent a low proportion of overall types of unintentional sources of injury in children but are a high risk for severe disability. These results provide updated epidemiologic data for targeted intervention programs, as well as raise awareness for continued education and advocacy.

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center.

The authors looked at all of the pediatric patients with a head injury who were transferred from other hospitals to their own over 12 years and tried to identify factors that would allow patients to stay closer to home at their local hospitals and not be transferred. Many patients with isolated, nondisplaced skull fractures or negative CT imaging likely could have avoided transfer. While hospitals should be cautious, this may help families stay closer to home.

Magnetic resonance imaging as an alternative to computed tomography in select patients with traumatic brain injury: a retrospective comparison.

OBJECT: Traumatic head injury (THI) is a highly prevalent condition in the United States, and concern regarding excess radiation-related cancer mortality has placed focus on limiting the use of CT in the evaluation of pediatric patients with THI. Given the success of rapid-acquisition MRI in the evaluation of ventriculoperitoneal shunt malfunction in pediatric patient populations, this study sought to evaluate the sensitivity of MRI in the setting of acute THI. METHODS: Medical records of 574 pediatric admissions for THI to a Level 1 trauma center over a 10-year period were retrospectively reviewed to identify patients who underwent both CT and MRI examinations of the head within a 5-day period. Thirty-five patients were found, and diagnostic images were available for 30 patients. De-identified images were reviewed by a neuroradiologist for presence of any injury, intracranial hemorrhage, diffuse axonal injury (DAI), and skull fracture. Radiology reports were used to calculate interrater reliability scores. Baseline demographics and concordance analysis was performed with Stata version 13. RESULTS: The mean age of the 30-patient cohort was 8.5 ± 6.7 years, and 63.3% were male. The mean Injury Severity Score was 13.7 ± 9.2, and the mean Glasgow Coma Scale score was 9 ± 5.7. Radiology reports noted 150 abnormal findings. CT scanning missed findings in 12 patients; the missed findings included DAI (n = 5), subarachnoid hemorrhage (n = 6), small subdural hematomas (n = 6), cerebral contusions (n = 3), and an encephalocele. The CT scan was negative in 3 patients whose subsequent MRI revealed findings. MRI missed findings in 13 patients; missed findings included skull fracture (n = 5), small subdural hematomas (n = 4), cerebral contusions (n = 3), subarachnoid hemorrhage (n = 3), and DAI (n = 1). MRI was negative in 1 patient whose preceding CT scan was read as positive for injury. Although MRI more frequently reported intracranial findings than CT scanning, there was no statistically significant difference between CT and MRI in the detection of any intracranial injury (p = 0.63), DAI (p = 0.22), or intracranial hemorrhage (p = 0.25). CT scanning tended to more frequently identify skull fractures than MRI (p = 0.06). CONCLUSIONS: MRI may be as sensitive as CT scanning in the detection of THI, DAI, and intracranial hemorrhage, but missed skull fractures in 5 of 13 patients. MRI may be a useful alternative to CT scanning in select stable patients with mild THI who warrant neuroimaging by clinical decision rules.

Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center?

PURPOSE: To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging. METHODS: A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry. RESULTS: A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score <14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%). CONCLUSION: The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging.

Utility of STIR MRI in pediatric cervical spine clearance after trauma.

OBJECT: Although MRI with short-term T1 inversion recovery (STIR) sequencing has been widely adopted in the clearance of cervical spine in adults who have sustained trauma, its applicability for cervical spine clearance in pediatric trauma patients remains unclear. The authors sought to review a Level 1 trauma center's experience using MRI for posttraumatic evaluation of the cervical spine in pediatric patients. METHODS: A pediatric trauma database was retrospectively queried for patients who received an injury warranting radiographic imaging of the cervical spine and had a STIR-MRI sequence of the cervical spine performed within 48 hours of injury between 2002 and 2011. Demographic, radiographic, and outcome data were retrospectively collected through medical records. RESULTS: Seventy-three cases were included in the analysis. The mean duration of follow-up was 10 months (range 4 days-7 years). The mean age of the patients at the time of trauma evaluation was 8.3 ± 5.8 years, and 65% were male. The majority of patients were involved in a motor vehicle accident. In 70 cases, the results of MRI studies were negative, and the patients were cleared prior to discharge with no clinical suggestion of instability on follow-up. In 3 cases, the MRI studies had abnormal findings; 2 of these 3 patients were cleared with dynamic radiographs during the same admission. Only 1 patient had an unstable injury and required surgical stabilization. The sensitivity of STIR MRI to detect cervical instability was 100% with a specificity of 97%. The positive predictive value was 33% and the negative predictive value was 100%. CONCLUSIONS: Although interpretation of our results are diminished by limitations of the study, in our series, STIR MRI in routine screening for pediatric cervical trauma had a high sensitivity and slightly lower specificity, but may have utility in future practices and should be considered for implementation into protocols.