Personal Protective Equipment Adherence of Pediatric Resuscitation Team Members During the COVID-19 Pandemic.

STUDY OBJECTIVE: During the COVID-19 pandemic, health care workers have had the highest risk of infection among essential workers. Although personal protective equipment (PPE) use is associated with lower infection rates, appropriate use of PPE has been variable among health care workers, even in settings with COVID-19 patients. We aimed to evaluate the patterns of PPE adherence during emergency department resuscitations that included aerosol-generating procedures. METHODS: We conducted a retrospective, video-based review of pediatric resuscitations involving one or more aerosol-generating procedures during the first 3 months of the COVID-19 pandemic in the United States (March to June 2020). Recommended adherence (complete, inadequate, absent) with 5 PPE items (headwear, eyewear, masks, gowns, gloves) and the duration of potential exposure were evaluated for individuals in the room after aerosol-generating procedure initiation. RESULTS: Among the 345 health care workers observed during 19 resuscitations, 306 (88.7%) were nonadherent (inadequate or absent adherence) with the recommended use of at least 1 PPE type at some time during the resuscitation, 23 (6.7%) of whom had no PPE. One hundred and forty health care workers (40.6%) altered or removed at least 1 type of PPE during the event. The aggregate time in the resuscitation room for health care workers across all events was 118.7 hours. During this time, providers had either absent or inadequate eyewear for 46.4 hours (39.1%) and absent or inadequate masks for 35.2 hours (29.7%). CONCLUSION: Full adherence with recommended PPE use was limited in a setting at increased risk for SARS-CoV-2 virus aerosolization. In addition to ensuring appropriate donning, approaches are needed for ensuring ongoing adherence with PPE recommendations during exposure.

Patterns of paediatric massive blood transfusion protocol use in trauma and non-trauma patients.

BACKGROUND: Massive blood transfusion is infrequently required by children but can be a lifesaving intervention for haemorrhage or coagulopathy. Product volumes and ratios administered during the initiation of paediatric massive blood transfusion protocol (MBTP) are highly variable and the optimal component ratio is unknown. METHODS/MATERIALS: We performed a single-centre retrospective chart review of patients (<20 years) who received MBTP activation from August 2012 through January 2018. Logistic regression was used to determine the association between MBTP use characteristics (including blood product type and volume transfused, extracorporeal membrane oxygenation [ECMO] support, and cardiac arrest occurrence) and 24-h mortality. "Low" product ratio was defined as a ratio of plasma or platelets to red blood cells (RBCs) of <1:2 and "high" as ≥1:2. RESULTS: Ninety-eight MBTPs were activated for 89 patients (range 1-4 per patient). The most common underlying diagnoses were congenital heart disease (CHD, n = 28, 31.5%), followed by cardiopulmonary disease, and trauma. CHD patients required the greatest volume of RBCs (226.3 ml/kg, 95%CI [160.0, 292.7], p = 0.002) and platelets (46.7 ml/kg, 95%CI [33.2, 60.2], p < 0.001). A "low" product ratio was more common for the MBTP, with its incidence similar among the underlying diagnoses. CONCLUSION: An MBTP developed for trauma patients can be applied to non-trauma patients but standard MBTP components may not be optimal for all children. These findings show that underlying patient diagnoses may be a factor when designing an MBTP for a heterogeneous paediatric population.

Effect of Family Presence on Advanced Trauma Life Support Task Performance During Pediatric Trauma Team Evaluation.

IMPORTANCE: In many hospitals, family members are separated from their children during the early phases of trauma care. Including family members during this phase of trauma care varies by institution and is limited by concerns for adverse effects on clinical care. OBJECTIVE: The aim of this study is to evaluate the effect of family presence (FP) on advanced trauma life support primary and secondary survey task performance by pediatric trauma teams. We hypothesized that trauma care with FP would be noninferior to care when families were absent. DESIGN: We performed a retrospective video review of consecutive pediatric trauma evaluations. Family presence status was determined by availability of the family. SETTING: The study was conducted at an American College of Surgeons-designated level I pediatric trauma center that serves the Washington, DC, metropolitan area. PARTICIPANTS: Participants included patients younger than 16 years of age who met trauma activation criteria and were evaluated by the trauma team in our emergency department. OUTCOME MEASURES: We compared task performance between patients with and without FP. RESULTS: Video recordings of 135 trauma evaluations were reviewed. Family was present for 88 (65%) evaluations. Patients with FP were younger (mean age, 6.4 years [SD = 4.1] vs 9.0 years [SD = 4.9]; P < 0.001) and more likely to have sustained blunt injuries (95% vs 85%, P = 0.03). Noninferiority of frequency and timeliness of completion of all primary survey tasks were confirmed for evaluations with FP. Noninferiority of frequencies of secondary survey task completion was confirmed for most tasks except for examination of the neck, pelvis, and upper extremities. Family members did not directly interfere with patient care in any case. CONCLUSIONS: Performance of most advanced trauma life support tasks during pediatric trauma evaluation was not worsened by FP. Our data provide additional evidence supporting FP during the acute management of injured children.

Assessment of the Need for Immediate Trauma Team Presence for Infants Presenting in Cardiac Arrest.

OBJECTIVES: Out-of-hospital cardiac arrest (OHCA) is rare in infants, with the cause of arrest often unknown upon presentation. Nonaccidental trauma is a potential etiology of OHCA among infants, but its occult presentation makes this etiology challenging to diagnose. In the absence of apparent injuries, identifying the need for trauma team activation is difficult during the initial resuscitation of infants with OHCA. METHODS: We performed a retrospective chart review of infants younger than 1 year old who presented to Children's National Health System from 2012 to 2016 with cardiopulmonary resuscitation in progress. Medical records and the trauma registry were reviewed for relevant resuscitation information. Autopsy records provided the cause and manner of death, contributing factors to death, and evidence of injury. RESULTS: Among 592 infants undergoing resuscitation during the study period, 34 infants (5.7%) presented in cardiac arrest. The average age on presentation was 101.2 days (standard deviation 78.7). Most of the patients (n = 32, 94.1%) died in the emergency department, with none surviving to discharge. Among the 32 infants for whom autopsy records were available, the cause of death was nonaccidental trauma in one patient (3.1%). CONCLUSIONS: Infant OHCA had poor outcomes, with trauma as a rare etiology. In the absence of external signs of injury or known injury mechanism, immediate trauma team presence was not beneficial for these infants during the initial resuscitation phase.

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.

Reducing the Time to Blood Administration after Pediatric Injury: A Quality Improvement Initiative.

Introduction: Hemorrhage is the leading cause of preventable death in pediatric trauma patients. Timely blood administration is associated with improved outcomes in children and adults. This study aimed to identify delays to transfusion and improve the time to blood administration among injured children. Methods: A multidisciplinary team identified three activities associated with blood transfusion delays during the acute resuscitation of injured children. To address delays related to these activities, we relocated the storage of un-crossmatched blood to the emergency department (ED), created and disseminated an intravenous access algorithm, and established a nursing educator role for resuscitations. We performed comparative and regression analyses to identify the impact of these factors on the timeliness and likelihood of blood administration. Results: From January 2017 to June 2021, we treated 2159 injured children and adolescents in the resuscitation area, 54 (2.5%) of whom received blood products in the ED. After placing a blood storage refrigerator in the ED, we observed a centerline change that lowered the adjusted time-to-blood administration to 17 minutes (SD 11), reducing the time-to-blood administration by 11 minutes (ß = -11.0, 95% CI = -22.0 to -0.9). The likelihood of blood administration was not changed after placement of the blood refrigerator. We observed no reduction in time following the implementation of the intravenous access algorithm or a nursing educator. Conclusions: Relocation of un-crossmatched blood storage to the ED decreased the time to blood transfusion. This system-based intervention should be considered a strategy for reducing delays in transfusion in time-critical settings.

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation.

BACKGROUND: Errors directly causing serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement in this setting. Errors not causing harm because of mitigation or chance may have similar causation and are more frequent than those causing adverse outcomes. Analyzing these error types is an alternative to adverse outcome analysis. The purpose of this study was to identify errors of any type during pediatric trauma resuscitation and evaluate team responses to their occurrence. METHODS: Errors identified using video analysis were classified as errors of omission or commission and selection errors using input from trauma experts. The responses to error types and error frequency based on patient and event features were compared. RESULTS: Thirty-nine resuscitations were reviewed, identifying 337 errors (range, 2-26 per resuscitation). The most common errors were related to cervical spine stabilization (n = 93, 27.6%). Errors of omission (n = 135) and commission (n = 106) were more common than errors of selection (n = 96). Although 35.9% of all errors were acknowledged and compensation occurred after 43.6%, no response (acknowledgement or compensation) was observed after 51.3% of errors. Errors of omission and commission were more often acknowledged (40.7% and 39.6% vs. 25.0%, p = 0.03 and p = 0.04, respectively) and compensated for (50.4% and 47.2% vs. 29.2%, p = 0.004 and p = 0.01, respectively) than selection errors. Response differences between errors of omission and commission were not observed. The number of errors and the number of high-risk errors that occurred did not differ based on patient or event features. CONCLUSIONS: Errors are common during pediatric trauma resuscitation. Teams did not respond to most errors, although differences in team response were observed between error types. Determining causation of errors may be an approach for identifying latent safety threats contributing to adverse outcomes during pediatric trauma resuscitation. LEVEL OF EVIDENCE: Therapeutic study, level III.

Effect of a checklist on advanced trauma life support task performance during pediatric trauma resuscitation.

OBJECTIVES: Advanced Trauma Life Support (ATLS) has been shown to improve outcomes related to trauma resuscitation; however, omissions from this protocol persist. The objective of this study was to evaluate the effect of a trauma resuscitation checklist on performance of ATLS tasks. METHODS: Video recordings of resuscitations of children sustaining blunt or penetrating injuries at a Level I pediatric trauma center were reviewed for completion and timeliness of ATLS primary and secondary survey tasks, with and without checklist use. Patient and resuscitation characteristics were obtained from the trauma registry. Data were collected during two 4-month periods before (n = 222) and after (n = 213) checklist implementation. The checklist contained 50 items and included four sections: prearrival, primary survey, secondary survey, and departure plan. RESULTS: Five primary survey ATLS tasks (cervical spine immobilization, oxygen administration, palpating pulses, assessing neurologic status, and exposing the patient) and nine secondary survey ATLS tasks were performed more frequently (p ≤ 0.01 for all) and vital sign measurements were obtained faster (p ≤ 0.01 for all) after the checklist was implemented. When controlling for patient and event-specific characteristics, primary and secondary survey tasks overall were more likely to be completed (odds ratio [OR] = 2.66, primary survey; OR = 2.47, secondary survey; p < 0.001 for both) and primary survey tasks were performed faster (p < 0.001) after the checklist was implemented. CONCLUSIONS: Implementation of a trauma checklist was associated with greater ATLS task performance and with increased frequency and speed of primary and secondary survey task completion.

Factors associated with patient exposure and environmental control during pediatric trauma resuscitation.

BACKGROUND: Exposure and environmental control are essential components of the advanced trauma life support primary survey, especially during the resuscitation of pediatric patients. Proper exposure aids in early recognition of injuries in patients unable to communicate their injuries, while warming techniques, such as the use of blankets, assist in maintaining normothermia. The purpose of this study was to identify factors associated with exposure compliance and duration during pediatric trauma resuscitation. METHODS: All pediatric trauma resuscitations over a 4-month period were reviewed for compliance and time to completion of clothing removal and warm blanket placement. Video review data were then linked with clinical data obtained from the trauma registry. Univariate and multivariate analyses were used to determine the associations of patient characteristics, injury mechanism, and clinical factors on exposure compliance and duration. RESULTS: Of 145 patients, 65 (52%) were never exposed. Lower exposure compliance was associated with increasing age (odds ratio, [OR], 0.90; 95% confidence interval [CI], 0.83-0.98), Glasgow Coma Scale (GCS) score of 14 or greater (OR, 0.16; 95% CI, 0.03-0.76), Injury Severity Score (ISS) of 15 or less (OR, 0.27; 95% CI, 0.09-0.82), and the absence of head injury (OR, 0.26; 95% CI, 0.08-0.87). Among those exposed, the duration of exposure was longer among children with GCS score of less than 14 (4.3 [1.6], p = 0.009), head injuries (3.33 [1.6], p = 0.04), and the need for intubation (8.4 [2.2], p < 0.001). In multivariate analyses, older age and ISS of 15 or less were associated with a decreased odds of exposure (p = 0.009, p = 0.04, respectively), while intubation was associated with increased exposure duration (p = 0.007). CONCLUSION: Despite the importance of exposure and environmental control during pediatric trauma resuscitation, compliance with these tasks was low, even among severely injured patients. Interventions are needed to promote the proper exposure of patients during the initial evaluation, while also limiting the duration of exposure during examinations and procedures in the trauma bay. LEVEL OF EVIDENCE: Epidemiologic study, level III.