Population-based study of factors associated with severe paediatric drowning events in Maryland.

INTRODUCTION: Paediatric drowning is an injury associated with significant morbidity and mortality. OBJECTIVE: The objective is to describe drowning trends, including associations with inpatient hospitalisation or fatality, in a state-wide paediatric cohort to inform prevention strategies. METHODS: In this retrospective cohort study using the Health Services Cost Review Commission database, we used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify patients aged 0-19 years with an outpatient (including emergency department) or inpatient medical encounter following a non-fatal or fatal drowning event between 2016 and 2019. Descriptive statistics and logistic regression were used to summarise the data and evaluate associations with inpatient hospitalisation or fatality. RESULTS: There were 541 medical encounters for drowning events, including 483 non-fatal outpatient encounters, 42 non-fatal inpatient encounters and 16 fatal cases. Overall, most patients were boys, 0-4 years, white and lived in urban settings. White children accounted for 66% of encounters among those aged 0-4 years, whereas non-white children accounted for 62% of visits among those aged 10-19 years. Non-white children were more likely than white children to experience a fatal drowning (OR 3.6, 95% CI: 1.2 to 11.5). Adolescents were more likely than younger children to be hospitalised (OR 3.1, 95% CI: 1.6 to 6.5) and had higher charges in outpatient (p=0.002) and inpatient settings (p=0.003). DISCUSSION: Our study revealed high fatality rates among non-white children and high admission rates among adolescents.

A Study of Households with Children and Firearms in Baltimore, Maryland.

Firearm injuries are the leading cause of death among children and adolescents in the US. Safe storage of firearms in the home is one of the most effective ways of preventing firearm injuries in children. This feasibility study was conducted in both the pediatric and general Emergency Departments of a large urban academic medical center in a community with high rates of firearm injuries in children. The objective was to pilot a survey seeking to describe sociodemographic characteristics, firearm specific risk factors, and firearm storage practices of households with children in the community. One hundred participants completed a survey containing items regarding participant demographics, household features, firearm ownership, firearm characteristics, and storage practices. Descriptive statistics were used to define sociodemographic characteristics of the enrolled population, comparing those with firearms to those without, and to describe firearms and storage practices of firearm owners in households with children. Of 100 participants, 30 lived in households with firearms and children. Most firearms in homes with children were stored locked and unloaded most of the time; however, 30% of participants with firearms and children in the home reported not consistently storing a firearm locked and unloaded. The most common reason given for not storing a firearm in the safest manner possible was that storing a firearm locked and unloaded would make it difficult to access quickly. Engaging families with children in discussions around firearm prevention during Emergency Department visits is feasible and may have implications for future efforts to promote safe firearm storage practices.

Medication Safety Counseling Practices of Pediatric Primary Care Clinicians.

Medication exposures and poisonings are a major cause of pediatric morbidity and mortality. Unsafe patient practices are well documented despite the American Academy of Pediatrics recommending that pediatric primary care clinicians discuss medication safety with patients. Current clinician counseling practices for pediatric patients are unknown. Studies of adult patients suggest that physician counseling practices often focus on administration but not storage or disposal. To address this gap, we administered a web-based survey to clinically active pediatric primary care clinicians in two mid-Atlantic health care systems. Survey content focused on characteristics of medication safety counseling practices by age group, including safe medication storage, administration, and disposal. Of 151 clinicians emailed, 40 (26.5%) responded. The majority were physicians (93.5%), female (87.1%), and completed residency/clinical training in pediatrics >15 years ago (58.1%). Most (82.5%) reported having >1 pediatric patient (aged < 19 years) in their practice who experienced an unintentional or intentional medication exposure or poisoning event. Reported practices for medication safety counseling often varied by patient age but safe disposal was rarely addressed for any age group. Respondents generally felt less knowledgeable and less comfortable with providing counseling on safe disposal in comparison to safe storage and safe administration. Nearly all respondents (97%) would like to provide more counseling about medication safety, and the majority (81.3%) wanted additional educational resources. In this survey, we identified several modifiable deficits in pediatric medical counseling practices and a need for additional clinician training and resources, most notably in the content area of safe disposal.

Epidemiology and clinical characteristics of drowning patients presenting to a pediatric emergency department from 2017 to 2020.

BACKGROUND: Drowning is a common mechanism of injury in the pediatric population that often requires hospitalization. The primary objective of this study was to describe the epidemiology and clinical characteristics of pediatric drowning patients evaluated in a pediatric emergency department (PED), including the clinical interventions and outcomes of this patient population. METHODS: A retrospective cohort study was conducted of pediatric patients evaluated in a mid-Atlantic urban pediatric emergency department from January 2017 to December 2020 after a drowning event. RESULTS: Eighty patients ages 0-18 were identified, representing 57 79 unintentional events and 1 intentional self-injury event. The majority of patients (50%) were 1-4 years of age. The majority (65%) of patients 4 years of age or younger were White, whereas racial/ethnic minority patients accounted for the majority (73%) of patients 5 years of age or older. Most drowning events (74%) occurred in a pool, on Friday through Saturday (66%) and during the summer (73%). Oxygen was used in 54% of admitted patients and only in 9% of discharged patients. Cardiopulmonary resuscitation (CPR) was performed in 74% of admitted patients and 33% of discharged patients. CONCLUSIONS: Drowning can be an intentional or unintentional source of injury in pediatric patients. Among the patients who presented to the emergency department for drowning, more than half received CPR and/or were admitted, suggesting high acuity and severity of these events. In this study population, outdoor pools, summer season and weekends are potential high yield targets for drowning prevention efforts.

Epidemiology of Injuries to Early Adolescents from Family Violence Evaluated in an Urban Pediatric Emergency Department.

BACKGROUND: Exposure to family violence during childhood and adolescence increases the risk for experiencing or perpetrating future violence. Social distancing protocols combined with reduction in access to youth/family services during the COVID-19 pandemic may have intensified the risk of exposure to familial violence. OBJECTIVES: This study describes the epidemiology of violence-related injuries to 10- to 15-year-old children from family violence, including child maltreatment and physical fighting, resulting in emergency department (ED) evaluation. METHODS: This retrospective cohort study located in an urban academic pediatric ED in the mid-Atlantic region is a review of electronic medical records between January 2019 and March 2020 (prepandemic period) and March to December 2020 (pandemic period). This review focused on visits for youth aged 10 to 15 years who presented for evaluation of an injury due to a violent event involving a family member. Demographic and clinical data were abstracted, including circumstances of the event. Descriptive statistics were used to summarize data and compare prepandemic to postpandemic proportions. RESULTS: Of 819 youth aged 10 to 15 years evaluated for a violence-related injury, 448 (54.7%) involved a family member. Of these, most involved parents/guardians, 343 (76.6%), and occurred at home (83.9%). Most patients were girls (54.0%), Black/African American (84.4%), and were enrolled in a public insurance plan (71.2%). Most youth were transported to the hospital by police (66.7%). Overall, alcohol, drugs, and weapons were involved in 10.0%, 6.5%, and 10.7% of events, respectively, and their involvement significantly increased during the pandemic period to 18.8%, 14.9%, and 23.8% ( P < 0.001). Most patients (98.7%) were discharged from the ED. CONCLUSIONS: More than half of violence-related injuries treated in the ED in this population resulted from family violence. Family violence is a prevalent and possibly underrecognized cause of injuries during adolescence. Further research should explore the potential of the ED as a setting for preventive interventions.

Impact of an Emergency Department Saturation Tool on a Pediatric Hospital's Capacity Management Policy.

OBJECTIVE: We sought to describe how the Emergency Department Work Index (EDWIN) saturation tool (1) correlates with PED overcrowding during a capacity management activation policy, known internally as Purple Alert and (2) compare overall hospital-wide capacity metrics on days in which the alert was instituted versus days it was not. METHODS: This study was conducted between January 1, 2017 and December 31, 2019 in a 30-bed academic quaternary care, urban PED within a university hospital. The EDWIN tool was implemented in January 2019 and objectively measured the busyness of the PED. To determine correlation with overcrowding, EDWIN scores were calculated at alert initiation. Mean alert hours per month were plotted on a control chart before and after EDWIN implementation. We also compared daily numbers of PED visits, inpatient admissions, and patients left without being seen (LWBS) for days with and without alert initiation to assess whether or not Purple Alert correlated with high PED usage. RESULTS: During the study period, the alert was activated a total of 146 times; 43 times after EDWIN implementation. Mean EDWIN score was 2.5 (SD 0.5, min 1.5, max 3.8) at alert initiation. There were no alert occurrences for EDWIN scores less than 1.5 (not overcrowded). There was no statistically significant difference for mean alert hours per month before and after EDWIN was instituted (21.4 vs 20.2, P = 0.08). Mean numbers of PED visits, inpatient admissions, and patients left without being seen were higher on days with alert activation ( P < 0.001 for all). CONCLUSIONS: The EDWIN score correlated with PED busyness and overcrowding during alert activation and correlated with high PED usage. Future studies could include implementing a real-time Web-based EDWIN score as a prediction tool to prevent overcrowding and verifying EDWIN generalizability at other PED sites.

The COVID-19 Pandemic: Effects on Pediatric Fracture Patterns in the Emergency Department and Subspecialty Follow-up Care.

PURPOSE: The COVID-19 pandemic affected pediatric fracture injury patterns and volume. There is a paucity of research evaluating this trend throughout the pandemic and also follow-up to orthopaedic subspecialty care after emergency fracture management. METHODS: This retrospective cohort study reviewed patients 2 to 18 years of age presenting for fracture care to an urban pediatric emergency department. We assessed patient demographics, clinical care, and follow-up to surgical subspecialist. Time periods investigated included March 30 to September 4, 2020 (pandemic), March 30 to September 4, 2019, and March 30 to September 4, 2018 (prepandemic). Subanalysis within the pandemic was during the "stay-at-home order" verses the phased re-opening of the state. Descriptive statistical analysis, Pearson's χ 2 or Fisher exact tests, and Mann-Whitney U tests were performed. RESULTS: In this population, fractures overall declined by 40% (n=211) during the pandemic compared with 2019 (n=349) and 28% compared with 2018 (n=292). Lower extremity fractures accounted for a greater percentage of injuries during the pandemic compared with prepandemic. Time to surgical subspecialty follow-up was shortest during the 2020 pandemic peak at 9 days and was significantly longer during phased reopening (phase 1: 18 d, P =0.001; phase 2: 14 d, P =0.005). These patterns were also consistent for days to repeat imaging. CONCLUSIONS: We found differences in fracture prevalence, mechanisms, and follow-up care during the pandemic. Time to subspecialty follow-up care was longer during pandemic phased reopening despite overall fewer fractures. Plans to absorb postponed visits and efficiently engage redeployed staff may be necessary to address difficulties in follow-up orthopaedic management during public health crises. LEVEL OF EVIDENCE: Level II.

Factors Associated With Repeat Emergency Department Visits in a State-wide Cohort of Pediatric Patients With Mild Traumatic Brain Injury.

OBJECTIVE: To describe demographic, injury, and clinical characteristics of pediatric patients treated in the ED for mild traumatic brain injury (mTBI), and to evaluate characteristics associated with mTBI-related return emergency department (ED) visit within 1 month of initial presentation. METHODS: Retrospective cohort study from April 1, 2012, to September 30, 2017, of children 19 years or younger presenting to any Maryland ED for mTBI identified in the Maryland Health Services Cost Review Commission database using ICD-9/10 codes. Demographic, injury, and clinical characteristics of individuals were collected. The primary outcome was mTBI-related return ED visit within 4 weeks. Multiple logistic regression tested the associated of individual demographic, injury, and clinical characteristics with mTBI-related return ED visit. RESULTS: There were 25,582 individuals who had an ED visit for mTBI, of which 717 (2.8%) returned to the ED within 4 weeks and 468 (1.8%) within 1 week with a mTBI-related diagnosis. In multivariable logistic regression analyses, public insurance (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.21-1.72) and female sex (aOR, 1.34; 95% CI, 1.15-1.56) were associated with increased odds of return to the ED within 4 weeks. Age younger than 2 years (aOR, 0.39; 95% CI, 0.21-0.72) was associated with decreased odds of return visit. There was a trend toward decreased odds of return patients receiving computed tomography head imaging (aOR, 0.86; 95% CI, 0.74-1.01). CONCLUSIONS: Although return to the ED for mTBI-related complaints is uncommon, girls, older children, and publicly insured individuals may be at increased risk. Future targeted study may identify areas to improve access to appropriate longitudinal care and justify ED programs to better coordinate follow-up for mTBI.

An Exploration of Emergency Department Visits for Home Unintentional Injuries Among Children With Autism Spectrum Disorder for Evidence to Modify Injury Prevention Guidelines.

OBJECTIVES: Current childhood injury prevention guidance is anchored by a child's age. For example, children are considered at high risk for falls at ages 4 years and less, and guidance for prevention focuses on these ages. However, these guidelines may not be adequate for children with autism spectrum disorders (ASD). METHODS: This retrospective chart review examined injury characteristics for children with ASD receiving treatment in a pediatric emergency department between 2014 and 2016. Bivariate statistics determined injury demographic correlates. Chart narratives were also coded using traditional content analysis to determine the mechanism that caused the home injury. RESULTS: The sample (27 cases) was mostly male (89%), Black (48%), with a mean age of 7.8 (SD, 4.9) years. The most common mechanism was a fall (44%), followed by self-injurious behavior (33%), and then burns (22%). All cases identified at least 1 mechanism contributing to the injury, in 2 cases, 2 items were mentioned. Of the 29 items identified, most involved a house feature that was not stairs (24%); some included stairs, furniture, or a combination of foreign object and grill (21%); and few identified food/beverage/liquid (11%). CONCLUSIONS: Analyses suggest that unintentional home injury prevention for children with ASD may require prevention guidance extended through older ages.

Factors Associated With Urban Youth and Parent Perceptions of the Preventability of Assault Injury: An Emergency Department Sample.

OBJECTIVES: This study aimed to identify factors associated with urban youth and parent's perception of the preventability of medically attended youth assault injuries to guide future violence prevention strategies. METHODS: Assault-injured youth (n = 188; ages, 10-15 years; 60% male; 96% black) and their parents were recruited from 2 pediatric emergency departments in 2 cities. Mental health, injury severity, circumstances of injury, and family composition were some of the factors explored as cross-sectional predictors of the perception of the preventability of youth assault injury. Separate models were developed using stepwise regression for youth and parents. RESULTS: Sixty-eight (38%) youth and 123 parents (68%) reported that the injury was definitely preventable (χ2 = 9.6250, P < 0.05). For youth, identifying themselves as the aggressor (odds ratio [OR], 0.23, 95% confidence interval [CI], 0.07-0.70) or having been hospitalized for psychiatric illness (OR, 0.21; 95% CI, 0.05-0.85) was associated with lower odds of perceiving their injury as preventable, while being under the care of a mental health professional (OR, 3.87; 95% CI, 1.21-12.39) was associated with higher odds. For parents, being in a household with grandparents (OR, 0.21; 95% CI, 0.04-0.99) or having a child with a learning disability (OR, 0.16; 95% CI, 0.05-0.57) was associated with lower odds of perceiving the injury as preventable. CONCLUSIONS: Several factors in youth and parents were identified as being associated with perception of preventability of injuries in this high-risk population of youth. Youth and parents identified different factors. In addition, although most parents reported that the assault injury sustained by their child was preventable, the opposite was true for youth perceptions. Future violence prevention programs should consider youth and parent perspectives and develop unique strategies to address both their needs.

An Analysis of Computed Tomography-Related Radiation Exposure in Pediatric Trauma Patients.

OBJECTIVE: To compare radiation doses used for pediatric computed tomography (CT) scans at community-based referring facilities (RF) to those at a designated pediatric trauma center (PTC) to assess the consistency of radiation exposure. METHODS: In this retrospective study, patients 0 to 18 years of age with CT imaging performed either at a RF or at a PTC from January 1, 2015, to January 5, 2016, were identified. Data about patients, CT radiation dose, and characteristics of the RFs were compared. RESULTS: We identified 502 patients (156 RF, 346 PTC) with 281 head CTs (79 RF, 202 PTC) and 86 abdominal/pelvis CTs (28 RF, 58 PTC). The radiation dose (measured in mean dose-length product [DLP] ± 1 standard deviation) was significantly higher for RF scans compared with PTC scans (head, RF DLP = 545 ± 334 vs PTC DLP = 438 ± 186 (P < 0.001); abdomen/pelvis, RF DLP = 279 ± 160 vs PTC DLP = 181 ± 201 [P = 0.027]). There was a nonsignificant trend toward lower head CT radiation dosages at RFs with a dedicated pediatric emergency department compared with RFs without a pediatric emergency department. CONCLUSIONS: Our data suggest that CT scans performed at RFs expose pediatric patients to significantly higher doses of radiation when compared with a PTC. These data support further study to identify factors associated with increased radiation and educational outreach to RFs.

Factors associated with successful mentor matching in an intervention study of youth violence.

One challenge of conducting intervention studies is ensuring that study participants are exposed to the intervention. For example, in our randomized controlled trial of Take Charge!, a mentor-implemented and research-informed violence prevention program that partners with one-on-one community-based mentoring agencies, only 50% of intervention youth with fight-related injuries were successfully matched with a mentor. We examined the differences between matched (n = 49) and unmatched (n = 49) youth with regard to demographics, time from injury to study enrollment, perceived seriousness of injury, belief that future injury can be avoided, and household chaos. Youth who were successfully matched with a mentor were more likely to perceive the injury as very serious or somewhat serious compared with unmatched youth (95.9% vs. 79.6%, p = .028). All other factors were not significantly associated with successful mentor matching. Future violence prevention interventions should consider youth perceptions as a factor that may influence the completion of desired interventions.

Mode of Transport and Trauma Activation Status in Admitted Pediatric Trauma Patients.

BACKGROUND: Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS). MATERIALS AND METHODS: We performed a retrospective cohort study at two level I pediatric trauma centers. INCLUSION CRITERIA: <15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics. RESULTS: We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82). CONCLUSIONS: Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.

An Evaluation of a New Debriefing Framework: REFLECT.

BACKGROUND: Postresuscitation debriefing (PRD) is recommended by the American Heart Association guidelines but is infrequently performed. Prior studies have identified barriers for pediatric emergency medicine (PEM) fellows including lack of a standardized curriculum. OBJECTIVE: Our objective was to create and assess the feasibility of a time-limited, structured PRD framework entitled REFLECT: Review the event, Encourage team participation, Focused feedback, Listen to each other, Emphasize key points, Communicate clearly, and Transform the future. METHODS: Each PEM fellow (n = 9) at a single center was a team leader of a pre-intervention and post-intervention videotaped, simulated resuscitation followed by a facilitated team PRD. Our intervention was a 2-hour interactive, educational workshop on debriefing and the use of the REFLECT debriefing aid. Videos of the pre-intervention and post-intervention debriefings were blindly analyzed by video reviewers to assess for the presence of debriefing characteristics contained in the REFLECT debriefing aid. PEM fellow and team member assessments of the debriefings were completed after each pre-intervention and post-intervention simulation, and written evaluations by PEM fellows and team members were analyzed. RESULTS: All 9 PEM fellows completed the study. There was an improvement in the pre-intervention and post-intervention assessment of the REFLECT debriefing characteristics as determined by fellow perception (63% to 83%, P < 0.01) and team member perception (63% to 82%, P < 0.001). All debriefings lasted less than 5 minutes. There was no statistical difference between pre-intervention and post-intervention debriefing time (P = 1.00). CONCLUSIONS: REFLECT is a feasible debriefing aid designed to incorporate evidence-based characteristics into a PRD.

Evaluation of a Culturally Tailored Educational Video Intervention to Promote Bike Helmet Safety for Urban Children: A Pilot Study.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. Given the lack of educational interventions for urban youth, our research team created a youth-informed, culturally relevant educational video on bike helmet safety, which was informed by focus groups with Baltimore City youth. This video, You Make the Call, linked the concept of use of cases to protect phones to use of helmets to protect heads and can be viewed at http://bit.ly/2Kr7UCN. The impact of the video as part of an intervention (coupled with a free helmet, fit instructions, and a parent guidance document) was tested with 20 parent-child dyads. The majority (80%) of youth (mean age 9.9 ± 1.8 years) reported not owning or wearing a helmet. At 1-month follow-up (n = 12, 60% response rate), helmet use was higher in the five youth reporting bike-riding after the intervention; 100% "always" used helmets compared to 0% preintervention. There were increases in youth reporting that parents required helmet use (35% pre vs. 67% post) and that is was possible to fall when bike-riding (60% pre vs. 92% post). These pilot results support the use of this video and educational intervention along with further evaluation in a larger sample size. This youth-informed and culturally tailored approach could be explored as a strategy to address other pediatric injury topics.

Promoting Bike Helmet Safety for Urban Children Through a Culturally Tailored Educational Video Intervention.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. We recruited eleven 8- to 15-year-old youth to participate in focus groups to inform the creation of a video promoting helmet use. Key emerging themes included that youth were responsible for keeping themselves safe and that most youth had cell phones with cases to protect them. A video was created that linked the concept of use of cases to protect phones to use of helmets to protect heads. Soliciting information from urban youth was helpful for developing this educational video.

A MARGINAL COST ANALYSIS OF A BIG BROTHERS BIG SISTERS OF AMERICA YOUTH MENTORING PROGRAM: NEW EVIDENCE USING STATISTICAL ANALYSIS.

The objective of this study was to evaluate the cost of serving one additional youth in the Big Brothers Big Sisters of America (BBBS) program. We used a marginal cost approach which offers a significant improvement over previous methods based on average total cost estimates. The data consisted of eight years of monthly records from January 2008 to August 2015 obtained from program administrators at one BBBS site in the Mid-Atlantic. Results show that the BBBS marginal cost to serve one additional youth was $80 per mentor-month of BBBS mentoring (irrespective of program type). The cost to offer services for the average match duration of 19 months per marginal added youth was $1,503. The marginal costs per treated program participant in school-based versus community-based programs were $1,199 and $3,301, respectively. Marginal cost estimates are in the range of youth mentoring programs with significant returns on investment but are substantially higher than prior BBBS unit cost estimates reported using less robust estimation methods. This cost analysis can better inform policy makers and donors on the cost of expanding the scale of local BBBS programs as well as suggest opportunities for cost savings.

Home Fire Safety Practices and Smoke Detector Program Awareness in an Urban Pediatric Emergency Department Population.

OBJECTIVES: Risk factors for residential fire death (young age, minority race/ethnicity, and low socioeconomic status) are common among urban pediatric emergency department (ED) patients. Community-based resources are available in our region to provide free smoke detector installation. The objective of our study was to describe awareness of these resources and home fire safety practices in this vulnerable population. METHODS: In this cross-sectional study, a brief survey was administered to a convenience sample of caregivers accompanying patients 19 years of age or younger in an urban pediatric ED in Washington, DC. Survey contents focused on participant knowledge of available community-based resources and risk factors for residential fire injury. RESULTS: Five hundred eleven eligible caregivers were approached, and 401 (78.5%) agreed to participate. Patients accompanying the caregivers were 48% male, 77% African American, and had a mean (SD) age of 6.5 (5.9) years. Of study participants, 256 (63.8%) lived with children younger than 5 years. When asked about available community-based resources for smoke detectors, 240 (59.9%) were unaware of these programs, 319 (79.6%) were interested in participating, and 221 (55.1%) enrolled. Presence of a home smoke detector was reported by 396 respondents (98.7%); however, 346 (86.3%) reported testing these less often than monthly. Two hundred fifty-six 256 (63.8%) lacked a carbon monoxide detector, and 202 (50.4%) had no fire escape plan. Sixty-five (16%) reported indoor smoking, and 92 (22.9%) reported space heater use. CONCLUSIONS: In this urban pediatric ED population, there is limited awareness of community-based resources but high rates of interest in participating once informed. Whereas the self-reported prevalence of home smoke detectors is high in our study population, other fire safety practices are suboptimal.

Factors Associated With Orthopedic Aftercare in a Publicly Insured Pediatric Emergency Department Population.

OBJECTIVES: Children with public insurance are less likely than children with private insurance to obtain follow-up care after emergency department (ED) care. This study aimed to determine if specific demographic and clinical factors are associated with aftercare compliance in a population of publicly insured pediatric ED patients with orthopedic injuries. METHODS: This was a retrospective case-control study of Washington, DC, children aged 0 to 17 years with public insurance discharged with isolated forearm fractures from the Children's National Medical Center ED from 2003 to 2006. Bivariable analyses and multivariable logistic regression were performed to measure the association between sociodemographic variables and failure to follow up. RESULTS: Six hundred children met the inclusion criteria. The overall cohort was 63.7% male and 81.7% African American, with a mean age of 8.8 (SE, 0.2) years. Overall, 85.7% of patients went to a follow-up orthopedic appointment, and 68.2% of patients had timely orthopedic follow-up, defined as 14 days or less after discharge from the ED. Treatment with orthopedic reduction (adjusted odds ratio [OR], 2.0 [1.33-2.93]) was positively associated with timely orthopedic follow-up, whereas older age (adjusted OR, 0.9 [0.88-0.97]) was significantly associated with failure to follow up. In the subset of patients who required orthopedic reduction in the ED, older age was significantly associated with failure to follow up (adjusted OR, 0.80 [0.74-0.94]). CONCLUSIONS: Mild fracture severity is associated with lack of orthopedic follow-up for patients with public insurance. Older age was associated with lack of follow-up, even in the subgroup with severe fractures. Targeted interventions to improve orthopedic aftercare compliance should focus on older patients with severe forearm fractures.

National Survey of Pediatric Emergency Medicine Fellows on Debriefing After Medical Resuscitations.

BACKGROUND: Medical resuscitations of critically ill children in the emergency department are stressful events requiring a coordinated team effort. Current guidelines recommend debriefing after such events to improve future performance. Debriefing practices within pediatric emergency departments by pediatric emergency medicine (PEM) fellows in the United States has not been studied. OBJECTIVE: The aim of this study was to describe the current debriefing experience of PEM fellows in the United States. METHODS: A 10-item, anonymous questionnaire regarding debriefing characteristics was distributed to fellows in US Accreditation Council for Graduate Medical Education-accredited PEM programs via e-mail and paper format from December 2011 to March 2012. Results were summarized using descriptive statistics. RESULTS: Of 393 eligible PEM fellows, 201 (51.1%) completed the survey. The 201 respondents included 82 first-year fellows (40.8%), 71 second-year fellows (35.3%), and 48 third-year fellows (23.9%). Ninety-nine percent had participated in medical resuscitations during their fellowship training, yet 88.0% reported no formal teaching on how to debrief. There was wide variability in the format and timing of debriefings. The majority of debriefings were led by PEM attending physicians (65.5%) and PEM fellows (19.6%). Most (91.5%) of the fellows indicated they would like further education about debriefing. CONCLUSIONS: The majority of PEM fellows do not receive formal training on how to debrief after a critical event and may have limited experience in leading debriefings. Debriefing training should be considered part of the educational curriculum during PEM fellowship.