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.

Use of Payer as a Proxy for Health Insurance Status on Admission Results in Misclassification of Insurance Status among Pediatric Trauma Patients.

The purpose of this study was to quantify health insurance misclassification among children treated at a pediatric trauma center and to determine factors associated with misclassification. Demographic, medical, and financial information were collected for patients at our institution between 2008 and 2010. Two health insurance variables were created: true (insurance on hospital admission) and payer (source of payment). Multivariable logistic regression was used to determine which factors were independently associated with health insurance misclassification. The two values of health insurance status were abstracted from the hospital financial database, the trauma registry, and the patient medical record. Among 3630 patients, 123 (3.4%) had incorrect health insurance designation. Misclassification was highest in patients who died: 13.9 per cent among all deaths and 30.8 per cent among emergency department deaths. The adjusted odds of misclassification were 6.7 (95% confidence interval: 1.7, 26.6) among patients who died and 16.1 (95% confidence interval: 3.2, 80.77) among patients who died in the emergency department. Using payer as a proxy for health insurance results in misclassification. Approaches are needed to accurately ascertain true health insurance status when studying the impact of insurance on treatment outcomes.

Assessment of workload during pediatric trauma resuscitation.

BACKGROUND: Trauma resuscitations are high-pressure, time-critical events during which health care providers form ad hoc teams to rapidly assess and treat injured patients. Trauma team members experience varying levels of workload during resuscitations resulting from the objective demands of their role-specific tasks, the circumstances surrounding the event, and their individual previous experiences. The goal of this study was to determine factors influencing workload experienced by trauma team members during pediatric trauma resuscitations. METHODS: Workload was measured using the National Aeronautics and Space Administration Task Load Index (TLX). TLX surveys were administered to four trauma team roles: charge nurse, senior surgical resident (surgical coordinator), emergency medicine physician, and junior surgical resident or nurse practitioner (bedside clinician). A total of 217 surveys were completed. Univariate and multivariate statistical techniques were used to examine the relationship between workload and patient and clinical factors. RESULTS: Bedside clinicians reported the highest total workload score (208.7), followed by emergency medicine physicians (156.3), surgical coordinators (144.1), and charge nurses (129.1). Workload was higher during higher-level activations (235.3), for events involving intubated patients (249.0), and for patients with an Injury Severity Score greater than 15 (230.4) (p, 0.001 for all). When controlling for potential confounders using multiple linear regression, workload was increased during higher level activations (79.0 points higher, p = 0.01) and events without previous notification (38.9 points higher, p = 0.03). Workload also remained significantly higher for the bedside clinician compared with the other three roles (p ≤ 0.005 for all). CONCLUSION: Workload during pediatric trauma resuscitations differed by team role and was increased for higher-level activations and events without previous notification. This study demonstrates the validity of the TLX as a tool to measure workload in trauma resuscitation. LEVEL OF EVIDENCE: Prognostic study, level II.