Overtriage of transfers to the pediatric trauma center: the importance of minor head injury.

OBJECTIVE: Accurate triage of minor head injuries remains a challenge for mature trauma systems. More than one-third of trauma transfers are overtriaged, and minor head injuries predominate. Overtriage is inefficient, wasteful of resources, and burdensome for families. The authors studied overtriage at the sole level I pediatric trauma center (PTC) in a small state with a view toward improvement of processes. METHODS: Data on transfer patients were extracted from an institutional trauma registry over an 8-year period. Three definitions of overtriage were examined: one based on transfer criteria from the American College of Surgeons Committee on Trauma, one based on resource utilization, and one adapted to the regional environment of the PTC. Associations of demographic, geographic, clinical, and social factors with overtriage were examined. RESULTS: There were 1754 unique patients transferred from the emergency departments (EDs) of other institutions to the PTC. Thirty-six percent of transfers were overtriaged by all 3 criteria, and 23% of all transfers were minor head injuries overtriaged by all criteria. Infants were more likely to be overtriaged than other age groups. Among racial categories, Black patients were least likely to be overtriaged. Patients with commercial insurance were more likely to be overtriaged. Overtriaged patients averaged shorter trips from the referring ED to the PTC, even though the PTC was farther from their homes. These observations suggest a sensitivity to social expectations in the exercise of ED physician judgments about transfer. CONCLUSIONS: More than one-third of all transfers to the study PTC were overtriaged, and almost one-quarter of all transfers were overtriaged minor head injuries. Minor head injuries are a potentially rewarding focus for system-wide quality improvement, but the interplay of social factors with ED physician judgments must be recognized.

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis.

OBJECTIVE: Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care. DESIGN: Systematic mapping review and narrative synthesis. DATA SOURCES: Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. ELIGIBILITY CRITERIA: Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury. DATA EXTRACTION AND SYNTHESIS: We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis. RESULTS: Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories. CONCLUSION: Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.

The effect of traumatic head injuries on the outcome of middle-aged and geriatric orthopedic trauma patients.

BACKGROUND: The purpose of this study is to characterize the effects of head injuries amongst the middle-aged and geriatric populations on hospital quality measures, costs, and outcomes in an orthopedic trauma setting. METHODS: Patients with head and orthopedic injuries aged >55 treated at an academic medical center from October 2014-April 2021 were reviewed for their Abbreviated Injury Score for Head and Neck (AIS-H), baseline demographics, injury characteristics, hospital quality measures and outcomes. Univariate comparative analyses were conducted across AIS-H groups with additional regression analyses controlling for confounding variables. All statistical analyses were conducted with a Bonferroni adjusted alpha. RESULTS: A total of 1,051 patients were included. The mean age was 74 years, and median AIS-H score was 2 (range 1-6). While outcomes worsened and costs increased as AIS-H scores increased, the most drastic (and clinically relevant) rise occurs between scores 2-3. Patients who sustained a head injury warranting an AIS-H score of 3 experienced a significantly higher rate of major complications, need for ICU admission, inpatient and 1-year mortality with longer lengths of stay and higher total costs despite no differences in demographics or injury characteristics. Regression analysis found a higher AIS-H score was independently associated with greater mortality risk. CONCLUSION: AIS-H scores >2 correlate with significantly worse outcomes and higher hospital costs. Concomitant head injuries impact both outcomes and direct variable costs for middle-aged and geriatric orthopedic trauma patients. Clinicians, hospitals, and payers should consider the significant effect of head injuries on the hospitalization of these patients.

Biomarkers used as risk assessment of mild head injuries.

In Denmark, head injuries are generally managed according to the Scandinavian Neurotrauma Committee Guideline (SNC), which aims to safely reduce head CTs. This review investigates how pre-injury vitamin K-antagonist treatment is associated with adverse outcome in head injury patients, but the significance of other antithrombotics is uncertain. Implementation of S100B in the SNC Guideline has reduced CT usage by approx. 30%. However, S100B could likely be used in a wider array of patients. Despite its usefulness, S100B's popularity is still hampered, likely due to poor practical implementation in Danish emergency rooms.

The epidemiology of and management of pediatric patients with head trauma: a hospital-based study from Southern Sweden.

BACKGROUND: Traumatic brain injury (TBI) is a common cause of morbidity and mortality in children worldwide. In Scandinavia, the epidemiology of pediatric head trauma is poorly documented. This study aimed to investigate and compare the epidemiology and management of pediatric patients with isolated head trauma (IHT) and head trauma in connection with multitrauma (MHT). METHODS: We conducted a retrospective review of medical records of patients < 18 years of age who attended any of the five emergency departments (ED) in Scania County in Sweden in 2016 due to head trauma. Clinical data of patients with IHT were analyzed and compared with those of patients with MHT. RESULTS: We identified 5046 pediatric patients with head trauma, 4874 with IHT and 186 with MHT, yielding an incidence of ED visits due to head trauma of 1815/100,000 children/year. There was male predominance, and the median age was four years. Falls were the dominating trauma mechanism in IHT patients, while motor vehicle accidents dominated in MHT patients. The frequencies of CT head-scans, ward admissions and intracranial injuries (ICI) were 5.4%, 11.1% and 0.7%, respectively. Four patients (0.08%) required neurosurgical intervention. The relative risks for CT-scans and admissions to a hospital ward and ICI were 10, 4.5 and 19 times higher for MHT compared with IHT patients. CONCLUSION: Head trauma is a common cause of ED visits in our study. Head-CTs and ICIs were less frequent than in previous studies. MHT patients had higher rates of CT-scans, admissions, and ICIs than IHT patients, suggesting that they are separate entities that should ideally be managed using different guidelines to optimize the use of CT-scans of the head.

Characteristics and costs of electric scooter injuries in Helsinki: a retrospective cohort study.

BACKGROUND AND PURPOSE: The incidence of electric scooter (e-scooter) injuries has increased drastically in numerous countries after widespread availability of shared e-scooters. The economic impact on society from a broader perspective has not been studied. We aimed to estimate the incidence of e-scooter injuries, describe the injury patterns, and estimate the costs of e-scooter injuries. PATIENTS AND METHODS: We performed a retrospective cohort study including all e-scooter-related injuries presented in the three adult emergency departments in Helsinki in 2021. We collected the patient data from the university hospital information system. Injury severity was evaluated based on the Abbreviated Injury Score. The cost of the hospital treatment was analyzed based on our hospital district's service price listing. In addition, we recorded the total amount of sick leave days and estimated their economic impact. RESULTS: In total, 446 e-scooter injuries were identified and taken into the analysis (434 affecting riders and 12 non-riders). The median age of the patients was 26 (IQR 22-33), and 59% were male. 257 (58%) of the of the injuries were minor, whereas 155 (35%) were moderate, 30 (7%) serious, 3 (0.7%) severe, and one (0.2%) critical. Furthermore, 220 (49%) of the patients sustained head injuries. A major spike in accident incidence was seen during the weekend (Friday to Sunday) nights, accompanied by a proportional increase in patients with alcohol intoxication. Including both the costs of the hospital care and absence from work, the approximated total cost of e-scooter injuries was 1.7 million euros, with a median cost of a single accident being 1148 euros (IQR 399-4263 €). INTERPRETATION: Considerable number of the injuries are moderate, severe, or worse. Comprehensive preventive measures must be conducted to decrease the incidence of e-scooter injuries. The use of helmets should be strongly encouraged to prevent severe head injuries. The nighttime bans during weekends and speed limits on e-scooters appear to be justifiable.

Abusive head trauma: current practice of investigation and management in Taiwan.

INTRODUCTION: Abusive head trauma (AHT) is a worldwide leading cause of fatal head injuries in children under 2 years. This study aims to present the development of child protection medical service in Taiwan in the past decade. MATERIALS AND METHODS: This study reviews the evolution of the pediatric protection network and the cross-system professional training in Taiwan from 2013 to 2022. The recommendations of Taiwan Pediatric Association on the prevention and management of AHT and the Medical Professionals Manual of Child Abuse and Neglect proposed by the Ministry of Health and Welfare were reviewed. RESULTS: Considering the impact of the high incidence of severe sequelae and the mortality caused by of AHT, 10 regional centers for child protection medical service were founded in Taiwan to identify, recognize, and properly manage cases of AHT, which is easily overlooked by the healthcare providers. The child protection network across the healthcare, social welfare administration, and judicial systems facilitate the early detection, management, and proper disposition of the children with AHT. CONCLUSION: An increasing of the incidence of AHT is expected after the setting up of the child protection network and the continuing cross-system professional trainings. There is more consensus of the diagnosis and management of AHT than before in Taiwan. However, there is no end to protecting children from AHT.

Patient costs and patient flow after implementation of S100B in Scandinavian head trauma guidelines.

INTRODUCTION: The serum biomarker S100B has been implemented in the Scandinavian Neurotrauma Committee (SNC) 2013 Head Injury Guidelines for patients classified with mild head injury (MHI). Patients with a serum S100B level less-than 0.10 µg/l sampled within six hours after trauma can be discharged without further observation or investigation. The aim of this study was to examine the influence of S100B implementation on patient costs and patient flow in an emergency department. METHODS: In this retrospective study, we included MHI patients (≥ 18 years) admitted to Rigshospitalet, Copenhagen, Denmark, between 1 February 2013 and 31 January 2014. Medical records were examined for the time of trauma, time of S100B sampling, serum S100B level, the severity of the head injury, clinical symptoms, radiological examinations, hospitalisation, discharge, surgical intervention, readmission and mortality. RESULTS: Among 2,033 patients screened for potential study candidates, 227 patients met the inclusion criteria and were enrolled in the study. Among these patients, 119 (52%) were not treated according to SNC 2013 Head Injury Guidelines, leaving 108 (48%) with full guideline adherence. Compared with MHI management without S100B, implementation of S100B produced an additional cost of €1.26 per patient. Overall, the addition of S100B did not affect the waiting time for examination with S100B sampling or CT. CONCLUSION: The use of S100B in the SNC 2013 Head Injury Guidelines did not reduce patient costs, nor did it cause substantial additional patient costs or delayed patient flow. FUNDING: none. TRIAL REGISTRATION: The Danish Data Protection Agency (journal number 2012-58-0004 and I-suite number RH-2017-164).

Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children's Hospitals.

Importance: The scope of low-value care in children's hospitals is poorly understood. Objective: To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services. Design, Setting, and Participants: This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort. Exposures: Eligible condition-specific hospital encounters. Main Outcomes and Measures: The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes. Results: There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866). Conclusions and Relevance: This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.

Managing Craniomaxillofacial Injury Without Inpatient Consult: Outcomes and Patient Cost Savings.

BACKGROUND: We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients. METHODS: A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded. RESULTS: 303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS (P < .001) and needed surgery on admission (P < .001), while no-CMF consults had shorter length of stay (P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96. DISCUSSION: Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

Epidemiology and Management of Pediatric Head and Neck Burns: An Institutional Review.

BACKGROUND: Pediatric head and neck burns (HNBs) require special attention due to the potential for long-term disfigurement, functional impairment, and psychosocial stigma. METHODS: We performed a retrospective review of patients <18 years old admitted to Grady Memorial Hospital with a diagnosis of HNB from 2009-2017. Demographic data, burn characteristics, management, and hospital course were analyzed. RESULTS: Of the 272 patients included, 65.4% were male with a mean age of 63.2 months. Burn mechanism was primarily secondary to scalding liquids (70.2%) or flames (23.9%). The average total body surface area involved was 10.3%, and 3.0% for the head/neck. Average length of stay was 5.2 days and overall mortality was 1.1%. Twenty-five patients (9.2%) required surgery in the acute setting, and 5 (1.8%) required secondary surgery for hypertrophic scarring or contracture. DISCUSSION: Pediatric HNBs occur most commonly in males <6 years old secondary to scalding liquids or open flames. Most patients can be managed nonoperatively without long-term sequelae.

Professional practice assessment for minor head injury management in emergency department and clinical impact of a simulation-based training: Interventional study (before/after).

BACKGROUND: Minor head injury is a frequent reason for consultation in the emergency department. The use of computed tomography (CT) has increased dramatically in patients' care. Good time management implementation and interpretation are required. To study the level of agreement with recommendations for a minor head injury in emergency department management and the impacts of simulation-based training (SBT) on professional practice changes. METHODS: Evaluation of professional practice for patient care in an emergency department according to the recommendations of the French Emergency Medicine Society (SFMU) established in 2012 before and after an SBT, including theoretical and simulation courses. It was based on the analysis of time to carry out a CT scan. It was also based on analysis of adherence to brain and spine scan indications and to hospitalization criteria. RESULTS: The SBT carried out in the evaluation of the professional practices makes it possible to acquire the notion of urgency to obtain the CT Scan within one hour when the criteria are met (p=0.007). Rater reliability for agreement with the hospitalization recommendations was better after SBT (p=0.03, increased Kappa from 0.73 to 0.93). On the other hand, there appeared to be a lack of essential information in the medical file, such as time of onset of head trauma. CONCLUSION: Management of this type of patient appeared to be satisfactory. It can be improved by SBT on the basis of the SFMU 2012 consensus conference. There is a need to improve the software used by the emergency departments, which should include the time of trauma and recommendations. The association of the clinic and the biomarkers could help to limit the indications of the CT scan, and thus to have it organized more rapidly.

Trauma in Iraq's Wars: Assessment and Management of Craniofacial Injury.

As the most prominent portion of the human body, the face embraces a multifaceted responsibility for functionality and survival while contributing to identity and self-image. Inopportunely, due to its distinctive anatomical location, the face as a unit is highly suspectable to trauma, particularly in warfare. As a result, facial injury creates a physical and psychological trauma that needs to be addressed immediately. In the following article, a detailed literature review was conducted to examine the interplay between facial injuries throughout multiple wars in Iraq and their management. The authors found a significant increase in facial injuries due to shell fragments corresponding with modern advances in warfare targeting mass casualties. The capacity to manage the magnitude and level of trauma observed in Iraq requires a substantial amount of resources and a systematic approach that unfortunately is unattainable in a country that is still struggling to rebuild after decades of oppression and war. Due to the circumstances, surgeons have to rely on training and experience to provide the best care for their patients and it is imperative that we continue to train our surgeons to rely on their skills and experience to ensure a high level of care with limited resources and lack of technology.

Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers.

BACKGROUND: Studies spanning the last three decades demonstrated the injury causing capability of air gun (AG) projectiles. Recent studies have suggested the impact and incidence of these injuries may be declining because of edcational efforts. We hypothesize that injuries in the pediatric population resulting from AGs remain a significant health concern. METHODS: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institutional review board approval, patients were identified by ICD code from the trauma registry. Included were demographic data, injury severity scores, length of stay (LOS), outcome at discharge, and overall cost of admission. Descriptive statistics and parametric tests were employed. RESULTS: A total of 499 patients sustained injuries. Mean age 9.5 (±4.0) y; 81% of victims were male; all survived to hospital discharge. 30% (n = 151) required operative intervention. Hospital LOS was 2.3 (±2.2) d; with mean cost of $23,756 (±$34,441). Injury severity score mean of 3.7 (±4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS ≥ 3) required operative intervention (P < 0.001). CONCLUSIONS: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern.

The costs of traumatic head injury and associated factors at University of Gondar Specialized Referral Hospital, Northwest Ethiopia.

BACKGROUND: Head injuries account for 650,000 annual deaths worldwide. The cost for treating head injury was estimated at US $200 million annually. This contributes to economic impoverishment in low income countries like Ethiopia. Hence, this study was aimed to assess the cost of Traumatic Head Injury (THI) and associated factors in the University of Gondar Specialized Referral Hospital. METHOD: An institution-based cross-sectional study was conducted from March 01 to May 30, 2017. A total of 387 THI patients were included in the study. An interviewer-administered questionnaire was used for data collection. Direct costs and indirect costs were measured by using the bottom-up approach. Data were entered into Epi-Info version 7 and imported to SPSS version 20 for analysis. Simple and multiple linear regression analysis were done to identify factors associated with cost of THI. RESULTS: The mean cost of THI per patient was 4673.43 Ethiopian Birr (ETB), 95% CI (4523.6-4823.3), and length of hospital stay averaged 1.73, 95% CI (1.63-1.82). Direct non-medical cost, like transportation fee 1896.19 ETB (±762.56 SD) and medical costs 1101.66 ETB (±534.13 SD) were account for 40.57 and 23.58% of total costs respectively. The indirect cost, loss of income by patient and their attendant due to injury, was 1675.58 ETB (+ 459.26 SD). Patients with moderate and severe levels of injury have 635.167 ETB (Standardized coefficient = 0.173, p < 0.001) and 773.621 ETB (Standardized coefficient = 0. 132, p < 0.001) increased costs, respectively, compared to mild level THI patients. Costs for patients ages 31-45 years were 252.504 ETB (Standardized coefficient = - 0.066, p = 0.046) lower than costs for those 5-14 years old. The cost of THI patients increased by 1022.853 ETB for each additional day of hospital length of stay (Standardized coefficient = 0.648, p < 0.001). CONCLUSION: Most expenses of the THI were from direct non-medical cost. Prior health service use, length of stay, level of injury, and age were significant predictors of cost of THI.

The Incidence and Management of Moderate to Severe Head Injury.

BACKGROUND: The comprehensive expansion of the Trauma Register of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie; TR-DGU) now enables, for the first time, studies on traumatic brain injury (TBI) with special attention to care processes, clinical course, and outcomes of treatment on discharge or transfer from the acute-care hospital. METHODS: Retrospective analysis of patients documented in the TR-DGU in the period 2013-2017 who had moderate to severe head injury as defined by the Abbreviated Injury Scale (AIS). RESULTS: In the period 2013-2017, 41 101 patients with moderate to severe TBI were treated in TR-DGU-associated hospitals in Germany (n = 605 hospitals), corresponding to 8220 cases per year and thus to a population-wide incidence of 10.1 cases per 100 000 persons per year. TBI was present as an isolated injury in 39.1% of cases. The mean age of the patients was 60 years (median; range 0-104 years), and the male-to-female ratio was 2:1. 97.5% of the patients had blunt trauma. Falls from a low height were the most common cause of TBI (38.7%). 43.6% of the patients were intubated before arriving at the hospital, and more than 95% underwent cranial tomographic imaging within 22 minutes of arrival (standard deviation [SD] = 17 minutes). 18.4% underwent an emergency neurosurgical procedure. The in-hospital mortality was 23.5%, corresponding to a population-wide mortality from TBI of 2.4 per 100 000 persons per year. More than half of the patients recovered well or with only mild disability; 14.9% had persistent severe disability or remained in a vegetative state. CONCLUSION: Putting these figures in the appropriate international context requires the acquisition of comparable data in multiple countries and is the main task of international TBI consortia.

Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique.

Situation awareness (SA) is an important human factor and necessary for effective teamwork and patient safety. Human patient simulation (HPS) with video feedback allows for a safe environment where health care professionals can develop both technical and teamwork skills. It is, however, very difficult to observe and measure SA directly. The Situation Global Assessment Technique (SAGAT) was developed by Endsley to measure SA during real-time simulation. Our objective was to measure SA among team members during simulation of acute pediatric care scenarios on the medical ward and its relationship with team effectiveness. Twenty-four pediatric teams, consisting of two nurses, one resident, and one consultant, participated in three acute care scenarios, using high-fidelity simulation. Individual SAGAT scores contained shared and complimentary knowledge questions on different levels of SA. Within each scenario, two "freezes" were incorporated to assess SA of each team members' clinical assessment and decision-making. SA overlap within the team (team SA) was computed and compared to indicators of team effectiveness (time to goal achievement, consensus on primary problem, diagnosis, task prioritization, leadership, and teamwork satisfaction). In 13 scenarios (18%), the team failed to reach the primary goals within the prescribed time of 1200 s. There was no significant difference in failure of goal completion between the scripted scenarios; however, there was a significant difference between scenario 3 and the other scenarios in time to goal completion. In all three scenarios, SA overlap level 2 (consensus on primary problem during the first freeze and consensus on diagnosis during the second freeze) leads to significantly faster achievement of the predefined goals. There was a strong relationship between team SA on the primary problem and diagnosis and team SA on task prioritization. Consensus on leadership within the team was low. Teamwork satisfaction was more influenced by knowledge about the importance of the assigned task than outcome of the scenario.Conclusion: The use of SAGAT enables us to measure SA of team members during real-time simulation of acute care scenarios. Although there is no direct connection between team SA and goal achievement, SAGAT provides insight in differences in SA among team members, and the process of shared mental model formation. By measuring SA, issues that may improve team effectiveness (prioritizing tasks, enhancing shared mental models, and providing leadership) can be trained and assessed during medical team simulation, enhancing teamwork in health care settings. What is known? • Teamwork skills such as communication, leadership, and situational awareness have become increasingly recognized as essential for good performance in pediatric resuscitation. However, the assessment of pediatric team performance in these clinical situations has been traditionally difficult. • The Situation Awareness Global Assessment Technique (SAGAT) is a method of objectively and directly measuring SA during a team simulation using "freezes" at predetermined points in time with participants reporting on "what is going on" from their perspective on the situation. What is new? • We assessed SA, and its relationship with team effectiveness, in multidisciplinary pediatric teams performing simulated critical events in critically ill children on the medical ward using the SAGAT model, outside the emergency room setting. • In all three scenarios, consensus on the primary problem (shared mental model) leads to faster achievement of predefined goals. Consensus on leadership was overall low, without a significant impact on goal achievement.

A Cost-Effectiveness Analysis Comparing Clinical Decision Rules PECARN, CATCH, and CHALICE With Usual Care for the Management of Pediatric Head Injury.

STUDY OBJECTIVE: To determine the cost-effectiveness of 3 clinical decision rules in comparison to Australian and New Zealand usual care: the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), the Pediatric Emergency Care Applied Research Network (PECARN), and the Canadian Assessment of Tomography for Childhood Head Injury (CATCH). METHODS: A decision analytic model was constructed from the Australian health care system perspective to compare costs and outcomes of the 3 clinical decision rules compared with Australian and New Zealand usual care. The study involved multicenter recruitment from 10 Australian and New Zealand hospitals; recruitment was based on the Australian Pediatric Head Injury Rules Study involving 18,913 children younger than 18 years and with a head injury, and with Glasgow Coma Scale score 13 to 15 on presentation to emergency departments (EDs). We determined the cost-effectiveness of the 3 clinical decision rules compared with usual care. RESULTS: Usual care, CHALICE, PECARN, and CATCH strategies cost on average AUD $6,390, $6,423, $6,433, and $6,457 per patient, respectively. Usual care was more effective and less costly than all other strategies and is therefore the dominant strategy. Probabilistic sensitivity analyses showed that when simulated 1,000 times, usual care dominated all clinical decision rules in 61%, 62%, and 60% of simulations (CHALICE, PECARN, and CATCH, respectively). The difference in cost between all rules was less than $36 (95% confidence interval -$7 to $77) and the difference in quality-adjusted life-years was less than 0.00097 (95% confidence interval 0.0015 to 0.00044). Results remained robust under sensitivity analyses. CONCLUSION: This evaluation demonstrated that the 3 published international pediatric head injury clinical decision rules were not more cost-effective than usual care in Australian and New Zealand tertiary EDs. Understanding the usual care context and the likely cost-effectiveness is useful before investing in implementation of clinical decision rules or incorporation into a guideline.