Unnecessary imaging, not hospital distance, or transportation mode impacts delays in the transfer of injured children.

OBJECTIVES: Timely transfer of injured children to pediatric trauma centers (PTCs) that can address their unique needs is important. This study was designed to understand the characteristics of transferred injured children. METHODS: Data from our level I PTC over 5 years (2002-2006) were reviewed. Transferred patients were divided based on time from injury to arrival at our PTC: early (<2 hours) and late (>2 hours). Data collected included demographics, Injury Severity Scale score, Glasgow Coma Scale score, mode of transportation, referring hospital information including pretransfer imaging, and disposition from our emergency room. RESULTS: Seven hundred forty-eight patients were included. Eighty-two percent (n = 612) were in the late group and arrived, on average, 6 hours after those transferred early (420 vs 69.9 minutes, P < 0.05). Seventy-nine percent (n = 147) of transfers with severe injuries (Injury Severity Scale score >15) and 47% (n = 15) of those with severe head injuries (Glasgow Coma Scale score <8) arrived late. The disproportionate number of late transfers was consistent among all transferring hospitals regardless of distance and only slightly improved in the group transferred by air ambulance. In addition, those transferred late had significantly more pretransfer imaging (49% vs 23%, P = 0.0025). CONCLUSIONS: Despite the advantages of care in trauma centers, a significant number of severely injured children are transferred well beyond 2 hours after injury. This study has demonstrated that this pattern of delayed transfer is a systemic problem occurring among all transferring hospitals regardless of distance or mode of patient transfer and is associated with increased use of imaging before transfer.

Pediatric SBIRT: understanding the magnitude of the problem.

Screening and brief intervention with referral to treatment (SBIRT) have recently been instituted for the adult and older adolescent trauma populations. However, questions persist regarding prevalence in the younger than 18-year population, youngest age for providing alcohol and drug screening, and whether an opportunity is being missed for this population. This article provides a review of literature for the 12-to 17-year-old population regarding alcohol and drug use, adolescent brain maturation, specific adolescent risk considerations, and results of a national survey regarding the frequency and methodology of providing SBIRT for the 12-to 17-year-old population.

Pediatric trauma resuscitation: initial fluid management.

Fluid management is a vital component in the resuscitative care of the injured child. The goal of fluid resuscitation is to restore tissue perfusion without compromising the body's natural compensatory mechanism. Recent literature has questioned the timing, type, and amount of fluid administration during the resuscitative phase. When managing a pediatric resuscitation, it is imperative to use a variety of age-appropriate physiologic parameters because reliance on blood pressure alone will lead to delayed recognition of shock. Establishing vascular access, via peripheral intravenous, central venous, or intraosseous catheter, should be a high nursing priority. Hemorrhage control and fluid resuscitation of an injured child remains a top priority of trauma care. Early intravenous access with appropriate fluid administration continues to be a universal treatment for the hypotensive trauma patient. Fluid resuscitation in the early phase of care, whether in the field, emergency department, or operating room, should be targeted toward perfusing critical organs, such as the brain and heart. Once obvious bleeding is controlled, the overall goal for fluid management centers on maintaining oxygen delivery to perfuse vital structures with enough oxygen and energy substrates to maintain cellular function, thus avoiding tissue ischemia. However, specific issues around timing and type of fluid administration, once thought to be straightforward, have triggered increasing investigation of current beliefs.

Pediatric trauma nursing education requirements: a national overview.

This study describes current trauma nursing education requirements and nursing perception for additional pediatric trauma education. A web-based survey was electronically distributed to members of Society of Trauma Nurses. Overall, a lack of consistent standards across the United States for what constitutes pediatric trauma education was noted. Many hospital trauma programs expend time and money developing their own hospital course. Strong support exists for the development of an additional pediatric trauma course with a skills station. Basic concepts of primary/secondary survey, airway management, and fluid management for hypovolemic shock should be a high priority within this curriculum.

Mild traumatic brain injury in children: just another bump on the head?

Mild traumatic brain injury (MTBI) is frequently encountered in pediatrics and challenges healthcare practitioners to provide safe, consistent, cost-effective care. Clinical management of children who sustain MTBI poses dilemmas for healthcare practitioners. This article will provide an overview of pediatric MTBI including definition, issues impacting diagnosis and management, risk factors for intracranial injury, indications for diagnostic imaging, disposition, and return to sports/activity. Knowledge and understanding of MTBI in children aid healthcare practitioners to make informed competent recommendations for care. Clinicians must have a thorough understanding and working knowledge of pediatric MTBI to aid clinical decisions and optimize patient outcomes.

Family perception: quality of life following a child's traumatic injury.

This prospective research study evaluated the parent's perception of their child's quality of life at 1 and 6 months following injury, using the Child Health Questionnaire to measure outcomes. At both 1 and 6 months postinjury, the physical summary and psychosocial summary scores were significantly lower than US norms for all levels of injury severity. Predictors of lower physical and psychosocial scores, such as the Injury Severity Score and specific location of injury, were determined. This study demonstrates the long-term impact of injury and validates the need for earlier intervention and anticipatory guidance for the child and family.

Pediatric trauma nurse practitioners increase bedside nurses' satisfaction with pediatric trauma patient care.

PURPOSE: Our Level I Pediatric Trauma Center employs pediatric nurse practitioners (PNP) to manage inpatients. We hypothesized that the involvement of a PNP would lead to increased nursing staff satisfaction with patient care. METHODS: Children admitted to the trauma service were randomized to PNP or resident care groups. Nurses caring for these children were asked to fill out a satisfaction survey regarding the care that the child received. FINDINGS: Sixty-five nurses participated. Nurses scored the PNP group significantly higher in human qualities, information given about the tests, management of the child's pain, and response time to pages/questions. CONCLUSIONS: Involvement of the PNP leads to higher nursing satisfaction scores compared with residents while providing equivalent care for injured children.

Traumatic injury to the pancreas: the challenges of care in the pediatric patient.

Traumatic pancreatic injury is infrequently encountered in children. Diagnosis and treatment of this injury can be complicated. Signs and symptoms are often subtle with presentation frequently delayed leading to increased morbidity and mortality. This delay is compounded by lack of specific diagnostic tools to aid diagnosis. Clinicians should maintain a high index of suspicion for pancreatic injury in any child who sustains blunt abdominal trauma. Ongoing clinical evaluation is essential. This article presents a case study of a child with a traumatic pancreatic injury and discusses tools utilized to aid diagnosis of pancreatic injury, treatment options, and potential complications.

Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation.

BACKGROUND: Trauma resuscitations require a high level of team performance. This study evaluated the impact of a comprehensive effort to improve trauma care through multidisciplinary education and the use of simulation training to reinforce training and evaluate performance. METHODS: For a 1-year period, expanded trauma education including monthly trauma simulation sessions using high-fidelity simulators was implemented. All members of the multidisciplinary trauma resuscitation team participated in education, including simulations. Each simulation session included 2 trauma scenarios that were videotaped for debriefing as well as subsequent analysis of team performance. Scored simulations were divided into early (initial 4 months) and late (final 4 months) for comparison. RESULTS: For the first year of the program, 160 members of our multidisciplinary team participated in the simulation. In the early group, the mean percentage of appropriately completed tasks was 65%, whereas in the late group, this increased to 75% (P < .05). Improvements were also observed in initial assessment, airway management, management of pelvic fractures, and cervical spine care. CONCLUSIONS: Training of a multidisciplinary team in the care of pediatric trauma patients can be enhanced and evaluated through the use of high-fidelity simulation. Improvements in team performance using innovative technology can translate into more efficient care with fewer errors.

Pediatric trauma nurse practitioners provide excellent care with superior patient satisfaction for injured children.

PURPOSE: Work hour restrictions for house staff have forced a reevaluation of the traditional roles of all health care providers. In 2001, our level I pediatric trauma center augmented the role of our trauma pediatric nurse practitioners (PNPs) to include in-patient management. We hypothesized that a PNP can provide injured children a level of care commensurate with a resident (RES). METHODS: All children between 2 months and 17 years old admitted to the Trauma Service were considered for the study. Patients were randomized to PNP or RES care groups. Types of injuries, injury severity score, missed injuries, readmissions, hospital length of stay (LOS), and cost were recorded. Satisfaction surveys were administered to all families. RESULTS: A total of 76 children were enrolled. During the study period, there were no missed injuries or readmissions. The PNP group had a significantly shorter LOS and received significantly higher satisfaction survey scores with regard to information on injuries, tests and treatment, and frequency of visits provided to the patient/family. CONCLUSIONS: PNPs provide equivalent care for injured children with significantly shorter LOS and higher patient satisfaction than RESs. In-patient trauma nurse practitioners provide added value to the care of the injured child in the era of reduced RES work hours.