Improved identification of severely injured pediatric trauma patients using reverse shock index multiplied by Glasgow Coma Scale.

BACKGROUND: The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients. METHODS: Patients (aged 1-18 years) in the 2014 to 2018 Pediatric Trauma Quality Improvement Program database with complete heart rate, systolic blood pressure, and total GCS were included. Optimal cut points of rSIG were calculated for predicting blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. From the optimal thresholds, sensitivity, specificity, and area under the curve were calculated from receiver operating characteristics analyses to predict each outcome and compared with SI and SIPA. RESULTS: A total of 604,931 patients with a mean age of 11.1 years old were included. A minority of patients had a penetrating injury mechanism (5.6%) and the mean Injury Severity Score was 7.6. The mean SI and rSIG scores were 0.85 and 18.6, respectively. Reverse shock index multiplied by Glasgow Coma Scale performed better than SI and SIPA at predicting early trauma outcomes for the overall population, regardless of age. CONCLUSION: Reverse shock index multiplied by Glasgow Coma Scale outperformed SI and SIPA in the early identification of traumatically injured children at risk for early interventions, such as blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. Reverse shock index multiplied by Glasgow Coma Scale adds neurological status in initial patient assessment and may be used as a bedside triage tool to rapidly identify pediatric patients who will likely require early intervention and higher levels of care. LEVEL OF EVIDENCE: Prognostic, level III.

Factors affecting management of children's low-risk distal radius fractures in the emergency department: a population-based retrospective cohort study.

BACKGROUND: Ten randomized controlled trials over the last 2 decades support treating low-risk pediatric distal radius fractures with removable immobilization and without physician follow-up. We aimed to determine the proportion of these fractures being treated without physician follow-up and to determine whether different hospital and physician types are treating these injuries differently. METHODS: We conducted a retrospective population-based cohort study using ICES data. We included children aged 2-14 years (2-12 yr for girls and 2-14 yr for boys) with distal radius fractures having had no reduction or operation within a 6-week period, and who received treatment in Ontario emergency departments from 2003 to 2015. Proportions of patients receiving orthopedic, primary care and no follow-up were determined. Multivariable log-binomial regression was used to quantify associations between hospital and physician type and management. RESULTS: We analyzed 70 801 fractures. A total of 20.8% (n = 14 742) fractures were treated without physician follow-up, with the proportion of physician follow-up consistent across all years of the study. Treatment in a small hospital emergency department (risk ratio [RR] 1.86, 95% confidence interval [CI] 1.72-2.01), treatment by a pediatrician (RR 1.22, 95% CI 1.11-1.34) or treatment by a subspecialty pediatric emergency medicine-trained physician (RR 1.73, 95% CI 1.56-1.92) were most likely to result in no follow-up. INTERPRETATION: While small hospital emergency departments, pediatricians and pediatric emergency medicine specialists were most likely to manage low-risk distal radius fractures without follow-up, the majority of these fractures in Ontario were not managed according to the latest research evidence. Canadian guidelines are required to improve care of these fractures and to reduce the substantial overutilization of physician resources we observed.

Clinical guideline for retained button batteries.

OBJECTIVE: To design a clinical guideline for the emergency management of retained button batteries (RBBs) through analysis of UK National Health Service hospital guidelines and published literature. METHOD: 49 acute hospitals were contacted, and their guidelines were analysed. A consensus guideline was then created with multidisciplinary input. The final guideline was independently peer reviewed by the British Association of Otorhinolaryngology and Head and Neck Surgery (ENT UK) clinical guidelines committee. RESULTS: 40 (82%) trusts responded. 28 had a guideline for the management of a RBB in the aerodigestive tract. Significant variation between guidelines assessment, investigation and management of a RBB was identified. CONCLUSION: A single-page guideline was designed to improve frontline healthcare professional's immediate investigation and management of a RBB on presentation to emergency care. This has been published by ENT UK as a clinical guideline.

Taquicardia paroxística supraventricular desde la perspectiva del transporte interhospitalario / Supraventricular tachycardia in children from the perspective of a specialised between-hospital transport team

OBJETIVO: Determinar la frecuencia de taquicardia paroxística supraventricular (TPSV) como motivo de traslado interhospitalario en la edad pediátrica, describir la forma de presentación clínica, evolución y tratamiento, y factores de riesgo de presentar compromiso hemodinámico y proponer un protocolo de manejo específico para el transporte. MÉTODO: Estudio retrospectivo observacional de los pacientes atendidos en el Sistema de Emergencias Médicas Pediátricas (SEM-P) del Hospital Vall d'Hebron entre enero 2005 y junio 2017. RESULTADOS: De un total de 7.348 traslados, 67 fueron pacientes con TPSV (0,9%). Edad mediana de 57 días de vida (2h a 18 años). Catorce pacientes (20,9%), presentaban signos de compromiso hemodinámico en el momento del diagnóstico. La edad ≤1 año fue el único factor de riesgo independiente para presentar compromiso hemodinámico al diagnóstico con un OR de 10,2 (IC 95%: 1,2-89,9; p: 0,004). La mayoría de pacientes revirtieron con las intervenciones del hospital emisor, exceptuando la intubación y la cardioversión eléctrica, realizadas más frecuentemente por el equipo de trasporte (ET). El tiempo mediano de estabilización fue de 35min (9-169), con un tiempo mediano de traslado de 30min (9-165). CONCLUSIONES: El transporte de pacientes pediátricos con TPSV es poco frecuente, pero puede requerir un manejo altamente especializado. La edad ≤1 año es el único factor de riesgo independiente para presentar compromiso hemodinámico. La coordinación entre el equipo del hospital emisor y el ET es de gran importancia para un buen resultado asistencial

AIMS: The aim of this study is to establish the incidence of supraventricular tachycardia (SVT) as a main reason for between-hospital transfer in children, as well as to describe the clinical presentation, prognosis and treatment, risk factors presenting with haemodynamic compromise, and to propose a specific management protocol for the transport. METHODS: A retrospective observational study was conducted on all patients with supraventricular tachycardia transferred by the Hospital Vall d'Hebron Sistema de Emergencias Médicas Pediátricas (SEM-P) between January 2005 and June 2017. RESULTS: During the study period, 67 (0.9%) patients (out of a total number of 7348 transfers) suffered from SVT. The median age was 57 days (2 hours-18 years old). There was clinical evidence of cardiogenic shock on admission in 14 (20.9%) patients. Age ≤ 1 year was the only independent risk factor associated with presenting with cardiogenic shock on admission, with an OR of 10.2 (95% CI: 1.2-89.9; P=.004). The majority of patients could be treated appropriately by the local hospital team, except for oral intubation and cardioversion that were performed mainly by the transport team on arrival at the local hospital. Median stabilisation time was 35minutes (9-169), and median total transport time was 30minutes (9-165). CONCLUSIONS: Only 0.9% of transport cases are due to SVT, but this can be highly demanding as patients can be critically ill. Age ≤ 1 year was the only independent risk factor associated with presenting with cardiogenic shock on admission. Coordination between the local and the transport teams is crucial for a good clinical outcome

COVID-19 Pandemic: Perspective From Italian Pediatric Emergency Physicians.

OBJECTIVES: To document the lived experience of Italian pediatric emergency physicians during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We developed a structured interview to collect the lived experience of the staff of the pediatric emergency department (PED) of a tertiary referral university hospital in Northern Italy. The open-ended questions were draft according to the suggestions of Canadian colleagues and administered by 1 interviewer, who was part of the PED staff, at the end of March 2020. All the PED staff was interviewed, on a voluntary basis, using purposive sampling. RESULTS: Most respondents declared to be afraid of becoming infected and of infecting their families. The number of patients seen in the PED has decreased, and the cases tend to be more severe. A shift in the clinical approach to the ill child has occurred, the physical examination is problem-oriented, aiming to avoid un-necessary maneuvers and to minimize the number of practitioners involved. The most challenging aspects reported are: (1) performing a physical examination in personal protective equipment (PPE), (2) being updated with rapidly evolving guidelines, and (3) staying focused on the possible COVID-19 clinical presentation without failing in differential diagnosis. CONCLUSIONS: During the COVID-19 pandemic, it seems that pediatric emergency physicians are radically changing their clinical practice, aiming at prioritizing essential interventions and maneuvers and self-protection.

High-flow nasal cannula and noninvasive ventilation in pediatric emergency medicine.

The use of high-flow nasal cannula and noninvasive ventilation has become increasingly common in emergency medicine as a first-line treatment of pediatric patients with respiratory distress secondary to asthma and bronchiolitis. When implemented in clinical practice, close monitoring of vital signs and ventilation parameters is warranted to identify possible signs of respiratory failure. This issue provides evidence-based recommendations for the appropriate use of noninvasive ventilation modalities in pediatric patients including high-flow nasal cannula, continuous positive airway pressure, and bilevel positive airway pressure in the setting of acute respiratory distress. Contraindications and complications associated with these modalities are also discussed.

A Resident-Led QI Initiative to Improve Pediatric Emergency Department Boarding Times.

BACKGROUND: Pediatric emergency department (PED) overcrowding and prolonged boarding times (admission order to PED departure) decrease quality of care. Timely transfer of patients from the PED to inpatient units is a key driver that relieves overcrowding. In 2015, PED boarding time at our hospital was 10% longer than the national benchmark. We described a resident-led quality-improvement initiative to decrease PED mean boarding times by 10% (from 173 to 156 minutes) within 6 months among general pediatric admissions. METHODS: We applied Plan-Do-Study-Act (PDSA) methodology. PDSA 1 (October 2016) interventions were bundled to include streamlined mobile communications, biweekly educational presentations, and reminder signs. PDSA 2 (August 2017) provided alternative workflows for senior residents. Outcomes were mean PED boarding times for general pediatrics admissions. The proportion of PICU transfers within 12 hours of admission served as a balancing measure. Statistical process control charts were used to analyze boarding times and PICU transfer rates. RESULTS: Leading up to PDSA 1, monthly mean boarding times decreased from 173 to 145 minutes and were sustained throughout the study period and up to 1 year after study completion. The X-bar chart demonstrated a shift with 57 consecutive months of mean boarding times below the preintervention mean. There were no changes in PICU transfer rates within 12 hours of admission. CONCULSIONS: Resident-led quality improvement efforts, including education and streamlined workflow, significantly improved PED boarding time without causing harm to patients.

Using rapid cycle deliberate practice to improve primary and secondary survey in pediatric trauma.

BACKGROUND: Optimal performance of the primary and secondary survey is the foundation of Advance Trauma Life Support care. Despite its importance, not all primary surveys completed at level 1 pediatric trauma centers are performed according to established guidelines (Gala et al., Pediatr Emerg Care 32:756-762, 2016, Carter et al., Resuscitation 84:66-71, 2013). We hypothesize that rapid cycle deliberate practice (RCDP) will improve surgical residents' confidence in performing the primary and secondary survey. METHODS: We developed a curriculum to teach surgical interns the principles of performing the primary and secondary survey using RCDP. Surveys distributed after each session assessed the impact of the curriculum on learner confidence and perception that this curriculum would benefit patient care. Questions were scored on a 5-point Likert scale. Sixteen surgical interns participated during intern orientation and 100% of the participants completed the post curriculum survey. RESULTS: Thirteen (81%) of participants agreed or strongly agreed that the simulation would impact future performance in the pediatric trauma bay. The curriculum also significantly improved the confidence of our learners to perform trauma surveys (p < 0.001). CONCLUSION: This curriculum improves the confidence of junior surgical residents in learning the primary and secondary survey. Most learners enjoyed the session and felt that the curriculum would positively impact their performance.

National rotavirus vaccination programme implementation and gastroenteritis presentations: the paediatric emergency medicine perspective.

BACKGROUND: Throughout the developed world, the introduction of rotavirus vaccination has led to reductions in the incidence and severity of acute gastroenteritis (AGE) in young children and consequently to reductions in paediatric emergency department (PED) attendances with AGE. Rotavirus vaccination was added to the Irish National Immunisation Schedule in November 2016. AIMS: To assess the impact of vaccine introduction on citywide PED attendances and hospital admissions with all-cause AGE during rotavirus season. METHODS: In an observational study, a retrospective search was performed of electronic records in three independent PEDs in Dublin. Weekly presentations and admissions with AGE in the first 30 weeks (gastroenteritis season) of the years 2012-2018 were counted and stratified by age. RESULTS: Median weekly presentations in 2017-2018, 126 (interquartile range (IQR) 103-165) were significantly lower than in 2012-2016, 160 (IQR 128-214) (p < 0.001). A reduction in presentations was seen across the three hospitals and in those aged less than 5 years. In one PED, median admissions in 2017-2018 were 10 (IQR 7-13) in comparison with nine (IQR 7-13) in 2012-2016, (p = 0.463). The emergency department AGE presentations to hospital ward admission rate was 6.7:1. CONCLUSION: A reduction in PED presentations with AGE is demonstrated post-rotavirus vaccine introduction into the Irish National Immunisation Schedule. No significant change in paediatric hospital admissions was demonstrated.

Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study.

OBJECTIVES: We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome. METHODS: This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED). We enrolled children who presented to an ED with an extremity injury and received radiographs. ED physicians documented their radiograph interpretation, which was compared to a radiology reference standard. Patients received telephone follow-up and had institutional medical records reviewed in 3 weeks. An AE occurred if there were clinical sequelae and/or repeat health care visits due to a delay in correct radiograph interpretation. RESULTS: We enrolled 2,302 children (mean [±SD] age = 9.0 [4.4] years; 1,288 (56.0%) male]. Of these, 180 (7.8%; 95% confidence interval = 6.8 to 9.0) ED physician discordant interpretations resulted in an AE. Specifically, there were no negative clinical outcomes; however, relative to cases diagnosed correctly at the index ED, patients whose fracture was not initially identified encountered 77.2% more subsequent ED visits, while those falsely diagnosed with a fracture experienced 41.5% additional orthopedic clinic visits. Odds of an ED discrepant interpretation was significantly higher if a physician's pretest probability of a fracture was ≤ 20% versus> 20% (adjusted odds ratio [aOR] = 1.6), patient's pain score was ≤ 2 versus> 2 (aOR = 1.6), and injury was located in a joint versus other location (aOR = 1.7). CONCLUSIONS: Emergency physician discordant pediatric MSK radiograph interpretations that resulted in an AE occurred with regular frequency in a pediatric ED setting. AEs were primarily an increase in subsequent health care visits. Importantly, a low clinical suspicion for a fracture or injury located in the joint were risk factors for ED physician discordant interpretations.

Immersive simulation training at 6-week intervals for 1 year and multidisciplinary team performance scores: a randomized controlled trial of simulation training for life-threatening pediatric emergencies. / El efecto de las simulaciones inmersivas repetidas cada 6 semanas en la evolución del rendimiento de un equipo multidisciplinar durante un año: un ensayo controlado aleatorizado en situaciones pediátricas de riesgo vital.

OBJECTIVES: To demonstrate an effect of 1 year of training using immersive simulations repeated every 6 weeks versus every 6 months to improve the performance of multidisciplinary teams (MDTs) working with children in lifethreatening situations. MATERIAL AND METHODS: Randomized controlled trial in 12 MDTs of emergency responders in France. Each MDT consisted of 4 persons: a physician, a resident, a nurse, and the ambulance driver. Six MDTs participated in 9 different high-fidelity simulations of pediatric shock over the course of a year. Six control MDTs were presented with 3 of the experimental group's simulations at 3 time points (starting point, 6 months, and 1 year). Technical performance was assessed with the Team Average Performance Assessment Scale (TAPAS) and an intraosseous (IO) access performance scale. Nontechnical performance assessment instruments were the Clinical Teamwork Scale (CTS) and, for leadership, the Behavioral Assessment Tool (BAT). Progress over time was analyzed by comparing the 2 groups during the 3 simulations they experienced in common. RESULTS: Performance scores rose significantly over the study period in the experimental group (P=.01 for the TAPAS score, P=.008 for IO access, P=.03 for the CTS score, and P=.02 for the BAT score) but did not change in the control group (P=.46 for TAPAS, P=.55 for IO access, P=.62 for CTS, and P=.58 for BAT). All mean (SD) scores were higher in the experimental group than in the control group in the last session: TAPAS, 55.8 ± 6.3 vs 31.2 ± 10.3, P=.01; IO access, 91.7 ± 8.0 vs 62.9 ± 16.2, P=.01; CTS, 63.2 ± 9.3 vs 47.2 ± 13.1, P=.03; and BAT, 72.8 ± 5.1 vs 51.2 ± 14.3, P=.01). The 6-month assessment showed significant between-group differences on 2 technical performance measures (P=.02 for TAPAS and P=.03 for IO access); the experimental group's scores were higher. We also observed close correlations between the performance of the leader and the group on both nontechnical (rho > 0.9) and technical (rho > 0.7) assessments. CONCLUSION: Simulation-based training should be repeated more than 3 times per year. Our findings suggest the advisability of repeating simulations of infrequent, high-risk scenarios every 6 weeks to improve all performance scores and guarantee acceptable technical and nontechnical performance throughout the year.

OBJETIVO: Demostrar el efecto de simulaciones inmersivas repetidas cada 6 semanas, en comparación con su repetición cada 6 meses, sobre la evolución del rendimiento de un equipo multidisciplinar en situaciones pediátricas de riesgo vital durante un año. METODO: Ensayo controlado aleatorizado unicéntrico que incluyó 12 equipos multidisciplinares (EMD) del servicio de emergencias médicas (SEM) de Francia compuesto por 4 miembros (médico/residente/enfermera/conductor de ambulancia). En el grupo experimental, 6 EMD se enfrentaron a 9 escenarios diferentes de shock pediátrico en simulaciones de alta fidelidad durante un año. En el grupo de control, 6 EMD tuvieron 3 escenarios comunes a los del grupo experimental (inicial, intermedio ­después de seis meses­ y final ­después de un año­). Se evaluó el rendimiento técnico, mediante la Team Average Performance Assessment Scale (TAPAS) y la escala de rendimiento de acceso intraóseo (IO), y el no técnico, mediante la Clinical Teamwork Scale (CTS) y la Behavioral Assessment Tool (BAT) para los líderes. Se analizó la evolución en el tiempo y se compararon los dos grupos durante los simulacros comunes. RESULTADOS: Las puntuaciones del rendimiento se incrementaron significativamente a lo largo del tiempo en el grupo experimental (p = 0,01 para TAPAS, p = 0,008 para IO, p = 0,03 para CTS y p = 0,02 para BAT) en comparación con el grupo control (p = 0,46 para TAPAS, p = 0,55 para IO, p = 0,62 para CTS y p = 0,58 para BAT). Todas las puntuaciones fueron más altas en el grupo experimental que en el grupo control durante la última sesión (55,8 ± 6,3 vs 31,2 ± 10,3, p = 0,01 para TAPAS; 91,7 ± 8,0 vs 62,9 ± 16,2, p = 0,01 para IO, 63,2 ± 9,3 vs 47,2 ± 13,1, p = 0,03 para CTS; y 72,8 ± 5,1 vs 51,2 ± 14,3, p = 0,01 para BAT). Se observó una diferencia significativa en las dos escalas de puntuación de rendimiento técnico (p = 0,02 para TAPAS y p = 0,03 para IO) a favor del grupo experimental durante la sesión intermedia. También hubo una estrecha relación entre los rendimientos del líder y del equipo, tanto para el rendimiento no técnico (rho > 0,9) como el técnico (rho > 0,7). CONCLUSIONES: La formación basada en la simulación debería repetirse más de tres veces al año. Nuestros resultados favorecen la repetición de una situación poco común de alto riesgo cada seis semanas para mejorar todas las escalas de puntuación de rendimiento y garantizar puntuaciones aceptables de rendimiento técnico y no técnico durante un año.

Quality, Trustworthiness, Readability, and Accuracy of Medical Information Regarding Common Pediatric Emergency Medicine-Related Complaints on the Web.

BACKGROUND: The Internet is a universal source of information for parents of children with acute complaints. OBJECTIVES: We sought to analyze information directed at parents regarding common acute pediatric complaints. METHODS: Authors searched three search engines for four complaints (child + fever, vomiting, cough, stomach pain), assessing the first 20 results for each query. Readability was evaluated using: Flesch-Kincaid Grade Level, Gunning Fog, Simple Measure of Gobbledygook, and the Coleman-Liau Index. Two reviewers independently evaluated Journal of the American Medical Association (JAMA) Benchmark Criteria and National Library of Medicine (NLM) Trustworthy scores. Two physicians (emergency medicine/EM, pediatric EM) analyzed text accuracy (number correct divided by total number of facts). Disagreements were settled by a third physician. Accuracy was defined as ≥ 95% correct, readability as an 8th-grade reading level, high quality as at least three JAMA criteria, and trustworthiness as an NLM score ≥ 3. Accurate and inaccurate websites were compared using chi-squared analysis and Mann-Whitney U test. RESULTS: Eighty-seven websites (60%) were accurate (k = 0.94). Sixty (42%) of 144 evaluable websites were readable, 38 (26%) had high-quality JAMA criteria (kappa/k = 0.68), and 44 (31%) had reliable NLM trustworthy scores (k = 0.66). Accurate websites were more frequently published by professional medical organizations (hospitals, academic societies, governments) compared with inaccurate websites (63% vs. 33%, p < 0.01). There was no association between accuracy and physician authorship, search rank, quality, trustworthiness, or readability. CONCLUSION: Many studied websites had inadequate accuracy, quality, trustworthiness, and readability. Measures should be taken to improve web-based information related to acute pediatric complaints.

Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management.

OBJECTIVES: Few studies have evaluated impact of emergency department (ED) management on delayed transfers to the pediatric intensive care unit (PICU). Our study objectives were to describe patient characteristics of PICU transfers less than or equal to 12 hours of admission and determine the reason for transfer. METHODS: We conducted a retrospective chart review of patients transferred to PICU less than or equal to 12 hours of admission. We extracted patient demographics, emergency severity index category, ED, floor and PICU length of stay (LOS), and PICU "significant" interventions. Charts were reviewed independently by the study principal investigator and a PICU attending who classified transfers as secondary to progression of disease or error in ED management. Furthermore, errors were classified as diagnostic, management, or disposition errors. RESULTS: A total of 164 patients met inclusion criteria. Most were male (86/164, 52.4%), with emergency severity index category 2 (116/164, 70.7%) and respiratory diagnosis (98/164, 59.8%). Most transfers (136/164, 82.9%) resulted from progression of illness. No significant interventions were performed in 48.8% (80/164) of patients. Of 164 transfers, 28 (17.1%) resulted from ED error, and half of these were management errors. Compared with disease progression, the ED error group had a significantly shorter median floor LOS {3.45 [interquartile range (IQR): 2.15, 7.56] vs 6.58 (IQR: 3.70, 9.20); P = 0.005}, more PICU interventions [1.5 (IQR: 0, 4) vs 0 (IQR: 0, 2); P = 0.006], and longer PICU LOS [2.50 (IQR: 1.09, 4.25) vs 1.36 (IQR: 0.80, 2.50); P = 0.013]. CONCLUSIONS: Most PICU transfers less than or equal to 12 hours after admission result from illness progression. Half of these do not require significant interventions. The PICU transfers after ED management error had significantly shorter floor LOS, longer PICU LOS, and more interventions.

Implementation of a Highly Accurate Rapid Point-of-Care Test for Group a Streptococcus Detection at a Large Pediatric Emergency Department in South London.

Rapid group A Streptococcus point-of-care testing is not currently used in the United Kingdom in the management of acute tonsillitis. This prospective, observational study describes a strong association between a molecular-based point-of-care testing result and outpatient antibiotic prescribing (odds ratio = 48; P < 0.001) in 339 children seen at our center. It highlights challenges in implementing new rapid diagnostics.

Does Mentoring by Orthopedic Surgeons Improve Forearm Fracture Reduction Outcomes by Pediatric Emergency Physicians? Evaluation of a Process Improvement Intervention Program.

BACKGROUND: Forearm fractures are among the most frequently encountered orthopedic injuries in children. The maintenance of satisfactory alignment can be problematic and postreduction displacement with resultant malunion can occur. OBJECTIVES: The objective of the study was to evaluate pediatric emergency medicine (PEM) physicians' performance on forearm fracture reduction to determine the impact of a Process Improvement Intervention Program (PIIP) on postreduction displacement rates after initial reduction. The PIIP was designed to improve our PEM physicians' skills and knowledge in how to properly apply and mold casts to better maintain the alignment of reduced forearm fractures. METHODS: A PIIP was implemented during 2015-2016 when orthopedic surgeons mentored postfellowship-trained PEM physicians. Patient cohorts from pre- and post-PIIP implementation were investigated and compared to evaluate the impact of the PIIP on PEM physicians' initial fracture reduction success rates and postreduction displacement rates. Descriptive and analytical statistics including univariate and multivariate models were tested to understand changes in physicians' performance. RESULTS: Pre- and postcohorts had similar demographic and clinical characteristics and similarly high initial reduction success rates. When distal and midshaft fracture types were combined, there was no significant difference in postreduction displacement rates between the 2 cohorts, but when stratified based on fracture type, the distal radius postcohort showed a statistically significant improvement in postreduction maintenance. CONCLUSIONS: A PIIP by pediatric orthopedic surgeons did not change the PEM physicians' initial fracture reduction success rate, but it did result in a statistically significant improvement in maintenance of reduction rates.

Error traps and culture of safety in pediatric trauma.

Trauma is the leading cause of morbidity and mortality in the pediatric population. Due to a variety of factors, many pediatric trauma patients are initially evaluated and stabilized at adult hospitals that lack pediatric specific emergency medicine and surgical expertise. While similar to adult patients, the initial evaluation and resuscitation of pediatric patients does differ. Many of these key differences contribute to missed injury and susceptibility to error in the treatment of children. Here, we highlight a variety of differences between pediatric and adult trauma patients and clarify reasoning for these differences. Error traps that are discussed include missed cases of non-accidental trauma, missed blunt cerebrovascular injury, over use of CT (computed tomography) scans with unnecessary radiation exposure, missed small bowel or mesenteric injury, and unrecognized hemodynamic instability.