Decreased Pediatric Trauma Length of Stay and Improved Disposition With Implementation of Lewin's Change Model.

Although often cared for nonoperatively, trauma is a surgical disease managed by surgical services in a multidisciplinary manner. The American College of Surgeons Committee on Trauma (ACS COT) emphasizes this as part of the ACS COT verification process and expects nonsurgical service admission rate of less than 10%. In this project, we developed a collaborative care model captained by surgical services with medical service consultation to achieve this goal for optimal care of injured patients. The project was conducted at a freestanding pediatric trauma center undergoing verification as a Level 1 ACS COT pediatric trauma center. The trauma registry was utilized to obtain nonsurgical service admission rate from January 2011 to June 2015. Lewin's 3-Step Model was utilized to guide change. Adherence to the new ACS standards was continually tracked and fallouts were addressed on an individual basis. Overall compliance was reported routinely through trauma and hospital quality programs. Individual successes and accomplishments were recognized and reinforced. At the inception of the project, nonsurgical admission rate was 30%. Implementation of Lewin's 3-Step Model nonsurgical admission rate decreased to 3%, representing a reduction of 27%. In addition, a 21% reduction in hospital length of stay, 3.78-3 days, was demonstrated with no change in 30-day readmission rate. Lewin's change model facilitated culture change to achieve ACS COT standards and reduced nonsurgical admissions to less than 10%. Reduction in hospital length of stay supports an improvement in the efficiency of care when directed by the pediatric trauma surgery team.

Closed-Loop Communication Improves Task Completion in Pediatric Trauma Resuscitation.

BACKGROUND: Pediatric trauma care requires effective and clear communication in a time-sensitive manner amongst a variety of disciplines. Programs such as Crew Resource Management in aviation have been developed to systematically prevent errors. Similarly, teamSTEPPS has been promoted in healthcare with a strong focus on communication. We aim to evaluate the ability of closed-loop communication to improve time-to-task completion in pediatric trauma activations. METHODS: All pediatric trauma activations from January to September, 2016 at an American College of Surgeons verified level I pediatric trauma center were video recorded and included in the study. Two independent reviewers identified and classified all verbal orders issued by the trauma team leader for order audibility, directed responsibility, check-back, and time-to-task-completion. The impact of pre-notification and level of activation on time-to-task-completion was also evaluated. All analyses were performed using SAS® version 9.4(SAS Institute Inc., Cary, NC). RESULTS: In total, 89 trauma activation videos were reviewed, with 387 verbal orders identified. Of those, 126(32.6%) were directed, 372(96.1%) audible, and 101(26.1%) closed-loop. On average each order required 3.85 minutes to be completed. There was a significant reduction in time-to-task-completion when closed-loop communication was utilized (p < 0.0001). Orders with closed-loop communication were completed 3.6 times sooner as compared to orders with an open-loop [HR = 3.6 (95% CI: 2.5, 5.3)]. There was not a significant difference in time-to-task-completion with respect to pre-notification by emergency service providers (p < 0.6100). [HR = 1.1 (95% CI: 0.9, 1.3)]. There was also not a significant difference in time-to-task-completion with respect to level of trauma team activation (p < 0.2229). [HR = 1.3 (95% CI: 0.8, 2.1)]. CONCLUSION: While closed-loop communication prevents medical errors, our study highlights the potential to increase the speed and efficiency with which tasks are completed in the setting of pediatric trauma resuscitation. Trauma drills and systems of communication that emphasize the use of closed-loop communication should be incorporated into the training of trauma team leaders. LEVEL OF EVIDENCE: This is a prospective observational study with intervention level II evidence.

Reduction of pediatric pedestrian hazardous road conditions in a school drop-off zone using video review.

BACKGROUND: In 2012, 76,000 pedestrians were struck by motor vehicles. This resulted in 20% of all pediatric mortalities between the ages of 5 and 15. We hypothesize that children are exposed to increased risk as pedestrians to motor vehicle injury when arriving to school and that identification of these hazards would improve targeting of injury prevention efforts. METHODS: Within a county containing 355 public schools, we identified a primary school with 588 students located in an urban setting with concerns for a high-risk traffic environment. Field surveys observed traffic patterns and established an optimal surveillance period 30 minutes before school. Three observation periods, from two discreet and blinded locations, were conducted from January to March 2016. Videos were evaluated by two independent reviewers to identify and score quantifiable hazards. Three controlled observations were conducted on non-school days, followed by three post-intervention observations from October to December 2016. Comparison was made using Student's t test. Data was analyzed using SAS version 9.4 (SAS Institute Inc., Cary, NC). RESULTS: We identified nine safety hazards including double parking (29.3 ± 5.5), dropping off in a bus stop (23.3 ± 7.6), and jaywalking (9.3 ± 3.1). Combining all hazards seen in each observation resulted in an overall hazard average of 83.0 ± 3.6 events/period. Comparing control periods to school observation identified significantly increased hazard events on school days (p < 0.0001). Targeted safety intervention demonstrated a 26% reduction in hazard events (p < 0.0005). CONCLUSION: We identified the most common hazards associated with children arriving at a primary school in an urban setting, used our analysis to develop an intervention, and demonstrated the impact of our intervention. Our novel use of video review to identify hazards provides a metric against which the impact of pedestrian road safety interventions might be measured. LEVEL OF EVIDENCE: Epidemiological, level II; Therapeutic, level IV.