Preparing for an American College of Surgeons Virtual Trauma Reverification Site Visit: One Center's Experience.

BACKGROUND: The American College of Surgeons (ACS), Committee on Trauma, trauma center verification process is designed to help hospitals improve trauma care. Due to the COVID-19 pandemic social distancing restrictions, performing virtual site visits was piloted. OBJECTIVE: The purpose of this article is to describe the first pilot ACS pediatric trauma center virtual reverification visit performed in the United States. METHODS: This is a descriptive review of a 2020 pilot virtual Level I pediatric trauma center reverification visit. In-person site visit checklists were altered to adjust to the virtual format. All documents, prereview questionnaire, patient charts, and resource documents were prepared electronically. Collaboration with the departments of information technology, clinical education and informatics, and the general counsel's office prepared the infrastructure to allow reviewers access to protected health information. RESULTS: Multiple hospital departments collaborated to facilitate the transition to an electronic format. Organized virtual meeting room scheduling, communications, and coordination between the ACS staff, the reviewers, and the various hospital departments resulted in a successful virtual visit. CONCLUSION: Lessons learned and opportunities for improvement were identified for this first-ever pilot virtual pediatric trauma center reverification site visit. Once the information technology logistic questions were answered, allowing reviewers protected health information access, the general program and document preparation for a virtual trauma reverification site visit was similar to an in-person site visit. Although the review day agenda was similar, execution challenges were identified.

Moving Toward Standardized Pediatric Performance Improvement Measures in Child Physical Abuse: A Modified Delphi Approach.

BACKGROUND: Limited guidance exists for pediatric trauma centers (PTCs) regarding best practice for measuring and reviewing performance improvement (PI) in the child physical abuse population. To move PTC programs toward standardized guidelines and PI practices, current practice and points of consensus among level 1 and 2 PTCs across the United States were assessed. METHODS: Utilizing a two-round, modified Delphi methodology, electronic surveys were distributed to pediatric trauma program managers and coordinators representing 125 PTCs. Survey data included demographics, coding practices, definitions, current PI measures, prevention programs, and opinions regarding key components of child physical abuse guidelines. RESULTS: In Round 1, responses were received from 90 (72%) PTCs [47 (84%) ACS-verified level 1 PTCs; 29 (73%) ACS-verified level 2 PTCs; and 14 (48%) state PTCs]. Of the respondents, 87% agreed that establishing a national consensus for child physical abuse PI is important, and 92% agreed that their institution would benefit from standardized guidelines. Although PI process varied among PTCs in terms of measures, review, and coding practices, several points of consensus were achieved. CONCLUSION: Survey results demonstrate areas of consistency and a foundation for consensus among PTCs. Results also identify areas of practice diversity that may benefit from an attempt to standardize PI across centers.

Twenty-years of splenic preservation at a level 1 pediatric trauma center.

BACKGROUND: Splenic preservation is the standard of care for hemodynamically stable children with splenic injuries. We report a 20-year single-institutional series of children with splenic injuries managed without a splenectomy. METHODS: Children evaluated and treated for blunt splenic injury at Boston Children's Hospital from 1994 to 2014 were extracted from the trauma registry. Demographics, clinical characteristics, complications, and outcomes were reviewed. Three time-periods were evaluated based upon the development and modification of splenic injury clinical pathway guidelines (CPGs). Survival was defined as being discharged from the hospital alive. RESULTS: 502 suffered isolated splenic injuries. The median AAST grade of splenic injury increased across the three CPG time periods (p<0.001). No splenic-injury related mortalities occurred. Hospital length of stay decreased significantly secondary to splenic injury CPGs (p<0.001). 99% of the patients were discharged home. CONCLUSION: In children managed over the last 20years for isolated splenic injury, no patient died or underwent splenectomy. Hospital length of stay decreased across time, despite an increase in the severity of splenic injuries encountered. Splenectomy has become so unusual in the management of hemodynamically stable children with a splenic injury that it may no longer be a legitimate outcome marker.

Successful percutaneous management of traumatic abdominal compartment syndrome in a child.

Posttraumatic abdominal compartment syndrome (ACS) is an unusual and potentially lethal entity in pediatric patients. Early recognition and/or prevention of the syndrome, as well as prompt treatment of ACS, can reduce its associated morbidity and mortality but has traditionally required a laparotomy. Herein, we describe a case of posttraumatic ACS successfully treated percutaneously.

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.

OBJECTIVE: We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. BACKGROUND: Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. METHODS: A collaborative effort among Boston's trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. RESULTS: A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. CONCLUSIONS: Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

An Inpatient Child Passenger Safety program.

Background. Our institution implemented an Inpatient Child Passenger Safety (CPS) program for hospitalized children to improve knowledge and compliance with the Massachusetts CPS law, requiring children less than 8 years old or 57 inches tall to be secured in a car seat when in a motor vehicle. Methods. After the Inpatient CPS Program was piloted on 3 units in 2009, the program was expanded to all inpatient units in 2010. A computerized nursing assessment tool identifies children in need of a CPS consult for education and/or car seat. Results. With the expanded Inpatient CPS Program, 3650 children have been assessed, 598 consults initiated, and 325 families have received CPS education. Car seats were distributed to 419 children; specialty car seats were loaned to 134 families. Conclusions. With a multidisciplinary approach, we implemented an Inpatient CPS Program for hospitalized children providing CPS education and car seats to families in need.

Who will care for me? The debate of orphanages versus foster care.

The issue of how best to address current problems in the foster care system while at the same time considering past problems with the orphanage concept is a cause of national debate. Among the questions being examined are, is a return to orphanage care feasible and if so, would the re-creation of orphanages benefit the children who would be placed in them. The advanced practice nurse is perfectly situated to participate in this discussion and to advance a theory of harmony by addressing social, economic, and political factors within a patient's environment. Nurse practitioners can also fill an important gap in care for these children who often suffer the consequences of well-intentioned but flawed child care systems.