Implementation of a Pharmacist-Led Antimicrobial Time-Out for Medical-Surgery Services in an Academic Pediatric Hospital.

OBJECTIVE: This report describes a quality improvement initiative to implement a pharmacist-led antimicrobial time-out (ATO) in a large, freestanding pediatric hospital. Our goal was to reach 90% ATO completion and documentation for eligible patients hospitalized on general pediatric medicine or surgery services. METHODS: A multidisciplinary quality improvement team developed an ATO process and electronic documentation tool. Clinical pharmacists were responsible to initiate and document an ATO for pediatric medicine or surgery patients on or before the fifth calendar day of therapy. The quality improvement team educated pharmacists and physicians and provided ATO audit and feedback to the pharmacists. We used statistical process control methods to track monthly rates of ATO completion retrospectively from October 2017 through March 2018 and prospectively from April 2018 through April 2019. Additionally, we retrospectively evaluated the completion of 6 data elements in the ATO note over the final 12-month period of the study. RESULTS: Among 647 eligible antimicrobial courses over the 19-month study period, the mean monthly documentation rate increased from 54.6% to 83.5% (p < 0.001). The mean ATO documentation rate increased from 32.8% to 74.2% (p < 0.001) for the pediatric medicine service and from 65.0% to 88.1% for the pediatric surgery service (p = 0.006). Among 302 notes assessed for completeness, 35.8% had all the required data fields completed. A tentative antimicrobial stop date was the data element completed least often (49.3%). CONCLUSIONS: We implemented a pharmacist-led ATO, highlighting the role pharmacists play in antimicrobial stewardship. Additional efforts are needed to further increase ATO completion rates and to define treatment duration.

Plan-Do-Study-Act Methodology: Refining an Inpatient Pediatric Sepsis Screening Process.

Pediatric sepsis remains a leading cause of death of children in the United States. Timely recognition and treatment are critical to prevent the onset of severe sepsis and septic shock. Electronic screening tools aid providers in identifying patients at risk for sepsis. Our overall project goal was to decrease the number of sepsis-related emergent transfers to the pediatric intensive care unit by optimizing sepsis screening tools, interruptive alerts, and a new paper tool and huddle process using Plan-Do-Study-Act (PDSA) methodology. METHODS: Our team utilized historical data to develop inpatient electronic sepsis screening tools to identify pediatric patients at risk for sepsis. Using PDSA iterative cycles over 3 months, we tested the design of an interruptive alert, paper tool, and a new sepsis huddle process. RESULTS: During the PDSA, the clinical teams conducted huddles on all patients who received an interruptive alert (n = 35). Eighty percent of huddles had a 5.7 minute average response time and an average duration of 5.3 minutes. Completion of the huddle outcome notes occurred 83% of the time, and 70% had feedback related to the alert, paper form, and huddle process. The number of days between sepsis-related emergent transfers to the pediatric intensive care unit increased from a median of 17.5 to 57.5 days, with a single point as high as 195 days between events. CONCLUSIONS: The inpatient sepsis team learned valuable lessons using PDSA methodology. The results of the iterative cycles allowed the team to optimize and refine the tests of change. System-wide implementation benefited from the application of this quality improvement tool.

The Cancer Care Index: A Novel Metric to Assess Overall Performance of a Pediatric Oncology Program.

OBJECTIVE: Childhood cancer metrics are currently primarily focused on survival rates and late effects of therapy. Our objectives were to design and test a metric that reflected overall quality and safety performance, across all cancer types, of an oncology-bone marrow transplant service line and to use the metric to drive improvement. METHOD: The Cancer Care Index (CCI) aggregates adverse safety events and missed opportunities for best practices into a composite score that reflects overall program performance without regard to cancer type or patient outcome. Fifteen domains were selected in 3 areas as follows: (1) treatment-related quality and safety, (2) provision of a harm-free environment, and (3) psychosocial support. The CCI is the aggregate number of adverse events or missed opportunities to provide quality care in a given time frame. A lower CCI reflects better care and improved overall system performance. Multidisciplinary microsystem-based teams addressed specific aims for each domain. The CCI was widely followed by all team members, particularly frontline providers. RESULTS: The CCI was easy to calculate and deploy and well accepted by the staff. The annual CCI progressively decreased from 278 in 2012 to 160 in 2014, a 42% reduction. Improvements in care were realized across most index domains. Multiple new initiatives were successfully implemented. CONCLUSIONS: The CCI is a useful metric to document performance improvement across a broad range of domains, regardless of cancer type. By the use of quality improvement science, progressive reduction in CCI has occurred over a 3-year period.

Comparison of manual and computer assigned injury severity scores.

BACKGROUND: The study objective was to compare the ISS manually assigned by hospital personnel and those generated by the ICDPIC software for value agreement and predictive power of length of stay (LOS) and mortality. METHODS: We used data from the 2010-2016 trauma registry of a paediatric trauma centre (PTC) and 2014 National Trauma Data Bank (NTDB) hospitals that reported manually coded ISS. Agreement analysis was performed between manually and computer assigned ISS with severity groupings of 1-8, 9-15, 16-25 and 25-75. The prediction of LOS was compared using coefficients of determination (R2) from linear regression models. Mortality predictive power was compared using receiver operating characteristic (ROC) curves from logistic regression models. RESULTS: The proportion of agreement between manually and computer assigned ISS in PTC data was 0.84 and for NTDB was 0.75. Analysing predictive power for LOS in the PTC sample, the R2=0.19 for manually assigned scores, and the R2=0.15 for computer assigned scores (p=0.0009). The areas under the ROC curve indicated a mortality predictive power of 0.95 for manually assigned scores and 0.86 for computer assigned scores in the PTC data (p=0.0011). CONCLUSIONS: Manually and computer assigned ISS had strong comparative agreement for minor injuries but did not correlate well for critical injuries (ISS=25-75). The LOS and mortality predictive power were significantly higher for manually assigned ISS when compared with computer assigned ISS in both PTC and NTDB data sets. Thus, hospitals should be cautious about transitioning to computer assigned ISS, specifically for patients who are critically injured.

A new weighted injury severity scoring system: better predictive power for adult trauma mortality.

BACKGROUND: An accurate injury severity measurement is essential in the evaluation of trauma care and in outcome research. The traditional Injury Severity Score (ISS) does not consider the differential risks of the Abbreviated Injury Scale (AIS) from different body regions, and the three AIS involved in the calculation of ISS are given equal weights. The objective of this study was to develop a weighted injury severity scoring (wISS) system for adult trauma patients with better predictive power than the traditional Injury Severity Score (ISS). METHODS: The 2007-2014 National Trauma Data Bank (NTDB) Research Datasets were used. We identified adult trauma patients from the NTDB and then randomly split it into a study sample and a test sample. Based on the association between mortality and the Abbreviated Injury Scale (AIS) from each of the six ISS body regions in the study sample, we evaluated 12 different sets of weights for the component AIS scores used in the calculation of ISS and selected one best set of weights. Discrimination (areas under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, concordance) and calibration were compared between the wISS and ISS. RESULTS: The areas under the receiver operating characteristic curves from the wISS and ISS are all 0.83, and 0.76 vs. 0.73 for patients with ISS = 16-74 and 0.68 vs. 0.53 for patients with ISS = 25-74. The wISS showed higher specificity, positive predictive value, negative predictive value, and concordance when they were compared at similar levels of sensitivity. The wISS had better calibration than the ISS. CONCLUSIONS: By weighting the AIS from different body regions, the wISS had significantly better predictive power for mortality than the ISS, especially in critically injured adults.

Clinical Decision Support Tools and a Standardized Order Set Enhances Early Enteral Nutrition in Critically Ill Children.

BACKGROUND: Critically ill children in a pediatric intensive care unit (PICU) have unique nutrition needs that are challenging to achieve and thus are at high risk of malnutrition. There is increasing evidence that children who reach caloric goals early have improved outcomes. The purpose of this initiative was to implement an enteral nutrition (EN) algorithm in a tertiary care PICU utilizing clinical decision support tools (CDSTs) and a standardized order set within an electronic health record. METHODS: A quality improvement initiative was undertaken to implement an EN feeding protocol using electronic CDSTs, including a new standardized order set. RESULTS: In a historical cohort of 376 patients, only 18% met goal EN in the first 48 hours of admission. The EN protocol was implemented in 272 patients who met 88% goal feed volume within 48 hours of intensive care unit admission. Median time to start EN (1.7 vs 1.3 days, P < 0.0001) and time to goal nutrition (2.8 vs 2.2 days, P < 0.001) improved after project implementation. Length of stay in the PICU was significantly reduced following protocol implementation (202 hours pre-implementation vs 156 hours post implementation, P < 0.0001). CONCLUSIONS: We used CDSTs and standardized order sets to implement a nutrition algorithm to facilitate and likely improve the nutrition care of critically ill children.

Using podcasts to deliver pediatric educational content: Development and reach of PediaCast CME.

OBJECTIVE: Pediatricians have used podcasts to communicate with the public since 2006 and medical students since 2008. Previous work has established quality criteria for medical education podcasts and examined the benefit of offering continuing medical education (CME) credit for online activities. This is the first descriptive study to outline the development and reach of a pediatric podcast that targets post-graduate healthcare providers, enhances communication by incorporating quality criteria, and offers free accredited CME to listeners. METHODS: We produced 26 podcast episodes from March 2015 to May 2017. Episodes incorporated quality criteria for medical education podcasts and offered free CME credit. They were published on a website, available for listening on multiple digital platforms and promoted through several social media channels. Data were analyzed for frequency of downloads and geographic location of listeners. RESULTS: The cumulative total of episode downloads was 91,159 with listeners representing 50 U.S. states and 108 countries. Podcast listenership grew over time. Individual episodes had their largest number of downloads immediately following release, but continued recruiting new listeners longitudinally, suggesting use of the archive as an "on-demand" source of educational content. CONCLUSIONS: Pediatric podcasts that incorporate quality criteria and offer free CME credit can be used to deliver educational content to a large global audience of post-graduate healthcare providers. Since podcast communication is rapidly growing, future work should focus on identifying the professional roles of listeners; exploring listener perceptions of quality, value and satisfaction; and examining podcast impact on knowledge transfer, clinical practice, public policy and health outcomes.

Automating a Manual Sepsis Screening Tool in a Pediatric Emergency Department.

OBJECTIVE: This article describes the method of integrating a manual pediatric emergency department sepsis screening process into the electronic health record that leverages existing clinical documentation and keeps providers in their current, routine clinical workflows. METHODS: Criteria in the manual pediatric emergency department sepsis screening tool were mapped to standard documentation routinely entered in the electronic health record. Data elements were extracted and scored from the medical history, medication record, vital signs, and physical assessments. Scores that met a predefined sepsis risk threshold triggered interruptive system alerts which notified emergency department staff to perform sepsis huddles and consider appropriate interventions. Statistical comparison of the new electronic tool to the manual process was completed by a two-tail paired t-test. RESULTS: The performance of the pediatric electronic sepsis screening tool was evaluated by comparing flowsheet row documentation of the manual, sepsis alert process against the interruptive system alert instance of the electronic sepsis screening tool. In an 8-week testing period, the automated pediatric electronic sepsis screening tool identified 100% of patients flagged by the manual process (n = 29), on average, 68 minutes earlier. CONCLUSION: Integrating a manual sepsis screening tool into the electronic health record automated identification of pediatric sepsis screening in a busy emergency department. The electronic sepsis screening tool is as accurate as a manual process and would alert bedside clinicians significantly earlier in the emergency department course. Deployment of this electronic tool has the capability to improve timely sepsis detection and management of patients at risk for sepsis without requiring additional documentation by providers.

A new weighted injury severity scoring system: Better predictive power for pediatric trauma mortality.

BACKGROUND: An accurate injury severity measurement is essential for the evaluation of pediatric trauma care and outcome research. The traditional Injury Severity Score (ISS) does not consider the differential risks of the Abbreviated Injury Scale (AIS) from different body regions nor is it pediatric specific. The objective of this study was to develop a weighted ISS (wISS) system for pediatric blunt trauma patients with better predictive power than ISS. METHODS: Based on the association between mortality and AIS from each of the six ISS body regions, we generated different weights for the component AIS scores used in the calculation of ISS. The weights and wISS were generated using the National Trauma Data Bank. The Nationwide Emergency Department Sample (NEDS) was used to validate our main results. Pediatric blunt trauma patients younger than 16 years were included, and mortality was the outcome. Discrimination (areas under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, concordance) and calibration (Hosmer-Lemeshow statistic) were compared between the wISS and ISS. RESULTS: The areas under the receiver operating characteristic curves from the wISS and ISS are 0.88 versus 0.86 in ISS of 1 to 74 and 0.77 versus 0.64 in ISS of 25 to 74 (p < 0.0001). The wISS showed higher specificity, positive predictive value, negative predictive value, and concordance when they were compared at similar levels of sensitivity. The wISS had better calibration (smaller Hosmer-Lemeshow statistic) than the ISS (11.6 vs. 19.7 for ISS = 1-74 and 10.9 vs. 12.6 for ISS = 25-74). The wISS showed even better discrimination with the Nationwide Emergency Department Sample. CONCLUSION: By weighting the AIS from different body regions, the wISS had significantly better predictive power for mortality than the ISS, especially in critically injured children. LEVEL OF EVIDENCE AND STUDY TYPE: Prognostic/epidemiological, level IV.

Managing moderately injured pediatric patients without immediate surgeon presence: 10 years later.

PURPOSE: Beginning in 2003, the pediatric emergency medicine (PEM) physician replaced the surgeon as the team leader for all level II trauma resuscitations at a busy pediatric trauma center. The purpose was to review the outcomes 10 years after implementing this practice change. METHODS: Trauma registry data for all level II activations requiring admission were extracted for the 21 months (April 1, 2001-December 31, 2002) prior to policy change (period 1, **n=627) and compared to the admitted patients from the 10 subsequent years (2003-2013; period 2, n=2694). Data included demographics, length of stay (LOS), injury severity score (ISS), readmissions, complications, and mortality. RESULTS: Mean ISS scores for admitted patients during period 1 (8.5) were higher than during period 2 (7.8). During period 1, 53.6% of patients underwent abdominal CT versus 41.8% in period 2 (p<.001), and the median ED LOS was 135 versus 191 minutes in period 2. From 2000 to 2003, 91% of patients seen as level II trauma alerts were admitted compared to 56.6% of patients in period 2 (p<0.001). There were no missed abdominal injuries identified, and readmission rate was low. CONCLUSIONS: We conclude that level II trauma resuscitations can be safely evaluated and managed without immediate surgeon presence. Although ED LOS increased, admission rate and CT scan usage decreased significantly without an increase in missed injuries.

Symptoms of Persistent Behavior Problems in Children With Mild Traumatic Brain Injury.

OBJECTIVE: To investigate the effects of mild traumatic brain injury (mTBI) in children on symptom ratings of behavior problems across the first-year postinjury. SETTING: Emergency departments of 2 regional children's hospitals. PARTICIPANTS: Parents of 176 children with mTBI and 90 children with orthopedic injury aged 8 to 15 years. DESIGN: Group comparisons of postinjury parent and teacher ratings of child behavior problems controlling for background factors. MAIN MEASURES: Child Behavior Checklist and Teacher's Report Form. RESULTS: For younger but not older children in the sample, children with mTBI compared with children with orthopedic injury had higher postinjury ratings on the Child Behavior Checklist Total Behavior Problem scale (t264 = 3.34, P < .001) and higher rates of T-scores of 60 or more on this scale (odds ratio = 3.00; 95% confidence interval, 1.33-6.77; P = .008). For children with mTBI, hospitalization, motor vehicle accidents, loss of consciousness, and magnetic resonance imaging abnormality were associated with higher parent or teacher ratings. CONCLUSIONS: School-aged children with mTBI are at risk for persistent symptoms of behavior problems, especially if mTBI is more severe or occurs at a younger age. The findings justify monitoring of behavior long after injury and further research to identify risk factors for these symptoms and their association with clinical disorders.

Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury.

OBJECTIVE To examine reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury (TBI) over the first year postinjury as compared with children with orthopedic injuries. DESIGN Prospective, longitudinal cohort. SETTING Emergency departments at 2 children's hospitals. PARTICIPANTS Eight- to 15-year-old children with mild TBI (n = 186) or orthopedic injuries (n = 99). MAIN EXPOSURE Closed-head or orthopedic trauma. MAIN OUTCOME MEASURES Parents rated preinjury symptoms retrospectively shortly after injury and postconcussive symptoms at 2 weeks and 3 and 12 months postinjury. A regression-based approach was used to determine whether each child displayed reliable increases in postconcussive symptoms at each postinjury occasion. Health-related quality of life was assessed at 3 and 12 months postinjury. Information regarding children's educational programming was collected at the initial and 12-month assessments. RESULTS Children with mild TBI were significantly more likely than those with orthopedic injuries to show reliable increases in both cognitive and somatic symptoms. Group differences in the likelihood of reliable increases became less common with time for somatic symptoms but persisted to 12 months postinjury for cognitive symptoms. Among children with mild TBI, reliable increases in symptoms were more common among children with loss of consciousness or abnormalities on neuroimaging. Reliable increases in symptoms were associated with significant declines in health-related quality of life and an increased likelihood of educational intervention. CONCLUSION Many children with mild TBI show reliable increases in postconcussive symptoms that are associated with significant functional impairment in their daily lives.

Quality of life in pediatric mild traumatic brain injury and its relationship to postconcussive symptoms.

OBJECTIVES: Mild traumatic brain injury (TBI) and injury-related outcomes such as postconcussive symptoms (PCS) may influence health-related quality of life (HRQOL) in children. METHODS: We evaluated HRQOL in 186 8- to 15-year-old children with mild TBI and 99 children with orthopedic injuries (OI). Parents rated the frequency and severity of PCS at an initial assessment within 2-weeks postinjury and rated HRQOL at 3- and 12-months postinjury. RESULTS: The mild TBI and OI groups did not differ in psychosocial HRQOL, but the mild TBI group showed lower physical HRQOL at the 12-month follow-up. Somatic PCS were a significant predictor of physical HRQOL over time, and both cognitive and somatic PCS were significant predictors of psychosocial HRQOL over time. Children with higher PCS at the initial assessment had lower HRQOL scores at later time points. CONCLUSIONS: Effective management of PCS may be associated with improvements in HRQOL following pediatric mild TBI.

Premorbid child and family functioning as predictors of post-concussive symptoms in children with mild traumatic brain injuries.

STUDY AIM: This study sought to determine whether premorbid child and family functioning accounts for or moderates group differences in post-concussive symptoms following mild traumatic brain injury (TBI) in childhood. METHODS: This prospective, longitudinal cohort study recruited 8- to 15-year-old children, 186 with mild TBI and 99 with orthopedic injuries (OI), from consecutive emergency department admissions. Parents and children rated post-concussive symptoms within 3 weeks of injury and at 1, 3, and 12 months post injury. Parents also provided retrospective ratings of pre-injury symptoms, as well as of premorbid child behavioral adjustment, overall family functioning, and other stressors and resources in the family environment. RESULTS: Children with mild TBI reported more post-concussive symptoms than those with OI, as did their parents, although premorbid child behavioral adjustment and symptoms also were significant predictors of post-concussive symptoms. Group differences in somatic symptoms as reported by parents were more pronounced among children from families that were higher functioning and had more environmental resources. DISCUSSION: Mild TBI during childhood results in more post-concussive symptoms than OI, even after children's premorbid adjustment is taken into account. Counter to expectations, post-concussive symptoms following mild TBI may actually be more apparent among children from higher-functioning families with greater resources.

Do postconcussive symptoms discriminate injury severity in pediatric mild traumatic brain injury?

OBJECTIVES: To assess whether postconcussive symptoms (PCS) can be used to discriminate injury severity among children with mild traumatic brain injury (TBI). PARTICIPANTS: One hundred eighty-six children with mild TBI, divided into high and low injury severity depending on whether the injury was associated with a loss of consciousness (LOC), and a comparison group of 99 children with orthopedic injuries (OI), all aged 8 to 15 years at the time of injury. MAIN MEASURES: Parent-rated frequency and severity of PCS at initial assessment within 2 weeks postinjury and again at 3 and 12 months postinjury. RESULTS: Ratings of PCS obtained at the initial and 3-month assessments differentiated children with mild TBI from OI, although only ratings at the initial assessment discriminated among all 3 groups. Somatic PCS accounted for most of the discriminatory power. CONCLUSIONS: Overall, the accuracy of group classification was relatively modest, with a large proportion of misclassifications of children in the mild-TBI groups. Although children with mild TBI have more PCS than children with OI, PCS do not permit sufficiently accurate discrimination of mild TBI and injury severity to warrant diagnostic decisions at this time.

Coping strategies as a predictor of post-concussive symptoms in children with mild traumatic brain injury versus mild orthopedic injury.

This study examined whether children's coping strategies are related to post-concussive symptoms following mild traumatic brain injury (TBI) versus orthopedic injury (OI). Participants were 8- to 15-year-old children with mild TBI (n = 167) or OI (n = 84). They rated their current preferred coping strategies and post-injury symptoms at 2 weeks (baseline) and 1, 3, and 12 months post-injury. Children's reported use of coping strategies did not vary significantly over time, so their baseline coping ratings were examined as predictors of post-concussive symptoms across time. Self-ratings of symptoms were positively related to emotion-focused strategies and negatively related to problem-focused engagement after both mild TBI and OI. Higher problem-focused disengagement predicted larger group differences in children's ratings of symptoms, suggesting that problem-focused disengagement moderates the effects of mild TBI. Coping strategies collectively accounted for approximately 10-15% of the variance in children's post-concussive symptoms over time. The findings suggest that coping may play an important role in accounting for children's perceptions of post-concussive symptoms after mild TBI.

Agreement between parents and children on ratings of post-concussive symptoms following mild traumatic brain injury.

The level of parent-child agreement on post-concussive symptoms (PCS) was examined in children following mild traumatic brain injuries (TBI). As part of a larger longitudinal study, 186 children with mild TBI and 99 with orthopedic injuries (OI), from 8 to 15 years of age, were recruited prospectively. Parents and children completed the PCS Interview (PCS-I) and the Health and Behavior Inventory (HBI) at 2 weeks, 1 month, 3 months, and 12 months postinjury. Item-level correlations between child and parent ratings on both measures of PCS were significant but modest in both groups. Parent-child correlations for composite scales on the HBI and the total score on the PCS-I were significant in both groups, but somewhat higher in the OI group than in the mild TBI group. Mean symptom ratings tended to be significantly higher for children as compared to parents, especially for somatic symptoms. Parents and children display modest agreement when reporting PCS; their ratings correlate significantly, but children report higher mean levels of symptoms than parents.

Post-concussive symptoms in children with mild traumatic brain injury.

To investigate postconcussive symptoms (PCS) following pediatric mild traumatic brain injury (mTBI), 8- to 15-year-old children with mTBI (n = 186) and a comparison group with uncomplicated orthopedic injuries (OI, n = 99) were recruited from two emergency departments. Parent and child ratings of PCS and symptom counts were obtained within 3 weeks after injury (baseline) and at 1, 3, and 12 months postinjury. The mTBI group also completed magnetic resonance imaging at baseline. Group differences were examined using growth modeling, controlling for age at injury, sex, socioeconomic status, and (for parent-based measures) preinjury symptom levels. Relative to the OI group, the mTBI group had higher ratings of somatic PCS and parent counts of PCS at the initial assessments, but higher parent ratings of cognitive PCS and child counts of PCS throughout follow-up. Higher levels of PCS in the mTBI group were associated with motor-vehicle-related trauma, loss of consciousness, neuroimaging abnormalities, and hospitalization. The findings validate both transient and persistent PCS in children with mTBI and document associations of symptoms with injury and noninjury factors.

Relationships among post-concussive symptoms and symptoms of PTSD in children following mild traumatic brain injury.

PRIMARY OBJECTIVE: To investigate the occurrence of post-concussive symptoms (PCS) and symptoms of post-traumatic stress disorder (PTSD) in children following mild traumatic brain injuries (TBI). RESEARCH DESIGN: Longitudinal study comparing the outcomes of mild TBI and orthopaedic injuries (OI) in children aged 8-15. METHODS AND PROCEDURES: One hundred and eighty-six children with mild TBI and 99 with OI were recruited prospectively. Parents rated children's PCS and symptoms of PTSD at 2 weeks, 3 months and 12 months post-injury. One hundred and sixty-seven with mild TBI and 84 with OI completed all assessments. MAIN OUTCOMES AND RESULTS: Controlling for symptoms of PTSD, the mild TBI group demonstrated more PCS than the OI group, although the magnitude of group differences diminished with time. Controlling for PCS, the OI group displayed more symptoms of PTSD than the mild TBI group at baseline, but not thereafter. Symptoms of PTSD and PCS were correlated significantly, but more highly in the OI group than the mild TBI group. CONCLUSIONS: Although PCS and symptoms of PTSD are correlated, children with mild TBI are more distinguishable from children with OI based on PCS than on symptoms of PTSD. The latter symptoms, moreover, do not account for increased PCS following mild TBI in children.

Cognitive reserve as a moderator of postconcussive symptoms in children with complicated and uncomplicated mild traumatic brain injury.

The occurrence of postconcussive symptoms (PCS) following mild traumatic brain injury (TBI) in children may depend on cognitive reserve capacity. This prospective, longitudinal study examined whether the relationship between mild TBI and PCS is moderated by cognitive ability, which served as a proxy for cognitive reserve. Participants included 182 children with mild TBI and 99 children with orthopedic injuries (OI), ranging from 8 to 15 years of age when injured. Mild TBI were classified as complicated (n = 32) or uncomplicated (n = 150) depending on whether they were associated with trauma-related intracranial abnormalities on magnetic resonance imaging. PCS were assessed initially within 3 weeks of injury, and again at 1, 3, and 12 months post injury. The initial assessment also included standardized tests of children's cognitive skills and retrospective parent ratings of pre-injury symptoms. Hierarchical linear modeling indicated that ratings of PCS were moderated jointly by cognitive ability and injury severity. Children of lower cognitive ability with a complicated mild TBI were especially prone to cognitive symptoms across time according to parents and to high acute levels of PCS according to children's self-ratings. Cognitive reserve is an important moderator of the outcomes of mild TBI in children and adolescents.