Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Computer Simulation to Assess Emergency Department Length of Stay in Pediatric Traumatic Brain Injury.

OBJECTIVES: Our study aimed to identify how emergency department (ED) arrival rate, process of care, and physical layout can impact ED length of stay (LOS) in pediatric traumatic brain injury care. METHODS: Process flows and value stream maps were developed for 3 level I pediatric trauma centers. Computer simulation models were also used to examine "what if" scenarios based on ED arrival rates. RESULTS: Differences were observed in prearrival preparation time, ED physical layouts, and time spent on processes. Shorter prearrival preparation time, trauma bed location far from diagnostic or treatment areas, and ED arrival rates that exceed 20 patients/day prolonged ED LOS. This was particularly apparent in 1 center where computer simulation showed that relocation of trauma beds can reduce ED LOS regardless of the number of patients that arrive per day. CONCLUSIONS: Exceeding certain threshold ED arrival rates of children with traumatic brain injury can substantially increase pediatric trauma center ED LOS but modifications to ED processes and bed location may mitigate this increase.

Strategies to Obtain and Deliver Blood Products Into Critically Injured Children: A Survey of Pediatric Trauma Society Members.

OBJECTIVES: Timely transfusion is associated with improved survival and a reduction in in-hospital morbidity. The benefits of early hemorrhagic shock recognition may be limited by barriers to accessing blood products and their timely administration. We examined how pediatric trauma programs obtain blood products, the types of rapid infusion models used, and the metrics tracked to improve transfusion process efficiency in their emergency department (ED). METHODS: We developed and distributed a self-report survey to members of the Pediatric Trauma Society. The survey consisted of 6 initial questions, including the respondent's role and institution, whether a blood storage refrigerator was present in their ED, the rapid infuser model used to transfuse critically injured children in their ED, if their program tracked 4 transfusion process metrics, and if a video recording system was present in the trauma bay. Based on these responses, additional questions were prompted with an option for a free-text response. RESULTS: We received 137 responses from 77 institutions. Most pediatric trauma programs have a blood storage refrigerator in the ED (n = 46, 59.7%) and use a Belmont rapid infuser to transfuse critically injured children (n = 45, 58.4%). The American College of Surgeons Level 1 designated trauma programs, or state-based equivalents, and "pediatric" trauma programs were more likely to have video recording systems for performance improvement review compared with lower designated trauma programs and "combined pediatric and adult" trauma programs, respectively. CONCLUSIONS: Strategies to improve the timely acquisition and infusion of blood products to critically injured children are underreported. This study examined the current practices that pediatric trauma programs use to transfuse critically injured children and may provide a resource for trauma programs to cite for transfusion-related quality improvement.

Benchmarking Pediatric Trauma Care in Mixed Trauma Centers: Adult Risk-Adjusted Mortality Is Not a Reliable Indicator of Pediatric Outcomes.

BACKGROUND: Trauma center benchmarking has become standard practice for assessing quality. The American College of Surgeons adult trauma center verification standards do not specifically require participation in a pediatric-specific benchmarking program. Centers that treat adults and children may therefore rely solely on adult benchmarking metrics as a surrogate for pediatric quality. This study assessed discordance between adult and pediatric mortality within mixed trauma centers to determine the need to independently report pediatric-specific quality metrics. STUDY DESIGN: A cohort of trauma centers (n = 493, including 347 adult-only, 44 pediatric-only, and 102 mixed) that participated in the American College of Surgeons TQIP in 2017 to 2018 was analyzed. Center-specific observed-to-expected mortality estimates were calculated using TQIP adult inclusion criteria for 449 centers treating adults (16 to 65 years) and using TQIP pediatric inclusion criteria for 146 centers treating children (0 to 15 years). We then correlated risk-adjusted mortality estimates for pediatric and adult patients within mixed centers and evaluated concordance of their outlier status between adults and children. RESULTS: The cohort included 394,075 adults and 97,698 children. Unadjusted mortality was 6.1% in adults and 1.2% in children. Mortality estimates had only moderate correlation ( r = 0.41) between adult and pediatric cohorts within individual mixed centers. Mortality outlier status for adult and pediatric cohorts was discordant in 31% (32 of 102) of mixed centers (weighted Kappa statistic 0.06 [-0.11 to 0.22]), with 78% (23 of 32) of discordant centers having higher odds of mortality for children than for adults (6 centers with average adult mortality and high pediatric mortality and 17 centers with low adult mortality and average pediatric mortality, p < 0.01). CONCLUSIONS: Adult mortality is not a reliable surrogate for pediatric mortality in mixed trauma centers. Incorporation of pediatric-specific benchmarks should be required for centers that admit children.

Survival Bias in Pediatric Hemorrhagic Shock: Are We Misrepresenting the Data?

BACKGROUND: Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. METHODS: We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (age < 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within four hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. RESULTS: We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio [OR] = 0.1, 95% CI = 0.1, 0.2) compared to those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. CONCLUSION: Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. LEVEL OF EVIDENCE: Prognostic and Epidemiological, Level III.

Transitioning Cognitive Aids into Decision Support Platforms: Requirements and Design Guidelines.

Digital cognitive aids have the potential to serve as clinical decision support platforms, triggering alerts about process delays and recommending interventions. In this mixed-methods study, we examined how a digital checklist for pediatric trauma resuscitation could trigger decision support alerts and recommendations. We identified two criteria that cognitive aids must satisfy to support these alerts: (1) context information must be entered in a timely, accurate, and standardized manner, and (2) task status must be accurately documented. Using co-design sessions and near-live simulations, we created two checklist features to satisfy these criteria: a form for entering the pre-hospital information and a progress slider for documenting the progression of a multi-step task. We evaluated these two features in the wild, contributing guidelines for designing these features on cognitive aids to support alerts and recommendations in time- and safety-critical scenarios.

Real-time Context-Aware Multimodal Network for Activity and Activity-Stage Recognition from Team Communication in Dynamic Clinical Settings.

In clinical settings, most automatic recognition systems use visual or sensory data to recognize activities. These systems cannot recognize activities that rely on verbal assessment, lack visual cues, or do not use medical devices. We examined speech-based activity and activity-stage recognition in a clinical domain, making the following contributions. (1) We collected a high-quality dataset representing common activities and activity stages during actual trauma resuscitation events-the initial evaluation and treatment of critically injured patients. (2) We introduced a novel multimodal network based on audio signal and a set of keywords that does not require a high-performing automatic speech recognition (ASR) engine. (3) We designed novel contextual modules to capture dynamic dependencies in team conversations about activities and stages during a complex workflow. (4) We introduced a data augmentation method, which simulates team communication by combining selected utterances and their audio clips, and showed that this method contributed to performance improvement in our data-limited scenario. In offline experiments, our proposed context-aware multimodal model achieved F1-scores of 73.2±0.8% and 78.1±1.1% for activity and activity-stage recognition, respectively. In online experiments, the performance declined about 10% for both recognition types when using utterance-level segmentation of the ASR output. The performance declined about 15% when we omitted the utterance-level segmentation. Our experiments showed the feasibility of speech-based activity and activity-stage recognition during dynamic clinical events.

Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers.

Importance: Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective: To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants: This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures: Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures: In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results: This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance: These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.

Functional impairment associated with nonfatal pediatric firearm injuries.

BACKGROUND: Firearm injury is now the leading cause of death for children in the United States. Functional morbidity among survivors also contributes to the public health burden of firearm injury but has not been quantified in children. This study aimed to assess functional impairment among survivors of pediatric firearm injury. METHODS: We analyzed an 8-year (2014-2022) retrospective cohort of children (0-18 years) treated for firearm injuries at 2 urban level 1 pediatric trauma centers. The Functional Status Scale was used to assess functional impairment among survivors at discharge and at follow-up. Functional impairment was defined using multisystem (Functional Status Scale ≥8) and single-system (Functional Status Scale = 7) definitions. RESULTS: The cohort included 282 children with a mean age of 11.1 (standard deviation 4.5) years. In-hospital mortality was 7% (n = 19). Functional impairment (Functional Status Scale ≥8) was present in 9% (n = 24) of children at discharge and in 7% (n = 13/192) at follow-up. Mild impairment in a single domain (Functional Status Scale = 7) was seen in 42% (n = 110) of the cohort at discharge. This impairment persisted to follow-up in most (67%, n = 59/88) of these children. CONCLUSION: Functional impairment at discharge after firearm injury is common among children surviving transport in these trauma centers. These data highlight the added value of non-mortality metrics in assessing the health burden of pediatric firearm injuries. The collective impact of mortality and functional morbidity should be considered when advocating for resources to protect children.

Using Billing Codes to Create a Pediatric Functional Status e-Score for Children Receiving Inpatient Rehabilitation.

OBJECTIVE: Provide proof-of-concept for development of a Pediatric Functional Status eScore (PFSeS). Demonstrate that expert clinicians rank billing codes as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling. DESIGN: Retrospective chart review, modified Delphi, and nominal group techniques. SETTING: Large, urban, quaternary care children's hospital in the Midwestern United States. PARTICIPANTS: Data from 1955 unique patients and 2029 hospital admissions (2000-2020); 12 expert consultants representing the continuum of rehabilitation care reviewed 2893 codes (procedural, diagnostic, pharmaceutical, durable medical equipment). MAIN OUTCOME MEASURES: Consensus voting to determine whether codes were associated with functional status at discharge and, if so, what domains they informed (self-care, mobility, cognition/ communication). RESULTS: The top 250 and 500 codes identified by statistical modeling were mostly composed of codes selected by the consultant panel (78%-80% of the top 250 and 71%-78% of the top 500). The results provide evidence that clinical experts' selection of functionally meaningful codes corresponds with codes selected by statistical modeling as most strongly associated with WeeFIM domain scores. The top 5 codes most strongly related to functional independence ratings from a domain-specific assessment indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS. CONCLUSIONS: Development of a PFSeS that is predicated on billing data would improve researchers' ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to 3 important domains: self-care, mobility, and cognition/communication.

Interrater reliability of chart-based assessment of functional impairment after pediatric injury using the functional status scale.

BACKGROUND: Functional impairment has been proposed as an alternative outcome for quality improvement in pediatric trauma. The functional status scale (FSS) has been used in studies of injured children, but has only been validated with resource-intensive in-person assessment. Implementation with retrospective chart-based FSS assessment would offer a simplified and scalable alternative. The purpose of this study was to evaluate interrater reliability of retrospective FSS assessment and to identify factors associated with unreliable assessment. METHODS: A retrospective cohort of admissions to a Level I pediatric trauma center between July 2020 and June 2021 was analyzed. Two physicians and two nurse registrars reviewed charts to obtain measures of six FSS domains (mental status, sensory functioning, communication, motor functioning, feeding, and respiratory status) at discharge. Functional impairment was categorized by total FSS scores as good (6,7), mild impairment (8,9), moderate impairment (10-15), severe impairment (16-21), or very severe impairment (>21). Interrater reliability was assessed using intraclass correlation (ICC). Predictors of rater disagreement were evaluated using multivariable logistic regression. RESULTS: The cohort included 443 children with a mean age of 7.4 years (standard deviation, 5.4 years) and median Injury Severity Score of 9 (interquartile range, 5-12). The median time per chart to assess FSS was 2 minutes (interquartile range, 1-2). Thirty-seven patients (8%) had functional impairment at discharge. Interrater reliability was excellent for total FSS score (ICC = 0.87) and good for FSS impairment categorization (ICC = 0.80). Rater disagreement of functional impairment categorization occurred in 14% of cases overall. Higher level of functional impairment and use of therapies (occupational and speech language therapy) were independently associated with more frequent rater disagreement. CONCLUSION: Chart-based FSS assessment is feasible and reliable, but may require more detailed review for patients with higher level of impairment that require allied health therapy. Validation of chart-based assessment is needed before widespread implementation. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level III.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A multicenter, citywide report on recurrent violent injury.

INTRODUCTION: The incidence of and risk factors for recurrent violent trauma are not well known. This information is needed to focus violence prevention efforts on at-risk cohorts. The purpose of this study was to determine the incidence of and risk factors for recurrence following violent injury in a large urban setting. We hypothesize that the overall incidence of recurrent violent injury is low but there are specific at-risk cohorts. METHODS: A retrospective, citywide study of patients who sustained blunt assault or penetrating trauma from 2013 to 2019 was performed. Patients were tracked across all trauma centers using their name and date of birth. The primary outcome was incidence of recurrent violent injury, which was calculated by dividing the number of readmitted patients by the number who survived previous admissions due to penetrating trauma or blunt assault. Associations between readmission and injury severity score, abbreviated injury score, age, sex, hospital, mechanism of injury (MOI), and disposition were determined. Kaplan-Meier curves were plotted to determine the incidence of recurrent injury over time. A multivariable Cox proportional hazard model was used to examine the relationships between characteristics at first admission and time-to-readmission. RESULTS: The recurrent injury rate was 836 patients (6.33%) out of 13,211 injured patients. Male, age 14-45 years old, discharge to jail or left against medical advice, and moderate/severe head injury were associated with re-injury. There was no association between recurrence and mechanism of injury or overall injury severity. Discharge to home was associated with a lower re-injury rate. CONCLUSION: The low recurrent injury rate despite high injury prevalence suggests injury prevention efforts should target this demographic and their non-injured peers.

Development and validation of a Bayesian network predicting neurosurgical intervention after injury in children and adolescents.

BACKGROUND: Timely surgical decompression improves functional outcomes and survival among children with traumatic brain injury and increased intracranial pressure. Previous scoring systems for identifying the need for surgical decompression after traumatic brain injury in children and adults have had several barriers to use. These barriers include the inability to generate a score with missing data, a requirement for radiographic imaging that may not be immediately available, and limited accuracy. To address these limitations, we developed a Bayesian network to predict the probability of neurosurgical intervention among injured children and adolescents (aged 1-18 years) using physical examination findings and injury characteristics observable at hospital arrival. METHODS: We obtained patient, injury, transportation, resuscitation, and procedure characteristics from the 2017 to 2019 Trauma Quality Improvement Project database. We trained and validated a Bayesian network to predict the probability of a neurosurgical intervention, defined as undergoing a craniotomy, craniectomy, or intracranial pressure monitor placement. We evaluated model performance using the area under the receiver operating characteristic and calibration curves. We evaluated the percentage of contribution of each input for predicting neurosurgical intervention using relative mutual information (RMI). RESULTS: The final model included four predictor variables, including the Glasgow Coma Scale score (RMI, 31.9%), pupillary response (RMI, 11.6%), mechanism of injury (RMI, 5.8%), and presence of prehospital cardiopulmonary resuscitation (RMI, 0.8%). The model achieved an area under the receiver operating characteristic curve of 0.90 (95% confidence interval [CI], 0.89-0.91) and had a calibration slope of 0.77 (95% CI, 0.29-1.26) with a y intercept of 0.05 (95% CI, -0.14 to 0.25). CONCLUSION: We developed a Bayesian network that predicts neurosurgical intervention for all injured children using four factors immediately available on arrival. Compared with a binary threshold model, this probabilistic model may allow clinicians to stratify management strategies based on risk. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Discovering interpretable medical process models: A case study in trauma resuscitation.

Understanding the actual work (i.e., "work-as-done") rather than theorized work (i.e., "work-as-imagined") during complex medical processes is critical for developing approaches that improve patient outcomes. Although process mining has been used to discover process models from medical activity logs, it often omits critical steps or produces cluttered and unreadable models. In this paper, we introduce a TraceAlignment-based ProcessDiscovery method called TAD Miner to build interpretable process models for complex medical processes. TAD Miner creates simple linear process models using a threshold metric that optimizes the consensus sequence to represent the backbone process, and then identifies both concurrent activities and uncommon-but-critical activities to represent the side branches. TAD Miner also identifies the locations of repeated activities, an essential feature for representing medical treatment steps. We conducted a study using activity logs of 308 pediatric trauma resuscitations to develop and evaluate TAD Miner. TAD Miner was used to discover process models for five resuscitation goals, including establishing intravenous (IV) access, administering non-invasive oxygenation, performing back assessment, administering blood transfusion, and performing intubation. We quantitively evaluated the process models with several complexity and accuracy metrics, and performed qualitative evaluation with four medical experts to assess the accuracy and interpretability of the discovered models. Through these evaluations, we compared the performance of our method to that of two state-of-the-art process discovery algorithms: Inductive Miner and Split Miner. The process models discovered by TAD Miner had lower complexity and better interpretability than the state-of-the-art methods, and the fitness and precision of the models were comparable. We used the TAD process models to identify (1) the errors and (2)the best locations for the tentative steps in knowledge-driven expert models. The knowledge-driven models were revised based on the modifications suggested by the discovered models. The improved modeling using TAD Miner may enhance understanding of complex medical processes.

EasyTBSA as a method for calculating total body surface area burned: a validation study.

BACKGROUND: Current methods of burn estimation can lead to incorrect estimates of the total body surface area (TBSA) burned, especially among injured children. Inaccurate estimation of burn size can impact initial management, including unnecessary transfer to burn centres and fluid overload during resuscitation. To address these challenges, we developed a smartphone application (EasyTBSA) that calculates the TBSA of a burn using a body-part by body-part approach. The aims of this study were to assess the accuracy of the EasyTBSA application and compare its performance to three established methods of burn size estimation (Lund-Browder Chart, Rule of Nines and Rule of Palms). METHODS: Twenty-four healthcare providers used each method to estimate burn sizes on moulaged manikins. The manikins represented different ages (infant, child and adult) with different TBSA burns (small <20%, medium 20%-49% and large >49%). We calculated the accuracy of each method as the difference between the user-estimated and actual TBSA. The true value of the complete body surface area of the manikins was obtained by three-dimensional scans. We used multivariable modelling to control for manikin size and method. RESULTS: Among all age groups and burn sizes, the EasyTBSA application had the greatest accuracy for burn size estimation (-0.01%, SD 3.59%) followed by the Rule of Palms (3.92%, SD 10.71%), the Lund-Browder Chart (4.42%, SD 5.52%) and the Rule of Nines (5.05%, SD 6.87%). CONCLUSIONS: The EasyTBSA application may improve the estimation of TBSA compared with existing methods.

Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care.

Importance: Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. Objective: To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. Design, Setting, and Participants: This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. Exposure: ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. Main Outcomes and Measures: The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. Results: There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. Conclusions and Relevance: These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.

Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated With Survival.

OBJECTIVE: We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. BACKGROUND: ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. METHODS: This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival. RESULTS: There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present. CONCLUSIONS: ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.

Factors Affecting Peripheral Intravenous Catheter Placement During Pediatric Trauma Resuscitation.

INTRODUCTION: Intravenous access is required for resuscitation of injured patients but may be delayed in children because of challenges associated with peripheral intravenous (PIV) catheter placement. Early identification of factors predisposing patients to difficult PIV placement can assist in deciding strategies for timely intravenous access. METHODS: We conducted a retrospective, video-based review of injured children and adolescents treated between April 2018 and May 2019. Patient demographic, physiological, injury, and resuscitation characteristics were obtained from the patient record, including age, race, weight, injury type, Injury Severity Score, initial systolic blood pressure, initial Glasgow Coma Score, intubation status, activation level, and presence of prearrival notification. Video review was used to determine the time to PIV placement, the number of attempts required, the purpose for additional access, and the reason for abandonment of PIV placement. Multivariable regressions were used to determine factors associated with successful placement. RESULTS: During the study period, 154 consented patients underwent attempts at PIV placement in the trauma bay. Placement was successful in 139 (90.3%) patients. Older patients (OR [odds ratio]: 0.9, 95% confidence interval [CI]: 0.9, 0.9) and patients who required the highest level activation response (OR: 0.0, 95% CI: 0.0, 0.3) were less likely to have an attempt at PIV placement abandoned. Children with nonblunt injuries (OR: 11.6, 95% CI: 1.3, 119.2) and pre-existing access (OR: 39.6, 95% CI: 7.0, 350.6) were more likely to have an attempt at PIV placement abandoned. Among patients with successful PIV placement, the time required for establishing PIV access was faster as age increased (-0.5 s, 95% CI: -1.1, -0.0). CONCLUSIONS: Younger age was associated with abandonment of PIV attempts and, when successful, increased time to placement. Strategies to improve successful PIV placement and alternate routes of access should be considered early to prevent treatment delays in younger children.

Evaluation of Missing Prehospital Physiological Values in Injured Children and Adolescents.

INTRODUCTION: Prehospital vital signs and the Glasgow Coma Scale score are often missing in clinical practice and not recorded in trauma databases. Our study aimed to identify factors associated with missing prehospital physiological values, including systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, and Glasgow Coma Scale. METHODS: We used our hospital trauma registry to obtain patient, injury, resuscitation, and transportation characteristics for injured children and adolescents (age <15 y). We evaluated the association of missing documentation of prehospital values with other patient, injury, transportation, and resuscitation characteristics using multivariable regression. We standardized vital sign values using age-adjusted z-scores. RESULTS: The odds of a missing physiological value decreased with age (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.9, 0.9) and were higher when prehospital cardiopulmonary resuscitation was required (OR = 3.3, 95% CI = 1.9, 5.7). Among the physiological values considered, we observed the highest odds of missingness of systolic blood pressure, respiratory rate, and oxygen saturation. The odds of observing normal emergency department physiological values were lower when prehospital physiological values were missing (OR = 0.9, 95% CI = 0.9, 1.0; P = 0.04). CONCLUSIONS: Missing prehospital physiological values were associated with younger age and cardiopulmonary resuscitation among the injured children treated at our hospital. Measurement and documentation of physiological variables of patients with these characteristics should be targeted.