Navigating an American College of Surgeons Virtual Verification Review Committee Visit: A Health System Perspective.

BACKGROUND: Faced with a global pandemic at the beginning of 2020, the American College of Surgeons Committee on Trauma (ACS-COT) canceled in-person site visits. Late in 2020, the focus shifted to recovery and returning to a "new normal," and the ACS transitioned to virtual visits. OBJECTIVE: This article provides insight from a health system perspective on how we developed a virtual platform, prepared our system and staff, organized our teams, and lessons learned during virtual ACS visits. METHODS: The Northwell Health Trauma Institute, a member of the largest health system in New York State, oversees seven centers ranging from Level I to Level III, including two pediatric centers. Preparations for virtual visits began with standardizing processes to ensure a smooth transition for our centers. We utilized the ACS virtual agenda as a framework. The methods we used will be divided into categories, including technology, personnel, and preparations. RESULTS: Having multiple sites engage in the virtual visit enabled us to gain insight as we completed each visit. We standardized processes and created a team site for uploading documents. As a result, we established best practices. CONCLUSION: Shifting focus from an in-person visit to a virtual visit provided us with an opportunity to assess our preparations and to determine the most effective and efficient ways to navigate this new process. Having multiple sites allowed us to critique our process and make changes as we proceeded with subsequent sites.

Seatbelts Save Lives, and Spines, in Motor Vehicle Accidents: A Review of the National Trauma Data Bank in the Pediatric Population.

STUDY DESIGN: Database study. OBJECTIVE: The purpose of this study was to use a large, nationwide database to determine prevalence of pediatric spine fractures in the United States, associated injuries, mechanisms of injury (MOI), use of safety devices, and mortality rates. SUMMARY OF BACKGROUND DATA: Spinal fractures account for 1% to 2% of pediatric injuries. However, they are associated with significant comorbidities and complications. Motor vehicle accidents (MVAs) are most responsible for increased incidence observed. METHODS: Retrospective review of National Trauma Data Bank between 2009 and 2014 (analysis in 2019) for all vertebral fractures in patients under 18 years of age. Subanalysis included those in MVAs where protective device use data were available. Patient demographics, MOI, geographical and anatomical region of injury, concomitant musculoskeletal/organ injury, protective device usage, hospital length of stay, surgical procedures, and mortality were all analyzed. RESULTS: A total of 34,563 patients with 45,430 fractured vertebrae included. Median age was 15 years. Most fractures (63.1%) occurred in patients aged 15 to 17 years, most frequent MOI was MVA (66.8%), and most common geographic location was the South (38%). Males sustained more spine fractures than females, overall (58.4% vs. 41.6%; P < 0.001) and in MVAs (54.4% vs. 45.6%; P < 0.001). Those in MVAs wearing seatbelts had lower odds of cranial (29.6% vs. 70.4%; odds ratio [OR] = 0.85, 95% confidence interval [CI]: 0.82-0.89; P < 0.001) and thoracic (30.1% vs. 69.9%; OR = 0.88, 95% CI: 0.84-0.91; P < 0.001) organ injury, multivertebral (30% vs. 70%; OR = 0.78, 95% CI: 0.73-0.83; P < 0.001) and concomitant nonvertebral fractures (30.9% vs. 69.1%; OR = 0.89, 95% CI:0.73-0.83; P < 0.001), and 21% lower odds of mortality (29.3% vs. 70.7%; OR = 0.79, 95% CI: 0.66-0.94; P = 0.009). Over 70% of drivers were not restrained during MVA, with majority of seatbelt violations incurred by males, ages 15 to 17, in the South. CONCLUSION: Over 60% of pediatric spinal fractures occur in children aged 15 to 17 years, coinciding with the beginning of legal driving. MVA is the most common cause and has significant association with morbidity/mortality. Nearly two- thirds pediatric spinal fractures sustained in MVAs occurred without seatbelts. Absence of seatbelts associated with >20% greater odds of mortality. Ensuring new drivers wear protective devices can greatly reduce morbidity/ mortality associated with MVA.Level of Evidence: 3.

Pediatric trauma triage: A Pediatric Trauma Society Research Committee systematic review.

BACKGROUND: Significant variability exists in the triage of injured children with most systems using mechanism of injury and/or physiologic criteria. It is not well established if existing triage criteria predict the need for intervention or impact morbidity and mortality. This study evaluated existing evidence for pediatric trauma triage. Questions defined a priori were as follows: (1) Do prehospital trauma triage criteria reduce mortality? (2) Do prehospital trauma scoring systems predict outcomes? (3) Do trauma center activation criteria predict outcomes? (4) Do trauma center activation criteria predict need for procedural or operative interventions? (5) Do trauma bay pediatric trauma scoring systems predict outcomes? (6) What secondary triage criteria for transfer of children exist? METHODS: A structured, systematic review was conducted, and multiple databases were queried using search terms related to pediatric trauma triage. The literature search was limited to January 1990 to August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the methodological index for nonrandomized studies tool used to assess the quality of included studies. Qualitative analysis was performed. RESULTS: A total of 1,752 articles were screened, and 38 were included in the qualitative analysis. Twelve articles addressed questions 1 and 2, 21 articles addressed question 3 to 5, and five articles addressed question 6. Existing literature suggest that prehospital triage criteria or scoring systems do not predict or reduce mortality, although selected physiologic parameters may. In contrast, hospital trauma activation criteria can predict the need for procedures or surgical intervention and identify patients with higher mortality; again, physiologic signs are more predictive than mechanism of injury. Currently, no standardized secondary triage/transfer protocols exist. CONCLUSION: Evidence supporting the utility of prehospital triage criteria for injured children is insufficient, while physiology-based trauma system activation criteria do appropriately stratify injured children. The absence of strong evidence supports the need for further prehospital and secondary transfer triage-related research. LEVEL OF EVIDENCE: Systematic review study, level II.

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.

Outcomes following operative vs. non-operative management of blunt traumatic pancreatic injuries: a retrospective multi-institutional study.

BACKGROUND: Traumatic pancreatic injuries are rare, and guidelines specifying management are controversial and difficult to apply in the acute clinical setting. Due to sparse data on these injuries, we carried out a retrospective review to determine outcomes following surgical or non-surgical management of traumatic pancreatic injuries. We hypothesize a higher morbidity and mortality rate in patients treated surgically when compared to patients treated non-surgically. METHODS: We performed a retrospective review of data from four trauma centers in New York from 1990-2014, comparing patients who had blunt traumatic pancreatic injuries who were managed operatively to those managed non-operatively. We compared continuous variables using the Mann-Whitney U test and categorical variables using the chi-square and Fisher's exact tests. Univariate analysis was performed to determine the possible confounding factors associated with mortality in both treatment groups. RESULTS: Twenty nine patients were managed operatively and 32 non-operatively. There was a significant difference between the operative and non-operative groups in median age (37.0 vs. 16.2 years, P = 0.016), grade of pancreatic injury (grade I; 30.8 vs. 85.2%, P value for all comparisons <0.0001), median injury severity score (ISS) (16.0 vs. 4.0, P = 0.002), blood transfusion (55.2 vs. 15.6%, P = 0.0012), other abdominal injuries (79.3 vs. 38.7%, P = 0.0014), pelvic fractures (17.2 vs. 0.00%, P = 0.020), intensive care unit (ICU) admission (86.2 vs. 50.0%, P = 0.003), median length of stay (LOS) (16.0 vs. 4.0 days, P <0.0001), and mortality (27.6 vs. 3.1%, P = 0.010). CONCLUSIONS: Patients with traumatic pancreatic injuries treated operatively were more severely injured and suffered greater complications than those treated non-operatively. The greater morbidity and mortality associated with these patients warrants further study to determine optimal triage strategies and which subset of patients is likely to benefit from surgery.