Strategies for Safely Maintaining Surgical Volume During the COVID-19 Pandemic: A Mixed-Methods Study.

Resuming elective surgeries that were canceled during the COVID-19 pandemic necessitated a change to preprocedure patient preparation at a pediatric tertiary care center in middle Tennessee. We conducted a prospective, observational, mixed-methods study to determine the effectiveness of a preprocedure COVID-19 testing team to prevent COVID-19-related cancellations among pediatric patients receiving planned anesthesia. The intervention involved family member and patient education and a change in health record reporting to include COVID-19 test results. A team tasked with follow-up reviewed test results, consulted with families, and coordinated the administration of rapid tests if necessary. We compared preimplementation and postimplementation cancellation rates in four procedural areas and found no significant difference in the cancellation or rescheduling rates (P = .89, 95% confidence interval = -4.29 to 3.09). The team-based intervention was associated with the preservation of low procedural cancellation rates by mitigating barriers to preprocedural testing.

A pilot hospital-school educational program to address teen motor vehicle safety.

BACKGROUND: Texting while driving has emerged as a significant distracted driving behavior among teenage drivers. A unique hospital-school collaborative pilot intervention (called "Be in the Zone" or "BITZ") was implemented to combat this growing problem. This intervention was hypothesized to lead to a decline in texting while driving among high school students. METHODS: This collaborative intervention consisted of two separate phases. In Phase 1, small groups of high school student leaders participated in a half-day interactive educational session in a pediatric hospital. Pre- and post-follow-up surveys were administered to this group. In Phase 2, these same students took the lessons they learned from the hospital to plan and implement a yearlong peer-to-peer campaign that focused on a clear "no texting while driving" message at their schools. Two unannounced driver observations were conducted to evaluate the effectiveness of the pilot program. RESULTS: Sixty-one high school students participated in Phase 1. Self-reported texting while driving rates decreased significantly among the participants after Phase 1. Two schools were recruited to participate in Phase 2. Unannounced driver observations were conducted before the campaign and toward the end of the campaign. Postintervention, there was a significant decrease in the percentage of drivers who texted while driving. CONCLUSION: Preliminary results from this pilot program suggest that a strategy of combining hospital-school partnerships with a peer-driven educational approach can be effective in reducing texting while driving among teenagers in the short-term.

Safety factors related to all-terrain vehicle injuries in children.

BACKGROUND: All-terrain vehicle (ATV)-related injuries are a significant source of pediatric trauma. We hypothesized that these injuries are caused by poor safety behavior. To test this hypothesis, we surveyed both injured and uninjured ATV riders. METHODS: A prospective convenience sample-based survey was initiated at Children's Hospital of Pittsburgh, a Level I pediatric trauma center. Patients with an ATV-related injury were asked to complete the survey for the study group (INJ), while uninjured pediatric ATV-riders completed the survey for the control group (UnINJ). The Fisher's exact probability test was used for data analysis. RESULTS: There were 38 surveys completed for INJ and 11 for UnINJ. Both groups had similar demographics. ATVs in both groups were mostly used for recreation, and most of the INJ patients were in a rural setting. Half of the ATVs were purchased second hand, and less than half were purchased from a dealer. Most dealers reviewed age recommendations for ATV use; however, many safety recommendations were not followed. INJ group had a higher percentage of children riding inappropriately sized ATVs and a lower rate of helmet use when compared with UnINJ group. In addition, there were a significant number of regulatory violations in the INJ group, including nine children (24%) riding as passengers and 5 (13%) driving on a road. CONCLUSION: These data suggest that there may be decreased safety behavior among injured pediatric ATV-riders; however, uninjured riders also demonstrate poor safety habits. The study showed that dealers do review safety regulations with consumers; however, most of the ATVs are not purchased through dealers. Therefore, we may need to shift our safety and educational focus to reach these families. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Analysis of pediatric all-terrain vehicle trauma data in Middle Tennessee: implications for injury prevention.

BACKGROUND: Trauma registries capture data about injuries that can be used to objectively guide injury prevention initiatives. This article analyzes trauma registry data to describe the nature and distribution of all-terrain vehicle (ATV) injuries in Middle Tennessee. A community injury prevention effort, based on this analysis, is also presented. METHODS: A retrospective analysis of data (2007-2009) from the trauma registry of a Level I pediatric trauma center in Middle Tennessee was conducted. Patients younger than 16 years with ATV-related injuries were included in the analysis (n = 163). The key variables examined were demographics, injury severity, helmet use, injury mechanism, length of stay, and patient's county of residence. In addition, Geographic Information Systems software was used to examine the distribution of injuries and graphically represent counties with highest injury rates in the youth population. RESULTS: ATV injuries were more prevalent among boys than girls (66% vs. 34%; p < 0.001). Approximately 64% of the ATV injuries were in the age group 10 years to 15 years. Most injuries were either moderately severe (44%) or severe (30%). Injury mechanism varied by age; younger children experienced more rollovers while older children tended to be injured from ejections (p < 0.05). Helmet use was low (33%). Data from this study suggest that helmet use resulted in fewer injuries to the head, neck, and face. Counties with high rates of ATV injuries were targeted for ATV training programs. 4-H agents trained by the ATV Safety Institute provided ATV training classes. CONCLUSION: Rural youth are clearly at greater risk for ATV injuries than urban populations. Young ATV riders are often self-taught and lack the knowledge to ride ATVs safely. Organizations such as the 4-H, provide effective injury prevention outreach. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Development of a hospital-based trauma registry in Haiti: an approach for improving injury surveillance in developing and resource-poor settings.

BACKGROUND: Trauma-related morbidity and mortality are a growing burden in the developing world. However, usable injury data in resource-poor and developing settings is lacking. Trauma registries can improve injury surveillance to enhance trauma care, outcomes, and prevention. This article provides, by example from Haiti, an approach to developing a hospital-based trauma registry in a resource-poor setting. METHODS: An assessment of trauma documentation was performed retrospectively with subsequent development and pilot testing of two injury surveillance systems. The system most promising for meeting the needs and capabilities of the institution was implemented. RESULTS: Retrospective medical record review from 1999 (n = 43) and 2002 (n = 43) revealed limitations in available data for trauma surveillance. Specific mechanism of injury was documented in 39.3% and 57.1% of 1999 and 2002 groups, respectively. Injury date and arrival vital signs were infrequently recorded. Two injury surveillance models were designed and pilot tested: provider-based (PTR) (pilot n = 19) and coordinator-based (CTR) (pilot n = 37) trauma registries. Analysis of the pilot testing resulted in revisions to operations and the trauma registry forms. Both registry models showed improved data collection compared with the retrospective study with CTR and PTR documenting specific mechanism of injury in 94.6% and 100% of patients, respectively. The PTR model was chosen for implementation at the hospital. CONCLUSIONS: Trauma registries in developing settings are plausible tools for injury surveillance. Successful trauma registries will be resource- and setting-specific in design and can potentially be the means by which trauma care and outcomes are improved, prevention programs are developed, and capacity-building goals realized.

Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma.

PURPOSE: The purpose of this study is to assess the role of emergent laparoscopy as a diagnostic and potentially therapeutic modality in pediatric trauma. We hypothesize that diagnostic laparoscopy provides important information for the treatment of children with abdominal trauma and is accompanied by improved diagnostic accuracy, reduction of nontherapeutic laparotomy rates, and a reduction of morbidity. METHODS: A 5-year (January 2000-December 2004) retrospective review of a pediatric level I trauma center database was performed after institutional review board approval was obtained, and information regarding patients who had operations for abdominal trauma was abstracted. Demographic variables, mechanism of injury, operative interventions, and patient outcomes were examined. Statistical analysis was performed using descriptive statistics and Student's t test (P < .05). RESULTS: There were 7127 trauma admissions, of which 113 had abdominal explorations for blunt (88%) and penetrating (12%) trauma. Thirty-two (28%) patients had laparoscopy performed. Laparotomy was avoided in 56% of these patients. Laparoscopic therapeutic interventions were performed in 6 (19%) patients. Laparoscopy assisted in the diagnosis and subsequent conventional repair of perforated viscera in 10, diaphragmatic rupture in 3, and distal pancreatic injury in 1. Patients who had a laparoscopic procedure of any kind were less severely injured leading to significantly lower number of intensive care unit (0.6 +/- 1.6, P = .0004) and hospital days (7.4 +/- 5.6, P = .002) than patients who had a laparotomy (3.7 +/- 7.1 and 12.5 +/- 11.4). No injuries were missed, or technical complications occurred, as a result of laparoscopic explorations. There were 6 deaths in the laparotomy group. No patients who underwent laparoscopy died. CONCLUSION: Laparoscopy in pediatric trauma is a safe method for the evaluation and treatment of selective blunt and penetrating abdominal injuries in hemodynamically stable patients. Laparoscopy serves as a diagnostic tool in abdominal trauma, which reduces the morbidity of a negative laparotomy.

The high morbidity associated with handlebar injuries in children.

BACKGROUND: Although injury prevention strategies for bicyclists have focused on legislation requiring helmet use to prevent head trauma, direct impact handlebar injuries account for a significant proportion of bicycle-related injuries. Little attention, however, has been paid to strategies that prevent direct impact handlebar injuries. We reviewed our experience with bicycle-related injuries and compared outcome for children who flipped over the handlebars to those for children who sustained direct impact from the handlebars. METHODS: We queried our prospective trauma database for all bicycle injuries from 1998 to 2003. All patients with the descriptor "handlebar" in the subtext were selected. Patients were divided into two groups: those who flipped over the handlebars (n = 160) and those who sustained direct impact from the handlebars (n = 61). We examined age, gender, helmet use, injury severity score (ISS), Glasgow Coma Score (GCS), length of stay (LOS) and the need for operation. The Student's t test was used to compare continuous variables when the data were normally distributed and the Mann-Whitney was used when the data were skewed. Chi-square analysis or Fisher's exact test was used to compare categorical data. RESULTS: There was no difference between the two groups with respect to age, gender, helmet use, ISS, and GCS. However, children who suffered from handlebar injuries were more likely to require operative intervention (19/61 versus 28/160, p = 0.04) and had a significantly longer LOS (3 days versus 1 day, p < 0.001). Children who sustained direct impact from the handlebars and required operative intervention were statistically more likely to suffer from abdominal or soft tissue injuries, while those who flipped over the handlebars were statistically more likely to suffer from facial or skeletal injuries. CONCLUSIONS: Children who suffer from direct impact of the handlebars are more likely to require operative intervention and have a longer LOS than those who flip over the handlebars. While helmet utilization by bicyclists may have reduced the number of serious head injuries, direct impact from the handlebars remains a major source of bicycle-related morbidity since nearly one third of these patients required surgery. Future injury prevention strategies for bicyclists should be aimed at reducing the incidence of direct impact handlebar-related injuries.

Nonmotorized scooters: a source of significant morbidity in children.

BACKGROUND: Nonmotorized scooters have increased rapidly in popularity over the past year. However, the morbidity associated with this new type of recreational vehicle is poorly defined. This study examined the pattern of scooter-related injuries sustained in children admitted to a level 1 pediatric trauma center. METHODS: The records of all children admitted to the authors' institution after a scooter-related injury between January 1, 2000 and December 31, 2001 were reviewed. Information regarding patient demographics, mechanism of injury, type of injury sustained, and hospital course was prospectively collected and retrospectively analyzed. RESULTS: During the study period, 27 children were admitted with scooter-related injures. The average age of the patients was 9.1 +/- 1.9 years, and 63% were boys. The average Injury Severity Score (ISS) was 7.9 +/- 6. The most common mechanism of injury was a fall. However, 26% of the patients were involved in a scooter collision with a motor vehicle. Injuries to the head occurred most frequently, followed by extremity injuries. Only 10 of the children (37%) were wearing a helmet at the time of injury. CONCLUSIONS: Scooters are an increasingly popular form of recreational vehicle among children. However, they can result in serious injury, particularly to the head and extremities. The authors recommend that all children riding scooters wear protective equipment and avoid riding in areas that have moving motor vehicles.

Duodenal injuries in children: beware of child abuse.

PURPOSE: It is frequently overlooked that child abuse may result in significant intraabdominal injury, particularly to the duodenum. The authors hypothesized that a significant number of duodenal injuries in young children would be the result of nonaccidental trauma. METHODS: An 8-year (1995 through 2002) retrospective review of a pediatric level I trauma center database was performed after Institutional Review Board approval was obtained, and information regarding patients with duodenal injury was abstracted. Demographic variables, injury severity, length of stay, mortality rate, and mechanism of injury were examined. Statistical analysis was performed using descriptive statistics and Student's t test. Statistical significance was defined as P less than.05. RESULTS: Over the 8-year study period, 8,968 patients were admitted, 2,179 (24%) were less than 3 years of age. Thirty children (0.3%) suffered injury to the duodenum, with 20 hematomas and 10 perforations. Patients were overwhelmingly boys (80%), with an average age of 7.6 +/- 4.4 years and Injury Severity Score (ISS) of 14 +/- 10. No patients died. Children were injured by a variety of mechanisms, including collisions involving motor vehicles (n = 9), bicycles (n = 4), and ATVs (n = 2). However, all children less than 4 years of age (n = 8) were victims of nonaccidental trauma, 2.8% of all child abuse admissions. Three of these children suffered perforations of the duodenum. Among the entire population, those children who suffered perforations had a significantly higher ISS (23.7 +/- 7.2 v 9.6 +/- 7.3; P <.0003) and longer length of stay (27.1 +/- 15.3 v 12.6 +/- 11.7; P <.007) than those with hematomas CONCLUSIONS: Injury to the duodenum is unusual in the pediatric trauma patient but does result in significant injury severity and prolonged hospitalization. In the young child, one must maintain a high index of suspicion regarding the etiology of the injury, because a large percentage is potentially the result of child abuse.

All-terrain vehicle rules and regulations: impact on pediatric mortality.

BACKGROUND/PURPOSE: All-terrain vehicles (ATV) use by children leads to severe injury and death. Since the US Consumer Product Safety Commission consent decree expired in 1998, there has been little movement in regulating ATV use for children (<16 yr). The authors hypothesized that states with laws and regulations restricting pediatric ATV use may abrogate excess death compared with states without such restrictions. METHODS: Pediatric mortality data reported to the consumer product safety commission from 1982 to 1998 were analyzed as well as state all-terrain vehicle requirements compiled by the Specialty Vehicle Institute of America in August 2001. The authors calculated ATV mortality rate by dividing ATV mortality frequency by 1980-2000 pediatric census results. They compared the top 26 states with the highest ATV mortality rates (TOP) with those of all other states (OTH) in terms of age, ATV type, ATV occupancy, and ATV laws. Chi-square analysis was performed. RESULTS: There were 1,342 ATV pediatric deaths during the 16-year period. The TOP states averaged approximately a 2-fold increase in adjusted ATV mortality rate compared with the national ATV pediatric mortality rate. Ninety-two percent of TOP states have no licensing laws compared with 73% of the OTH states (P <.07). There is no difference between groups with regard to minimum age requirements and safety certification. CONCLUSIONS: Current legal and regulatory standards have low probability of decreasing ATV-related pediatric mortality. States should adopt laws that restrict the use of ATV's for children less than 16 years of age and potentially prevent excess ATV-related pediatric mortality.

Falling televisions: The hidden danger for children.

BACKGROUND/PURPOSE: The United States Consumer Product Safety Commission (USCPSC) recently has reported a significant number of injuries and deaths in the home related to televisions (TV) falling on children. To date, little is known regarding the significance of this mechanism of injury in childhood trauma. The current investigation was designed to examine the risk factors, spectrum of injuries, and operative intervention required in children injured by falling televisions. METHODS: The records of all patients 0 to 16 years of age with television-related injuries and entered in the Pennsylvania Trauma Outcome Study (PTOS) between 1989 and 1999 were reviewed. The authors examined Glascow coma scale (GCS), injury severity score (ISS), length of hospital stay (LOS), major injuries sustained, and operative procedures performed. Fourteen of the children in the PTOS were seen at the Benedum Pediatric Trauma Center at the Children's Hospital of Pittsburgh. In these 14 children, a review of the medical records was performed for a detailed description of the accident scenario. RESULTS: Forty-three children sustained television-related injuries during this period. Nearly 56% of these children were