Developing and Implementing Electronic Consent Procedures in Response to Covid-19 Restrictions.

The Covid-19 pandemic resulted in unprecedented restrictions on many public, private, and workplace activities throughout the United States and elsewhere. When restrictions were imposed, we were conducting a type III hybrid effectiveness-implementation trial in 10 pediatric trauma centers. In response to several pandemic-based restrictions, we had to develop procedures for engaging with potential research participants while limiting nonclinical, in-person interactions. This manuscript describes the procedures and challenges of obtaining electronic informed consent and assent in a multisite trauma center-based research study. We developed, tested, and trained staff to implement three options for obtaining informed consent. Twenty-five participants were enrolled in the effectiveness-implementation multisite trial during the first six months of utilization of the consent options, with eleven of these individuals enrolled using hybrid or electronic consent procedures. The challenges we identified involving electronic consent procedures included confusion over who would complete the electronic consent process and difficulties reconnecting with families. Lessons learned can strengthen electronic consent and assent procedures for future studies. More research is needed to further strengthen this process and increase its utilization.

Variability in opioid pain medication prescribing for adolescent trauma patients in a sample of US pediatric trauma centers.

Objectives: The primary objective of this study was to examine opioid prescription frequency and identify differences across a national cohort of pediatric trauma centers in rates of prescribing opioids to injured adolescents at discharge. Methods: This was a retrospective observational study using electronic health records of injured adolescents (12-17 years) admitted to one of 10 pediatric trauma centers. Results: Of the 1345 electronic health records abstracted, 720 (53.5%, 95% CI 50.8 to 56.2) patients received opioid prescriptions at discharge with variability across sites (28.6%-72%). There was no association between patient factors and frequency of prescribing opioids. Center's trauma volume was significantly positively correlated with a higher rate of opioid prescribing at discharge (r=0.92, p=0.001). There was no significant difference between the frequency of opioid prescriptions at discharge among alcohol and other drugs (AOD)-positive patients (53.8%) compared with AOD-negative patients (53.5%). Conclusions: Across a sample of 10 pediatric trauma centers, just over half of adolescent trauma patients received an opioid prescription at discharge. Prescribing rates were similar for adolescent patients screening positive for AOD use and those screening negative. The only factor associated with a higher frequency of prescribing was trauma center volume. Consensus and dissemination of outpatient pain management best practices for adolescent trauma patients is warranted. Level of evidence: III-prognostic. Trial registration number: NCT03297060.

23.4% Hypertonic Saline and Intracranial Pressure in Severe Traumatic Brain Injury Among Children: A 10-Year Retrospective Analysis.

OBJECTIVE: To explore the effect of 23.4% hypertonic saline for management of elevated intracranial pressure in children admitted to our institution for severe traumatic brain injury. DESIGN: Single-center, retrospective medical chart analysis. SETTING: A PICU at a level 1 pediatric trauma center in the United States. PATIENTS: Children admitted for severe traumatic brain injury from 2006 to 2016 who received 23.4% hypertonic saline and whose intracranial pressures were measured within 5 hours of receiving 23.4% hypertonic saline. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over the 10-year period, 1,587 children were admitted for traumatic brain injury, 155 of whom were deemed severe per this study's criteria. Forty of these children received at least one dose of hypertonic saline, but 14 were excluded for insufficient intracranial pressure data. Among the remaining 26 children, one hundred one 23.4% hypertonic saline boluses were used in the analysis. Use of 23.4% hypertonic saline was associated with a decrease in intracranial pressure of approximately 7 mm Hg at both within 1 hour after the bolus (p < 0.01) and 4 hours after the bolus (p < 0.01) when compared with the intracranial pressure measured within 1 hour before the hypertonic saline bolus. These effects remained significant after adjusting for Functional Status Scale score and CT Marshall scores. There was no statistically significant association between adjunctive therapies, such as antiepileptics and analgesics, and changes in intracranial pressure. There was no laboratory evidence of hyperkalemia or renal injury after use of 23.4% hypertonic saline. Across all hospitalizations, 65% of the study population demonstrated an abnormally elevated creatinine at least once, but only three episodes of acute kidney injury occurred in total, all before hypertonic saline administration. Eight of the 26 children in this analysis died during their hospitalization. The Functional Status Scale scores ranged from 6 to 26 with a mean of 12.2 and SD of 5.7. CONCLUSIONS: Use of 23.4% hypertonic saline with children admitted for severe traumatic brain injury is associated with a statistically significant decrease in intracranial pressure within 1 hour of use.

Pediatric Trauma Care in Low Resource Settings: Challenges, Opportunities, and Solutions.

Trauma constitutes a significant cause of death and disability globally. The vast majority -about 95%, of the 5.8 million deaths each year, occur in low-and-middle-income countries (LMICs) 3-6. This includes almost 1 million children. The resource-adapted introduction of trauma care protocols, regionalized care and the growth specialized centers for trauma care within each LMIC are key to improved outcomes and the lowering of trauma-related morbidity and mortality globally. Resource limitations in LMICs make it necessary to develop injury prevention strategies and optimize the use of locally available resources when injury prevention measures fail. This will lead to the achievement of the best possible outcomes for critically ill and injured children. A commitment by the governments in LMICs working alone or in collaboration with international non-governmental organizations (NGOs) to provide adequate healthcare to their citizens is also crucial to improved survival after major trauma. The increase in global conflicts also has significantly deleterious effects on children, and governments and international organizations like the United Nations have a significant role to play in reducing these. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs.

Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned.

Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs) remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU) and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals.

Pediatric Trauma Care in Low- and Middle-Income Countries: A Brief Review of the Current State and Recommendations for Management and a Way Forward.

Traumatic injuries are a significant cause of death and disability worldwide. The vast majority of these injuries occur in low- and middle-income countries (LMICs). Attention to protocolized care and adaptations to treatments based on availability of resources, regionalization of care, and the development of centers of excellence within each LMIC are crucial to improving outcomes and lowering trauma-related morbidity and mortality worldwide. Given limitations in the availability of the resources necessary to provide the levels of care found in high-income countries, strategies to prevent trauma and make the best use of available resources when prevention fails, and thus achieve the best possible outcomes for injured and critically ill children, are vital. Overall, a commitment on the part of governments in LMICs to the provision of adequate health care services to their populations will improve the outcomes of injured children. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs.

Pediatric injury prevention: methods of booster seat education.

Sixty elementary schools in Minneapolis were asked to participate in a study to evaluate the most effective education method to increase booster seat knowledge and use in kindergarten-age children. School personnel selected one of the following interventions: (1) written information, (2) parent education class and a free booster seat, or (3) student education and a free booster seat. Twenty schools participated, with 132 parents completing the telephone interview 3 to 6 months post-survey. Providing instructions to parent groups and teaching children in the classroom, along with providing an incentive booster seat, was shown to increase booster seat use. Providing information only was found to be ineffective. Pediatric and school nurses should focus their injury prevention efforts beyond written materials. Results indicate that presentations for children and their parents, along with incentives, can result in changes in behavior.

Utility of blood cultures in postoperative pediatric intensive care unit patients.

OBJECTIVE: To determine the frequency of positive blood cultures in patients with fevers in the initial 48-hour postoperative period. STUDY DESIGN: All patients who had blood cultures drawn during the initial 48 hours postoperatively while in the pediatric intensive care unit (PICU) at the University of Minnesota Children's Hospital-Fairview during an 18-month period were included in the current study. Six hundred two postoperative patients were admitted to the PICU during the study period. Patients with a temperature >100.4 degrees F and who had blood cultures drawn were identified. Patients for whom the operative procedure was not the first in that admission, those discharged in <48 hours, and those with an indwelling central venous catheter for >24 hours before their admission were excluded. RESULTS: Sixty-six of these patients were febrile and had blood cultures drawn in the initial 48 hours postoperatively. One hundred eleven blood cultures were obtained. A single (0.9%) blood culture was positive. The cost per positive culture was estimated at $23,532. CONCLUSIONS: Even in patients admitted to the PICU, fever in the initial 48-hour postoperative period is unlikely to represent bacteremia in low-risk pediatric patients. Blood cultures in these patients are, therefore, unlikely to yield positive results. Procurement of blood cultures in this patient population is not justified. Cessation of the practice of blood culture procurement in this patient population may both focus care and provide enable meaningful cost savings.