Emergency department visits for mild traumatic brain injury in early childhood.

BACKGROUND: Brain injury during early childhood may disrupt key periods of neurodevelopment. Most research regarding mild traumatic brain injury (mTBI) has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED). METHODS: The Nationwide Emergency Department Sample was queried for children age 0-6 years with mTBI from 2016 to 2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion. RESULTS: National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was "unspecified injury of head" (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children's hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head and cervical spine were performed in 18.7% and 1.6% of patients, respectively, less often at children's hospitals (OR = 0.55, 95%CI = 0.41-0.76 for head and OR = 0.19, 95%CI = 0.11-0.34 for cervical spine). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid. CONCLUSIONS: Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide variation in diagnostic coding and computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies.

The association between traumatic dental and brain injuries in American children.

BACKGROUND/AIM: It is crucial that dentists who treat traumatic dental injuries rule out concomitant brain injuries. Despite anatomic proximity, controversy exists regarding association between facial trauma and head injury. The aim of this study was to examine the association between dento-alveolar trauma (DAT) and traumatic brain injuries (TBI) using a national dataset of emergency department (ED) visits. MATERIAL AND METHODS: Nationwide Emergency Department Sample (NEDS) data, one of the Healthcare Cost and Utilization Project (HCUP) datasets, were analyzed. Encounters of patients age 0-18 years with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with DAT and TBI in the 2010-2014 NEDS were identified. Data were analyzed using descriptive statistics, chi-square test, and logistic regression models to investigate the association between DAT and TBI and factors associated with TBI in DAT-positive patients. RESULTS: During the study period, 6 281 658 ED visits were associated with traumatic injuries. DAT was recorded in 93 408 (1.5%) and TBI was recorded in 996 334 (15.9%) of these traumatic injury visits. Within the group of DAT-positive encounters, 7035 (7.5%) had codes associated with TBI. Of trauma encounters where a DAT was not involved (6 188 250 encounters), 989 299 (16%) had an associated TBI code. Patients with DAT had 0.20 odds of having TBI (95% CI, 0.19-0.20, P < .0001) compared with patients who did not have DAT when all other confounding variables were kept constant. Having multiple injuries, being involved in motor vehicle crashes, and injuries due to assault were associated with higher odds of concomitant TBI in patients who sustained DAT. CONCLUSIONS: There was an inverse association between DAT and TBI in this study population.

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.

The impact of driving time on pediatric TBI follow-up visit attendance.

Objective: Examine the effect of driving time on follow-up visit attendance for children hospitalized with a traumatic brain injury (TBI). We hypothesized that families who lived further from the hospital would show poorer follow-up attendance.Participants: 368 children admitted to the hospital with TBI.Design & Outcome Measures: Using a retrospective chart review, we calculated driving time from patients' homes. The primary outcome was attendance at the first appointment post-discharge. We used logistic regression to examine the effect of driving time on attendance, including an analysis of the effects of injury and sociodemographic covariates on the model.Results: Majority of children attended their first appointment. Patients living 30-60 min from the hospital were most likely to attend, and those living 15 min away were least likely to attend. After adjusting for patient characteristics, families with driving time of 30-60 min had significantly higher odds of returning for follow-up than those with driving time <15 min, though the significance of this relationship disappeared after specific socioeconomic (SES) factors were included.Conclusions: Distance plays a significant role on follow-up attendance for pediatric patients with TBI. However, neighborhood SES may be an additional factor that influences the significance of the distance effect.Abbreviations: TBI: Traumatic brain injury; SES: socioeconomic status; ISS: Injury severity scale; AIS: Abbreviated injury scale.

Impact of a Dedicated Advanced Practice Provider Model for Pediatric Trauma and Burn Patients.

BACKGROUND: A free-standing, academic Level 1 pediatric trauma and verified pediatric burn center created a dedicated trauma and burn service advanced practice provider role, and restructured rounds. The changes were implemented to improve patient care. METHODS: A pre and postintervention study using historical controls was performed to compare 18 months prior (preintervention) and 18 months following (postintervention) practice changes. Data collection included demographics, injury characteristics, length of stay (LOS), complications, and patient satisfaction results. RESULTS: When compared with the preintervention period, the postintervention period had a higher patient volume and an increased number of severely injured patients. Mean LOS was stable for all patients and trauma patients, as were the complication rates related to trauma and burns. However, the mean LOS/total body surface area (TBSA) burned decreased from 1.36 to 1.04 days/TBSA (p = .160) in burn patients and from 0.84 to 0.62 days/TBSA (p = .060) in those with more than 5% TBSA. Patient satisfaction scores were stable in the categories of nursing care and the child's physician. Despite an increase in the volume and severity of patients, there was a clinically meaningful decrease in burn patient LOS/TBSA. CONCLUSION: The addition of a dedicated advanced practice provider and restructured trauma service appears to provide a benefit to pediatric burn patients.

Prehospital Versus Trauma Center Glasgow Coma Scale in Pediatric Traumatic Brain Injury Patients.

BACKGROUND: Traumatic brain injury (TBI) is a major source of morbidity and mortality in children. The Glasgow Coma Scale (GCS) can be challenging to calculate in pediatric patients. Our objective was to determine its reproducibility between prehospital providers and pediatric trauma hospital personnel. MATERIALS AND METHODS: The institutional trauma database for a level 1 pediatric trauma center was queried for patients aged ≤18 y who presented with a TBI. Demographics, mechanism, prehospital GCS, and trauma center GCS were collected. Agreement was evaluated with weighted kappa (κ) coefficients (0 = agreement no better than that expected by chance alone, 1 = perfect agreement). RESULTS: The inclusion criteria were met by 1711 patients, 263 of whom were aged <3 y. Prehospital GCS and trauma center GCS differed in 766 patients (44.8%). Agreement between prehospital GCS and trauma center GCS was moderate for all patients (κ = 0.61, 95% confidence interval [CI] 0.57-0.64). Agreement was slightly better than chance alone in patients with trauma center GCS between 9 and 12 y (κ = 0.09, 95% CI 0.03-0.15) and was lower for children aged 0-2 y (κ = 0.51, 95% CI 0.42-0.61) than for those aged between 3 and 18 y (κ = 0.63, 95% CI 0.59-0.66). Younger children were more likely to have score differences of at least 3 points (21.3% versus 13.6% of 3- to 18-y-olds, P < 0.001). CONCLUSIONS: Prehospital and trauma center GCS scores frequently disagree in children, particularly in TBI patients aged <3 y and those with moderate TBI. Centers should consider the inconsistency of the pediatric GCS when triaging TBI patients.

Alcohol and drug screening of adolescent trauma alert patients at a level 1 pediatric trauma center.

BACKGROUND: Adolescent trauma patients are reported to have increased incidence of alcohol and other drug (AOD) use, but previous studies have included inadequate screening of the intended populations. A Level 1 Pediatric Trauma Center achieved a 94% rate of AOD screening. We hypothesized that a positive AOD screening result is associated with males, increasing age, lower socioeconomic status, violent injury mechanism, higher Injury Severity Score (ISS), lower GCS, need for operation and increased hospital length of stay. METHODS: After achieving high rates of screening among admitted trauma alert patients 12-17 years old, we evaluated patients presenting during 2014-2015. Chi-square tests were used to compare the percentage of patients with positive test results across sociodemographic, injury severity measures and patient outcomes. RESULTS: Three hundred and one patients met criteria for AOD screening during the study period. Ninety-four percent of these patients received screening and 18% were positive. Males (21.4%) were more often positive than females (11.6%). Increasing age was directly correlated with AOD use. Race was associated with a positive screen. Black patients more often had positive screens (40.9%), as compared with White patients (13.8%) and other races (23.5%). Patients with commercial insurance (6.6%) were less likely to be positive than those with no insurance (19.0%) or Medicaid (30.9%). Lower median household income was associated with positive AOD screening. Patients with violent injury mechanisms were more likely to screen positive (36.2%) than those with non-violent mechanisms (18.0%). No statistical differences were found with injury severity scores, the need for operation, or hospital length of stay. CONCLUSIONS: With near universal screening of adolescent trauma alert admissions, positive AOD results were more often found with males, increasing age, lower socioeconomic status, and violent injury mechanism. LEVEL OF EVIDENCE: Level III, Retrospective comparative study without negative criteria. STUDY TYPE: Prognostic.

Attending Follow-up Appointments After Pediatric Traumatic Brain Injury: Caregiver-Perceived Barriers and Facilitators.

OBJECTIVE: To examine barriers and facilitators for follow-up care of children with traumatic brain injury (TBI). SETTING: Urban children's hospital. PARTICIPANTS: Caregivers of children (aged 2-18 years) discharged from an inpatient unit with a TBI diagnosis in 2014-2015. DESIGN: Survey of caregivers. MAIN MEASURES: Caregiver-reported barriers and facilitators to follow-up appointment attendance. RESULTS: The sample included 159 caregivers who completed the survey. The top 3 barriers were "no need" (38.5%), "schedule conflicts" (14.1%), and "lack of resources" (10.3%). The top 5 identified facilitators were "good hospital experience" (68.6%), "need" (37.8%), "sufficient resources" (35.8%), "well-coordinated appointments" (31.1%), and "provision of counseling and support" (27.6%). Caregivers with higher income were more likely to report "no need" as a barrier; females were less likely to do so. Nonwhite caregivers and those without private insurance were more likely to report "lack of resources" as a barrier. Females were more likely to report "good hospital experience" and "provision of counseling and support" as a facilitator. Nonwhite caregivers were more likely to report "need" but less likely to report "sufficient resources" as facilitators. CONCLUSIONS: Care coordination, assistance with resources, and improvements in communication and the hospital experience are ways that adherence might be enhanced.

Abnormal lymphocyte response after pediatric thermal injury is associated with adverse outcomes.

BACKGROUND: Burns are a leading cause of morbidity in children, with infections representing the most common group of complications. Severe thermal injuries are associated with a profound inflammatory response, but the utility of laboratory values to predict infections in pediatric burn patients is poorly understood. MATERIALS AND METHODS: Our institutional burn database was queried for patients aged 18 y and younger with at least 10% total body surface area burns. Demographics, mechanism, laboratory results, and outcomes were extracted from the medical record. Patients were classified as having an abnormal or normal total white blood cell count, neutrophil percentage, and lymphocyte percentage using the first complete blood count drawn 72 or more hours postinjury. Outcomes were compared between groups. RESULTS: White blood cell data were available for 90 patients, 84 of whom had neutrophil and lymphocyte percentages. Abnormal lymphocyte percentage 72 h or more after burn injury was associated with a significant increase in infections (67.9% versus 32.3%, P = 0.003), length of stay (33.1 versus 18.8 d, P = 0.02), intensive care unit length of stay (13.1 versus 3.7 days, P = 0.01), and ventilator days (5.8 versus 2.3, P = 0.02). It was also an independent predictor of infection (odds ratio 7.2, 95% confidence interval 2.1-24.5). CONCLUSIONS: Abnormal lymphocyte percentage at or after 72 h after burn injury is associated with adverse outcomes, including increased infectious risk.

Follow-Up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury.

OBJECTIVE: To investigate factors associated with follow-up care adherence in children hospitalized because of traumatic brain injury (TBI). DESIGN: An urban level 1 children's hospital trauma registry was queried to identify patients (2-18 years) hospitalized with a TBI in 2013 to 2014. Chart reviewers assessed discharge summaries and follow-up instructions in 4 departments. MAIN MEASURES: Three levels of adherence-nonadherence, partial adherence, and full adherence-and their associations with care delivery, patient, and injury factors. RESULTS: In our population, 80% were instructed to follow up within the hospital network. These children were older and had more severe TBIs than those without follow-up instructions and those referred to outside providers. Of the 352 eligible patients, 19.9% were nonadherent, 27.3% were partially adherent, and 52.8% were fully adherent. Those recommended to follow up with more than 1 department had higher odds of partial adherence over nonadherence (adjusted odds ratio [AOR] = 5.8, 95% CI: 1.9-17.9); however, these patients were less likely to be fully adherent (AOR = 0.1; 95% CI: 0.1-0.3). Privately insured patients had a higher AOR of full adherence. CONCLUSIONS: Nearly 20% of children hospitalized for TBI never returned for outpatient follow-up and 27% missed appointments. Care providers need to educate families, coordinate service provision, and promote long-term monitoring.

Emergency medical services (EMS) versus non-EMS transport among injured children in the United States.

OBJECTIVES: This study aimed to assess the proportions of injured children transported to trauma centers by different transportation modes and evaluate the effect of transportation mode on inter-facility transfer rates using the US national trauma registry. METHODS: We analyzed data from the 2007-2012 National Trauma Data Bank (NTDB) to study trends of EMS versus non-EMS transport. Multivariable logistic regression was used to evaluate the association between transport mode and inter-facility transfer. RESULTS: There were 286,871 pediatric trauma patients in the 2007-2012 NTDB; 45.8% arrived by ground ambulance, 8.6% arrived by air ambulance, and 37.5% arrived by non-EMS. From 2007 to 2012, there was no significant change in transportation mode. Moderate to severely injured patients (ISS>15) comprised 13.3% of arrivals by ground ambulance, 26.7% of arrivals by air ambulance, and 8.3% of arrivals by non-EMS; those who used EMS were significantly less likely to be transferred to another facility than patients who used non-EMS transport. Moderate and severe pediatric patients arriving by non-EMS to adult trauma centers were more often transferred than those arriving at mixed trauma centers (45.8% and 6.8%, respectively). CONCLUSIONS: Over one third of US pediatric trauma patients used non-EMS transport to arrive at trauma centers. Moderate to severely injured children benefit from EMS transport and professional field triage to reach the appropriate trauma facility. Our study suggests that national efforts are needed to increase awareness among parents and the general public of the benefits of EMS transportation and care.

Unmeasured Confounding in Observational Studies with Multiple Treatment Arms: Comparing Emergency Department Mortality of Severe Trauma Patients by Trauma Center Level.

Comparing emergency department mortality across different levels of trauma care (nontrauma centers, level I and II centers) is important in evaluating regionalized care. Patient population characteristics differ across different levels of trauma care and it is essential to adjust for baseline covariates to make valid comparisons. Propensity score matching has been established as a more robust method to infer causal relationship in observational studies than conventional regression adjustment. We designed and implemented a three group matching methodology. First, we conducted optimal pair matching between the treatment group (nontrauma centers) and the first control group (level I trauma centers); second, we conducted optimal pair matching between the nontrauma centers and the second control group (level II trauma centers); the final step was to link the two sets of matched pairs by the common treatment subjects to form matched triplets. We then implemented a sensitivity analysis with three treatment arms, Lu's imputation based method, to assess the impact due to potential unmeasured confounding. The results showed that if the most severe adult trauma patients treated in nontrauma centers were to be treated in level I or II trauma centers, the odds of emergency department death would be reduced dramatically (odds ratio [OR] = 0.61 and 0.49). There was no difference between being treated in level I or II trauma centers. The sensitivity analysis revealed that the positive association between being treated at level I or II trauma centers and the reduced odds of mortality would remain present even in the presence of strong unmeasured confounding.

Resource use in pediatric blunt and penetrating trauma.

BACKGROUND: Trauma is one of the leading causes of pediatric morbidity and mortality with significant patient and economic impacts that necessitate constant study. Significant differences in outcomes and resource use exist between blunt and penetrating mechanisms. METHODS: The National Trauma Data Bank was analyzed for patients aged 0-18 y with International Classification of Diseases, 9th Revision injury codes for blunt and penetrating trauma from 2007-2012. Demographic information, causes, treatments, complications, and outcomes were assessed. RESULTS: A total of 748,347 pediatric trauma patients were assessed. Blunt trauma was identified as the cause in 601,898 (80.43%) patients compared with 55,597 (7.4%) patients with penetrating trauma. Blunt trauma patients were younger on average and more likely to be female. Despite having a slightly higher mean injury severity scores, blunt trauma patients had shorter length of stay in the hospital (2.9 versus 4.3 d, P < 0.001), fewer complications (34.8% versus 38.6%, P < 0.001), and a much lower mortality rate (1.3% versus 7.1%, P < 0.001). Blunt trauma patients were more likely to undergo computed tomography scanning but less likely to receive transfusions (1.79% versus 5.5%, P < 0.001) and to undergo exploratory laparotomy (0.9% versus 9.4%, P < 0.001) and thoracotomy (0.07% versus 1.7%, P < 0.001). Variations in outcome and resource use were also noted by age. CONCLUSIONS: Compared with penetrating trauma, blunt trauma is more common and patients have shorter length of stay, less complications, lower mortality, and are less likely to need operative intervention or blood transfusion. Resource use also varied by age.

Comparative study of ED mortality risk of US trauma patients treated at level I and level II vs nontrauma centers.

BACKGROUND: Prior studies of undertriage have not made comparisons across multiple trauma levels. METHODS: Emergency department data was extracted from the Nationwide Emergency Department Sample for major trauma patients. We considered patients with moderate injuries (Injury Severity Score, ISS=16-24) and severe injuries (ISS=25-75) separately. Conditional logistic regression modeling was used to compare the odds of ED mortality for level I trauma centers (TC I) vs. nontrauma centers (NTC) and level II trauma centers (TC II) vs. NTC. An innovative 1:1:1 optimal matching (an extension of the traditional pair matching) was used to balance patient characteristics in three groups. To facilitate matching of all NTC patients, 3 subgroups were developed for ISS=16-24 and 2 subgroups for ISS=25-75. Sensitivity analyses were performed to assess the strength of the association between trauma center designation and ED mortality. RESULTS: For ISS=16-24, 2 of 3 subgroups had marginally significant reduced odds of ED mortality when properly triaged (TC I vs. NTC [T1:OR=0.63; 95%CI: 0.45 - 0.89, T2:OR=0.71;95%CI:0.51-0.99]). For ISS=25-75, both subgroups had significantly reduced odds of emergency department mortality when properly triaged (H1: TC I vs. NTC [OR=0.61; 95%CI: 0.50-0.74]; TC II vs. NTC [OR=0.49; 95%CI: 0.38 - 0.63]; H2: TC I vs. NTC [OR=0.50; 95%CI: 0.41 - 0.60]; TC II vs. NTC [OR=0.42; 95%CI: 0.33 - 0.53]). Conclusions for ISS 25-75 were robust to a hypothesized unobserved confounding variable as shown in sensitivity analysis. CONCLUSIONS: Trauma patients with ISS≥25 received most benefit from proper triage. Efforts to reduce undertriage should focus on this population.

Characteristics of nonfatal occupational injuries among U.S. workers with and without disabilities.

BACKGROUND: Workers with disabilities have a higher risk of nonfatal occupational injuries than workers without disabilities. The characteristics of these injuries are not well described. METHODS: Using 1997-2011 National Health Interview Survey (NHIS) data, we compared the nonfatal occupational injuries sustained by U.S. workers with and without disabilities. RESULTS: Overexertion or strenuous movements and falls accounted for 56.7% of all occupational injuries in workers with disabilities, compared with 45.6% in workers without a disability. Workers with disabilities were more frequently injured in the lower extremity (32.3% vs. 26.6%) or torso (22.9% vs. 16.9%). Workers with disabilities sustained more unspecified injuries (13.5% vs. 7.9%) and fewer open wound injuries (15.7% vs. 24.2%) than their counterparts without a disability. CONCLUSIONS: U.S. workers with disabilities had a higher rate of occupational injuries and these injuries tended to be more severe and were more likely to be caused by overexertion/ strenuous movement or falls.

Undertriage of major trauma patients in the US emergency departments.

BACKGROUND: There is evidence that regionalized trauma care and appropriate triage of major trauma patients improve patient outcomes. However, the national rate of undertriage and diagnoses of undertriaged patients are unknown. METHODS: We used the 2010 Nationwide Emergency Department Sample to estimate the national rate of undertriage, identify the prevalent diagnoses, and conduct a simulation analysis of the capacity increase required for level I and II trauma centers (TCs) to accommodate undertriaged patients. Undertriaged patients were those with major trauma, injury severity score ≥ 16, who received definitive care at nontrauma centers (NTCs), or level III TCs. The rate of undertriage was calculated with those receiving definitive care at an NTC center or level III center as a fraction of all major trauma patients. RESULTS: The estimated number of major trauma patient discharges in 2010 was 232448. Level of care was known for 197702 major trauma discharges, and 34.0% were undertriaged in emergency departments (EDs). Elderly patients were at a significantly higher risk of being undertriaged. Traumatic brain injury (TBI) was the most common diagnosis, 40.2% of the undertriaged patient diagnoses. To accommodate all undertriaged patients, level I and II TCs nationally would have to increase their capacity by 51.5%. CONCLUSIONS: We found that more than one-third of US ED major trauma patients were undertriaged, and more than 40% of undertriaged diagnoses were TBIs. A significant capacity increase at level I and II TCs to accommodate these patients appears not feasible.

Surveillance of paediatric traumatic brain injuries using the NEISS: choosing an appropriate case definition.

OBJECTIVE: To evaluate the definition of traumatic brain injury (TBI) in the National Electronic Injury Surveillance System (NEISS) and compare TBI case ascertainment using NEISS vs. ICD-9-CM diagnosis coding. METHODS: Two data samples from a NEISS participating emergency department (ED) in 2008 were compared: (1) NEISS records meeting the recommended NEISS TBI definition and (2) Hospital ED records meeting the ICD-9-CM CDC recommended TBI definition. The sensitivity and positive predictive value were calculated for the NEISS definition using the ICD-9-CM definition as the gold standard. Further analyses were performed to describe cases characterized as TBIs in both datasets and to determine why some cases were not classified as TBIs in both datasets. RESULTS: There were 1834 TBI cases captured by the NEISS and 1836 TBI cases captured by the ICD-9-CM coded ED record, but only 1542 were eligible for inclusion in NEISS. There were 1403 cases classified as TBIs by both the NEISS and ICD-9-CM diagnosis codes. The NEISS TBI definition had a sensitivity of 91.0% (95% CI = 89.6-92.4%) and positive predictive value of 76.5% (95% CI = 74.6-78.4%). CONCLUSIONS: Using the NEISS TBI definition presented in this paper would standardize and improve the accuracy of TBI research using the NEISS.

Paediatric patients with abusive head trauma treated in US Emergency Departments, 2006-2009.

OBJECTIVE: To study characteristics and outcomes of paediatric patients with abusive head trauma (AHT) treated in emergency departments. METHODS: Nationwide Emergency Department Sample (NEDS) data were analysed. The CDC recommended AHT definition was used to classify children ≤ 4 years with head trauma into AHT and non-AHT groups. Outcomes were compared between patients with AHT and patients with non-AHT. Logistic models were fitted to identify risk factors. RESULTS: An estimated 10 773 paediatric patients with AHT were treated in EDs in 2006-2009. The average annual rate was 12.83 per 100 000 for children ≤ 4 years. Children < 1 year of age accounted for most AHT cases (60.6%) and males had a significantly higher AHT rate than females. Medicaid was the primary payer for 66.1% of AHT injuries and 40.3% of non-AHT injuries. The case mortality rate was 53.9 (95% CI = 41.0-66.7) per 1000 patients with AHT compared with 1.6 (95% CI = 1.4-1.9) per 1000 patients with non-AHT. CONCLUSIONS: Child caregivers should be educated about the serious consequences of AHT and proper techniques for caring for infants. Unbiased and accurate documentation of AHT by physicians and medical coders is crucial for monitoring AHT injuries.

Nonoccupational and occupational injuries to US workers with disabilities.

OBJECTIVES: We examined medically treated injuries among US workers with disability. METHODS: Using 2006-2010 National Health Interview Survey data, we compared 3-month rates of nonoccupational and occupational injuries to workers with disability (n = 7729) and without disability (n = 175 947). We fitted multivariable logistic regression models to calculate odds ratios and 95% confidence intervals of injuries by disability status, controlling for sociodemographic variables. We also compared leading causes of injuries by disability status. RESULTS: In the 3-month period prior to the survey, workers with disability were more likely than other workers to have nonoccupational injuries (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 2.04, 2.71) and occupational injuries (OR = 2.39; 95% CI = 1.89, 3.01). For both groups, the leading cause was falls. CONCLUSIONS: Disability status was strongly associated with risk of nonoccupational and occupational injuries among US workers. The safety issues facing US workers with disability in the workplace warrant future research. Federal agencies with an interest in the employment of workers with disability and their safety in the workplace should take a lead in further assessing injury risk and in promoting a safe working environment for workers with disability.

Medical expenditures associated with nonfatal occupational injuries among immigrant and U.S.-born workers.

BACKGROUND: No national study has investigated whether immigrant workers are less likely than U.S.-workers to seek medical treatment after occupational injuries and whether the payment source differs between two groups. METHODS: Using the 2004-2009 Medical Expenditure Panel Survey (MEPS) data, we estimated the annual incidence rate of nonfatal occupational injuries per 100 workers. Logistic regression models were fitted to test whether injured immigrant workers were less likely than U.S.-born workers to seek professional medical treatment after occupational injuries. We also estimated the average mean medical expenditures per injured worker during the 2 year MEPS reference period using linear regression analysis, adjusting for gender, age, race, marital status, education, poverty level, and insurance. Types of service and sources of payment were compared between U.S.-born and immigrant workers. RESULTS: A total of 1,909 injured U.S.-born workers reported 2,176 occupational injury events and 508 injured immigrant workers reported 560 occupational injury events. The annual nonfatal incidence rate per 100 workers was 4.0% (95% CI: 3.8%-4.3%) for U.S.-born workers and 3.0% (95% CI: 2.6%-3.3%) for immigrant workers. Medical treatment was sought after 77.3% (95% CI: 75.1%-79.4%) of the occupational injuries suffered by U.S.-born workers and 75.6% (95% CI: 69.8%-80.7%) of the occupational injuries suffered by immigrant workers. The average medical expenditure per injured worker in the 2 year MEPS reference period was $2357 for the U.S.-born workers and $2,351 for immigrant workers (in 2009 U.S. dollars, P = 0.99). Workers' compensation paid 57.0% (95% CI: 49.4%-63.6%) of the total expenditures for U.S.-born workers and 43.2% (95% CI: 33.0%-53.7%) for immigrant workers. U.S.-born workers paid 6.7% (95% CI: 5.5%-8.3%) and immigrant workers paid 7.1% (95% CI: 5.2%-9.6%) out-of-pocket. CONCLUSIONS: Immigrant workers had a statistically significant lower incidence rate of nonfatal occupational injuries than U.S.-born workers. There was no significant difference in seeking medical treatment and in the mean expenditures per injured worker between the two groups. The proportion of total expenditures paid by workers' compensation was smaller (marginally significant) for immigrant workers than for U.S.-born workers.