Current management of children with minor head trauma (MHT) and intracranial injuries is not evidence-based and may place some children at risk of harm. Evidence-based electronic clinical decision ...support (CDS) for management of these children may improve patient safety and decrease resource use. To guide these efforts, we evaluated the sociotechnical environment impacting the implementation of electronic CDS, including workflow and communication, institutional culture, and hardware and software infrastructure, among other factors.
Between March and May, 2020 semi-structured qualitative focus group interviews were conducted to identify sociotechnical influences on CDS implementation. Physicians from neurosurgery, emergency medicine, critical care, and pediatric general surgery were included, along with information technology specialists. Participants were recruited from nine health centers in the United States. Focus group transcripts were coded and analyzed using thematic analysis. The final themes were then cross-referenced with previously defined sociotechnical dimensions.
We included 28 physicians and four information technology specialists in seven focus groups (median five participants per group). Five physicians were trainees and 10 had administrative leadership positions. Through inductive thematic analysis, we identified five primary themes: (1) clinical impact; (2) stakeholders and users; (3) tool content; (4) clinical practice integration; and (5) post-implementation evaluation measures. Participants generally supported using CDS to determine an appropriate level-of-care for these children. However, some had mixed feelings regarding how the tool could best be used by different specialties (e.g. use by neurosurgeons versus non-neurosurgeons). Feedback from the interviews helped refine the tool content and also highlighted potential technical and workflow barriers to address prior to implementation.
We identified key factors impacting the implementation of electronic CDS for children with MHT and intracranial injuries. These results have informed our implementation strategy and may also serve as a template for future efforts to implement health information technology in a multidisciplinary, emergency setting.
IntroductionSepsis affects 25.2 million children per year globally and causes 3.4 million deaths, with an annual cost of hospitalisation in the USA of US$7.3 billion. Despite being common, severe and ...expensive, therapies and outcomes from sepsis have not substantially changed in decades. Variable case definitions, lack of a reference standard for diagnosis and broad spectrum of disease hamper efforts to evaluate therapies that may improve sepsis outcomes. This landscape analysis of community-acquired childhood sepsis in Australia and New Zealand will characterise the burden of disease, including incidence, severity, outcomes and cost. Sepsis diagnostic criteria and risk stratification tools will be prospectively evaluated. Sepsis therapies, quality of care, parental awareness and understanding of sepsis and parent-reported outcome measures will be described. Understanding these aspects of sepsis care is fundamental for the design and conduct of interventional trials to improve childhood sepsis outcomes.Methods and analysisThis prospective observational study will include children up to 18 years of age presenting to 12 emergency departments with suspected sepsis within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand. Presenting characteristics, management and outcomes will be collected. These will include vital signs, serum biomarkers, clinician assessment of severity of disease, intravenous fluid administration for the first 24 hours of hospitalisation, organ support therapies delivered, antimicrobial use, microbiological diagnoses, hospital and intensive care unit length-of-stay, mortality censored at hospital discharge or 30 days from enrolment (whichever comes first) and parent-reported outcomes 90 days from enrolment. We will use these data to determine sepsis epidemiology based on existing and novel diagnostic criteria. We will also validate existing and novel sepsis risk stratification criteria, characterise antimicrobial stewardship, guideline adherence, cost and report parental awareness and understanding of sepsis and parent-reported outcome measures.Ethics and disseminationEthics approval was received from the Royal Children’s Hospital of Melbourne, Australia Human Research Ethics Committee (HREC/69948/RCHM-2021). This included incorporated informed consent for follow-up. The findings will be disseminated in a peer-reviewed journal and at academic conferences.Trial registration numberACTRN12621000920897; Pre-results.
Study objective We aimed to determine the prevalence of traumatic brain injuries in children who vomit after minor blunt head trauma, particularly when the vomiting occurs without other findings ...suggestive of traumatic brain injury (ie, isolated vomiting). We also aimed to determine the relationship between the timing and degree of vomiting and traumatic brain injury prevalence. Methods This was a secondary analysis of children younger than 18 years with minor blunt head trauma. Clinicians assessed for history and characteristics of vomiting at the initial evaluation. We assessed for the prevalence of clinically important traumatic brain injury and traumatic brain injury on computed tomography (CT). Results Of 42,112 children enrolled, 5,557 (13.2%) had a history of vomiting, of whom 815 of 5,392 (15.1%) with complete data had isolated vomiting. Clinically important traumatic brain injury occurred in 2 of 815 patients (0.2%; 95% confidence interval CI 0% to 0.9%) with isolated vomiting compared with 114 of 4,577 (2.5%; 95% CI 2.1% to 3.0%) with nonisolated vomiting (difference –2.3%, 95% CI –2.8% to –1.5%). Of patients with isolated vomiting for whom CT was performed, traumatic brain injury on CT occurred in 5 of 298 (1.7%; 95% CI 0.5% to 3.9%) compared with 211 of 3,284 (6.4%; 95% CI 5.6% to 7.3%) with nonisolated vomiting (difference –4.7%; 95% CI –6.0% to –2.4%). We found no significant independent associations between prevalence of clinically important traumatic brain injury and traumatic brain injury on CT with either the timing of onset or time since the last episode of vomiting. Conclusion Traumatic brain injury on CT is uncommon and clinically important traumatic brain injury is very uncommon in children with minor blunt head trauma when vomiting is their only sign or symptom. Observation in the emergency department before determining the need for CT appears appropriate for many of these children.
Study objective We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect ...of a mandatory age triage criterion for field triage. Methods This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ≥16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume. Results Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers. Conclusion Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.
Study objective Traumatic and unsuccessful lumbar punctures can cause substantial diagnostic ambiguity that may lead to unnecessary antibiotic use and hospitalization, in addition to patient ...discomfort. Risk factors for obtaining traumatic and unsuccessful lumbar punctures have been studied in a limited fashion only. We sought to determine patient, physician, and procedural factors associated with traumatic and unsuccessful lumbar punctures in children. Methods The study included a prospective cohort of all children undergoing lumbar punctures in a single emergency department between July 2003 and January 2005. Our main outcome was either a traumatic lumbar puncture (cerebrospinal fluid RBC counts ≥10,000 cells/mm3 ) or unsuccessful lumbar puncture (failure of the procedure to yield fluid for cell counts) after the first lumbar puncture attempt. We performed multiple logistic regression analyses to identify independent predictors of traumatic or unsuccessful lumbar punctures. Results Of the 1,474 eligible lumbar punctures, 1,459 (99%) were included in the analysis. Of these, 513 (35%) were traumatic or unsuccessful on the first attempt. After adjustment for patient characteristics, physician and procedural factors associated with an increased risk of a traumatic or unsuccessful lumbar puncture included less physician experience (adjusted odds ratio for an ordinal decrease in experience 1.08; 95% confidence interval CI 1.01 to 1.15), lack of local anesthetic use (adjusted odds ratio 1.6; 95% CI 1.1 to 2.2), advancement of the spinal needle with stylet in place versus stylet removed (adjusted odds ratio 1.3; 95% CI 1.04 to 1.7), and increased patient movement (adjusted odds ratio 2.1; 95% CI 1.6 to 2.6). Conclusion Of the factors associated with traumatic or unsuccessful lumbar punctures in children, advancement of the spinal needle with the stylet in place and lack of local anesthetic use are the most modifiable. Modification of these procedural factors may reduce the risk of traumatic or unsuccessful lumbar punctures in children.
Study objective Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. ...Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. Methods We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the model's sensitivity and specificity. Results We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. Conclusion We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.
IntroductionRelatively limited data are available regarding paediatric COVID-19. Although most children appear to have mild or asymptomatic infections, infants and those with comorbidities are at ...increased risk of experiencing more severe illness and requiring hospitalisation due to COVID-19. The recent but uncommon association of SARS-CoV-2 infection with development of a multisystem inflammatory syndrome has heightened the importance of understanding paediatric SARS-CoV-2 infection.Methods and analysisThe Paediatric Emergency Research Network-COVID-19 cohort study is a rapid, global, prospective cohort study enrolling 12 500 children who are tested for acute SARS-CoV-2 infection. 47 emergency departments across 12 countries on four continents will participate. At enrolment, regardless of SARS-CoV-2 test results, all children will have the same information collected, including clinical, epidemiological, laboratory, imaging and outcome data. Interventions and outcome data will be collected for hospitalised children. For all children, follow-up at 14 and 90 days will collect information on further medical care received, and long-term sequelae, respectively. Statistical models will be designed to identify risk factors for infection and severe outcomes.Ethics and disseminationSites will seek ethical approval locally, and informed consent will be obtained. There is no direct risk or benefit of study participation. Weekly interim analysis will allow for real-time data sharing with regional, national, and international policy makers. Harmonisation and sharing of investigation materials with WHO, will contribute to synergising global efforts for the clinical characterisation of paediatric COVID-19. Our findings will enable the implementation of countermeasures to reduce viral transmission and severe COVID-19 outcomes in children.Trial registration numberNCT04330261
Study objective Head trauma is common in children. In the absence of evidence-based recommendations, variations exist in the initial emergency department (ED) evaluation and treatment of children ...with head trauma. We sought to describe the use of computed tomography (CT) over time in the treatment of children with acute closed head trauma in US EDs. Methods This was a cross-sectional analysis of data from the National Hospital Ambulatory Care Survey database from 1995 to 2003. We identified patients aged 0 to 18 years, with head trauma by chief complaint or discharge diagnosis. We collected the following data: chief complaint, patient demographics, patient disposition, discharge diagnosis, and use of CT. Frequency and characteristics of the use of CT scan for evaluation of children with head trauma. We used descriptive statistics with appropriate weighting to account for the survey methodology. We determined the frequency and the characteristics of the use of CT scans for evaluation of children with head trauma. We used descriptive statistics with appropriate weighting to account for the survey methodology. Results We identified 2,747 patient encounters, representing 10,536,717 pediatric head trauma visits during the 9-year period. The use of CT increased from 12.8% to 22.4% from 1995 to 2003, with a peak of 28.6% in 2000. CT was used more frequently in the older age groups: 13% (<1 year), 11% (1 to 4 years), 20% (5 to 9 years), and 32% (10 to 18 years). CT was also used more frequently in general EDs (22%) than in pediatric-specific EDs (13%). There were no differences in CT use between teaching and nonteaching facilities (21% in each). Overall, 6.4% of children were either admitted to the hospital or transferred, and this rate remained stable over time. Conclusion The use of CT has increased substantially in the evaluation of children with head trauma from 1995 to 2003. Further study is needed to identify objective criteria for cranial CT in head-injured children and to evaluate the impact of increased CT use on patient outcomes.
Objective To characterize regional differences in brain water distribution and content during diabetic ketoacidosis (DKA) in children and determine whether these differences correlate with regional ...vascular supply. Study design We compared changes in brain water distribution and water content in different brain regions during DKA by analyzing magnetic resonance diffusion weighted imaging data collected during DKA and after recovery in 45 children (<18 years of age). We measured the apparent diffusion coefficient (ADC) of water in the frontal and occipital cortex, basal ganglia, thalamus, hippocampus, and medulla. Brain water content was also measured in a subset of patients. Results ADC values were elevated (suggesting vasogenic cerebral edema) in the frontal cortex, basal ganglia, thalamus, and hippocampus during DKA. In contrast, ADC values in the medulla and the occipital cortex were not increased during DKA, and ADC changes in the medulla tended to be negatively correlated with other regions. Regions supplied by the anterior/middle cerebral artery circulation had greater elevations in both ADC and brain water content during DKA compared with regions supplied by the posterior cerebral artery circulation. Conclusions ADC changes during DKA in the brainstem contrast with those of other brain regions, and changes in both ADC and brain water content during DKA vary according to regional vascular supply. These data suggest that brainstem blood flow might possibly be reduced during DKA concurrent with hyperemia in other brain regions.
PDF
