It is unclear which pediatric disaster triage (PDT) strategy yields the best accuracy or best patient outcomes.
We conducted a cross-sectional analysis on a sample of emergency medical services ...providers from a prospective cohort study comparing the accuracy and triage outcomes for 2 PDT strategies (Smart and JumpSTART) and clinical decision-making (CDM) with no algorithm. Participants were divided into cohorts by triage strategy. We presented 10-victim, multi-modal disaster simulations. A Delphi method determined patients' expected triage levels. We compared triage accuracy overall and for each triage level (RED/Immediate, YELLOW/Delayed, GREEN/Ambulatory, BLACK/Deceased).
There were 273 participants (71 JumpSTART, 122 Smart, and 81 CDM). There was no significant difference between Smart triage and CDM. When JumpSTART triage was used, there was greater accuracy than with either Smart (P<0.001; OR odds ratio: 2.03; interquartile range IQR: 1.30, 3.17) or CDM (P=0.02; OR: 1.76; IQR: 1.10, 2.82). JumpSTART outperformed Smart for RED patients (P=0.05; OR: 1.48; IQR: 1.01,2.17), and outperformed both Smart (P<0.001; OR: 3.22; IQR: 1.78,5.88) and CDM (P<0.001; OR: 2.86; IQR: 1.53,5.26) for YELLOW patients. Furthermore, JumpSTART outperformed CDM for BLACK patients (P=0.01; OR: 5.55; IQR: 1.47, 20.0).
Our simulation-based comparison suggested that JumpSTART triage outperforms both Smart and CDM. JumpSTART outperformed Smart for RED patients and CDM for BLACK patients. For YELLOW patients, JumpSTART yielded more accurate triage results than did Smart triage or CDM.
Purpose: Workflow analysis is an important approach for understanding clinical care in complex systems. This is particularly true for low frequency events such as the care of children in the ...out-of-hospital setting. The purpose of this study was to characterize emergency medical service (EMS) workflow in the care of children during simulated emergency, prehospital encounters.
Methods: This is a secondary analysis exploring high-fidelity videorecorded simulations, performed by emergency personnel. Two scenarios were used in 19 simulations which consisted of a 15-month and a 1-month old with respiratory decompensation and shock requiring intravenous fluid, respiratory support, and medication administration. One trained investigator performed review of the videos of teams EMS practitioners, quantifying the sequence and number of tasks performed and time to completion of the simulated intervention. The variance in sequence of tasks was quantified using the Levenshtein distance. We quantified the proportion of time with no activity (idle time) and temporal overlap (team multitasking time).
Results: We identified 17 types of distinct tasks performed during the simulation. There was high variability across simulations in the sequences, types, and number of tasks performed. Team multitasking was noted in all scenarios, with a mean of 99% multitasking ratio (range: 52-202%). Mean proportion of idle time was 4% (range: 0-11%). Weight estimate, intravenous or intraosseous access, radio report, blood glucose level (BGL), medication administration, pulse check and respiration check were observed in all videos. Other tasks were observed in only a proportion of scenarios with varying frequencies. Median number of differences in sequence of tasks between scenarios was 15.
Conclusions: Our analysis found a high percentage of team multitasking and significant variability in frequency and sequence of task completion. Further research is needed to assess the reasons and effect of this degree of variability on the efficiency and effectiveness of prehospital interventions.
AbstractObjective. There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS ...provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. Methods. We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. Results. After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation. Conclusions. The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.
Background
Computed tomography (CT) with enteric contrast is frequently used to evaluate children with suspected appendicitis. The use of CT with intravenous (IV) contrast alone (CT IV) may be ...sufficient, however, particularly in patients with adequate intra‐abdominal fat (IAF).
Objectives
The authors aimed 1) to determine the ability of radiologists to visualize the normal (nondiseased) appendix with CT IV in children and to assess whether IAF adequacy affects this ability and 2) to assess the association between IAF adequacy and patient characteristics.
Methods
This was a retrospective 16‐center study using a preexisting database of abdominal CT scans. Children 3 to 18 years who had CT IV scan and measured weights and for whom appendectomy history was known from medical record review were included. The sample was chosen based on age to yield a sample with and without adequate IAF. Radiologists at each center reread their site's CT IV scans to assess appendix visualization and IAF adequacy. IAF was categorized as “adequate” if there was any amount of fat completely surrounding the cecum and “inadequate” if otherwise.
Results
A total of 280 patients were included, with mean age of 10.6 years (range = 3.1 to 17.9 years). All 280 had no history of prior appendectomy; therefore, each patient had a presumed normal appendix. A total of 102 patients (36.4%) had adequate IAF. The proportion of normal appendices visualized with CT IV was 72.9% (95% confidence interval CI = 67.2% to 78.0%); the proportions were 89% (95% CI = 81.5% to 94.5%) and 63% (95% CI = 56.0% to 70.6%) in those with and without adequate IAF (95% CI for difference of proportions = 16% to 36%). Greater weight and older age were strongly associated with IAF adequacy (p < 0.001), with weight appearing to be a stronger predictor, particularly in females. Although statistically associated, there was noted overlap in the weights and ages of those with and without adequate IAF.
Conclusions
Protocols using CT with IV contrast alone to visualize the appendix can reasonably include weight, age, or both as considerations for determining when this approach is appropriate. However, although IAF will more frequently be adequate in older, heavier patients, highly accurate prediction of IAF adequacy appears challenging solely based on age and weight.
Resumen
Tomografía Computarizada Únicamente con Contraste Intravenoso: El Papel de la Grasa Intrabadominal en la Capacidad para Visualizar el Apéndice Normal en los Niños
Introduction
La tomografía computarizada (TC) con contraste entérico es usada frecuentemente para evaluar a los niños con sospecha de apendicitis. El uso de la TC únicamente con contraste intravenoso (TC IV) puede ser suficiente, especialmente en pacientes con adecuada grasa intrabdominal (GIA).
Objetivos
1) Determinar la capacidad de los radiólogos para visualizar el apéndice normal (sin enfermedad) con TC IV en niños, y valorar si la cantidad de GIA afecta a esta capacidad; y 2) valorar la asociación entre la idoneidad de la GIA y las características del paciente.
Metodología
Estudio retrospectivo de 16 hospitales que utilizó una base de datos prexistente de TC abdominales. Se incluyó a los niños entre 3 y 18 años que tenían una TC IV, una medida del peso e historia de apendectomía conocida por la revisión de la historia clínica. La muestra se eligió en base a la edad con el fin de conseguir una muestra con y sin GIA adecuada. Los radiólogos de cada centro releyeron las TC IV de sus centros para valorar la visualización del apéndice y la adecuación de la GIA. La GIA se clasificó como “adecuada” si había cualquier cantidad de grasa completamente alrededor del ciego e “inadecuada” si era de otra manera.
Resultados
Se incluyeron 280 pacientes, con una media de edad de 10,6 años (rango 3,1 a 17,9 años). Ninguno tenía historia previa de apendectomía; por lo tanto todos los pacientes tuvieron un apéndice presumiblemente normal. Ciento dos pacientes (36,4%) tuvieron GIA adecuada. El porcentaje de apéndices normales visualizados con TC IV fue de 72,9% (IC 95% = 67,2% a 78,0%); la proporción fue 89% (IC 95% = 81,5% a 94,5%), y 63% (IC 95% = 56,0% a 70,6%) en aquéllos con y sin GIA adecuada (IC 95% para la diferencia de proporciones = 16% a 36%). El mayor peso y la mayor edad se asociaron fuertemente con la adecuación de la GIA (p < 0,001), y el peso resultó ser el mayor factor predictivo, especialmente en mujeres. Aunque se asoció estadísticamente, se vio un solapamiento en los pesos y edades de aquéllos con y sin GIA adecuada.
Conclusiones
Los protocolos que usan la TC IV para visualizar el apéndice pueden razonablemente incluir el peso, la edad, o ambas como consideraciones para determinar cuándo esta aproximación es apropiada. Sin embargo, aunque la cantidad de GIA será frecuentemente más apropiada en los pacientes más mayores y de mayor peso, la predicción certera de adecuación de GIA es altamente desafiante si se basa sólo en la edad y el peso.
To compare intranasal midazolam, using a Mucosal Atomization Device (IN-MMAD), with rectal diazepam (RD) for the home treatment of seizures in children with epilepsy.
Prospective randomized study.
...Patients' homes and a freestanding children's hospital that serves as a referral center for 5 states.
A total of 358 pediatric patients who visited a pediatric neurology clinic from July 2006 through September 2008 and were prescribed a home rescue medication for their next seizure.
Caretakers were randomized to use either 0.2 mg/kg of IN-MMAD (maximum, 10 mg) or 0.3 to 0.5 mg/kg of RD (maximum, 20 mg) at home for their child's next seizure if it lasted more than 5 minutes.
The primary outcome measure was total seizure time after medication administration. Our secondary outcome measures were total seizure time, time to medication administration, respiratory complications, emergency medical service support, emergency department visits, hospitalizations, and caretakers' ease of administration and satisfaction with the medication.
A total of 92 caretakers gave the study medication during a child's seizure (50 IN-MMAD, 42 RD). The median time from medication administration to seizure cessation for IN-MMAD was 1.3 minutes less than for RD (95% confidence interval, 0.0-3.5 minutes; P=.09). The median time to medication administration was 5.0 minutes for each group. No differences in complications were found between treatment groups. Caretakers were more satisfied with IN-MMAD and report that it was easier to give than RD.
There was no detectable difference in efficacy between IN-MMAD and RD as a rescue medication for terminating seizures at home in pediatric patients with epilepsy. Ease of administration and overall satisfaction was higher with IN-MMAD compared with RD. Trial Registration clinicaltrials.gov Identifier: NCT00326612.
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