Summary
This work is motivated by the need to accurately model a vector of responses related to pediatric functional status using administrative health data from inpatient rehabilitation visits. The ...components of the responses have known and structured interrelationships. To make use of these relationships in modeling, we develop a two‐pronged regularization approach to borrow information across the responses. The first component of our approach encourages joint selection of the effects of each variable across possibly overlapping groups of related responses and the second component encourages shrinkage of effects towards each other for related responses. As the responses in our motivating study are not normally‐distributed, our approach does not rely on an assumption of multivariate normality of the responses. We show that with an adaptive version of our penalty, our approach results in the same asymptotic distribution of estimates as if we had known in advance which variables have non‐zero effects and which variables have the same effects across some outcomes. We demonstrate the performance of our method in extensive numerical studies and in an application in the prediction of functional status of pediatric patients using administrative health data in a population of children with neurological injury or illness at a large children's hospital.
OBJECTIVETo determine the effect of implementation of an automated sepsis screening tool on the median cost of affected patient encounters. STUDY DESIGNThis retrospective cohort study used propensity ...score-matched comparison groups to assess the difference in median cost for comparable affected patient encounters before and after the implementation of an automated sepsis screening tool in a large US children's hospital emergency department (ED) with >90 000 annual visits. All patient encounters in 2018 impacted by the automated sepsis screening tool were included and compared with a propensity score-matched comparison group drawn from patient encounters in 2012 that might have been affected by the screening tool had it been active at that time. The main outcome was the change in the median cost for comparable affected patient encounters. RESULTSThe overall median cost for those affected by an automated sepsis screening tool decreased by 21.2%, from $6454 (IQR, $968-$21 697) to $5084 (IQR, $802-$16 618). The median cost for encounters with an associated International Classification of Diseases sepsis code decreased by 51.1%, from $58 685 (IQR, $32 224-$134 895) to $28 672 (IQR, $16 796-$60 657). CONCLUSIONSThe median cost for comparable patient encounters decreased with implementation of an automated sepsis screening tool in the pediatric ED. Costs were decreased even more substantially for patients with sepsis. In addition to improving outcomes, an automated sepsis screening tool appears to be at least cost-effective and may be cost-saving, an incentive for more widespread use of this technology.
Objective
Pediatric dog bite injuries are a major public health concern and antibiotic prophylaxis is often prescribed due to concern about the development of infection. The Infectious Diseases ...Society of America recommends 3‒5 days of antibiotic prophylaxis for high‐risk dog bites. The purpose of our study was to compare infection rates among patients receiving antibiotic prophylaxis and those who did not receive antibiotic prophylaxis.
Methods
We conducted a retrospective cohort study of children aged 3 months to 17 years enrolled in the healthcare systems’ affiliated accountable care organization (ACO). Eligible children with a dog bite injury presented at an urgent care center or emergency department between 2016 and 2019. We excluded children who were immunosuppressed or had bites that required closure by a surgeon. An electronic health record review was completed and ACO claims data were used to determine if a prescription was filled. Patients with an International Classification of Diseases (ICD)‐10 code concerning for infection within 7 days of injury were recorded as having a bite infection.
Results
A total of 2653 non‐immunosuppressed children presented for care of dog bite injuries and 672 children met eligibility criteria. Thirty‐five children developed an infection of their injury. Of the 539 children who received antibiotic prophylaxis, 5.8% developed an infection and 3.0% of the 133 children who did not receive antibiotic prophylaxis developed an infection (p = 0.28).
Conclusion
The overall infection rate for pediatric dog bite injuries was 5.2%. In our single‐center study, no difference in infection rates was found between those receiving and not receiving antibiotic prophylaxis.
Emergency Medical Services (EMS) use for children is correlated with areas of resource deprivation as well as child maltreatment. Households using EMS may have more social needs and be willing to ...accept services.
To compare social service needs and willingness to accept services in families arriving to a pediatric emergency department (ED) via EMS vs non-EMS, before and during COVID-19.
Caregivers of children 0–5 years old in a quaternary pediatric ED, with a 1:1 ratio of EMS vs non-EMS arrivals.
Participants completed a survey of demographics, social service needs, and willingness to accept services, before and during COVID-19.
Of 220 participants, 84 were enrolled before COVID-19. The EMS group reported less full-time employment (34.6% vs 51.8%, p < 0.05) and more social service needs (2.47 vs 1.76 needs, p < 0.05). Mean score for willingness to accept a service provider in the home was 3.62 for EMS and 3.19 for non-EMS (p = 0.09). Mean score for accepting a phone referral was 3.84 for EMS and 3.40 for non-EMS (p = 0.07). COVID-19 impacted needs for both groups (20.9% EMS vs 30.3% non-EMS). For all subjects presenting to the ED, COVID-19 was associated with decreased food insecurity (28.6% vs 15.4%) and children with a chronic medical condition (31.0% vs 12.5%).
The EMS group had more social service needs. There was no difference in social services acceptance. COVID-19 affected both groups' needs. Future interventions may use EMS systems to mitigate social service needs which may be risk factors for child abuse.
•Caregivers using EMS to bring children to the ED reported multiple social needs.•Caregivers of children in the ED preferred telephone referrals for social services.•Caregivers using EMS for a child had high rates of accepting in-home social services.•COVID-19 impacted the social needs of caregivers of children in the pediatric ED.•Caregivers were less likely to accept referrals for home services during COVID-19.
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.
To determine the Screening Tool for Early Predictors of Post-Traumatic Stress Disorder (STEPP) test accuracy in identifying children with new mental health diagnoses and psychotropic medications ...prescribed within 12 months after unintentional injuries in a managed-Medicaid population.
We conducted a secondary analysis of a retrospective cohort that investigated mental health diagnoses and psychotropic medications pre- and post-injury in children ≤18 years of age treated at a pediatric trauma center from 2005 to 2015 (n = 2208). For this study, we analyzed children with STEPP scores from their injury admission (n = 85). For children without previous mental health diagnoses or psychotropic prescriptions, we calculated the sensitivity, specificity, and positive and negative predictive values for the child and parent STEPP.
Of 78 children without previous diagnoses, 12 had post-injury mental health diagnoses. Of 68 children without previous psychotropic medication use, 10 had psychotropic medications prescribed. The child STEPP sensitivity was 8.3% for mental health diagnoses (95% CI 0.2, 38.5) and 10% for psychotropic medications (95% CI 0.3, 44.5). The child STEPP specificity was 77.3% for mental health diagnoses (95% CI 65.3, 86.7) and 75.9% for psychotropic medication (95% CI 62.8, 86.1).
We found that the STEPP performed poorly in identifying children who received new mental health diagnoses and new psychotropic medications following injury.
Introduction
Transfusion may increase the risk of organ failure through immunomodulatory effects. The primary objective of this study was to assess for patient or transfusion‐related factors that are ...independently associated with the risk of acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) in a cohort of children with life‐threatening bleeding from all etiologies.
Methods
In a secondary analysis of the prospective observational massive transfusion in children (MATIC) study, multivariable logistic regression was performed in an adjusted analysis to determine if blood product ratios or deficits were independently associated with AKI or ARDS in children with life‐threatening bleeding.
Results
There were 449 children included with a median (interquartile range, IQR) age of 7.3 years (1.7–14.7). Within 5 days of the life‐threatening bleeding event, AKI occurred in 18.5% and ARDS occurred in 20.3% of the subjects. Every 10% increase in the platelet to red blood cell transfusion ratio is independently associated with a 12.7% increase in the odds of AKI (adjusted odds ratio 1.127; 95% confidence interval 1.025–1.239; p‐value .013). Subjects with operative or medical etiologies were independently associated with an increased risk of AKI compared to those with traumatic injury. No transfusion‐related variables were independently associated with the risk of developing ARDS.
Conclusion
The use of increased platelet to red blood cell transfusion ratios in children with life‐threatening bleeding of any etiology may increase the risk of AKI but not ARDS. Prospective trials are needed to determine if increased platelet use in this cohort increases the risk of AKI to examine possible mechanisms.
To assess the impact of plasma and platelet ratios and deficits in injured children with life-threatening bleeding.
Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children ...study dataset, a prospective observational study of children with life-threatening bleeding events.
Twenty-four childrens hospitals in the United States, Canada, and Italy.
Injured children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under activation of massive transfusion protocol.
Weight-adjusted blood product volumes received during the bleeding event were recorded. Plasma:RBC ratio (plasma/RBC weight-adjusted volume in mL/kg) and platelet:RBC ratio (platelet/RBC weight-adjusted volume in mL/kg) were analyzed. Plasma deficit was calculated as RBC mL/kg - plasma mL/kg; platelet deficit was calculated as RBC mL/kg - platelet mL/kg.
Of 191 patients analyzed, median (interquartile range) age was 10 years (5-15 yr), 61% were male, 61% blunt mechanism, and median (interquartile range) Injury Severity Score was 29 (24-38). After adjusting for Pediatric Risk of Mortality score, cardiac arrest, use of vasoactive medications, and blunt mechanism, a high plasma:RBC ratio (> 1:2) was associated with improved 6-hour survival compared with a low plasma:RBC ratio (odds ratio 95% CI = 0.12 0.03-0.52; p = 0.004). Platelet:RBC ratio was not associated with survival. After adjusting for age, Pediatric Risk of Mortality score, cardiac arrest, and mechanism of injury, 6-hour and 24-hour mortality were increased in children with greater plasma deficits (10% and 20% increased odds of mortality for every 10 mL/kg plasma deficit at 6 hr p = 0.04 and 24 hr p = 0.01, respectively); 24-hour mortality was increased in children with greater platelet deficits (10% increased odds of 24-hr mortality for every 10 mL/kg platelet deficit p = 0.02)).
In injured children, balanced resuscitation may improve early survival according to this hypothesis generating study. Multicenter clinical trials are needed to assess whether clinicians should target ratios and deficits as optimal pediatric hemostatic resuscitation practice.
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