Regionalization of pediatric emergency care in Korea

In order to care for an ill or injured child, it is crucial that every emergency department (ED) has a minimum set of personnel and resources because the majority of children are brought to the geographically nearest ED. In addition to adequate preparation for basic pediatric emergency care, a comprehensive, specialized healthcare system should be in place for a critically-ill or injured victim. Regionalization of healthcare means a system providing high-quality and cost-effective care for victims who present with alow frequency, but critical condition, such as multiple trauma or cardiac arrest. Within the pediatric field, neonatal intensive care and pediatric trauma care are good examples of regionalization. For successful regionalized pediatric emergency care, all aspects of a pediatric emergency system, from pre-hospital field to hospital care, should be categorized and coordinated. Efforts to set up the pediatric emergency care regionalization program based on a nationwide healthcare system are urgently needed in Korea.     

Delayed diagnosis in pediatric blunt trauma

OBJECTIVE: Identification of injuries of a traumatized patient is a mandate for the emergency department (ED) and the trauma team. Delayed diagnosis of injury in trauma patients leads to increased morbidity, mortality, dissatisfaction, and risk of litigation. Comparing children admitted for blunt trauma, with and without delay, this study examines risk factors for delayed diagnosis. METHODS: Delays in diagnosis from 1991 to 1996 were identified during prospective collection of trauma registry data. Controls were randomly selected from the trauma registry. Charts from both groups were retrospectively reviewed. RESULTS: Fifty-eight patients had 65 delays in diagnosis. Significant independent delay variables included: female, motor vehicle crash (MVC)-related mechanism, altered consciousness, higher injury severity score, and multiple injuries (P < 0.05). Trauma team activation, documentation of tertiary survey, and length of hospitalization were greater in patients with delay injuries (P < 0.05). Logistic regression identified MVC-related mechanism, female, facial, and extremity injuries as a combination of predictors. CONCLUSIONS: Delays occurred in 1% of patients. Trauma team care itself did not protect all patients from delay. Injury severity at presentation alone is not an adequate predictor of delayed diagnosis in the pediatric patient. A combination of variables was identified as negative predictors of delay. Further study is needed to validate these criteria, and determine if earlier diagnosis would effect quality.     

Effectiveness of a pediatric trauma team protocol

OBJECTIVE: To determine the effectiveness of a pediatric trauma triage system and resource allocation for emergency medicine and trauma services. TRAUMA SYSTEM: Two-tier trauma team activation system that triages patients into Level 1 and Level 2 trauma alert categories based on information provided by pre-hospital providers to pediatric emergency physicians at an American College of Surgeons' Level 1 pediatric trauma center in Columbus, Ohio. METHODS: Using the hospital trauma registry database and patient medical records, a retrospective chart review was conducted on all (n = 542) admitted pediatric trauma patients from January 1995 through December 1996. RESULTS: Level 1 patients had a higher median injury severity score and shorter emergency department (ED) length of stay time than Level 2 patients. Level 1 patients were more likely to be admitted to the pediatric intensive care unit and remain for more than 24 hours when compared to Level 2 patients. In addition, Level 1 patients were more likely to have procedures performed (eg, intubation, tube thoracostomy, thoracotomy, diagnostic peritoneal lavage) than Level 2 patients. The mortality rate was significantly higher for Level 1 patients and all ED deaths had been triaged to the Level 1 category. CONCLUSIONS: This pediatric trauma triage system effectively predicts which patients will be more likely to have serious injury. By using a two-tier system, select patients may be managed by a smaller trauma team, thus improving staff utilization and possibly reducing costs while ensuring favorable outcomes.     

Regionalized pediatric trauma systems

Over the last 30 years, trauma system development in the United States has evolved dramatically. Regionalized trauma care is generally believed to confer benefits to the injured, although evidence supporting such is scant. The advent of pediatric emergency medicine and emergency medical services for children has led to the development of coordinated systems of care for critically ill and injured children in many parts of the country. Incoporation of organized pediatric emergency and trauma care into regionalized trauma systems is the focus of this review. The history of regionalized trauma system development is discussed, and published evidence regarding efficacy is examined. Finally, optimal system components are summarized, and an example of a statewide pediatric trauma system is described.     

Teamwork in pediatric trauma centers

Various models have been proposed for optimal care of children in the trauma centers of general hospitals. The authors discuss the determinants of successful pediatric trauma care. In-house trauma surgeons, a consensus protocol for the first 20 minutes of resuscitation, real-time involvement of radiologists as part of the trauma team, and professional respect are the basis of teamwork.     

Authors' own assessment of TRISS method studies in the treatment of major trauma in children.

Evaluation of trauma care must be an integral part of any system designed for the care of seriously injured patients. This study analyses the validity of TRISS methodology in evaluating traumatised children admitted to the ICU. METHODS: A retrospective review of 586 children with major trauma admitted to the Children's Hospital Zagreb was conducted over a 4-year period. The outcome in each patient was assessed using the Trauma Injury Severity Score (TRISS) system to calculate the probability of survival based on anatomical extent of injury and grade of physiological disturbance at the time of admission. RESULTS: Mean age was 7.8 years and mortality was 5.5 %. Mean ISS of survivors was 9, Revised Trauma Score (RTS) was 6.6, and Glasgow Coma Scale (GCS) was 8. Statistical evaluation included TRISS survival analysis. There were no statistically significant differences between the predicted and the actual number of children who died (predicted 8.3 % vs. actual 5.5 %). CONCLUSIONS: This study documents and confirms TRISS methodology as an effective predictor of both severity of injury and potential for mortality in children with major trauma.     

地震中儿童创伤的类型和救治要点

肢体外伤在儿童地震创伤中最为常见。地震导致的颅脑外伤发生居多,而颅内损伤较少,但颅内损伤是地震创伤致死的首要原因。胸腹挤压伤易致内脏出血等危急情况,也是地震伤患儿主要致死原因之一。挤压综合征和骨筋膜室综合征常常并发急性肾脏功能衰竭。由于地震创伤出现时间集中,现场救援要遵循“救命第一,危重优先”的原则。条件允许时,伤员应及时转运。危重伤员治疗需采用多学科联合序贯方式,重视并发症的防治、康复治疗和心理疏导。     

Current use and perceived utility of ultrasound for evaluation of pediatric compared with adult trauma patients

OBJECTIVE: The objective of this study was to evaluate the current use and perceived utility of ultrasound in the assessment of pediatric compared with adult trauma patients. METHODS: A questionnaire was developed and mailed to 72 pediatric emergency physicians, 120 general emergency physicians, and 117 trauma attendings at 240 institutions. RESULTS: Of 309 surveys, 234 (75%) were completed. Ultrasound was available to 169 of 234 (72%) of the physicians, and 122 of 169 (72%) were performing the Focused Assessment by Sonography for Trauma examination to evaluate trauma patients. Seventy-three percent (110/150) of general emergency and trauma surgeons reported that ultrasound was available equally with or more readily than computed tomography (CT) scan. Only 26% (5/19) of pediatric emergency attendings considered ultrasound equally available with CT scan, and none considered it more readily available than CT scan. Ninety-two percent (137/149) of general emergency and trauma attendings responding to the question about utility considered ultrasound somewhat useful to extremely useful for assessing adult trauma patients, and 77% considered it useful for pediatric patients. Only 57% (12/21) of pediatric emergency attendings responding to the same question perceived ultrasound as useful for pediatric trauma evaluations. CONCLUSIONS: We conclude that ultrasound for the assessment of trauma patients is widely used by general emergency physicians and trauma surgeons, whereas pediatric emergency physicians report less use and perceived utility.     

The synergistic relationship between a level I trauma center and a regional pediatric trauma center

A regional pediatric trauma center and a level I trauma center with pediatric commitment in the same city developed a synergistic relationship addressing all aspects of care for pediatric trauma patients. Although it is unlikely that this model could be used in its entirety by all similar institutions, the principles may prove helpful in creating guidelines and relationships. Categorization, optimal use of resources, timely transportation of seriously injured children to the appropriate facility, and maintaining urgent care capabilities of each institution to care for seriously injured children are imperative. The combined effort resulted in our level I trauma center being verified by the American College of Surgeons and designated by our state Health Department as meeting all the criteria for pediatric trauma care. This experience should encourage every pediatric trauma center located in a children's hospital to become a regional pediatric trauma center. The real benefit from the relationship is that injured children receive optimal care at both institutions.     

Association of emergency department care factors with admission and discharge decisions for pediatric patients

OBJECTIVE: We evaluated overutilization or underutilization of inpatient resources to measure the emergency department (ED) decision-making process and its association with the following care factors: annual pediatric volume, presence or absence of a pediatric emergency medicine specialist; and presence or absence of ED residents. STUDY DESIGN: Block random selection, using the three care factors, of 16 hospitals with pediatric intensive care units. The Pediatric Risk of Admission (PRISA II) Score was used to measure illness severity. Decision-making was evaluated for admissions (Admission Index: observed minus predicted admissions) and returns (Return Index: observed minus predicted 72-hour returns). The Combined Index was a weighted average of the Admission and Return Indexes. RESULTS: There were 11,664 patients enrolled. Residents but not volume or pediatric emergency medicine specialists were associated with the decision-making performance indexes in multivariable analysis (no residents versus residents: Admission Index: 2.5 of 1000 patients versus 34.8 of 1000, P = .082; Return Index: -3.0 of 1000 versus 33.6 of 1000, P = .039; Combined Index: 1.9 of 1000 versus 35.5 of 1000, P = .024. CONCLUSIONS: There is significant variability in ED decision-making for children. Residents but not volume or presence of a pediatric emergency medicine specialist are associated with increased differences in admission decisions. The process by which these differences occur was not investigated.     

Ability of hospitals to care for pediatric emergency patients.

CONTEXT: The needs of children in emergency situations differ from those of adults and require special attention, yet there has been no study of the ability of U.S. hospitals to care for emergently or critically ill children. OBJECTIVE: To estimate the distribution of pediatric services available at U.S. hospitals with emergency departments (EDs). DESIGN: Self-report survey of 101 hospital EDs. PARTICIPANTS: Stratified probability sample of all U.S. hospitals operating EDs. RESULTS: The majority of hospitals that usually admit pediatric patients do not have separate pediatric facilities. Hospitals without a pediatric department, ward, or trauma service usually transfer critically injured pediatric trauma patients; however, nearly 10% of hospitals without pediatric intensive care facilities admit critically injured children to their own facilities. Likewise, 7% of hospitals routinely admit pediatric patients known to require intensive care to their adult intensive care units rather than transferring the patient to a facility with pediatric intensive care facilities. Few hospitals have protocols for obtaining pediatric consultation on pediatric emergencies. Appropriately sized equipment for successful care of infants and children in an emergency situation was more likely to be missing than adult-sized equipment, and significant numbers of hospitals did not have adequate equipment to care for newborn emergencies. CONCLUSION: Emergent and critical care of infants and children may not be well integrated and regionalized within our health care system, suggesting that there is room for improvement in the quality of care for children encountering emergent illness and trauma.     

Rethinking pediatric trauma triage

Despite advances in the delivery of trauma care, trauma remains the leading cause of death amongst the pediatric population within the United States and is one of the leading causes of death in children worldwide.  Accurately triaging pediatric trauma patients is essential to minimize preventable mortality without burdening the system by utilizing unnecessary resources.  This article will review the accuracy of current pediatric trauma triage practices and how it will evolve in the future including moving away from mechanism of injury towards physiologic scoring tools such as the pediatric age-adjust shock index, and intervention-based systems including. Need for Surgeon Presence and Need For Trauma Intervention. This paper will also present evidence regarding over-utilization of air transport for pediatric trauma patients and the associated unnecessary costs placed on the trauma system.     

Impact of trauma system development on pediatric injury care

Purpose

Trauma systems improve survival by directing severely injured patients to trauma centers. This study analyzes the impact of trauma systems on pediatric triage and injury mortality rates.

Methods

Population-based data were collected on injured children less than 15 years who were admitted to any hospital in New England from 1996 to 2006. Data from three trauma system states were compared to three non-trauma system states. The percentages of injured children, severely injured children, and brain-injured children admitted to trauma centers were determined as well as injury hospitalization and death rates. Time trend analysis examined the pace of change between the groups.

Results

A total of 58,583 injured children were hospitalized during the study period. Injury hospitalization rates were initially similar between the two groups (with and without trauma systems) and decreased over time in both. Rates decreased more rapidly in trauma system states compared to those without, (P = 0.003). Injury death rates decreased over time in both groups with no difference between the groups, (P = 0.20). A higher percentage of injured children were admitted to trauma centers in non-trauma system states throughout the study period, and this percentage increased in both groups of states. A higher percentage of severely injured children and brain-injured children were admitted to trauma centers in non-trauma system states and both percentages increased over time. The increase was more rapid in trauma system states for children with severe injuries (P < 0.001) and children with brain injuries (P < 0.001).

Discussion

Trauma systems decreased childhood injury hospitalization rates and increased the percentage of severely injured children and brain-injured children admitted to trauma centers. Mortality and overall triage rates were unaffected.     

Venous thromboembolism prophylaxis in the pediatric trauma patient

Although venous thromboembolism (VTE) occurs in less than 1% of hospitalized pediatric trauma patients, care providers must make decisions about VTE prophylaxis on a daily basis. The consequences of VTE are significant; the risks of developing VTE are variable; and the effectiveness of prophylaxis against VTE is not conclusive in children. While the value of VTE prophylaxis is well defined in adult trauma care, it is unclear how this translates to the care of injured children. This review evaluates the incidence and risks of VTE in pediatric trauma and assesses the merits of prophylaxis in children. Pharmacologic prophylaxis against VTE is a reasonable strategy in critically injured adolescent trauma patients. Further study is needed to establish the risks and benefits of VTE prophylaxis across the spectrum of injured children.     

Evaluation of the performance of general emergency physicians in pediatric emergencies: Obstructive airway diseases,seizures, and trauma

BACKGROUND: In the Lübeck region, as is usual in Germany, hospital-based emergency physicians are called for outside emergencies. They evaluate and stabilize patients and transfer them to hospital facilities of their choice (no emergency department system). These physicians are mainly anesthesiologists, surgeons, and internists-not pediatricians. Numerous quality management studies have shown an overall excellent performance of this system, but it has not been evaluated for pediatric emergencies. PATIENTS AND METHODS: In a prospective, observational study conducted over a 1-year period, all pediatric emergencies (patient age < 15 y) treated by the emergency physician service were studied. A syllabus with standards of care for children with trauma, obstructive airway disease, and seizures was distributed. In accordance with this syllabus, the actions taken were documented by the emergency physicians, and the cases were documented as life threatening or not and were classified as "trauma," "obstructive airway disease," "seizures," or "other" by the admitting pediatric intensivists and surgeons. The admitting attending physician compared these data and evaluated whether the standard management required by the syllabus was followed. RESULTS: A total of 422 pediatric cases out of 11,605 emergencies (3.5%) were recorded (147 [34.8%] trauma patients, 41 [9.7%] patients with obstructive airway disease, and 108 [25.6%] patients with seizures). Of the pediatric patients, 20.5% had life-threatening conditions; three children died before arrival, and the others required treatment in the intensive care unit. In 25% of trauma patients, deficiencies in primary treatment were observed: no documentation of neurologic status in 10.6%, no cervical immobilization in 15% of head trauma patients, and no adequate analgesia in 7%. In 25% of seizure patients, neurologic status was not documented, although treatment was in accordance with the standard of care. The worst results were observed in infants with obstructive airway disease: no documentation of oxygen saturation in 71.4%, no oxygen therapy despite hypoxemia in seven of 12 patients, and overall therapy not in accordance with the standard of care in 50%. CONCLUSIONS: The high quality of the emergency physician service documented for adults is not reproduced in the pediatric population. Trauma and seizures with similarities to adult cases are handled in a fair manner. However, the most important pediatric diagnostic entity of obstructive airway disease is often not treated adequately. Intensified educational programs for emergency physicians are warranted.     

Pediatric trauma management in a rural Wisconsin trauma center

OBJECTIVE: To determine the results of pediatric trauma care managed with a cooperative effort by general surgeons and pediatric intensivists in comparison to national standards. DESIGN: Retrospective chart review. SETTING: Referral level II trauma center in rural Wisconsin. PATIENTS: All pediatric trauma patients age 16 and younger admitted to the hospital from 1990 to 1993. METHODS: Demographics, mechanisms of injury, revised trauma score (RTS), injury severity score (ISS), surgical procedures, need for intensive care, and outcome were examined. All patients were primarily managed by the trauma surgery service. Those patients requiring intensive care were managed jointly by the trauma surgery service and pediatric intensivists. Outcome was predicted by TRISS analysis; patients identified as "unexpected deaths" underwent critical clinical review to determine potential for survival. RESULTS: There were 531 pediatric trauma admissions. The mean age was 9.0 +/- 6.2 (SEM) years and two thirds of the patients were boys. Over half of all injuries were from falls, recreational activities, and motor vehicle crashes. There were few penetrating injuries. The mean RTS was 7.58 +/- 0.05, and the majority of patients had an ISS below 10. Sixty-two percent of patients required surgical procedures, most of which were orthopedic. Fourteen percent of patients were admitted to the pediatric intensive care unit. There were 13 deaths for a mortality rate of 2.4%. TRISS analysis identified six deaths as unexpected. Four drownings were not included in TRISS analysis, and there were no unexpected survivors. Of the six unexpected deaths, there were no significant management errors identified on careful review. CONCLUSIONS: Cooperation between general surgeons and pediatric intensivists can result in excellent pediatric trauma care in a rural level II trauma center.     

Controversies in pediatric thoracic and abdominal trauma

The majority of pediatric thoracic and abdominal injuries are successfully treated with nonoperative management: thus, the role and clinical responsibility of the pediatric emergency physician or intensivist are increased. This review addresses some of the ongoing controversies in pediatric trauma care for the patient with truncal injury. The value of pediatric thoracic injury as a marker for overall severity. recent advances in diagnostic imaging for thonicic injuries, current recommendations for the evaluation of pediatric cardiac injury, and the potential benefits of minimally invasive thoracoscopy are discussed in detail. Recognition of pediatric intra-abdominal organ injury, often thought to be difficult in the acute care setting, can be quite accurate with the use of clinical information from physical examination. laboratory testing, and diagnostic imaging in the emergency department. A knowledge of the current trauma literature is required for effective care of the child with thoracoabdominal injury.