Consequences of pediatric undertriage and overtriage in a statewide trauma system.

BACKGROUND: With increasing attention to the quality of health care delivery, evaluating trauma triage decisions in a large system of emergency care can help decision makers reduce mortality, morbidity, unnecessary transfers, and health care costs. OBJECTIVES: To quantify the magnitude of pediatric traumatic injury undertriage (hospital mortality risk) and overtriage (early trauma center discharge after transfer) in a statewide trauma system. METHODS: A statewide population-based evaluation of pediatric trauma outcomes and secondary triage (interfacility transfers) patterns from 2001 to 2013 among 45 hospitals in Utah's statewide trauma system. RESULTS: The odds of pediatric transfer were 13 times lower (odds ratio, 13.15; p < 0.0001; 95% confidence interval, 11.0-15.7) in acute care hospitals meeting undertriage criteria than hospitals meeting overtriage criteria. Hospital triage practice was a stronger predictor of pediatric transfer than injury severity, injury diagnoses, age, and geographic distance. The likelihood of pediatric trauma mortality was more than twice higher in undertriage hospitals than overtriage hospitals (OR, 2.44; p < 0.0001; 95% confidence interval, 1.5-3.8). Among pediatric patients that survived the injury to transfer, 61% were discharged from the pediatric center in < 24 hours. CONCLUSION: Substantial opportunity exists in the state trauma system to improve pediatric trauma patient transfer practices to reduce pediatric trauma mortality, morbidity, and health care costs associated with unnecessary transfers. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Documentation of pediatric vital signs by EMS providers over time.

BACKGROUND: Pediatric patients make up approximately 10% of EMS transports nationwide. Previous studies demonstrated that pediatric patients do not consistently have a full set of vitals signs obtained in the prehospital setting [1]. In certain conditions, such as traumatic head injury and shock, unrecognized hypotension and/or hypoxia are associated with increased morbidity and mortality [2,3]. PRIMARY OBJECTIVE: To measure how often EMS providers obtain blood pressure (BP), heart rate (HR), pulse oximetry (Po), and respiratory rate (RR) on pediatric transport patients in the state of Utah from 2007 to 2014. SECONDARY OBJECTIVE: To assess whether educational interventions improved the percentage of pediatric transport patients with a full set of vital signs documented. RESULTS: The trend of documenting the four critical vital signs improved over time for all four categories. Measurement of Po increased most consistently across all age groups. Blood pressure remained the most inconsistently obtained vital sign, especially in younger pediatric patients. The educational interventions introduced in late 2010 correlated with an increase in vital sign attainment. CONCLUSIONS: Assessment of pediatric vitals signs is a critical part of the evaluation and care of pediatric patients in the prehospital setting. Utah EMS providers improved their practice of documenting four pediatric vital signs over time after educational interventions. Obtaining a BP, especially in younger children, continues to be a challenge. More work remains to achieve the state goal of documenting all vital signs in >90% of pediatric transports.

Premature mortality patterns among American Indians in South Dakota, 2000-2010.

BACKGROUND: American Indians in South Dakota have the highest mortality rates in the nation compared to other racial and ethnic groups and American Indians in other states. PURPOSE: Cause-related and age-specific mortality patterns among American Indians in South Dakota are identified to guide prevention planning and policy efforts designed to reduce mortality within this population, in both South Dakota and other parts of the U.S. METHODS: Death certificate data from South Dakota (2000-2010), on 5738 American Indians and 70,580 whites, were used to calculate age-specific mortality rates and rate ratios. These values were examined in order to identify patterns among the leading causes of death. Analyses were completed in 2011 and 2012. RESULTS: Within the South Dakota population, 70% of American Indians died before reaching age 70 years, compared to 25% of whites. Fatal injuries and chronic diseases were the leading causes of premature mortality. Nine leading causes of death showed consistent patterns of mortality disparity between American Indians and whites, with American Indians having significantly higher rates of mortality at lower ages. CONCLUSIONS: Premature mortality among American Indians in South Dakota is a serious public health problem. Unified efforts at the federal, tribal, state, and local levels are needed to reduce premature death within this population.

Trends of overweight and obesity among white and American Indian school children in South Dakota, 1998-2010.

OBJECTIVE: To investigate the prevalence of overweight and obesity among white and American Indian children in a predominantly rural state. DESIGN AND METHODS: Using a repeated, cross-sectional design of school children's height and weight, the study sample included 361,352 measures of children who were 5.0-19.9 years, attending school across 13 academic calendar years. Trained staff measured height, weight, and recorded gender, age, and race. Data were voluntarily reported to the State Department of Health. RESULTS: American Indian children consistently had higher rates of overweight and obesity compared to white children. Across the years, 16.3% of white students were overweight, whereas 19.3% of American Indian students were overweight. In addition, 14.5% of white children were obese and 25.9% of American Indian children were obese. Examining by rural versus urban schools, prevalence of overweight had been increasing among white male and female students and American Indian female students living in rural areas. Obesity is also increasing among rural white females and male and female American Indian children. CONCLUSIONS: The findings here suggest that although American Indian children are at higher risk, in general, compared to white children, rural populations in general are experiencing increases in childhood overweight and obesity. Targeted rural interventions beginning at an early age are necessary to improve the health of rural children, especially in American Indian communities.

Evaluating the reach of universal newborn hearing screening in Colorado.

BACKGROUND: Children's language and developmental delays can result from a late diagnosis of hearing loss. To improve population-based prevention efforts to reduce such delays, Colorado's early hearing detection and intervention program examined the determinants of receiving timely newborn hearing screening to better support early identification and treatment of hearing loss. METHODS: In 2006-2007, data were examined from the state's electronic birth certificate regarding hospital, infant, and maternal characteristics. From January 2002 through December 2004, there were 204,694 hospital births; 98% of newborns were screened for hearing loss. Of those receiving a positive (failed) result, 82% then received outpatient follow-up screening. RESULTS: Newborns with normal Apgar scores were ten times more likely than infants with low Apgar scores to receive initial hearing screening; newborns with normal birth weights were four times more likely than newborns with low birth weights to receive initial hearing screening. Outpatient follow-up screening was associated with hospitals' screening performance and mothers' education. One urban safety-net hospital substantially reduced the state's follow-up screening disparities. CONCLUSIONS: While newborns with low Apgar scores and birth weights are more likely to have a higher risk of hearing loss than infants with normal Apgar scores and birth weights, they are substantially less likely to receive screening to identify it.

Connecting national survey data with DSM-IV criteria.

PURPOSE: To show how connections can be made among items in a nationally representative survey of adolescents and criteria for "Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition" (DSM-IV) diagnoses. METHODS: Data for this study came from the Wave I in-home interview of the National Longitudinal Study of Adolescent Health (Add Health), a nationwide study of approximately 90,000 adolescents and their parents. Proxy variables were developed for four DSM-IV diagnoses based on Wave I survey questions: conduct disorder, alcohol abuse, cannabis abuse, and major depressive disorder (single episode). Prevalence rates, comorbidity rates, and detailed item analyses of these four constructs are reported. RESULTS: Of the adolescents in the sample under study, 3.4% scored above the threshold for conduct disorder. For the alcohol abuse proxy 4.7% scored above the threshold, compared with 6.3% for the cannabis abuse proxy, and 1% scored above the threshold for major depressive disorder (single episode). Adolescents who scored above the threshold for conduct disorder were three times more likely to receive psychological counseling than adolescents who scored below the threshold for conduct disorder. The rates for alcohol abuse, cannabis abuse, and major depressive disorder (single episode) were 2.0, 3.0, and 5.0, respectively. CONCLUSIONS: The prevalence rates for the four constructs in the Add Health data set were generally lower or comparable to prevalence rates found in other epidemiological studies in which DSM-IV criteria were applied. The approach described in this study provides a way to identify adolescents who are likely at risk for the development of mental health problems.