Managing moderately injured pediatric patients without immediate surgeon presence: 10 years later.

PURPOSE: Beginning in 2003, the pediatric emergency medicine (PEM) physician replaced the surgeon as the team leader for all level II trauma resuscitations at a busy pediatric trauma center. The purpose was to review the outcomes 10 years after implementing this practice change. METHODS: Trauma registry data for all level II activations requiring admission were extracted for the 21 months (April 1, 2001-December 31, 2002) prior to policy change (period 1, **n=627) and compared to the admitted patients from the 10 subsequent years (2003-2013; period 2, n=2694). Data included demographics, length of stay (LOS), injury severity score (ISS), readmissions, complications, and mortality. RESULTS: Mean ISS scores for admitted patients during period 1 (8.5) were higher than during period 2 (7.8). During period 1, 53.6% of patients underwent abdominal CT versus 41.8% in period 2 (p<.001), and the median ED LOS was 135 versus 191 minutes in period 2. From 2000 to 2003, 91% of patients seen as level II trauma alerts were admitted compared to 56.6% of patients in period 2 (p<0.001). There were no missed abdominal injuries identified, and readmission rate was low. CONCLUSIONS: We conclude that level II trauma resuscitations can be safely evaluated and managed without immediate surgeon presence. Although ED LOS increased, admission rate and CT scan usage decreased significantly without an increase in missed injuries.

Increased morbidity and mortality of traumatic brain injury in victims of nonaccidental trauma.

BACKGROUND: The purpose of this study was to determine if the morbidity and mortality associated with traumatic brain injury (TBI) are worse in children who experienced nonaccidental trauma (NAT) compared with TBI from other traumatic mechanisms. METHODS: We identified all pediatric patients admitted with the diagnosis of TBI between 2001 and 2010 in our institutional trauma registry with an Abbreviated Injury Scale (AIS) score greater than 1. Patients were divided into groups based on a nonaccidental (NAT) or accidental mechanism of injury. Need for gastrostomy tube insertion was used as a marker of more severe neurologic morbidity in survivors of TBI. Group comparisons were made using Fisher's exact tests. RESULTS: A total of 2,782 patients with TBI were included; 315 (11.3%) patients had TBI secondary to NAT. Overall mortality and AIS-specific mortality were higher in patients with TBI secondary to NAT. In comparison with patients with TBI secondary to accidental mechanisms, patients with TBI secondary to NAT were younger (mean, 1 year vs. 8 years), had longer intensive care unit stays (mean, 3 days vs. 1 day), and required gastrostomy tubes more often (6% vs. 1%, p < 0.0001). Even among the subgroup of patients with severe TBI, (AIS score 4 and 5), patients with NAT required gastrostomy tubes more often (5% vs. 2%, p = 0.014). CONCLUSION: Patients with TBI from NAT have increased morbidity and mortality compared with patients with TBI from accidental mechanisms; these differences are present at all levels of severity of injury. Patients with TBI from NAT represent a vulnerable group of pediatric trauma patients who are at increased risk for death and worse outcome and who will require greater short- and long-term medical resources.

Is the "seat belt sign" associated with serious abdominal injuries in pediatric trauma?

BACKGROUND: The "seat belt sign" (SBS) has been reported to be highly associated with intra-abdominal injury. This study defines its predictive value in identifying injuries in a large pediatric trauma population. METHODS: At a level I pediatric trauma center, we performed a retrospective review of trauma flow sheets for all motor vehicle crash victims (ages, 0-20) requiring trauma team activation during 2005 and 2006. All patients with an abdominal SBS recorded were included in the analysis. RESULTS: Of 331 patients (mean age, 9.96 years), an SBS was present in 54 (16%) of these children. Abdominal injury was identified by computed tomography scan or intraoperatively in 12 (22%) of these children. Three (6%) children with SBS required operative intervention. Two had a bowel injuries and one had a negative laparoscopy. SBS and abdominal tenderness were reported in 30 (56%) patients; 8 (15%) of whom sustained abdominal injury. Of the 277 (84%) children without SBS, 36 (13%) had abdominal injuries. Four (11%) of these had a positive laparotomy with three having a bowel injuries. The relative risk of an abdominal injury given an SBS was 1.7 (CI 0.96-2.69; p = 0.078). Four (1.4%) children without SBS died of head injuries compared with zero with SBS. The SBS had a sensitivity of 25% and a specificity of 85%. CONCLUSIONS: The SBS was not significantly associated with abdominal injury in our population. Patients without SBS had a higher Injury Severity Score and accounted for all of the deaths. SBS may not be as predictive of abdominal injury as previously reported.

The impact of managing moderately injured pediatric trauma patients without immediate surgeon presence.

PURPOSE: The purpose of this study was to determine the outcome of "minor resuscitation" trauma patients managed without the immediate presence of a surgeon. METHODS: In 2003, our hospital replaced surgeons with pediatric emergency medicine physicians for level 2 (minor resuscitation) trauma alerts, whereas the level 1 (major resuscitation) alerts remained surgeon directed. We compared patients treated in the 3 years before (period 1) and after (period 2) this change. Patient records were analyzed for discharges, alert upgrades, Injury Severity Score (ISS), time to destination, and mortality. RESULTS: There were 918 admissions and 93 discharges in period 1 compared with 815 admissions and 652 discharges in period 2. In period 1, 3% were upgraded to level 1 status compared with 9% in period 2 (P < .0001). The mean ISS of admitted patients and the percentage of critical (ISS >15) patients were greater in period 2 (P < .001). The time to inpatient floor was longer in period 2, but the elapsed times to operating room and to pediatric intensive care unit were not significantly different. CONCLUSION: Pediatric emergency medicine physicians discharged more patients than the surgeons, but also upgraded more to level 1 status. Level 2 trauma patients can be safely managed without immediate surgeon presence.

A silver impregnated antimicrobial dressing reduces hospital length of stay for pediatric patients with burns.

We sought to study whether the application of a novel silver impregnated antimicrobial dressing (Aquacel Ag, ConvaTec, Princeton, NJ) affects the hospital length of stay in pediatric patients with partial-thickness burns. A retrospective review of Burn Registry Data from a large children's hospital burn unit was conducted to answer this question. Pediatric patients admitted with partial-thickness burns treated with Aquacel Ag from January 2005 through August 2005 were included in the study (n = 39). The comparison group of patients treated with silver sulfadiazine (SSD; Par Pharmeceuticals, Woodcliff, NJ) cream was matched for age and %TBSA burned from the same time period the previous year (n = 40). Analysis was conducted for intent to treat. Mean length of stay for control patients treated with SSD was significantly longer (8.36 days) compared with Aquacel Ag-treated patients (4.48 days; p = .002, t-test for unequal variances). Length of stay for both groups was significantly associated with %TBSA burned (p < .001, r2 = .38). Post-hoc analysis controlling for %TBSA burned revealed an adjusted mean length of stay for the control group that was longer than that of the Aquacel Ag group (5.9 days vs. 3.8 days, respectively). These data confirm that application of a new burn dressing (Aquacel Ag) reduces hospital length of stay. Reduction in the complexity and number of dressing changes needed with use of Aquacel Ag, in combination with significantly reduced length of stay, should result in a significant cost savings in the care of this patient population.

A silver-impregnated antimicrobial dressing reduces hospital costs for pediatric burn patients.

PURPOSE: Since using a novel silver-impregnated antimicrobial dressing (Aquacel Ag, ConvaTec, Princeton, NJ) in our pediatric patients with partial-thickness burns, hospital LOS has been significantly reduced. Here we investigated whether there was concomitant cost-effectiveness of this approach. METHODS: We retrospectively reviewed Burn Registry Data from a large Children's Hospital Burn Unit from January 2005 through August 2005 for inpatients with partial-thickness burns treated with Aquacel Ag. A comparison group was composed of patients from the same period the previous year treated with silver sulfadiazine cream (SSD, Par Pharmaceuticals, Woodcliff, NJ) and matched for age and %TBSA burned. Patients with inhalation injury or full-thickness burns were excluded. Intent-to-treat analysis was limited to patients with less than 22% TBSA burn. Direct costs and total charges were compared statistically after log transformation due to the skewedness of the data. RESULTS: Total charges and direct costs were significantly lower for Aquacel Ag-treated patients (n = 38) than for SSD-treated patients (n = 39) (P = .004 and P < .001, respectively). In addition, Aquacel Ag-treated patients had a shorter LOS than SSD-treated patients. DISCUSSION: These data strongly support our findings that the application of Aquacel Ag reduces hospital LOS which results in a significant cost savings in the care of pediatric patients with partial-thickness burns.

History and development of trauma registry: lessons from developed to developing countries.

BACKGROUND: A trauma registry is an integral component of modern comprehensive trauma care systems. Trauma registries have not been established in most developing countries, and where they exist are often rudimentary and incomplete. This review describes the role of trauma registries in the care of the injured, and discusses how lessons from developed countries can be applied toward their design and implementation in developing countries. METHODS: A detailed review of English-language articles on trauma registry was performed using MEDLINE and CINAHL. In addition, relevant articles from non-indexed journals were identified with Google Scholar. RESULTS: The history and development of trauma registries and their role in modern trauma care are discussed. Drawing from past and current experience, guidelines for the design and implementation of trauma registries are given, with emphasis on technical and logistic factors peculiar to developing countries. CONCLUSION: Improvement in trauma care depends on the establishment of functioning trauma care systems, of which a trauma registry is a crucial component. Hospitals and governments in developing countries should be encouraged to establish trauma registries using proven cost-effective strategies.