Management of youth with suicidal ideation: Challenges and best practices for emergency departments.

Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self-harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self-harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home- and community-based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on-site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community- and home-based services, pediatric-receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.

Inter-Rater Reliability and Agreement Among Mass-Casualty Incident Algorithms Using a Pediatric Trauma Dataset: A Pilot Study.

INTRODUCTION: Many triage algorithms exist for use in mass-casualty incidents (MCIs) involving pediatric patients. Most of these algorithms have not been validated for reliability across users. STUDY OBJECTIVE: Investigators sought to compare inter-rater reliability (IRR) and agreement among five MCI algorithms used in the pediatric population. METHODS: A dataset of 253 pediatric (<14 years of age) trauma activations from a Level I trauma center was used to obtain prehospital information and demographics. Three raters were trained on five MCI triage algorithms: Simple Triage and Rapid Treatment (START) and JumpSTART, as appropriate for age (combined as J-START); Sort Assess Life-Saving Intervention Treatment (SALT); Pediatric Triage Tape (PTT); CareFlight (CF); and Sacco Triage Method (STM). Patient outcomes were collected but not available to raters. Each rater triaged the full set of patients into Green, Yellow, Red, or Black categories with each of the five MCI algorithms. The IRR was reported as weighted kappa scores with 95% confidence intervals (CI). Descriptive statistics were used to describe inter-rater and inter-MCI algorithm agreement. RESULTS: Of the 253 patients, 247 had complete triage assignments among the five algorithms and were included in the study. The IRR was excellent for a majority of the algorithms; however, J-START and CF had the highest reliability with a kappa 0.94 or higher (0.9-1.0, 95% CI for overall weighted kappa). The greatest variability was in SALT among Green and Yellow patients. Overall, J-START and CF had the highest inter-rater and inter-MCI algorithm agreements. CONCLUSION: The IRR was excellent for a majority of the algorithms. The SALT algorithm, which contains subjective components, had the lowest IRR when applied to this dataset of pediatric trauma patients. Both J-START and CF demonstrated the best overall reliability and agreement.

Comparison of Outcome Tools Used to Test Mass-Casualty Algorithms in the Pediatric Population.

INTRODUCTION: Mass-casualty incident (MCI) algorithms are used to sort large numbers of patients rapidly into four basic categories based on severity. To date, there is no consensus on the best method to test the accuracy of an MCI algorithm in the pediatric population, nor on the agreement between different tools designed for this purpose. STUDY OBJECTIVE: This study is to compare agreement between the Criteria Outcomes Tool (COT) to previously published outcomes tools in assessing the triage category applied to a simulated set of pediatric MCI patients. METHODS: An MCI triage category (black, red, yellow, and green) was applied to patients from a pre-collected retrospective cohort of pediatric patients under 14 years of age brought in as a trauma activation to a Level I trauma center from July 2010 through November 2013 using each of the following outcome measures: COT, modified Baxt score, modified Baxt combined with mortality and/or length-of-stay (LOS), ambulatory status, mortality alone, and Injury Severity Score (ISS). Descriptive statistics were applied to determine agreement between tools. RESULTS: A total of 247 patients were included, ranging from 25 days to 13 years of age. The outcome of mortality had 100% agreement with the COT black. The "modified Baxt positive and alive" outcome had the highest agreement with COT red (65%). All yellow outcomes had 47%-53% agreement with COT yellow. "Modified Baxt negative and <24 hours LOS" had the highest agreement with the COT green at 89%. CONCLUSIONS: Assessment of algorithms for triaging pediatric MCI patients is complicated by the lack of a gold standard outcome tool and variability between existing measures.

Prehospital Disaster Triage Does Not Predict Pediatric Outcomes: Comparing the Criteria Outcomes Tool to Three Mass-Casualty Incident Triage Algorithms.

INTRODUCTION: It remains unclear which mass-casualty incident (MCI) triage tool best predicts outcomes for child disaster victims. STUDY OBJECTIVES: The primary objective of this study was to compare triage outcomes of Simple Triage and Rapid Treatment (START), modified START, and CareFlight in pediatric patients to an outcomes-based gold standard using the Criteria Outcomes Tool (COT). The secondary outcomes were sensitivity, specificity, under-triage, over-triage, and overall accuracy at each level for each MCI triage algorithm. METHODS: Singleton trauma patients under 16 years of age with complete prehospital, emergency department (ED), and in-patient data were identified in the 2007-2009 National Trauma Data Bank (NTDB). The COT outcomes and procedures were translated into ICD-9 procedure codes with added timing criteria. Gold standard triage levels were assigned using the COT based on outcomes, including mortality, injury type, admission to the hospital, and surgical procedures. Comparison triage levels were determined based on algorithmic depictions of the three MCI triage tools. RESULTS: A total of 31,093 patients with complete data were identified from the NTDB. The COT was applied to these patients, and the breakdown of gold standard triage levels, based on their actual clinical outcomes, was: 17,333 (55.7%) GREEN; 11,587 (37.3%) YELLOW; 1,572 (5.1%) RED; and 601 (1.9%) BLACK. CareFlight had the best sensitivity for predicting COT outcomes for BLACK (83% [95% confidence interval, 80%-86%]) and GREEN patients (79% [95% CI, 79%-80%]) and the best specificity for RED patients (89% [95% CI, 89%-90%]). CONCLUSION: Among three prehospital MCI triage tools, CareFlight had the best performance for correlating with outcomes in the COT. Overall, none of three tools had good test characteristics for predicting pediatric patient needs for surgical procedures or hospital admission.

Decline in Pediatric Emergency Department Behavioral Team Activations After Institution of an Agitation Protocol.

OBJECTIVE: Aggressive behavior among pediatric patients with psychiatric complaints in emergency departments is a growing problem. An agitation protocol was instituted in 1 pediatric emergency department to provide scaled recommendations for differing levels of aggression. The study objective was to determine if the frequency of activation of an emergency behavioral response team changed after protocol initiation. METHODS: A protocol for escalating management of agitation in pediatric patients was introduced in February 2016. The electronic medical record was queried for subsequent behavioral response team activations over the next 16 months. Patient demographics and specific features surrounding the activation were retrospectively recorded from the medical record, including length of stay, medications administered, and documented deescalation techniques. Frequency and features of behavioral team activations were compared with activations from a period before the planning and implementation of the protocol (May 2014 to May 2015). RESULTS: Twenty-one patient visits were found to require behavioral response team activation over 16 months, compared with 31 for the 13-month preprotocol period. Attempts at verbal/ environmental redirection were seen in 77% and deescalation by medication administration before the activation occurred in 14% of patients. During the behavioral team activation, 81% of the patients were given psychiatric medications and 81% were placed in physical restraints. CONCLUSIONS: A decrease from a baseline of 2.4 to 1.3 behavioral response team activations per month, or a 46% decline, was noted following the institution of a clinical protocol for pediatric agitation.

Occult Pneumothorax Identification on Extended Focused Assessment with Sonography for Trauma Examination in Children.

OBJECTIVE: Occult pneumothoraces (OPTXs) are defined by air within the pleural space that is not visible on conventional chest radiographs (CXR). The aim of this study was to understand how frequently the Extended Focused Assessment with Sonography for Trauma (eFAST) examination identifies occult PTX in a pediatric blunt trauma population as compared with a criterion standard of chest computed tomography (CCT). METHODS: This study is a secondary analysis of blunt trauma patients younger than 18 years who underwent CCT at Los Angeles County +USC Medical Center Emergency Department from October 2015 to April 2017. The eFAST examination was performed and documented by an emergency medicine resident with attending oversight or by an emergency medicine attending for each trauma. The eFAST results were reviewed for patients diagnosed with small or trace pneumothoraces identified on CCT. RESULTS: Of 168 pediatric trauma patients undergoing CCT, 16 had OPTXs not seen on CXR and 4 patients had a small/trace PTX without a corresponding CXR performed. None were identified on eFAST. CONCLUSIONS: Although the sample size in this data set was small, our eFAST examinations identified none of 16 proven and 4 presumed OPTXs. The standard eFAST examination performed poorly in the detection of OPTXs in this single-center study of pediatric blunt trauma victims.

Tabletop Application of SALT Triage to 10, 100, and 1000 Pediatric Victims.

INTRODUCTION: The Sort, Access, Life-saving interventions, Treatment and/or Triage (SALT) mass-casualty incident (MCI) algorithm is unique in that it includes two subjective questions during the triage process: "Is the victim likely to survive given the resources?" and "Is the injury minor?" HYPOTHESIS/PROBLEM: Given this subjectivity, it was hypothesized that as casualties increase, the inter-rater reliability (IRR) of the tool would decline, due to an increase in the number of patients triaged as Minor and Expectant. METHODS: A pre-collected dataset of pediatric trauma patients age <14 years from a single Level 1 trauma center was used to generate "patients." Three trained raters triaged each patient using SALT as if they were in each of the following scenarios: 10, 100, and 1,000 victim MCIs. Cohen's kappa test was used to evaluate IRR between the raters in each of the scenarios. RESULTS: A total of 247 patients were available for triage. The kappas were consistently "poor" to "fair:" 0.37 to 0.59 in the 10-victim scenario; 0.13 to 0.36 in the 100-victim scenario; and 0.05 to 0.36 in the 1,000-victim scenario. There was an increasing percentage of subjects triaged Minor as the number of estimated victims increased: 27.8% increase from 10- to 100-victim scenario and 7.0% increase from 100- to 1,000-victim scenario. Expectant triage categorization of patients remained stable as victim numbers increased. CONCLUSION: Overall, SALT demonstrated poor IRR in this study of increasing casualty counts while triaging pediatric patients. Increased casualty counts in the scenarios did lead to increased Minor but not Expectant categorizations.

National trends in mental health-related emergency department visits by children and adults, 2009-2015.

OBJECTIVES: Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits. METHODS: Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis. RESULTS: Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours. CONCLUSIONS: Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study.

BACKGROUND: Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients. METHODS: Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival. RESULTS: Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001). CONCLUSIONS: Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Points & pearls: Anaphylaxis in pediatric patients: early recognition and treatment are critical for best outcomes

Anaphylaxis is a time-sensitive, clinical diagnosis that is often misdiagnosed because the presenting signs and symptoms are similar to those of other disease processes. This issue reviews the criteria for diagnosing a pediatric patient with anaphylaxis and offers evidence-based recommendations for first- and second-line treatment, including the use of epinephrine, antihistamines, and corticosteroids. Guidance is also provided for the appropriate disposition of patients with anaphylaxis, including prescribing epinephrine autoinjectors and offering training on how to use them, educating patients and families on avoidance of known offending allergens, and referring the patient to a specialist in allergy and immunology. [Points & Pearls is a digest of Pediatric Emergency Medicine Practice.]

Anaphylaxis in pediatric patients:early recognition and treatment are critical for best outcomes.

Anaphylaxis is a time-sensitive, clinical diagnosis that is often misdiagnosed because the presenting signs and symptoms are similar to those of other disease processes. This issue reviews the criteria for diagnosing a pediatric patient with anaphylaxis and offers evidence-based recommendations for first- and second-line treatment, including the use of epinephrine, antihistamines, and corticosteroids. Guidance is also provided for the appropriate disposition of patients with anaphylaxis, including prescribing epinephrine autoinjectors and offering training on how to use them, educating patients and families on avoidance of known offending allergens, and referring the patient to a specialist in allergy and immunology.

Review of Interventions and Radiation Exposure from Chest Computed Tomography in Children with Blunt Trauma.

OBJECTIVE: To determine the radiation risk to a child undergoing trauma evaluation with chest computed tomography (CCT) for every clinically actionable injury identified. STUDY DESIGN: This observational, cross-sectional study included all blunt trauma patients under 18 years of age undergoing CCT in a single urban emergency department. Via a retrospective chart review, therapeutic interventions done exclusively for chest injuries identified on CCT scan were identified. Effective radiation from each CCT was calculated and averaged and the dose required to diagnose 1 management-changing chest injury was determined. RESULTS: Of 209 children undergoing CCT over a 19-month period, 168 were victims of blunt trauma. Ten required an intervention specifically for a chest injury identified on CCT (suggesting development of 1 malignancy per 37 actionable injures identified). None required an intervention for an injury exclusively noted on CCT, as all 10 actionable injuries were apparent via other modalities (radiograph, ultrasound examination, clinical examination). CONCLUSION: Although 10 uniquely actionable injuries were identified on CCT, none were found only on CCT. Because CCTs rarely modified management, the amount of radiation administered per management change was sufficiently high to recommend reconsideration of current imaging practice in this single-center study.

Evaluation and Management of Dehydration in Children.

The article discusses the evaluation of dehydration in children and reviews the literature on physical findings of dehydration. Pediatric dehydration is a common problem in emergency departments and wide practice variation in treatment exists. Dehydration can be treated with oral, nasogastric, subcutaneous, or intravenous fluids. Although oral rehydration is underutilized in the United States, most children with dehydration can be successfully rehydrated via the oral route. Selection of oral rehydration solution and techniques for successful oral rehydration are presented. Appropriate selection and rate of administration of intravenous fluids are also discussed for isonatremic, hyponatremic, and hypernatremic dehydration.

Involuntary Psychiatric Holds in Preadolescent Children.

INTRODUCTION: Little is known about the use of involuntary psychiatric holds in preadolescent children. The primary objective was to characterize patients under the age of 10 years on involuntary psychiatric holds. METHODS: This was a two-year retrospective study from April 2013 - April 2015 in one urban pediatric emergency department (ED). Subjects were all children under the age of 10 years who were on an involuntary psychiatric hold at any point during their ED visit. We collected demographic data including age, gender, ethnicity and details about living situation, child protective services involvement and prior mental health treatment, as well as ED disposition. RESULTS: There were 308 visits by 265 patients in a two-year period. Ninety percent of involuntary psychiatric holds were initiated in the prehospital setting. The following were common characteristics: male (75%), in custody of child protective services (23%), child protective services involvement (42%), and a prior psychiatric hospitalization (32%). Fifty-six percent of visits resulted in discharge from the ED, 42% in transfer to a psychiatric hospital and 1% in admission to the pediatric medical ward. Median length of stay was 4.7 hours for discharged patients and 11.7 hours for patients transferred to psychiatric hospitals. CONCLUSION: To our knowledge, this study presents the first characterization of preadolescent children on involuntary psychiatric holds. Ideally, mental health screening and services could be initiated in children with similar high-risk characteristics before escalation results in placement of an involuntary psychiatric hold. Furthermore, given that many patients were discharged from the ED, the current pattern of utilization of involuntary psychiatric holds in young children should be reconsidered.

Special Considerations in the Pediatric Psychiatric Population.

Youth with psychiatric and behavioral complaints commonly present to emergency departments (EDs), which often lack dedicated mental health staff. This article addresses techniques EDs can use to better care for children in need of psychiatric assessment and medical clearance, specifically addressing the evaluation of youth with suicidal ideation and coexisting medical and psychiatric needs. The evaluation and management of youth with agitation and aggression are also discussed. The article concludes with a discussion of systems changes needed to truly improve emergency care for psychiatrically ill youth.

Use of a Novel, Portable, LED-Based Capillary Refill Time Simulator within a Disaster Triage Context.

Introduction A simple, portable capillary refill time (CRT) simulator is not commercially available. This device would be useful in mass-casualty simulations with multiple volunteers or mannequins depicting a variety of clinical findings and CRTs. The objective of this study was to develop and evaluate a prototype CRT simulator in a disaster simulation context. METHODS: A CRT prototype simulator was developed by embedding a pressure-sensitive piezo crystal, and a single red light-emitting diode (LED) light was embedded, within a flesh-toned resin. The LED light was programmed to turn white proportionate to the pressure applied, and gradually to return to red on release. The time to color return was adjustable with an external dial. The prototype was tested for feasibility among two cohorts: emergency medicine physicians in a tabletop exercise and second year medical students within an actual disaster triage drill. The realism of the simulator was compared to video-based CRT, and participants used a Visual Analog Scale (VAS) ranging from "completely artificial" to "as if on a real patient." The VAS evaluated both the visual realism and the functional (eg, tactile) realism. Accuracy of CRT was evaluated only by the physician cohort. Data were analyzed using parametric and non-parametric statistics, and mean Cohen's Kappas were used to describe inter-rater reliability. RESULTS: The CRT simulator was generally well received by the participants. The simulator was perceived to have slightly higher functional realism (P=.06, P=.01) but lower visual realism (P=.002, P=.11) than the video-based CRT. Emergency medicine physicians had higher accuracy on portrayed CRT on the simulator than the videos (92.6% versus 71.1%; P<.001). Inter-rater reliability was higher for the simulator (0.78 versus 0.27; P<.001). CONCLUSIONS: A simple, LED-based CRT simulator was well received in both settings. Prior to widespread use for disaster triage training, validation on participants' ability to accurately triage disaster victims using CRT simulators and video-based CRT simulations should be performed. Chang TP , Santillanes G , Claudius I , Pham PK , Koved J , Cheyne J , Gausche-Hill M , Kaji AH , Srinivasan S , Donofrio JJ , Bir C . Use of a novel, portable, LED-based capillary refill time simulator within a disaster triage context. Prehosp Disaster Med. 2017;32(4):451-456.

Accuracy of Magnetic Resonance Imaging and Ultrasound for Appendicitis in Diagnostic and Nondiagnostic Studies.

OBJECTIVES: Suggestive radiographic studies with nonvisualization of the appendix can present a challenge to clinicians in the evaluation of pediatric abdominal pain. The primary objective of this study was to quantify the accuracy of magnetic resonance imaging (MRI) and of ultrasound (US) in the setting of nonvisualization of the appendix. Secondary objectives reported include sensitivity of MRI and US overall and correlation between MRI and US for diagnosis of appendicitis. METHODS: Records of pediatric emergency department patients aged 3 to 21 years undergoing MRI and/or US for the evaluation of appendicitis were retrospectively reviewed. Radiographs were categorized as a normal appendix, neither demonstrating the appendix nor demonstrating abnormalities consistent with appendicitis; equivocal, not demonstrating the appendix but showing evidence of appendicitis; demonstrating an abnormal appendix consistent with appendicitis; or demonstrating an alternate pathology. The reading was compared with the final diagnosis for accuracy. RESULTS: Of the 589 patients included, 146 had appendicitis. Diagnostic accuracy for studies with a nonvisualized appendix without secondary signs of appendicitis was 100% for MRI and 91.4% (95% CI = 87.3% to 94.2%) for US. Diagnostic accuracy for studies with a nonvisualized appendix with secondary signs of appendicitis was 50% (95% CI = 2.5% to 97.5%) for MRI and 38.9% (95% CI = 18.2% to 64.5%) for US. Appendicitis was ultimately diagnosed in 8.6% of patients with an otherwise negative right lower quadrant (RLQ) US that failed to directly identify the appendix. There was a moderate correlation between US and MRI (ρ = 0.573, p = 0.0001) when all studies were considered. CONCLUSIONS: Magnetic resonance imaging without secondary signs of appendicitis is effective in excluding appendicitis regardless of whether the appendix is directly visualized, while otherwise negative RLQ US that fail to identify the appendix are less useful. Secondary signs of appendicitis without visualization of the appendix were not helpful regardless of radiographic modality. Results of MRI and US correlated moderately well.

Does Right Lower Quadrant Abdominal Ultrasound Accurately Identify Perforation in Pediatric Acute Appendicitis?

BACKGROUND: Acute appendicitis is the most common cause of acute abdomen in pediatric emergency department (ED) visits, and right lower quadrant abdominal ultrasound (RLQUS) is a valuable diagnostic tool in the clinical approach. The utility of ultrasound in predicting perforation has not been well-defined. OBJECTIVES: We sought to determine the sensitivity of RLQUS to identify perforation in pediatric patients with appendicitis. METHODS: A chart review of all patients 3 to 21 years of age who received a radiographic work-up and who were ultimately diagnosed with perforated appendicitis between 2010 and 2013 at a pediatric ED was conducted. The final read for ultrasonography was compared to either the operative diagnosis, surgical pathology diagnosis, or further imaging results (if the patient was managed nonoperatively). Test characteristics were calculated for the identification of appendicitis and identification of perforation. RESULTS: Of the 539 patients evaluated for appendicitis, 144 (26.7%) patients had appendicitis, and 40 of these (27.8%) were perforated. Thirty-nine had RLQUS performed as part of their evaluation. Of these, 28 had positive findings for appendicitis, and 9 were read as definite or possible perforated appendicitis. The sensitivity of RLQUS for the diagnosis of appendicitis in the group with perforation was 77.1% (95% confidence interval [CI], 59.4-89%) and the sensitivity for diagnosing a perforation was 23.1% (95% CI, 11.1-39.3%). CONCLUSION: There was a low rate of detection of perforation by RLQUS in our pediatric population. If larger studies confirm this, additional imaging should be recommended in patients with a high suspicion of perforation and in whom a diagnosis of perforation would change management.

Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool.

BACKGROUND: Rapid, accurate evaluation and sorting of victims in a mass casualty incident (MCI) is crucial, as over-triage of victims may overwhelm a trauma system and under-triage may lead to an increase in morbidity and mortality. At this time, there is no validation tool specifically developed for the pediatric population to test an MCI algorithm's inherent capabilities to correctly triage children. OBJECTIVE: To develop a set of criteria for outcomes and interventions to be used as a validation tool for testing an MCI algorithm's ability to correctly triage patients from a cohort of pediatric trauma patients. METHODS: Expert opinion and literature review was used to formulate an initial Criteria Outcomes Tool (COT) that retrospectively categorizes pediatric (≤14 years of age) MCI victims based on resource utilization and clinical outcomes using the classic Red to Black MCI triage designations: Red - cardiopulmonary or mental status compromise needing intervention, Yellow - stable cardiopulmonary status but may require life or limb therapy, Green - minimally injured, and Black - deceased or likely to die given the circumstances. Using an anatomic approach, a list of criteria were defined and a modified-Delphi approach was used to create a summative COT that was reviewed by the American Academy of Pediatrics Disaster Preparedness Advisory Council. The resulting COT was independently applied to a weighted retrospective cohort of 25 pediatric victims from a single Level I trauma center by two reviewers to determine reproducibility. RESULTS: We created a Criteria Outcomes Tool (COT) with 47 outcomes and interventions to validate an MCI algorithm's triage designation. When the COT was applied to a cohort of 25 weighted pediatric charts, we identified the following resource utilization and outcome based triage designations: six Red, six Yellow, six Green, and seven Black triage outcomes. The 100% agreement was obtained between the two reviewers in each of the four categories. CONCLUSIONS: We designed an outcomes and resource utilization tool, the COT, to evaluate the ability of an MCI algorithm to correctly triage pediatric patients. Our tool has good reproducibility on initial study. KEY WORDS: pediatric; disaster; validation tools; triage algorithms; emergency.

Accuracy, Efficiency, and Inappropriate Actions Using JumpSTART Triage in MCI Simulations.

INTRODUCTION: Using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) algorithm for the triage of pediatric patients in a mass-casualty incident (MCI) requires assessing the results of each step and determining whether to move to the next appropriate action. Inappropriate application can lead to performance of unnecessary actions or failure to perform necessary actions. Hypothesis/Problem To report overall accuracy and time required for triage, and to assess if the performance of unnecessary steps, or failure to perform required steps, in the triage algorithm was associated with inaccuracy of triage designation or increased time to reach a triage decision. METHODS: Medical students participated in an MCI drill in which they triaged both live actors portraying patients and computer-based simulated patients to the four triage levels: minor, delayed, immediate, and expectant. Their performance was timed and compared to intended triage designations and a priori determined critical actions. RESULTS: Thirty-three students completed 363 scenarios. The overall accuracy was 85.7% and overall mean time to assign a triage designation was 70.4 seconds, with decreasing times as triage acuity level decreased. In over one-half of cases, the student omitted at least one action and/or performed at least one action that was not required. Each unnecessary action increased time to triage by a mean of 8.4 seconds and each omitted action increased time to triage by a mean of 5.5 seconds. Discussion Increasing triage level, performance of inappropriate actions, and omission of recommended actions were all associated with increasing time to perform triage.