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Papillon SC, Pennell CP, Bauer SE, DiBello A, Master SA, Prasad R, Arthur LG, Grewal H. Presence of Microscopic Hematuria Does Not Predict Clinically Important Intra-Abdominal Injury in Children. Pediatr Emerg Care 2024; 40:e139-e142. [PMID: 38849150 DOI: 10.1097/pec.0000000000003210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
OBJECTIVE Screening for blunt intra-abdominal injury in children often includes directed laboratory evaluation that guides need for computed tomography. We sought to evaluate the use of urinalysis in identifying patients with clinically important intraabdominal injury ( ci -IAI). METHODS A retrospective chart review was performed for all patients less than 18 years who presented with blunt mechanisms at a level I trauma center between 2016 and 2019. Exclusion criteria included transfer from an outside facility, physical abuse, and death within thirty minutes of arrival. Demographics, physical exam findings, serum chemistries, urinalysis, and imaging were reviewed. Clinically important intraabdominal injury was defined as injury requiring ≥2 nights admission, blood transfusion, angiography with embolization, or therapeutic surgery. RESULTS Two hundred forty patients were identified. One hundred sixty-five had a completed urinalysis. For all patients an abnormal chemistry panel and abnormal physical exam had a sensitivity of 88.9% and a negative predictive value of 99.3%. Nine patients had a ci -IAI. Patients with a ci -IAI were more likely to have abdominal pain, tenderness on exam, and elevated hepatic enzymes. When patients were stratified by the presence of an abnormal chemistry or physical exam with or without microscopic hematuria, urinalysis did not improve the ability to identify patients with a ci -IAI. In fact, presence of microscopic hematuria increased the rate of false positives by 12%. CONCLUSIONS Microscopic hematuria was not a useful marker for ci -IAI and may lead to falsely assuming a more serious injury.
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Affiliation(s)
- Stephanie C Papillon
- From the Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St Christopher's Hospital for Children
| | - Christopher P Pennell
- From the Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St Christopher's Hospital for Children
| | | | | | - Sahal A Master
- From the Department of Pediatric General, Thoracic and Minimally Invasive Surgery, St Christopher's Hospital for Children
| | - Rajeev Prasad
- St. Luke's University Health Network, Pediatric Surgery, Bethlehem, PA
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Lyttle BD, Williams RF, Stylianos S. Management of Pediatric Solid Organ Injuries. CHILDREN (BASEL, SWITZERLAND) 2024; 11:667. [PMID: 38929246 PMCID: PMC11202015 DOI: 10.3390/children11060667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 06/28/2024]
Abstract
Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.
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Affiliation(s)
- Bailey D. Lyttle
- Department of Surgery, University of Colorado School of Medicine and Children’s Hospital Colorado, 12631 East 17th Avenue, Room 6111, Aurora, CO 80045, USA;
| | - Regan F. Williams
- Department of Surgery, Le Bonheur Children’s Hospital, 49 North Dunlap Avenue, Second Floor, Memphis, TN 38105, USA;
| | - Steven Stylianos
- Division of Pediatric Surgery, Columbia University Vagelos College of Physicians & Surgeons, Morgan Stanley Children’s Hospital, 3959 Broadway—Rm 204 N, New York, NY 10032, USA
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Mahdi E, Toscano N, Pierson L, Ndikumana E, Ayers B, Chacon A, Brayer A, Chess M, Davis C, Dorman R, Livingston M, Arca M, Wakeman D. Sustaining the gains: Reducing unnecessary computed tomography scans in pediatric trauma patients. J Pediatr Surg 2023; 58:111-117. [PMID: 36272813 DOI: 10.1016/j.jpedsurg.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE "Pan-scanning" pediatric blunt trauma patients leads to exposure to harmful radiation and increased healthcare costs without improving outcomes. We aimed to reduce computed tomography (CT) scans that are not indicated (NI) by imaging guidelines for injured children. METHODS In July 2017, our Pediatric Trauma Center prospectively implemented validated imaging guidelines to direct CT imaging for trauma activations and consultations for children younger than 16 years old with blunt traumatic injuries. Patients with suspected physical abuse, CT imaging prior to arrival, penetrating mechanism, and instability precluding CT imaging were excluded. We compared CT scanning rates for pre-implementation (01/2016-06/2017) and post-implementation (07/2017-08/2021) time periods. Guideline compliance was evaluated by chart review and sustained through iterative process improvement cycles. RESULTS During the pre-implementation era, 61 patients underwent 171 CT scans of which 87 (51%) scans were not indicated by guidelines. Post-implementation, 363 patients had 531 scans and only 134 (25%) CTs were not indicated. Total CTs performed declined after initiation of guidelines (2.80 vs 1.46 scans/patient, p<0.0001). Total NI CTs declined (1.41 vs 0.37 NI scans/patient, p<0.0001) reflected in significant reductions in all anatomic regions: head, cervical spine, chest, and abdomen/pelvis. Charges related to NI scans decreased from $1,490.31/patient to $408.21/patient, saving $218,000 in charges. Based on prior utilization, 146 children were spared excessive radiation with no clinically significant missed injuries since guideline implementation. CONCLUSIONS Quality improvement and implementation science methodologies to enhance compliance with imaging guidelines for children with blunt injuries can significantly reduce unnecessary CT scanning without compromising care. This practice reduces harmful radiation exposure in a sensitive patient population and may save healthcare systems money and resources.
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Affiliation(s)
- Elaa Mahdi
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Nicole Toscano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Lauren Pierson
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Eric Ndikumana
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Brian Ayers
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Alexander Chacon
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Anne Brayer
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Mitchell Chess
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Colleen Davis
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Robert Dorman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Michael Livingston
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Marjorie Arca
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Derek Wakeman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States.
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Kolousek A, Sharma B, Lian B, Koganti D, Smith RN, Sola R. Understanding abdominal pelvic computerized tomography scan usage amongst adolescent blunt trauma patients treated at adult trauma centers. Injury 2023; 54:100-104. [PMID: 35999064 DOI: 10.1016/j.injury.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The algorithm for evaluating adolescent patients with blunt trauma includes abdominal pelvic CT (APCT). The aim of this study is to evaluate the utility of APCT in this context. METHODS We performed a retrospective review of adolescent (11 to 18 years of age) blunt trauma patients at an urban adult level 1 trauma center from January 2015 to December 2019. The primary outcome was the prevalence of positive findings on APCT scan. Additionally, clinical risk factors concerning for intra-abdominal injury were analyzed. RESULTS There were 546 patients evaluated for blunt trauma and the prevalence of APCT within the population was 59.3% (95% CI 54.2%-64.9%). Of the patients who received APCT, 123 (37.9%) had positive findings on APCT. Only 25 patients (7.7% of those who underwent APCT) required abdominal surgery while 40 patients (12.3%) had intraabdominal injury that did not require surgery. Risk factors were present in 100% of patients with intraabdominal injury and absent in 28.7% of patients without intraabdominal injury. Abnormal abdominal exam, abnormal FAST, positive chest x-ray and elevated transaminases were independently associated with intraabdominal injury. CONCLUSIONS Our study found that adolescent blunt trauma patients treated at our trauma center had a higher rate of APCT usage, but a comparable rate of positive findings when compared with the most recent literature. Future studies should focus on reducing the number of patients who undergo APCT despite an absence of clinical risk factors.
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Affiliation(s)
- Anastasia Kolousek
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
| | - Bharath Sharma
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
| | - Brad Lian
- Mercer University School of Medicine, Department of Community Medicine, 1501 Mercer University Drive, Macon, GA 30341, United States.
| | - Deepika Koganti
- Emory University School of Medicine, Department of Surgery, 69 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, United States.
| | - Randi N Smith
- Emory University School of Medicine, Department of Surgery, 69 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, United States.
| | - Richard Sola
- Morehouse School of Medicine, Department of Surgery, 720 Westview Drive, Atlanta, GA 30310, United States.
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Huang S, Zhou Z, Qian X, Li D, Guo W, Dai Y. Automated quantitative assessment of pediatric blunt hepatic trauma by deep learning-based CT volumetry. Eur J Med Res 2022; 27:305. [PMID: 36572942 PMCID: PMC9793570 DOI: 10.1186/s40001-022-00943-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 12/08/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To develop an end-to-end deep learning method for automated quantitative assessment of pediatric blunt hepatic trauma based on contrast-enhanced computed tomography (CT). METHODS This retrospective study included 170 children with blunt hepatic trauma between May 1, 2015, and August 30, 2021, who had undergone contrast-enhanced CT. Both liver parenchyma and liver trauma regions were manually segmented from CT images. Two deep convolutional neural networks (CNNs) were trained on 118 cases between May 1, 2015, and December 31, 2019, for liver segmentation and liver trauma segmentation. Liver volume and trauma volume were automatically calculated based on the segmentation results, and the liver parenchymal disruption index (LPDI) was computed as the ratio of liver trauma volume to liver volume. The segmentation performance was tested on 52 cases between January 1, 2020, and August 30, 2021. Correlation analysis among the LPDI, trauma volume, and the American Association for the Surgery of Trauma (AAST) liver injury grade was performed using the Spearman rank correlation. The performance of severity assessment of pediatric blunt hepatic trauma based on the LPDI and trauma volume was evaluated using receiver operating characteristic (ROC) analysis. RESULTS The Dice, precision, and recall of the developed deep learning framework were 94.75, 94.11, and 95.46% in segmenting the liver and 72.91, 72.40, and 76.80% in segmenting the trauma regions. The LPDI and trauma volume were significantly correlated with AAST grade (rho = 0.823 and rho = 0.831, respectively; p < 0.001 for both). The area under the ROC curve (AUC) values for the LPDI and trauma volume to distinguish between high-grade and low-grade pediatric blunt hepatic trauma were 0.942 (95% CI, 0.882-1.000) and 0.952 (95% CI, 0.895-1.000), respectively. CONCLUSIONS The developed end-to-end deep learning method is able to automatically and accurately segment the liver and trauma regions from contrast-enhanced CT images. The automated LDPI and liver trauma volume can act as objective and quantitative indexes to supplement the current AAST grading of pediatric blunt hepatic trauma.
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Affiliation(s)
- Shungen Huang
- grid.452253.70000 0004 1804 524XPediatric Surgery, Children’s Hospital of Soochow University, Suzhou, 215025 China
| | - Zhiyong Zhou
- grid.9227.e0000000119573309Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163 China
| | - Xusheng Qian
- grid.9227.e0000000119573309Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163 China ,grid.59053.3a0000000121679639School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230026 China
| | - Dashuang Li
- grid.452253.70000 0004 1804 524XPediatric Surgery, Children’s Hospital of Soochow University, Suzhou, 215025 China
| | - Wanliang Guo
- grid.452253.70000 0004 1804 524XDepartment of Radiology, Children’s Hospital of Soochow University, Suzhou, 215025 China
| | - Yakang Dai
- grid.9227.e0000000119573309Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, 215163 China
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Rinnan JMA, Latreille J, Nanassy AD, Gaughan J, Lindholm EB, Grewal H, Kassutto Z, Arthur LG. Reducing Phlebotomy, Length of Stay, Cost: Development of a Blunt Abdominal Trauma Pathway in a Level I, Pediatric Trauma Center. Pediatr Emerg Care 2022; 38:550-554. [PMID: 35905444 DOI: 10.1097/pec.0000000000002613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Blunt abdominal trauma (BAT) is a leading cause of morbidity in children with higher hemodynamic stabilities when compared with adults. Pediatric patients with BAT can often be managed without surgical interventions; however, laboratory testing is often recommended. Yet, laboratory testing can be costly, and current literature has not identified appropriate pathways or specific tests necessary to detect intra-abdominal injury after BAT. Therefore, the present study evaluated a proposed laboratory testing pathway to determine if it safely reduced draws of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase and lipase levels orders, emergency department (ED) length of stay, and cost in pediatric BAT patients. METHODS A retrospective review of levels I, II, and III BAT pediatric patients (n = 329) was performed from 2015 to 2018 at our level I, pediatric trauma center. Patients were then grouped based on pre-post pathway, and differences were calculated using univariate analyses. RESULTS After implementation of the pathway, there was a significant decrease in the number of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase, and lipase levels orders ( P < 0.05). Postpathway patients had lower average ED lengths of stay and testing costs compared with the pre pathway patients ( P < 0.05). There was no increase in rates of return to the ED within 30 days, missed injuries, or readmissions of patients to the ED. CONCLUSIONS Results displayed that the adoption of a laboratory testing pathway for BAT patients reduced the number of laboratory tests, ED length of stay, and associated costs pediatric patients without impacting quality care.
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Affiliation(s)
| | | | - Autumn D Nanassy
- Research Department, St. Christopher's Hospital for Children, Philadelphia, PA
| | - John Gaughan
- Department of Medicine, Rowan University Cooper Medical School, Camden, NJ
| | - Erika B Lindholm
- Pediatric Surgery Department, St. Christopher's Hospital for Children, Philadelphia, PA
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Kornblith AE, Singh C, Devlin G, Addo N, Streck CJ, Holmes JF, Kuppermann N, Grupp-Phelan J, Fineman J, Butte AJ, Yu B. Predictability and stability testing to assess clinical decision instrument performance for children after blunt torso trauma. PLOS DIGITAL HEALTH 2022; 1:e0000076. [PMID: 36812570 PMCID: PMC9931266 DOI: 10.1371/journal.pdig.0000076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/14/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The Pediatric Emergency Care Applied Research Network (PECARN) has developed a clinical-decision instrument (CDI) to identify children at very low risk of intra-abdominal injury. However, the CDI has not been externally validated. We sought to vet the PECARN CDI with the Predictability Computability Stability (PCS) data science framework, potentially increasing its chance of a successful external validation. MATERIALS & METHODS We performed a secondary analysis of two prospectively collected datasets: PECARN (12,044 children from 20 emergency departments) and an independent external validation dataset from the Pediatric Surgical Research Collaborative (PedSRC; 2,188 children from 14 emergency departments). We used PCS to reanalyze the original PECARN CDI along with new interpretable PCS CDIs developed using the PECARN dataset. External validation was then measured on the PedSRC dataset. RESULTS Three predictor variables (abdominal wall trauma, Glasgow Coma Scale Score <14, and abdominal tenderness) were found to be stable. A CDI using only these three variables would achieve lower sensitivity than the original PECARN CDI with seven variables on internal PECARN validation but achieve the same performance on external PedSRC validation (sensitivity 96.8% and specificity 44%). Using only these variables, we developed a PCS CDI which had a lower sensitivity than the original PECARN CDI on internal PECARN validation but performed the same on external PedSRC validation (sensitivity 96.8% and specificity 44%). CONCLUSION The PCS data science framework vetted the PECARN CDI and its constituent predictor variables prior to external validation. We found that the 3 stable predictor variables represented all of the PECARN CDI's predictive performance on independent external validation. The PCS framework offers a less resource-intensive method than prospective validation to vet CDIs before external validation. We also found that the PECARN CDI will generalize well to new populations and should be prospectively externally validated. The PCS framework offers a potential strategy to increase the chance of a successful (costly) prospective validation.
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Affiliation(s)
- Aaron E. Kornblith
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Chandan Singh
- Department of Electrical Engineering & Computer Science, University of California, Berkeley, Berkeley, United States of America
| | - Gabriel Devlin
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Newton Addo
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Christian J. Streck
- Department of Surgery, Medical University of South Carolina, Children’s Hospital, Charleston, United States of America
| | - James F. Holmes
- Department of Emergency Medicine, University of California, Davis, Davis, United States of America
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis, Davis, United States of America
- Department of Pediatrics, University of California, Davis, Davis, United States of America
| | - Jacqueline Grupp-Phelan
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, United States of America
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Jeffrey Fineman
- Department of Pediatrics, University of California, San Francisco, San Francisco, United States of America
| | - Atul J. Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, United States of America
| | - Bin Yu
- Department of Electrical Engineering & Computer Science, University of California, Berkeley, Berkeley, United States of America
- Departments of Statistics, University of California, Berkeley, Berkeley, United States of America
- * E-mail:
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Thull-Freedman J. Reducing overuse of CT imaging in pediatric trauma: a model example of the Model for Improvement. CAN J EMERG MED 2022; 24:469-470. [PMID: 35917029 DOI: 10.1007/s43678-022-00347-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Jennifer Thull-Freedman
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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9
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Safely reducing abdominal/pelvic computed tomography imaging in pediatric trauma: a quality improvement initiative. CAN J EMERG MED 2022; 24:535-543. [PMID: 35505179 DOI: 10.1007/s43678-022-00311-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 03/30/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Intra-abdominal injury occurs in less than 15% of pediatric trauma activations but can be life-threatening. Computed tomography (CT) imaging is commonly ordered in pediatric trauma, even when intra-abdominal injury risk is low. We aimed to reduce abdominal/pelvic CT rates in children at very low risk for intra-abdominal injury requiring trauma activation at our pediatric trauma centre. METHODS We implemented a quality improvement initiative using the Model for Improvement in children 0-15.99 years of age who activated a trauma response and were evaluated for intra-abdominal injury. Interventions included clinical decision support, institutional education, and individual audit and feedback. Our primary outcome was abdominal/pelvic CT rate in patients at very low risk for intra-abdominal injury. Balancing measures included CT scans ordered within 24 h of emergency department (ED) assessment and return to ED or hospitalization within 72 h for missed intra-abdominal injury. Statistical process control was used to evaluate rates over time. RESULTS The baseline period (April 1, 2016 - November 30, 2017) included 359 trauma patients with a CT rate of 26.8% (95% CI 20.5-33.8%) in those at low risk for intra-abdominal injury. The intervention period (Dec 1, 2017-Dec 31, 2019) included 445 patients with a CT rate in low-risk patients of 6.8% (95% CI 3.2-12.6%), demonstrating an absolute reduction of 20.0% (95% CI 12.2-27.7%, p < 0.05). Interventions resulted in a significant decrease in abdominal/pelvic CT imaging corresponding with special cause variation. No clinically significant intra-abdominal injuries were missed. CONCLUSIONS This quality improvement initiative reduced abdominal/pelvic CT rates in pediatric trauma patients at low risk for intra-abdominal injury without any missed cases of significant injury. Leveraging standardized decision tools to reduce unnecessary CT imaging can be successfully accomplished without compromising care.
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The diagnostic value of laboratory tests in detecting solid organ injuries in pediatric patients with blunt abdominal trauma: A prospective, observational study. Am J Emerg Med 2022; 57:133-137. [DOI: 10.1016/j.ajem.2022.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/23/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
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Chaudhari PP, Rodean J, Spurrier RG, Hall M, Marin JR, Ramgopal S, Alpern ER, Shah SS, Freedman SB, Cohen E, Morse RB, Neuman MI. Epidemiology and management of abdominal injuries in children. Acad Emerg Med 2022; 29:944-953. [PMID: 35373473 DOI: 10.1111/acem.14497] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although more guideline-adherent care has been described in pediatric compared to adult trauma centers, we aimed to provide a more detailed characterization of management and resource utilization of children with intra-abdominal injury (IAI) within pediatric centers. Our primary objective was to describe the epidemiology, diagnostic evaluation, and management of children with IAI across U.S. children's hospitals. Our secondary objective was to describe the interhospital variation in surgical management of children with IAI. METHODS We conducted a cross-sectional study of 33 hospitals in the Pediatric Health Information System. We included children aged <18 years evaluated in the emergency department from 2010 to 2019 with IAI, as defined by ICD coding, and who underwent an abdominal computed tomography (CT). Our primary outcome was abdominal surgery. We categorized IAI by organ system and described resource utilization data. We used generalized linear regression to calculate adjusted hospital-level proportions of abdominal surgery, with a random effect for hospital. RESULTS We studied 9265 children with IAI. Median (IQR) age was 9.0 (6.0-13.0) years. Abdominal surgery was performed in 16% (n = 1479) of children, with the lowest proportion of abdominal surgery observed in children aged <5 years. Liver (38.6%) and spleen (32.1%) were the most common organs injured. A total of 3.1% of children with liver injuries and 2.8% with splenic injuries underwent abdominal surgery. Although there was variation in rates of surgery across hospitals (p < 0.001), only three of 33 hospitals had rates that were statistically different from the aggregate mean of 16%. CONCLUSIONS Most children with IAI are managed nonoperatively, and most children's hospitals manage children with IAI similarly. These data can be used to inform future benchmarking efforts across hospitals to assess concordance with guidelines for the management of children with IAI.
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Affiliation(s)
- Pradip P. Chaudhari
- Division of Emergency and Transport Medicine Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California Los Angeles California USA
| | | | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California Los Angeles California USA
| | - Matt Hall
- Children's Hospital Association Lenexa Kansas USA
| | - Jennifer R. Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute Cumming School of Medicine, University of Calgary Calgary Alberta Canada
| | - Eyal Cohen
- Division of Pediatric Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children and Department of Pediatrics and Institute of Health Policy, Management & Evaluation The University of Toronto and ICES Toronto Ontario Canada
| | - Rustin B. Morse
- Center for Clinical Excellence Nationwide Children's Hospital Columbus Ohio USA
| | - Mark I. Neuman
- Division of Emergency Medicine Boston Children's Hospital and Harvard Medical School Boston Massachusetts USA
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Ozcan A, Ahn T, Akay B, Menoch M. Imaging for Pediatric Blunt Abdominal Trauma With Different Prediction Rules: Is the Outcome the Same? Pediatr Emerg Care 2022; 38:e654-e658. [PMID: 33616315 DOI: 10.1097/pec.0000000000002346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computerized tomography (CT) of the abdomen and pelvis is the standard imaging modality to diagnose intra-abdominal injury (IAI). Clinicians must weigh the risk-benefit of CT compared with the degree of clinical suspicion for an IAI. Pediatric Emergency Care Applied Research Network (PECARN), Streck, and blunt abdominal trauma in children (BATiC) prediction rules have been published to help guide evaluation of these patients. Pediatric Emergency Care Applied Research Network uses history and physical examination findings, whereas Streck and BATiC use examination plus laboratory and imaging findings. At the time of the study, there was not a protocol that was more routinely sited. Our goal was to compare these different prediction rules. METHODS This was a retrospective electronic chart review of all children younger than 18 years presenting for either level 1 or 2 trauma activations at our pediatric emergency department (ED) between June 1, 2015, to June 30, 2017. Charts were manually reviewed for a mechanism concerning for abdominal trauma, and demographic data, history and physical examination findings, laboratory and imaging results per prediction rules, and revisits in 7 days were collected.The prediction rules were applied to all charts that had all data necessary. For study purposes, a score of zero for PECARN and Streck, and score of ≤5 for modified BATiC (mBATiC) were defined as "low risk." Patients with no CT, negative CT, and no new injury found on revisit were classified as "no IAI identified," and patients with positive CT or revisit with injury found as "IAI identified." The results were compared via Fisher exact test. RESULTS A total of 249 patients met the inclusion criteria with a median age of 12 years. Of the low-risk patients, 119 (98.7%) of 121 in PECARN group, 21 (100%) of 21 in Streck, and 48 (85.7%) of 56 in mBATiC group had no IAI identified. None of the low-risk patients required any intra-abdominal intervention. No missed IAI was identified during revisit review. Negative predictive values of all 3 rules were significant for PECARN, Streck, and mBATiC (98.35%, 100%, and 85.71%, respectively). Overall, 27 patients had positive CT results for IAI. CONCLUSIONS The PECARN and Streck rules have high negative predictive values to predict low-risk patients who do not require CT. When laboratory studies are not obtained, PECARN is an effective means of excluding IAI for low-risk patients. When laboratory tests were obtained, the Streck rule performed well. Overall, the results are similar to the past individual studies done on each individual rule. History and physical examination findings are of high importance in pediatric trauma. This study supports limited imaging when no abnormal findings are present in children with blunt torso trauma. This is the only study found in the literature that has compared 3 different prediction rules.
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Affiliation(s)
- Ali Ozcan
- From the Pediatric Emergency Department, Loma Linda University Medical Center, Loma Linda, CA
| | - Terrie Ahn
- Pediatric Allergy and Immunology Department, UCLA Mattel Children's Hospital, Los Angeles, CA
| | | | - Margaret Menoch
- Pediatric Emergency Department,William Beaumont Hospital, Royal Oak, MI
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13
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Patterson KN, Fabia R, Giles S, Verlee SN, Marx D, Aguayo P, Ziegfeld S, Parrish C, Stewart FD, Fritzeen J, Burd RS, Vitale L, Cloutier D, Shanti C, Klein J, Thakkar RK. Defining Benchmarks in Pediatric Burn Care: Inception of the Pediatric Injury Quality Improvement Collaborative (PIQIC). J Burn Care Res 2021; 43:277-280. [PMID: 33677547 DOI: 10.1093/jbcr/irab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Pediatric burn care is highly variable nationwide. Standardized quality and performance benchmarks are needed for guiding performance improvement within pediatric burn centers. A network of pediatric burn centers was established to develop and evaluate pediatric-specific best practices. A multi-disciplinary team including pediatric surgeons, nurses, advanced practice providers, pediatric intensivists, rehabilitation staff, and child psychologists from five pediatric burn centers established a collaborative to share and compare performance improvement data, evaluate outcomes, and exchange best care practices. In December 2016, the Pediatric Injury Quality Improvement Collaborative (PIQIC) was established. PIQIC members chose quality improvement indicators, drafted and approved a memorandum of understanding (MOU), data use agreement (DUA) and charter, formalized the multidisciplinary membership, and established a steering committee. Since inception, PIQIC has conducted monthly teleconferences and biannual in-person or virtual group meetings. A centralized data repository has been established where data is collated and analyzed for benchmarking in a blinded fashion. PIQIC has shown the feasibility of multi-institutional data collection, implementation of performance improvement metrics, publication of research, and enhancement of aggregate and institution-specific pediatric burn care.
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Affiliation(s)
- Kelli N Patterson
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Renata Fabia
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH.,Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Sheila Giles
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Sarah N Verlee
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Daniel Marx
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO
| | - Susan Ziegfeld
- Department of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD
| | - Carisa Parrish
- Department of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD
| | - F Dylan Stewart
- Department of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD
| | - Jennifer Fritzeen
- Division Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Randall S Burd
- Division Trauma and Burn Surgery, Children's National Hospital, Washington, DC
| | - Lisa Vitale
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, Detroit MI
| | - Dawn Cloutier
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, Detroit MI
| | - Christina Shanti
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, Detroit MI
| | - Justin Klein
- Department of Pediatric Surgery, Children's Hospital of Michigan, Detroit Medical Center, Detroit MI
| | - Rajan K Thakkar
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH.,Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
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14
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Isolated low-grade solid organ injuries in children following blunt abdominal trauma: Is it time to consider discharge from the emergency department? J Trauma Acute Care Surg 2021; 89:887-893. [PMID: 32769952 DOI: 10.1097/ta.0000000000002899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Acute intervention (AI) for solid organ injury (SOI) is rare in hemodynamically stable children. Pediatric guidelines recommend admission with follow-up laboratories, even for low-grade injuries. METHODS Data sets from two large multicenter prospective observational studies were used to analyze a cohort of children (age, <17 years) with grade I to III SOI following blunt abdominal trauma. Children with hollow viscus injuries were excluded. Patients were divided into (a) those with or without other major injuries (OMIs) (traumatic brain injury, hemothorax or pneumothorax, pelvic fracture, urgent orthopedic or neurosurgical operations) and (b) with grade I or II versus grade III injuries. Outcomes included AIs (transfusion, angiography, abdominal operation) and disposition (admission unit and length of stay). RESULTS There were 14,232 children enrolled in the two studies, and 791 patients had a SOI (5.6%). After excluding patients with hollow viscus injuries and higher-grade SOIs, 517 patients with a grade I to III SOI were included, and 262 of these had no OMI. Among patients with no OMI, none of 148 patients with grade I or II SOI underwent AI, while only 3 of 114 patients with grade III injuries underwent AI (3 transfusions/1 angioembolization). All three had hemoperitoneum; two of three had an additional organ with a grade II injury. Among grade I and II SOIs with no OMI, 28 (18.9%) of 148 were admitted to an intensive care unit, 110 (74.3%) of 148 to floor, and 7 (4.7%) of 148 discharged home from emergency department; median length of stay 2 days. Among grade III SOIs with no OMI, 38 (33.3%) of 114 were admitted to an intensive care unit and 61.4% to the floor; median length of stay was 4 days. Among 255 patients with a grade I to III SOI and other major organ system injuries, 31 (12.2%) underwent AI. CONCLUSION No patient with a grade I and II SOI and no OMI following blunt abdominal trauma received intervention, suggesting that patients with low-grade SOI without OMIs could be safely observed and discharged from the emergency department. LEVEL OF EVIDENCE Therapeutic study, level IV.
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15
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Gaffley M, Neff LP, Sieren LM, Zeller KA, Pranikoff T, Rush T, Petty JK. Evaluation of an evidence-based guideline to reduce CT use in the assessment of blunt pediatric abdominal trauma. J Pediatr Surg 2021; 56:297-301. [PMID: 32788046 DOI: 10.1016/j.jpedsurg.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/17/2020] [Accepted: 07/05/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE About half of pediatric blunt trauma patients undergo an abdominopelvic computed tomographic (CT) scan, while few of these require intervention for an intraabdominal injury. We evaluated the effectiveness of an evidence-based guideline for blunt abdominal trauma at a Level I pediatric trauma center. METHODS Pediatric blunt trauma patients (n = 998) age 0-15 years who presented from the injury scene were evaluated over a 10 year period. After five years, we implemented our guideline in which the decision for CT was standardized based on mental status, abdominal examination, and laboratory results (alanine aminotransferase, aspartate aminotransferase, hemoglobin, urinalysis). RESULTS There were no differences in age, GCS, SIPA or ISS scores between the patients before or after guideline implementation. Nearly half of the patients (48.3%) underwent CT scan before guideline implementation compared to 36.7% after (p < 0.0002). There was no difference in ISS (p = 0.44) between CT scanned patients in either group. No statistical differences were found in rate of intervention (p = 0.20), length of stay (p = 0.65), or readmission rate (0.2%) before versus after guideline implementation. There were no missed injuries. CONCLUSION Implementation of an evidence-based clinical guideline for pediatric patients with blunt abdominal trauma decreases the rate of CT utilization while accurately identifying significant injuries. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michaela Gaffley
- Wake Forest School of Medicine, General Surgery, Winston-Salem, North Carolina.
| | - Lucas P Neff
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - Leah M Sieren
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - Kristen A Zeller
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - Thomas Pranikoff
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - Tammy Rush
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
| | - John K Petty
- Wake Forest School of Medicine, General Surgery, Section of Pediatric Surgery, Winston-Salem, North Carolina
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16
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Zimmermann P, Schmidt T, Nelson J, Gosemann JH, Bassler S, Stahmeyer JT, Hirsch FW, Lacher M, Zeidler J. Pediatric solid organ injury - frequency of abdominal imaging is determined by the treating department. Medicine (Baltimore) 2020; 99:e23057. [PMID: 33157961 PMCID: PMC7647522 DOI: 10.1097/md.0000000000023057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate the use of abdominal CT scanning in the management of pediatric blunt abdominal trauma in pediatric and non-pediatric departments.In this observational cohort study, anonymized data were extracted from 2 large German statutory health insurances (∼5.9 million clients) in a 7-year period (2010-2016). All patients with inpatient International Classification of Diseases (ICD) codes S36.- and S37.- (injury of intra-abdominal organs; injury of urinary and pelvic organs) aged ≤18 years were included. Demographic and clinical data were analyzed by logistic regression analysis for associations with the use of abdominal CT.A total of 524 children with blunt abdominal trauma (mean age 11.0 ± 5.2 years; 62.6% males) were included; 164 patients (31.3%) received abdominal CT-imaging. There were no significant differences in traumatic non-intraabdominal comorbidity patterns (injuries of external causes; injuries to the head or thorax). There was substantial variability in the rate of abdominal CT imaging among different medical disciplines ranging from 11.6% to 44.5%. Patients admitted to pediatric departments (Pediatrics and Pediatric Surgery) underwent abdominal CT imaging significantly less frequently (19.7%; N = 55) compared to patients treated in non-pediatric departments (General/Trauma Surgery: 44.5%; N = 109) irrespective of concomitant injuries. The estimated OR for the use of abdominal CT by General/Trauma Surgery was 6.2-fold higher (OR: 6.15 [95-%-CI:3.07-13.21]; P < .001) compared to Pediatric Surgery. Other risk factors associated with the use of abdominal CT were traumatic extra-abdominal comorbidities, increasing age, male gender, and admission to a university hospital.Abdominal CT imaging was significantly less frequently used in pediatric departments. The substantial variability of the abdominal CT rate among different medical disciplines and centers indicates a potential for reduction of CT imaging by implementation of evidence-based guidelines. Furthermore, our study underlines the need for centralization of pediatric trauma care in Germany not only to improve patient outcome but to avoid radiation-induced cancer mortality.
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Affiliation(s)
| | - Torben Schmidt
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
| | - Jana Nelson
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | | | - Stefan Bassler
- AOK PLUS - Die Gesundheitskasse für Sachsen und Thüringen, Dresden
| | | | | | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
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