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Snyder CW, Kristiansen KO, Jensen AR, Sribnick EA, Anders JF, Chen CX, Lerner EB, Conti ME. Defining pediatric trauma center resource utilization: Multidisciplinary consensus-based criteria from the Pediatric Trauma Society. J Trauma Acute Care Surg 2024; 96:799-804. [PMID: 37880842 DOI: 10.1097/ta.0000000000004181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND Pediatric trauma triage and transfer decisions should incorporate the likelihood that an injured child will require pediatric trauma center (PTC) resources. Resource utilization may be a better basis than mortality risk when evaluating pediatric injury severity. However, there is currently no consensus definition of PTC resource utilization that encompasses the full scope of PTC services. METHODS Consensus criteria were developed in collaboration with the Pediatric Trauma Society (PTS) Research Committee using a modified Delphi approach. An expert panel was recruited representing the following pediatric disciplines: prehospital care, emergency medicine, nursing, general surgery, neurosurgery, orthopedics, anesthesia, radiology, critical care, child abuse, and rehabilitation medicine. Resource utilization criteria were drafted from a comprehensive literature review, seeking to complete the following sentence: "Pediatric patients with traumatic injuries have used PTC resources if they..." Criteria were then refined and underwent three rounds of voting to achieve consensus. Consensus was defined as agreement of 75% or more panelists. Between the second and third voting rounds, broad feedback from attendees of the PTS annual meeting was obtained. RESULTS The Delphi panel consisted of 18 members from 15 institutions. Twenty initial draft criteria were developed based on literature review. These criteria dealt with airway interventions, vascular access, initial stabilization procedures, fluid resuscitation, blood product transfusion, abdominal trauma/solid organ injury management, intensive care monitoring, anesthesia/sedation, advanced imaging, radiologic interpretation, child abuse evaluation, and rehabilitative services. After refinement and panel voting, 14 criteria achieved the >75% consensus threshold. The final consensus criteria were reviewed and endorsed by the PTS Guidelines Committee. CONCLUSION This study defines multidisciplinary consensus-based criteria for PTC resource utilization. These criteria are an important step toward developing a criterion standard, resource-based, pediatric injury severity metric. Such metrics can help optimize system-level pediatric trauma triage based on likelihood of requiring PTC resources. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level II.
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Affiliation(s)
- Christopher W Snyder
- From the Division of Pediatric Surgery (C.W.S.), Johns Hopkins All Children's Hospital, St. Petersburg, Florida; Department of Anesthesia (K.O.K., M.E.C.), Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Lebanon, New Hampshire; Division of Pediatric Surgery (A.R.J.), Benioff Children's Hospital, University of California-San Francisco, San Francisco, California; Department of Pediatric Neurosurgery (E.A.S.), Nationwide Children's Hospital, Columbus, Ohio; Division of Pediatric Emergency Medicine (J.F.A.), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pediatric Anesthesiology (C.X.C.), Seattle Children's Hospital, Seattle, Washington; and Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York
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Roche S, Crombé A, Benhamed A, Hak JF, Dabadie A, Fauconnier-Fatus C, Rega A, Pech-Gourg G, Tazarourte K, Seux M, Acquier A, Gorincour G. Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France. JAMA Netw Open 2023; 6:e2311092. [PMID: 37129895 PMCID: PMC10155067 DOI: 10.1001/jamanetworkopen.2023.11092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
Importance Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines. Objectives To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request. Design, Setting, and Participants This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022. Exposure All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines. Main Outcomes and Measures Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture. Results Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians. Conclusion and Relevance In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.
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Affiliation(s)
| | - Amandine Crombé
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
- Department of Radiology, Pellegrin University Hospital, Bordeaux, France
- Models in Oncology (MONC) Team, INRIA Bordeaux Sud-Ouest, CNRS UMR 5251 & Bordeaux University, Talence, France
| | - Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Jean-François Hak
- Assistance Publique-Hôpitaux de Marseille, Marseille, France
- LIIE, Aix Marseille University, Marseille, France
- CERIMED, Aix Marseille University, Marseille, France
| | - Alexia Dabadie
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
- Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | | | | | | | - Karim Tazarourte
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Mylène Seux
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
| | - Adrien Acquier
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
- CHU de Dijon, Dijon, France
| | - Guillaume Gorincour
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
- ELSAN, Clinique Bouchard, Marseille, France
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