Shelter in Place and an Alarming Increase in Penetrating Trauma in Children and Concerning Decrease in Child Abuse

BACKGROUND

On March 14, 2020, schools across North Carolina (NC) closed in response to Covid-19, forcing completion of the school year at home. Most pediatric trauma occurs at home with a higher prevalence when children are out of school. We queried the state trauma database to assess if the 2020 "shelter in place" was associated with an increase in pediatric trauma statewide.

METHODS

The NC trauma database was queried for injuries in children (age < 18 yrs) from 13 March-1 August 2020, and the corresponding months of 2018 and 2019. The number and type of injuries were compared. We also queried the NC death certificate and child welfare databases. Data were analyzed by standard statistical methods using chi-squared or Kruskal-Wallis test.

RESULTS

Total pediatric trauma cases were lower during 2020 (71.6 per 100,000) compared to 2018 (92.4 per 100,000) and 2019 (80 per 100,000) (P < .001); however, average injury severity score (ISS) was higher (P = .001). A significant increase in firearm injuries were seen in 2020 (P = .016), with an increase in mortality (P = .08) and ISS (P = .013). The rate of child abuse trauma decreased in 2020 (P = .005) as did the number of child abuse and neglect reports (P < .001). There were also significant decreases in trauma due to sports, burns, falls, and motor vehicle accidents.

CONCLUSION

While overall pediatric trauma decreased during the Covid-19 pandemic, there was an alarming increase in penetrating injuries in children. Child abuse trauma and reports decreased, which is concerning for lower identification of abuse.

Examining Diurnal Differences in Multidisciplinary Care Teams at a Pediatric Trauma Center Using Electronic Health Record Data: Social Network Analysis

BACKGROUND

The care of pediatric trauma patients is delivered by multidisciplinary care teams with high fluidity that may vary in composition and organization depending on the time of day.

OBJECTIVE

This study aims to identify and describe diurnal variations in multidisciplinary care teams taking care of pediatric trauma patients using social network analysis on electronic health record (EHR) data.

METHODS

Metadata of clinical activities were extracted from the EHR and processed into an event log, which was divided into 6 different event logs based on shift (day or night) and location (emergency department, pediatric intensive care unit, and floor). Social networks were constructed from each event log by creating an edge among the functional roles captured within a similar time interval during a shift. Overlapping communities were identified from the social networks. Day and night network structures for each care location were compared and validated via comparison with secondary analysis of qualitatively derived care team data, obtained through semistructured interviews; and member-checking interviews with clinicians.

RESULTS

There were 413 encounters in the 1-year study period, with 65.9% (272/413) and 34.1% (141/413) beginning during day and night shifts, respectively. A single community was identified at all locations during the day and in the pediatric intensive care unit at night, whereas multiple communities corresponding to individual specialty services were identified in the emergency department and on the floor at night. Members of the trauma service belonged to all communities, suggesting that they were responsible for care coordination. Health care professionals found the networks to be largely accurate representations of the composition of the care teams and the interactions among them.

CONCLUSIONS

Social network analysis was successfully used on EHR data to identify and describe diurnal differences in the composition and organization of multidisciplinary care teams at a pediatric trauma center.

Pediatric Trauma Arrival Times and the Swing Shift

BACKGROUND

Trauma center staff and trainees are often assigned to a day and night shift. However, for adult trauma, the swing shift has been found to offer superior clinical exposure compared with a standard day or night shift for trainees. We characterized patterns in pediatric trauma arrival times based on the hour, weekday, and month and studied whether or not the swing shift also maximizes exposure to hands-on experiences in managing pediatric trauma.

METHODS

We performed a retrospective review of the trauma database at our urban, level 2 pediatric trauma center. We identified all the pediatric trauma activations in the last 13 years (2006-2018). A retrospective shift log was created, which included day (7:00 am to 7:00 pm), night (7:00 pm to 7:00 am), and swing (noon to midnight) shifts. The shifts were compared using the Wilcoxon match-pairs signed rank test. Weekends data were also compared with weekdays, and comparisons were also made for pediatric patients with Injury Severity Scores (ISS) >15.

RESULTS

There were 3532 pediatric patients identified for our study. The swing shift had 1.98 times more activations than the night shift, and 1.33 more than the day shift (P < 0.001). The swing shift was also superior to both the day and night shifts for exposure to patients with Injury Severity Score greater than 15 (P < 0.001). Weekend days had 1.28 times more trauma than the weekdays (P < 0.001). Peak arrival time was between the hours of 3:00 pm and 9:00 pm, and patient age did not have an effect on this trend.

CONCLUSIONS

Experience in managing pediatric trauma patients will improve for trainees who utilize the swing shift. In addition, the hours between 3:00 pm and 9:00 pm on weekends may represent a time of particularly high likelihood of pediatric trauma arrivals, which may require extra staff and hospital resources.Level of Evidence: Therapeutic Study, Level IV.

Towards a more intelligent model of providing pediatric trauma care: identifying temporal variations in trauma team activations

Background

Trauma centers are resource-intensive environments, and pediatric-specific personnel are often limited resources. Identifying the temporal patterns of pediatric traumas can help guide resource allocation strategies to optimize patient care.

Methods

We conducted a retrospective, single-institution analysis of 575 injured patients less than 18 years old that triggered a trauma team activation (TTA). TTA volume according to time of day and day of the week was analyzed using a mixed Poisson regression model and monthly patterns were analyzed using an analysis of variance. Subset analyses were conducted for children and teenagers.

Results

Across all days, the 6-hour time frame between 15:00 and 21:00 had significantly more activations than average, encompassing nearly half (47.2%) of all pediatric TTAs (p=0.01). Saturdays had significantly more activations than the daily average (Saturdays: 26.0/year, Other: 14.8/year, p<0.01). A pediatric TTA was 3.6 times more likely to occur between 15:00 and 21:00 on a Saturday than any other time. Volume of activation did not significantly differ by month (p=0.880).

Conclusion

The volume of pediatric trauma activations varies significantly according to time of day and day of the week. These findings can direct or validate resource allocation strategies such as staffing physicians, nurses, and ancillary personnel according to TTA volume.

Type of study

Retrospective cohort study.

Level of evidence

Level III.

They only come out at night: Impact of time of day on outcomes after penetrating abdominal trauma

Background

Patients who present at night following penetrating abdominal trauma are thought to have more severe injuries and increased risk for morbidity and mortality. The current literature is at odds regarding this belief. The purpose of this study was to evaluate time of day on outcomes following laparotomy for penetrating abdominal trauma.

Methods

Patients undergoing laparotomy following penetrating abdominal trauma over a 12-month period at a level I trauma center were stratified by age, sex, severity of shock, injury, operative complexity, and time of day (DAY = 0700-1900, NIGHT = 1901-0659). Outcomes of damage control laparotomy, ventilator days, intensive care unit length of stay, hospital length of stay, morbidity, and mortality were compared between DAY and NIGHT.

Results

A total of 210 patients were identified: 145 (69%) comprised NIGHT, and 65 (31%) comprised DAY. Overall mortality was 2.9%. Both injury severity and intraoperative transfusions were increased with NIGHT with no difference in morbidity (37% vs 40%, P = 0.63) or mortality (2.1% vs 4.6%, P = 0.31). Adjusting for sex, time of day, injury severity, and operative complexity, only abdominal abbreviated injury severity (odds ratio 1.46; 95% confidence interval 1.07-1.99, P = .019) and operative transfusions (odds ratio 1.18; 95% confidence interval 1.09-1.28, P < .0001) were identified as independent predictors of damage control laparotomy using multivariable logistic regression (area under the curve 0.96).

Conclusion

The majority of operative penetrating abdominal trauma occurs at night with increased injury burden, more operative transfusions, and increased use of damage control laparotomy with no difference in morbidity and mortality. Outcomes at a fully staffed and operational trauma center should not be impacted by time of day.

Avocado-related knife injuries: Describing an epidemic of hand injury

INTRODUCTION

Recent media reports have described knife injuries sustained while preparing avocados; however, this rise has not been reported in the literature. The purpose of this study is to describe, quantify, and trend emergency department (ED) encounters associated with avocado-related knife injuries.

METHODS

The National Electronic Injury Surveillance System (NEISS) was queried for avocado-related knife injuries from 1998 to 2017. Patient demographic and injury data was collected and analyzed to describe trends in incidence, patient demographics, and injury patterns associated with an ED encounter for an avocado-related knife injury.

RESULTS

There were an estimated 50,413 (95% Confidence Interval: 46,333-54,492) avocado-related knife injuries from 1998 to 2017. The incidence of avocado-related knife injuries increased over this time period (1998-2002 = 3143; 2013-2017 = 27,059). This increase correlated closely with a rise in avocado consumption in the U.S. (Pearson's Correlation: 0.934, p < 0.001) Women comprised 80.1% of injuries. The most common demographic injured were 23 to 39-year old females (32.7%), while the least common was males under the age of 17 (0.9%). Most ED presentations occurred on Saturdays (15.9%) or Sundays (19.9%) and the majority occurred during the months of April through July (45.6%). Injuries were much more common on the left (and likely non-dominant) hand.

CONCLUSION

Avocado-related knife injuries are a preventable cause of hand injury. The incidence has risen significantly in recent years, possibly due to an increased consumption of avocados in the United States. Education on safe avocado preparation techniques and public safety initiatives, such as warning labels, could help prevent serious injuries in the future.