1
|
Palavani LB, Bertani R, de Barros Oliveira L, Batista S, Verly G, Andreão FF, Ferreira MY, Paiva WS. A Systematic Review and Meta-Analysis on the Management and Outcome of Isolated Skull Fractures in Pediatric Patients. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1913. [PMID: 38136115 PMCID: PMC10741641 DOI: 10.3390/children10121913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/02/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The impact of traumatic brain injury (TBI) on the pediatric population is profound. The aim of this study is to unveil the state of the evidence concerning acute neurosurgical intervention, hospitalizations after injury, and neuroimaging in isolated skull fractures (ISF). MATERIALS AND METHODS This systematic review was conducted in accordance with PRISMA guidelines. PubMed, Cochrane, Web of Science, and Embase were searched for papers until April 2023. Only ISF cases diagnosed via computed tomography were considered. RESULTS A total of 10,350 skull fractures from 25 studies were included, of which 7228 were ISF. For the need of acute neurosurgical intervention, the meta-analysis showed a risk of 0% (95% CI: 0-0%). For hospitalization after injury the calculated risk was 78% (95% CI: 66-89%). Finally, for the requirement of repeated neuroimaging the analysis revealed a rate of 7% (95% CI: 0-15%). No deaths were reported in any of the 25 studies. CONCLUSIONS Out of 7228 children with ISF, an almost negligible number required immediate neurosurgical interventions, yet a significant 74% were hospitalized for up to 72 h. Notably, the mortality was zero, and repeat neuroimaging was uncommon. This research is crucial in shedding light on the outcomes and implications of pediatric TBIs concerning ISFs.
Collapse
Affiliation(s)
- Lucca B. Palavani
- Faculty of Medicine, Max Planck University Center, Indaiatuba 13343-060, Brazil;
| | - Raphael Bertani
- Faculty of Medicine, São Paulo University, São Paulo 05508-220, Brazil
| | | | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 21941-617, Brazil; (S.B.); (G.V.)
| | - Gabriel Verly
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 21941-617, Brazil; (S.B.); (G.V.)
| | - Filipi Fim Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 21941-617, Brazil; (S.B.); (G.V.)
| | | | | |
Collapse
|
2
|
Pediatric Trauma. Emerg Med Clin North Am 2023; 41:205-222. [DOI: 10.1016/j.emc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
3
|
Genadry KC, Monuteaux MC, Neuman MI, Lowe DA, Lee LK. Disparities and Trends in Migraine Management in Pediatric Emergency Departments, 2009-19. Acad Pediatr 2023; 23:76-84. [PMID: 35609775 DOI: 10.1016/j.acap.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the variation in migraine management over time across US children's hospitals and to identify factors associated with disparities in management. METHODS We conducted a retrospective study of 32 hospitals in the Pediatric Health Information System from 2009 to 2019. We included children 7 to 21 years old with primary ICD-9 or ICD-10 diagnosis codes for migraine headache. We surveyed hospitals to assess for clinical guideline presence. We assessed medication use trends over time. To examine differences in medication and advanced head imaging use by patient characteristics and presence of clinical guideline, we performed multivariable logistic regression analyses reporting adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS We identified 112,077 eligible visits. Opioid use decreased over time, while nonopioid analgesic, dopamine antagonist, and diphenhydramine use increased. Multivariable analysis for opioids revealed increased odds of use for those 14 to 17 (aOR 1.19; 95% CI, 1.06, 1.34) and 18 to 21 years old (aOR 1.69; CI, 1.37, 2.08), and clinical guideline presence had decreased odds (aOR 0.64; CI, 0.48, 0.84). For head computed tomography, increased odds of use were reported for Hispanic ethnicity (aOR 1.15; CI, 1.06, 1.24) and decreased odds for 14 to 17 years (aOR 0.85; CI, 0.80, 0.90), 18 to 21 years (aOR 0.87; CI, 0.77, 0.98), and female sex (aOR 0.74; CI, 0.70, 0.79). CONCLUSIONS Opioid use decreased while other medications increased over time. Medication and imaging differed by demographic characteristics. Opioid use was less likely in hospitals with clinical guidelines. Standardization in management may decrease care disparities and variability.
Collapse
Affiliation(s)
- Katia C Genadry
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass.
| | - Michael C Monuteaux
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
| | - Mark I Neuman
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
| | - David A Lowe
- Department of Emergency Medicine, Nicklaus Children's Hospital (DA Lowe), Miami, Fla
| | - Lois K Lee
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass
| |
Collapse
|
4
|
Reynolds RA, Kelly KA, Ahluwalia R, Zhao S, Vance EH, Lovvorn HN, Hanson H, Shannon CN, Bonfield CM. Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center. J Neurosurg Pediatr 2022; 30:255-262. [PMID: 35901741 DOI: 10.3171/2022.6.peds227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy. METHODS Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020. RESULTS The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed. CONCLUSIONS Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.
Collapse
Affiliation(s)
- Rebecca A Reynolds
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Katherine A Kelly
- 3Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Ranbir Ahluwalia
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Shilin Zhao
- 4Department of Biostatistics, Vanderbilt University Medical Center, Nashville
| | - E Haley Vance
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Harold N Lovvorn
- 5Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville; and
| | - Holly Hanson
- 6Department of Pediatrics, Division of Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| |
Collapse
|
5
|
Green RS, Sartori LF, Lee BE, Linn AR, Samuels MR, Florin TA, Aronson PL, Chamberlain JM, Michelson KA, Nigrovic LE. Prevalence and Management of Invasive Bacterial Infections in Febrile Infants Ages 2 to 6 Months. Ann Emerg Med 2022; 80:499-506. [DOI: 10.1016/j.annemergmed.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/01/2022]
|
6
|
Cain CM, Mandell DJ, Thompson RR, Cummings AL, Van Horne BS, Greeley CS. Trends in Abusive and Nonabusive Injury Hospitalizations in Young Children in Texas, 2004-2018. CHILD MALTREATMENT 2022; 27:246-256. [PMID: 33291969 DOI: 10.1177/1077559520979572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hospitalization data provide context to understanding abusive and non-abusive injuries and how these hospitalizations change over time. The purpose of this study was to utilize Texas inpatient hospitalization data to assess age-related differences among infants (<12 months of age) and toddlers (12-59 months of age) in injury trends and patterns of injury among abusive and non-abusive hospitalization encounters over a 15-year time period. For both age groups, pediatric hospitalizations for non-abusive injuries decreased significantly over time; however, hospitalizations for abusive injuries did not. Compared to non-abusive injury hospitalizations, abusive injury hospitalizations were statistically more likely to involve more body regions and were associated with fractures, internal organ injuries, and superficial wounds. Abusive injury hospitalizations had longer lengths of stay and resulted in higher illness severity scores. Toddler injury hospitalizations were associated with most of the body regions, with the exception of traumatic brain injury for which the odds of hospitalization were higher for infants. This study confirms the persistence of abusive injury hospitalizations and the age-related susceptibility to certain injuries comparing infants and toddlers. The findings reflect the clinical documentation and decision making of pediatric practitioners in a large state over 15 years and inform the trends in identification of injuries which are most common and consistent by age and intent.
Collapse
Affiliation(s)
- Cary M Cain
- Section of Public Health and Child Abuse Pediatrics, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Dorothy J Mandell
- Population Health, The University of Texas Health Science Center at Tyler, TX, USA
| | - Ralph R Thompson
- Section of Public Health and Child Abuse Pediatrics, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Angela L Cummings
- Section of Public Health and Child Abuse Pediatrics, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Bethanie S Van Horne
- Section of Public Health and Child Abuse Pediatrics, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Christopher S Greeley
- Section of Public Health and Child Abuse Pediatrics, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
7
|
Lee LK, Porter JJ, Mannix R, Rees CA, Schutzman SA, Fleegler EW, Farrell CA. Pediatric Traumatic Injury Emergency Department Visits and Management in US Children's Hospitals From 2010 to 2019. Ann Emerg Med 2021; 79:279-287. [PMID: 34839942 DOI: 10.1016/j.annemergmed.2021.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 09/13/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To examine trends in trauma-related pediatric emergency department (ED) visits and management in US children's hospitals over 10 years. METHODS This is a retrospective, descriptive study of the Pediatric Health Information Systems database, including encounters from 33 US children's hospitals. We included patients aged 0 to 19 years with traumatic injuries from 2010 to 2019 identified using International Classification of Diseases-9 and -10 codes. The primary outcome was prevalence of trauma-related ED visits. The secondary outcomes included ED disposition, advanced imaging use, and trauma care costs. We examined trends over time with Poisson regression models, reporting incidence rate ratios (IRRs) with 95% confidence intervals (CIs). We compared demographic groups with rate differences with 95% CIs. RESULTS Trauma-related visits accounted for 367,072 ED visits (16.3%) in 2010 and 479,458 ED visits (18.1%) in 2019 (IRR 1.022, 95% CI 1.018 to 1.026). From 2010 to 2019, 54.6% of children with traumatic injuries belonged to White race and 23.9% had Hispanic ethnicity. Institutional hospitalization rates (range 3.8% to 14.9%) decreased over time (IRR 0.986, 95% CI 0.977 to 0.994). Hospitalizations from 2010 to 2019 were higher in White children (8.9%) than in children of other races (6.4%) (rate difference 2.56, 95% CI 2.51 to 2.61). Magnetic resonance imaging for brain (IRR 1.05, 95% CI 1.04 to 1.07) and cervical spine (IRR 1.03, 95% CI 1.02 to 1.05) evaluation increased. The total trauma care costs were $6.7 billion, with median costs decreasing over time. CONCLUSION During the study period, pediatric ED visits for traumatic injuries increased, whereas hospitalizations decreased. Some advanced imaging use increased; however, median trauma costs decreased over time.
Collapse
Affiliation(s)
- Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Chris A Rees
- Division of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Sara A Schutzman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Caitlin A Farrell
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| |
Collapse
|
8
|
Boruah AP, Potter TO, Shammassian BH, Hills BB, Dingeldein MW, Tomei KL. Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review. J Neurosurg Pediatr 2021; 28:268-277. [PMID: 34171842 DOI: 10.3171/2021.2.peds20872] [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: 11/01/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk. METHODS A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk. RESULTS A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup). CONCLUSIONS Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.
Collapse
Affiliation(s)
| | | | - Berje H Shammassian
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
| | - Byron B Hills
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
| | - Michael W Dingeldein
- 1Case Western Reserve University School of Medicine
- 3Surgery, University Hospitals Cleveland Medical Center
- and Divisions of4Pediatric Surgery and
| | - Krystal L Tomei
- 1Case Western Reserve University School of Medicine
- Departments of2Neurological Surgery and
- 5Pediatric Neurosurgery, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
| |
Collapse
|
9
|
Tang AR, Reynolds RA, Dallas J, Chen H, Vance EH, Bonfield CM, Shannon CN. Admission trends in pediatric isolated linear skull fracture across the United States. J Neurosurg Pediatr 2021; 28:183-195. [PMID: 34087799 DOI: 10.3171/2020.12.peds20659] [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: 07/31/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric isolated linear skull fractures commonly result from head trauma and rarely require surgery, yet patients are often admitted to the hospital-a costly care plan. In this study, the authors utilized a national database to investigate trends in admission for skull fractures across the United States. METHODS Children younger than 18 years with isolated linear skull fracture, according to ICD-9 diagnosis codes in the Kids' Inpatient Database of the Healthcare and Utilization Project (HCUP), who presented between 2003 and 2016 were included. HCUP collected data in 2003, 2006, 2009, 2012, and 2016. Children with a depressed skull fracture, multiple traumatic injuries, and acute intracranial findings were excluded. Sample-level data were translated into population-level data by using an HCUP-specific discharge weight. RESULTS Overall, 11,355 patients (64% males) were admitted to 1605 hospitals. National admissions decreased from 3053 patients in 2003 to 1203 in 2016. The mean ± SD age at admission also decreased from 6.3 ± 5.9 years to 1.2 ± 3.0 years (p < 0.001). The proportion of patients in the lowest quartile of median household income increased by 9%, while that in the highest income quartile decreased by 7% (p < 0.001). Admission was generally more common in the summer months (June, July, and August) and on weekdays (68%). The mean ± SD hospital length of stay decreased from 2.0 ± 3.1 days to 1.4 ± 1.4 days between 2003 and 2012, and then increased to 2.1 ± 6.8 days in 2016 (p < 0.001). When adjusted for inflation, the mean total hospital charges increased from $13,099 to $21,204 (p < 0.001). The greatest proportion of admissions was in the South (35%), and the lowest was in the Northeast (17%). The proportion of patients admitted to large hospitals increased (59% to 72%, p < 0.001), which corresponded to a decrease in patients admitted to small hospitals (16% to 9%, p < 0.001). Overall, the total proportion of admissions to rural hospitals decreased by 6%, and that to urban teaching centers increased by 15% (p < 0.001). Since 2003, no child has undergone a neurosurgical procedure or died as an inpatient. CONCLUSIONS This study identified a general nationwide decrease in admissions for pediatric linear isolated skull fracture, but associated costs increased. Admissions became less common at smaller rural hospitals and more common at larger urban teaching hospitals. This patient population required no inpatient neurosurgical intervention after 2003.
Collapse
Affiliation(s)
- Alan R Tang
- 1Vanderbilt University School of Medicine, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Rebecca A Reynolds
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Dallas
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 4Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California; and
| | - Heidi Chen
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 5Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - E Haley Vance
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
10
|
Syed S, Ashwick R, Schlosser M, Gonzalez-Izquierdo A, Li L, Gilbert R. Predictive value of indicators for identifying child maltreatment and intimate partner violence in coded electronic health records: a systematic review and meta-analysis. Arch Dis Child 2021; 106:44-53. [PMID: 32788201 PMCID: PMC7788194 DOI: 10.1136/archdischild-2020-319027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Electronic health records (EHRs) are routinely used to identify family violence, yet reliable evidence of their validity remains limited. We conducted a systematic review and meta-analysis to evaluate the positive predictive values (PPVs) of coded indicators in EHRs for identifying intimate partner violence (IPV) and child maltreatment (CM), including prenatal neglect. METHODS We searched 18 electronic databases between January 1980 and May 2020 for studies comparing any coded indicator of IPV or CM including prenatal neglect defined as neonatal abstinence syndrome (NAS) or fetal alcohol syndrome (FAS), against an independent reference standard. We pooled PPVs for each indicator using random effects meta-analyses. RESULTS We included 88 studies (3 875 183 individuals) involving 15 indicators for identifying CM in the prenatal period and childhood (0-18 years) and five indicators for IPV among women of reproductive age (12-50 years). Based on the International Classification of Disease system, the pooled PPV was over 80% for NAS (16 studies) but lower for FAS (<40%; seven studies). For young children, primary diagnoses of CM, specific injury presentations (eg, rib fractures and retinal haemorrhages) and assaults showed a high PPV for CM (pooled PPVs: 55.9%-87.8%). Indicators of IPV in women had a high PPV, with primary diagnoses correctly identifying IPV in >85% of cases. CONCLUSIONS Coded indicators in EHRs have a high likelihood of correctly classifying types of CM and IPV across the life course, providing a useful tool for assessment, support and monitoring of high-risk groups in health services and research.
Collapse
Affiliation(s)
- Shabeer Syed
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
- Oxford Institute of Clinical Psychology Training and Research, University of Oxford, Oxford, UK
| | - Rachel Ashwick
- Oxford Institute of Clinical Psychology Training and Research, University of Oxford, Oxford, UK
| | - Marco Schlosser
- Division of Psychiatry, University College London, London, UK
| | | | - Leah Li
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
| | - Ruth Gilbert
- UCL Great Ormond Street Institute of Child Health, Population, Policy and Practice, University College London, London, UK
- Institute of Health Informatics and Health Data Research UK, University College London, London, UK
| |
Collapse
|
11
|
Abstract
Supplemental Digital Content is available in the text. Variability exists in the management of childhood syncope as clinicians balance resource utilization with the need to identify serious diseases. Limited evidence exists regarding the long-term impact of evidence-based guidelines (EBGs) on clinical practices. This study’s objective was to measure long-term changes in the management of syncope after implementing a syncope EBG in a single pediatric emergency department following the redistribution of resources to facilitate compliance over time.
Collapse
|
12
|
A Framework for Maintenance and Scaling of an Evidence-based Guideline Program. Pediatr Qual Saf 2019; 4:e153. [PMID: 31321367 PMCID: PMC6494223 DOI: 10.1097/pq9.0000000000000153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 02/12/2019] [Indexed: 11/25/2022] Open
|
13
|
Kommaraju K, Haynes JH, Ritter AM. Evaluating the Role of a Neurosurgery Consultation in Management of Pediatric Isolated Linear Skull Fractures. Pediatr Neurosurg 2019; 54:21-27. [PMID: 30673671 DOI: 10.1159/000495792] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/23/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The purpose of this study was to determine if a pediatric neurosurgical consultation for isolated linear skull fractures (ILSF) in pediatric patients with Glasgow Coma Scale (GCS) scores of ≥14 changed their management. METHODS A 10-year retrospective chart review at a Level 1 Pediatric Trauma Center was performed. Exclusion criteria were age > 18 years, open, depressed, or skull base fractures, pneumocephalus, poly-trauma, any hemorrhage (intraparenchymal, epidural, subdural, subarachnoid), cervical spine fractures, penetrating head trauma, and initial GCS scores ≤13. Primary outcomes were neurosurgery recommendations to change acuity of care, obtain additional imaging studies, and perform invasive procedures. Secondary outcomes were patient demographics, injury type, transfer status, admitting service, length of hospital stay, consult location, and clinical course. RESULTS There were 127 cases of ILSF meeting study criteria with an average age of 2.36 years. Unilateral parietal bone fracture was the most common injury (46.5%). Falls were the most common mechanism (81.1%). All patients received pediatric neurosurgical consultations within 24 h of hospital arrival. There were no neurosurgical recommendations to obtain additional imaging studies, change acuity of care, or perform invasive procedures. CONCLUSIONS Routine neurosurgical consultation in children with ILSF and GCS 14-15 does not appear to alter clinical management.
Collapse
Affiliation(s)
- Kavya Kommaraju
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA,
| | - Jeffrey H Haynes
- Children's Trauma Center, Children's Hospital of Richmond, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Ann M Ritter
- Department of Neurosurgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| |
Collapse
|
14
|
Greenberg JK, Yan Y, Carpenter CR, Lumba-Brown A, Keller MS, Pineda JA, Brownson RC, Limbrick DD. Development of the CIDSS 2 Score for Children with Mild Head Trauma without Intracranial Injury. J Neurotrauma 2018; 35:2699-2707. [PMID: 29882466 DOI: 10.1089/neu.2017.5324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
While most children with mild traumatic brain injury (mTBI) without intracranial injury (ICI) can be safely discharged home from the emergency department, many are admitted to the hospital. To support evidence-based practice, we developed a decision tool to help guide hospital admission decisions. This study was a secondary analysis of a prospective study conducted in 25 emergency departments. We included children under 18 years who had Glasgow Coma Scale score 13-15 head injuries and normal computed tomography scans or skull fractures without significant depression. We developed a multi-variable model that identified risk factors for extended inpatient management (EIM; defined as hospitalization for 2 or more nights) for TBI, and used this model to create a clinical risk score. Among 14,323 children with mTBI without ICI, 20% were admitted to the hospital but only 0.76% required EIM for TBI. Key risk factors for EIM included Glasgow Coma Scale score less than 15 (odds ratio [OR] = 8.1; 95% confidence interval [CI] 4.0-16.4 for 13 vs. 15), drug/alcohol Intoxication (OR = 5.1; 95% CI 2.4-10.7), neurological Deficit (OR = 3.1; 95% CI 1.4-6.9), Seizure (OR = 3.7; 95% CI 1.8-7.8), and Skull fracture (odds ratio [OR] 24.5; 95% CI 16.0-37.3). Based on these results, the CIDSS2 risk score was created. The model C-statistic was 0.86 and performed similarly in children less than (C = 0.86) and greater than or equal to 2 years (C = 0.86). The CIDSS2 score is a novel tool to help physicians identify the minority of children with mTBI without ICI at increased risk for EIM, thereby potentially aiding hospital admission decisions.
Collapse
Affiliation(s)
- Jacob K Greenberg
- 1 Department of Neurological Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Yan Yan
- 2 Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Christopher R Carpenter
- 5 Division of Emergency Medicine, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Angela Lumba-Brown
- 8 Department of Emergency Medicine, Stanford University , Stanford, California
| | - Martin S Keller
- 2 Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Jose A Pineda
- 3 Department of Pediatrics, Washington University School of Medicine in St. Louis , St. Louis, Missouri.,4 Department of Neurology, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Ross C Brownson
- 2 Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri.,6 Alvin J. Siteman Cancer Center, Washington University School of Medicine in St. Louis , St. Louis, Missouri.,7 Prevention Research Center, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - David D Limbrick
- 1 Department of Neurological Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| |
Collapse
|
15
|
Sidhu S, Gorman SK, Slavik RS, Ramsey T, Bruchet N, Murray S. Positive and Negative Impacts of a Continuing Professional Development Intervention on Pharmacist Practice: A Balanced Measure Evaluation. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2018; 37:215-222. [PMID: 29140819 DOI: 10.1097/ceh.0000000000000166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Evaluations of behavior change interventions aimed at improving professional practice are increasingly focused on impacts at the practice and patient outcome levels. Many of these evaluations assume that if the intended changes occur, the result represents an improvement. However, given the systemic nature of clinical practice, a change in one area can produce changes in other areas as well, some of which may adversely affect the patient. Balancing measures are used to determine whether unintended consequences of an intervention have been introduced into other areas of the system. The aims of this study were to evaluate the impact of behavior change intervention-based continuing professional development (CPD) on pharmacist interventions (resolution of drug therapy problems-DTPs) and resolution of quality indicator DTPs and knowledge change for urinary tract infections (UTI) and pneumonia. As a balancing measure, we aimed to determine whether delivery of behavior change interventions targeting pneumonia and UTI practice results in a negative impact on other important pharmacist interventions, specifically the resolution of heart failure DTPs. METHODS A quasiexperimental study was conducted at a Canadian health authority that evaluated the impacts of an 8-week multifaceted behavior change intervention delivered to 58 ward-based pharmacists. The primary outcome was change in proportion of UTI and pneumonia DTPs resolved from the 6-month preintervention to 6-month postintervention phase. Secondary outcomes were changes in proportion of UTI and pneumonia quality indicator DTPs resolved, knowledge quiz scores, and proportion of quality indicator DTPs resolved for heart failure as a balancing measure. RESULTS A total of 58 pharmacists were targets of the intervention. The proportion of resolved UTI and pneumonia DTPs increased from 17.8 to 27.2% (relative risk increase 52.8%, 95% confidence interval [CI] 42.8-63.6%; P < 0.05). The proportion of resolved UTI and pneumonia quality indicator DTPs increased from 12.2% to 18.2% (relative risk increase 49.9%, 95% CI 34.5-67.0%; P < 0.05). Resolved heart failure DTPs decreased from 14.3 to 8.5% (RRR 40.4%, 95% CI 33.9-46.2%; P < 0.05). Thirty-six pharmacists completed the pre- and post-quiz. Scores increased from 11.3/20 ± 3.2/20 to 14.8/20 ± 2.9/20 (P < 0.05). DISCUSSION CPD using a multifaceted behavior change intervention improved pharmacist behavior and knowledge for UTI and pneumonia. However, these improvements may be offset by reduced interventions for other disease states, such as heart failure. Strategies to mitigate the unintended effects on other professional behaviors should be implemented when delivering CPD focused on changing one aspect of professional behavior.
Collapse
Affiliation(s)
- Sukhjinder Sidhu
- Sidhu: Pharmacy Department, Fraser Health Authority, Surrey, British Columbia, Canada. Gorman and Slavik: Interior Health Pharmacy Services, Faculty of Pharmaceutical Sciences, University of British Columbia, Kelowna, British Columbia, Canada. Ramsey: Pharmacy Department, Nova Scotia Health Authority, College of Pharmacy, Dalhousie University, Victoria General Hospital, Halifax, Nova Scotia, Canada. Bruchet: Interior Health Pharmacy Practice Residency Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Kelowna, British Columbia, Canada. Murray: Kelowna General Hospital Pharmacy Department, Kelowna, British Columbia, Canada
| | | | | | | | | | | |
Collapse
|
16
|
A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children. Ann Emerg Med 2018; 71:714-724.e2. [PMID: 29174834 PMCID: PMC10052777 DOI: 10.1016/j.annemergmed.2017.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/13/2017] [Accepted: 10/16/2017] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE Most studies of children with isolated skull fractures have been relatively small, and rare adverse outcomes may have been missed. Our aim is to quantify the frequency of short-term adverse outcomes of children with isolated skull fractures. METHODS PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, and gray literature were systematically searched to identify studies reporting on short-term adverse outcomes of children aged 18 years or younger with linear, nondisplaced, isolated skull fractures (ie, without traumatic intracranial injury on neuroimaging). Two investigators independently reviewed identified articles for inclusion, assessed quality, and extracted relevant data. Our primary outcome was emergency neurosurgery or death. Secondary outcomes were hospitalization and new intracranial hemorrhage on repeated neuroimaging. Meta-analyses of pooled estimate of each outcome were conducted with random-effects models, and heterogeneity across studies was assessed. RESULTS Of the 587 studies screened, the 21 that met our inclusion criteria included 6,646 children with isolated skull fractures. One child needed emergency neurosurgery and no children died (pooled estimate 0.0%; 95% confidence interval [CI] 0.0% to 0.0%; I2=0%). Of the 6,280 children with known emergency department disposition, 4,914 (83%; 95% CI 71% to 92%; I2=99%) were hospitalized. Of the 569 children who underwent repeated neuroimaging, 6 had new evidence of intracranial hemorrhage (0.0%; 95% CI 0.0% to 9.0%; I2=77%); none required operative intervention. CONCLUSION Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns.
Collapse
|
17
|
Farbman KS, Michelson KA, Neuman MI, Dribin TE, Schneider LC, Stack AM. Reducing Hospitalization Rates for Children With Anaphylaxis. Pediatrics 2017; 139:peds.2016-4114. [PMID: 28562277 PMCID: PMC5470504 DOI: 10.1542/peds.2016-4114] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Most children with anaphylaxis in the emergency department (ED) are hospitalized. Opportunities exist to safely reduce the hospitalization rate for children with anaphylaxis by decreasing unnecessary hospitalizations. A quality improvement (QI) intervention was conducted to improve care and reduce hospitalization rates for children with anaphylaxis. METHODS We used the Model for Improvement and began with development and implementation in 2011 of a locally developed evidence-based guideline based on national recommendations for the management of anaphylaxis. Guideline adoption and adherence were supported by interval reminders and feedback to providers. Patients from 2008 to 2014 diagnosed with anaphylaxis were identified, and statistical process control methods were used to evaluate change in hospitalization rates over time. The balancing measure was any return visit to the ED within 72 hours. To control for secular trends, hospitalization rates for anaphylaxis at 34 US children's hospitals over the same time period were analyzed. RESULTS Over the study period, there were 1169 visits for children with anaphylaxis, of which 731 (62%) occurred after the QI implementation. The proportion of children hospitalized decreased from 54% to 36%, with no increase in the 72-hour ED revisit rate. The hospitalization rate across 34 other US pediatric hospitals remained static at 52% over the study period. CONCLUSIONS We safely reduced unnecessary hospitalizations for children with anaphylaxis and sustained the change over 3 years by using a QI initiative that included evidence-based guideline development and implementation, reinforced by provider reminders and structured feedback.
Collapse
Affiliation(s)
| | | | | | | | - Lynda C. Schneider
- Allergy/Immunology, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
18
|
|