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Hwang CK, Matta R, Woolstenhulme J, Britt AK, Schaeffer AJ, Zakaluzny SA, Kleber KT, Sheikali A, Flynn-O'Brien KT, Sandilos G, Shimonovich S, Fox N, Hess AB, Zeller KA, Koberlein GC, Levy BE, Draus JM, Sacks M, Chen C, Luo-Owen X, Stephens JR, Shah M, Burks F, Moses RA, Rezaee ME, Vemulakonda VM, Halstead NV, LaCouture HM, Nabavizadeh B, Copp H, Breyer B, Schwartz I, Feia K, Pagliara T, Shi J, Neuville P, Hagedorn JC. Management of pediatric renal trauma: Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study. J Trauma Acute Care Surg 2024; 96:805-812. [PMID: 37966460 DOI: 10.1097/ta.0000000000004198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A nonoperative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury are not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This article describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. METHODS Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010 and 2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management, and outcomes. RESULTS In total, 1,216 cases were included in this study. Of all patients, 67.2% were male, and 93.8% had a blunt injury mechanism. In addition, 29.3% had isolated renal injuries, and 65.6% were high-grade (American Association for the Surgery of Trauma Grades III-V) injuries. The mean Injury Severity Score was 20.5. Most patients were managed nonoperatively (86.4%), and 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in patients with multiple injuries. The rate of avoidable transfer was 28.2%. CONCLUSION The management and outcomes of pediatric renal trauma lack data to inform evidence-based guidelines. Nonoperative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population and highlights opportunities for further investigation. With data made available through Mi-PARTS, we aimed to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Catalina K Hwang
- From the Department of Urology (C.K.H.), University of Washington, Seattle, Washington; Division of Urology, Department of Surgery (R.M.), School of Medicine (J.W.), and Division of Urology, Department of Surgery (R.M., J.W., A.K.B., A.J.S.), Intermountain Primary Children's Hospital, University of Utah, Salt Lake City, Utah; Department of Surgery (S.A.Z., K.T.K.), University of California Davis, Sacramento, California; Medical College of Wisconsin, School of Medicine (A.S.); Department of Surgery (K.T.F.-O'.B.), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin; Division of Trauma, Department of General Surgery (G.S., S.S., N.F.), Cooper University Health Care, Camden, New Jersey; Department of Surgery (A.B.H.), WakeMed, Raleigh; Department of General Surgery (K.A.Z.), Section of Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Radiology (G.C.K.), Nemours Children's Hospital, Orlando, Florida; Division of Pediatric Surgery, Department of Surgery (B.E.L.), University of Kentucky, Lexington, Kentucky; Nemours Children's Health (J.M.D.), Jacksonville, Florida; Department of Surgery (M.S.), Department of Urology (C.C.), and Department of Surgery (X.L.-O.), Loma Linda University Medical Center and Children's Hospital, Loma Linda, California; Department of Urology (J.R.S., M.S., F.B.), Beaumont Health-Royal Oak, Royal Oak, Michigan; Department of Surgery (R.A.M., M.E.R.), Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Pediatric Urology Research Enterprise, Department of Pediatric Urology (V.M.V., N.V.H., H.M.L.), Children's Hospital Colorado; Division of Urology, Department of Surgery (V.M.V., N.V.H., H.M.L.), University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado; Department of Urology (B.N.), Cornell University; Department of Urology (H.C., B.B.), University of California San Francisco, San Francisco, California; Division of Urology (I.S., K.F., T.P.), Hennepin Healthcare, Minneapolis, Minnesota; Harborview Injury Prevention and Research Center (J.S.); and Department of Urology (P.N., J.C.H.), University of Washington, Seattle, Washington
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Georgeades C, Collings AT, Farazi M, Bergner C, Fallat ME, Minneci PC, Speck KE, Van Arendonk KJ, Deans KJ, Falcone RA, Foley DS, Fraser JD, Gadepalli SK, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava NS, St Peter SD, Sato TT, Flynn-O'Brien KT. Relationship between the COVID-19 pandemic and structural inequalities within the pediatric trauma population. Inj Epidemiol 2023; 10:62. [PMID: 38017506 PMCID: PMC10683076 DOI: 10.1186/s40621-023-00475-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 11/22/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic disrupted social, political, and economic life across the world, shining a light on the vulnerability of many communities. The objective of this study was to assess injury patterns before and after implementation of stay-at-home orders (SHOs) between White children and children of color and across varying levels of vulnerability based upon children's home residence. METHODS A multi-institutional retrospective study was conducted evaluating patients < 18 years with traumatic injuries. A "Control" cohort from an averaged March-September 2016-2019 time period was compared to patients injured after SHO initiation-September 2020 ("COVID" cohort). Interactions between race/ethnicity or social vulnerability index (SVI), a marker of neighborhood vulnerability and socioeconomic status, and the COVID-19 timeframe with regard to the outcomes of interest were assessed using likelihood ratio Chi-square tests. Differences in injury intent, type, and mechanism were then stratified and explored by race/ethnicity and SVI separately. RESULTS A total of 47,385 patients met study inclusion. Significant interactions existed between race/ethnicity and the COVID-19 SHO period for intent (p < 0.001) and mechanism of injury (p < 0.001). There was also significant interaction between SVI and the COVID-19 SHO period for mechanism of injury (p = 0.01). Children of color experienced a significant increase in intentional (COVID 16.4% vs. Control 13.7%, p = 0.03) and firearm (COVID 9.0% vs. Control 5.2%, p < 0.001) injuries, but no change was seen among White children. Children from the most vulnerable neighborhoods suffered an increase in firearm injuries (COVID 11.1% vs. Control 6.1%, p = 0.001) with children from the least vulnerable neighborhoods having no change. All-terrain vehicle (ATV) and bicycle crashes increased for children of color (COVID 2.0% vs. Control 1.1%, p = 0.04 for ATV; COVID 6.7% vs. Control 4.8%, p = 0.02 for bicycle) and White children (COVID 9.6% vs. Control 6.2%, p < 0.001 for ATV; COVID 8.8% vs. Control 5.8%, p < 0.001 for bicycle). CONCLUSIONS In contrast to White children and children from neighborhoods of lower vulnerability, children of color and children living in higher vulnerability neighborhoods experienced an increase in intentional and firearm-related injuries during the COVID-19 pandemic. Understanding inequities in trauma burden during times of stress is critical to directing resources and targeting intervention strategies.
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Affiliation(s)
- Christina Georgeades
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92Nd St, Milwaukee, WI, 53226, USA.
| | | | - Manzur Farazi
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92Nd St, Milwaukee, WI, 53226, USA
| | - Carisa Bergner
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92Nd St, Milwaukee, WI, 53226, USA
| | - Mary E Fallat
- Norton Children's Hospital, Louisville, KY, USA
- Hiram C. Polk Jr., Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - K Elizabeth Speck
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, USA
| | - Kyle J Van Arendonk
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92Nd St, Milwaukee, WI, 53226, USA
| | - Katherine J Deans
- Department of Surgery, Nemours Children's Health Delaware Valley, Wilmington, DE, USA
| | - Richard A Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Foley
- Norton Children's Hospital, Louisville, KY, USA
- Hiram C. Polk Jr., Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, USA
| | - Martin S Keller
- Division of Pediatric Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Troy A Markel
- Department of Surgery, Indiana University, Indianapolis, IN, USA
| | - Nathan S Rubalcava
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Thomas T Sato
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92Nd St, Milwaukee, WI, 53226, USA
| | - Katherine T Flynn-O'Brien
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92Nd St, Milwaukee, WI, 53226, USA
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Martin MJ, Brasel KJ, Brown CVR, Hartwell JL, de Moya M, Inaba K, Ley EJ, Moore EE, Peck KA, Rizzo AG, Rosen NG, Weinberg JA, Coimbra R, Crandall M, Mukherjee K, Ignacio R, Longshore S, Flynn-O'Brien KT, Ng G, Selesner L, Jafri M. Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm. J Trauma Acute Care Surg 2023; 95:583-591. [PMID: 37337331 DOI: 10.1097/ta.0000000000004055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
LEVEL OF EVIDENCE Literature synthesis and expert opinion, Level V.
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Affiliation(s)
- Matthew J Martin
- From the Deparment of Surgery (M.J.M., K.I.), University of Southern California, Los Angeles, California; Deparment of Surgery (M.J.M.), Keck School of Medicine, Los Angeles, California; Deparment of Surgery (K.J.B.), Oregon Health Science University, Portland, Oregon; Deparment of Surgery (C.V.R.B.), Dell Medical School, University of Texas at Austin, Austin, Texas; Deparment of Surgery (J.L.H.), University of Kansas Medical Center, Kansas City, Kansas; Deparment of Surgery (M.d.M.), Medical College of Wisconsin, Milwaukee, Wisconsin; Deparment of Surgery (E.J.L.), Cedars-Sinai Medical Center, Los Angeles, California; Deparment of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center, Denver, Colorado; Deparment of Surgery (K.A.P.), Scripps Mercy Hospital, San Diego, California; Deparment of Surgery (A.G.R.), Guthrie Health System, Sayre, Pennsylvania; Deparment of Surgery (N.G.R.), Children's Hospital, Cincinnati, Ohio; Deparment of Surgery (J.A.W.), St. Joseph's Medical Center, Phoenix, Arizona; Deparment of Surgery (R.C.), Riverside University Health System Medical Center, Riverside, California; Deparment of Surgery (M.C.), University of Florida College of Medicine, Jacksonville, Florida; Deparment of Surgery (K.M.), Loma Linda University Medical Center, Loma Linda; Deparment of Surgery (R.I.), University of California San Diego/Rady Children's Hospital, San Diego, California; Deparment of Surgery (S.L.), East Carolina University, Greenville, North Carolina; Deparment of Surgery (K.T.F.-O'B.), Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin; Deparment of Surgery (G.N.), Texas Tech University Health Sciences Center, El Paso, Texas; and Deparment of Surgery (L.S., M.J.), Oregon Health and Sciences University, Portland, Oregon
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Gadepalli SK, Leraas HJ, Flynn-O'Brien KT, Van Arendonk KJ, Hall M, Tracy ET, Ricca RL, Goldin AB, Ehrlich PF. Changing Landscape of Routine Pediatric Surgery for Rural and Urban Children: A Report From the Child Health Evaluation of Surgical Services (CHESS) Group. Ann Surg 2023; 278:530-537. [PMID: 37497661 DOI: 10.1097/sla.0000000000005990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To describe the changes to routine pediatric surgical care over the past 2 decades for children living in urban and rural environments. BACKGROUND A knowledge gaps exists regarding trends in the location where routine pediatric surgical care is provided to children from urban and rural environments over time. METHODS Children (age 0-18) undergoing 7 common surgeries were identified using State Inpatient Databases (SID, 2002-2017). Rural-Urban Commuting Area codes were used to classify patient and hospital zip codes. Multivariable regression models for distance traveled >60 miles and transfer status were used to compare rural and urban populations, adjusting for year, age, sex, race, and insurance status. RESULTS Among 143,467 children, 13% lived in rural zip codes. The distance traveled for care increased for both rural and urban children for all procedures but significantly more for the rural cohort (eg, 102% vs 30%, P <0.001, cholecystectomy). Transfers also increased for rural children (eg, transfers for appendectomy increased from 1% in 2002 to 23% in 2017, P <0.001). Factors associated with the need to travel >60 miles included year [adjusted odds ratio (aOR)=2.18, 95% CI: 1.94-2.46: 2017 vs 2002], rural residence (aOR=6.55, 95% CI: 6.11-7.01), age less than 5 years (aOR=2.17, 95% CI: 1.92-2.46), and Medicaid insurance (aOR=1.35, 95% CI: 1.26-1.45). Factors associated with transfer included year (aOR=5.77, 95% CI: 5.26-6.33: 2017 vs 2002), rural residence (aOR=1.47, 95% CI: 1.39-1.56), age less than 10 years (aOR=2.34, 95% CI: 2.15-2.54), and Medicaid insurance (aOR=1.49, 95% CI: 1.42-1.46). CONCLUSION Rural children, younger age, and those on Medicaid disproportionately traveled greater distances and were more frequently transferred for common pediatric surgical procedures.
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Affiliation(s)
- Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Harold J Leraas
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC
| | | | - Kyle J Van Arendonk
- Department of Surgery, Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC
| | - Robert L Ricca
- Division of Pediatric Surgery, University of South Carolina, Prisma Health Upstate, Greenville Memorial Hospital, Greenville, SC
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Peter F Ehrlich
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
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Selesner L, Yorkgitis B, Martin M, Ng G, Mukherjee K, Ignacio R, Freeman J, Wong LY, Durbin S, Crandall M, Longshore SW, Gerall C, Flynn-O'Brien KT, Jafri M. Emergency department thoracotomy in children: A Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma systematic review and practice management guideline. J Trauma Acute Care Surg 2023; 95:432-441. [PMID: 37608453 DOI: 10.1097/ta.0000000000003879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023]
Abstract
BACKGROUND The role of emergency department resuscitative thoracotomy (EDT) in traumatically injured children has not been elucidated. We aimed to perform a systematic review and create evidence-based guidelines to answer the following PICO (population, intervention, comparator, and outcome) question: should pediatric patients who present to the emergency department pulseless (with or without signs of life [SOL]) after traumatic injuries (penetrating thoracic, penetrating abdominopelvic, or blunt) undergo EDT (vs. no EDT) to improve survival and neurologically intact survival? METHODS Using Grading of Recommendations Assessment, Development and Evaluation methodology, a group of 12 pediatric trauma experts from the Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma assembled to perform a systematic review. A consensus conference was conducted, a database was queried, abstracts and manuscripts were reviewed, data extraction was performed, and evidence quality was determined. Evidence tables were generated, and the committee voted on guideline recommendations. RESULTS Three hundred three articles were identified. Eleven studies met the inclusion criteria and were used for guideline creation, providing 319 pediatric patients who underwent EDT. No data were available on patients who did not undergo EDT. For each PICO, the quality of evidence was very low based on the serious risk of bias and serious or very serious imprecision. CONCLUSION Based on low-quality data, we make the following recommendations. We conditionally recommend EDT when a child presents pulseless with SOL to the emergency department following penetrating thoracic injury, penetrating abdominopelvic injury and after blunt injury if emergency adjuncts point to a thoracic source. We conditionally recommend against EDT when a pediatric patient presents pulseless without SOL after penetrating thoracic and penetrating abdominopelvic injury. We strongly recommend against EDT in the patient without SOL after blunt injury.
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Affiliation(s)
- Leigh Selesner
- From the Division of General Surgery (L.S., L.-Y.W., S.D.), Oregon Health & Sciences University, Portland, Oregon; Department of Surgery (B.Y., M.C.), University of Florida College of Medicine-Jacksonville, Florida; Department of Surgery (M.M.), Los Angeles County + University of Southern California Medical Center, Los Angeles, California; Department of Surgery (G.N.), Texas Tech University Health Sciences Center El Paso, El Paso, Texas; Division of Acute Care Surgery (K.M.), Loma Linda University Medical Center, Loma Linda, California; Department of Surgery (R.I.), University of California San Diego School of Medicine/Rady Childrens Hospital San Diego, San Diego, California; Department of Surgery (J.F.), Burnett School of Medicine at Fort Worth, Texas; Department of Surgery (S.W.L.), East Carolina University, Greenville, North Carolina; Department of Surgery (C.G.), University of Texas Health San Antonio, San Antonio, Texas; Department of Pediatric Surgery (K.T.F.-B.), Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin; and Division of Pediatric Surgery (M.J.), Doernbecher Children's Hospital, Oregon Health & Sciences University; and Randall Children's Hospital (M.J.), Legacy Emanuel Medical Center, Portland, Oregon
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Georgeades C, Farazi M, Bergner C, Bowder A, Cassidy L, Levas MN, Nimmer M, Flynn-O'Brien KT. Characteristics and neighborhood-level opportunity of assault-injured children in Milwaukee. Inj Epidemiol 2023; 10:43. [PMID: 37605186 PMCID: PMC10441698 DOI: 10.1186/s40621-023-00453-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 07/19/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Multiple studies have explored demographic characteristics and social determinants of health in relation to the risk of pediatric assault-related injuries and reinjury. However, few have explored protective factors. The Child Opportunity Index (COI) uses neighborhood-level indicators to measure 'opportunity' based on factors such as education, social environment, and economic resources. We hypothesized that higher 'opportunity' would be associated with less risk of reinjury in assault-injured youth. METHODS This was a single-institution, retrospective study at a Level 1 Pediatric Trauma Center. Trauma registry and electronic medical record data were queried for children ≤ 18 years old with assault-related injuries from 1/1/2016 to 5/31/2021. Reinjured children, defined as any child who sustained more than one assault injury, were compared to non-reinjured children. Area Deprivation Index (ADI), a marker of socioeconomic status, and COI were determined through census block and tract data, respectively. A post-hoc analysis examined COI between all assault-injured children, unintentionally injured children, and a state-based normative cohort representative of non-injured children. RESULTS There were 55,862 traumatic injury encounters during the study period. Of those, 1224 (2.3%) assault injured children were identified, with 52 (4.2%) reinjured children and 1172 (95.8%) non-reinjured children. Reinjured children were significantly more likely to be older (median age 15.0 [IQR 13.8-17.0] vs. median age 14.0 [IQR 8.8-16.0], p < 0.001) and female (55.8% vs. 37.5%, p = 0.01) than non-reinjured children. COI was not associated with reinjury. There were also no significant differences in race, ethnicity, insurance status, ADI, or mechanism and severity of injury between cohorts. Post-hoc analysis revealed that assault-injured children were more likely to live in areas of lower COI than the other cohorts. CONCLUSIONS Compared to children who sustained only one assault during the study period, children who experienced more than one assault were more likely to be older and female. Furthermore, living in an area with more or less opportunity did not influence the risk of reinjury. However, all assault-injured children were more likely to live in areas of lower COI compared to unintentionally injured and a state-based normative cohort. Identification of factors on a social or environmental level that leads to assaultive injury warrants further exploration.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92nd St, Milwaukee, WI, 53226, USA.
| | - Manzur Farazi
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92nd St, Milwaukee, WI, 53226, USA
| | - Carisa Bergner
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92nd St, Milwaukee, WI, 53226, USA
| | - Alexis Bowder
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92nd St, Milwaukee, WI, 53226, USA
| | - Laura Cassidy
- Department of Epidemiology and Social Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael N Levas
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mark Nimmer
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Katherine T Flynn-O'Brien
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Children's Corporate Center, Suite C320, 999 N 92nd St, Milwaukee, WI, 53226, USA
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Marquart JP, Mukherjee D, Canales BN, Flynn-O'Brien KT, Szabo A, Wagner AJ. Factors Associated with Hospital Readmission One Year Post-Discharge in Infants with Gastroschisis. Fetal Diagn Ther 2023; 50:344-352. [PMID: 37285815 DOI: 10.1159/000531449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Gastroschisis is the most common congenital abdominal wall defect with a rising prevalence. Infants with gastroschisis are at risk for multiple complications, leading to a potential increased risk for hospital readmission after discharge. We aimed to find the frequency and factors associated with an increased risk of readmission. METHODS A retrospective analysis of infants born with gastroschisis between 2013 and 2019 who received initial surgical intervention and follow-up care in the Children's Wisconsin health system was performed. The primary outcome was the frequency of hospital readmission within 1 year of discharge. We also compared maternal and infant clinical and demographic variables between those readmitted for reasons related to gastroschisis, and those readmitted for other reasons or not readmitted. RESULTS Forty of 90 (44%) infants born with gastroschisis were readmitted within 1-year of the initial discharge date, with 33 (37%) of the 90 infants being readmitted due to reasons directly related to gastroschisis. The presence of a feeding tube (p < 0.0001), a central line at discharge (p = 0.007), complex gastroschisis (p = 0.045), conjugated hyperbilirubinemia (p = 0.035), and the number of operations during the initial hospitalization (p = 0.044) were associated with readmission. Maternal race/ethnicity was the only maternal variable associated with readmission, with Black race being less likely to be readmitted (p = 0.003). Those who were readmitted were also more likely to be seen in outpatient clinics and utilize emergency healthcare resources. There was no statistically significant difference in readmission based on socioeconomic factors (all p > 0.084). CONCLUSION Infants with gastroschisis have a high hospital readmission rate, which is associated with a variety of risk factors including complex gastroschisis, multiple operations, and the presence of a feeding tube or central line at discharge. Improved awareness of these risk factors may help stratify patients in need of increased parental counseling and additional follow-up.
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Affiliation(s)
- John P Marquart
- Department of Pediatric Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Devashis Mukherjee
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Bethany N Canales
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy J Wagner
- Department of Pediatric Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
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Georgeades C, Farazi MR, Gainer H, Flynn-O'Brien KT, Leys CM, Gourlay D, Van Arendonk KJ. Distribution of acute appendicitis care in children: A statewide assessment of the surgeons and facilities providing surgical care. Surgery 2023; 173:765-773. [PMID: 36244816 DOI: 10.1016/j.surg.2022.06.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/06/2022] [Accepted: 06/21/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pediatric appendicitis is managed by general and pediatric surgeons at both children's hospitals and non-children's hospitals. A statewide assessment of surgeons and facilities providing appendicitis care was performed to identify factors associated with location of surgical care. METHODS Children aged <18 years undergoing appendectomy for appendicitis in Wisconsin from 2018-2020 were identified through the International Classification of Diseases, 10th revision, and Current Procedural Terminology codes using Wisconsin Hospital Association data. Patient residence and hospital locations were used to determine travel distance, rurality, and neighborhood-level socioeconomic status. RESULTS Among 3,604 children with appendicitis, 36.0% and 12.8% had an appendectomy at 2 major children's hospitals and 4 other children's hospitals, respectively, and 51.2% had an appendectomy at 99 non-children's hospitals. Pediatric surgeons performed 76.1% of appendectomies at children's hospitals and 2.9% at non-children's hospitals. Only 32.2% of patients received care at the hospital closest to their homes. Non-children's hospitals disproportionally cared for older, non-Hispanic White, and privately insured children, those with uncomplicated appendicitis, and those living in rural areas, in mid-socioeconomic status neighborhoods, and greater distances from children's hospitals (all P < .001). After multivariable adjustment, receipt of care at children's hospitals was associated with younger age, minority race, complicated appendicitis, shorter distance to children's hospitals, and urban residence. CONCLUSION Over half of surgical care for pediatric appendicitis occurred at non-children's hospitals, especially among older children and those living in rural areas far from children's hospitals. Future work is necessary to determine which children benefit most from care at children's hospitals and which can safely receive care at non-children's hospitals to avoid unnecessary time and resource utilization associated with travel to children's hospitals.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
| | - Manzur R Farazi
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Hailey Gainer
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - David Gourlay
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Kyle J Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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9
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Collings AT, Farazi M, Van Arendonk KJ, Fallat ME, Minneci PC, Sato TT, Speck KE, Deans KJ, Falcone Jr RA, Foley DS, Fraser JD, Gadepalli SK, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St. Peter SD, Flynn-O'Brien KT. The COVID-19 pandemic and associated rise in pediatric firearm injuries: A multi-institutional study. J Pediatr Surg 2022; 57:1370-1376. [PMID: 35501165 PMCID: PMC9001175 DOI: 10.1016/j.jpedsurg.2022.03.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Firearm sales in the United States (U.S.) markedly increased during the COVID-19 pandemic. Our objective was to determine if firearm injuries in children were associated with stay-at-home orders (SHO) during the COVID-19 pandemic. We hypothesized there would be an increase in pediatric firearm injuries during SHO. METHODS This was a multi institutional, retrospective study of institutional trauma registries. Patients <18 years with traumatic injuries meeting National Trauma Data Bank (NTDB) criteria were included. A "COVID" cohort, defined as time from initiation of state SHO through September 30, 2020 was compared to "Historical" controls from an averaged period of corresponding dates in 2016-2019. An interrupted time series analysis (ITSA) was utilized to evaluate the association of the U.S. declaration of a national state of emergency with pediatric firearm injuries. RESULTS Nine Level I pediatric trauma centers were included, contributing 48,111 pediatric trauma patients, of which 1,090 patients (2.3%) suffered firearm injuries. There was a significant increase in the proportion of firearm injuries in the COVID cohort (COVID 3.04% vs. Historical 1.83%; p < 0.001). There was an increased cumulative burden of firearm injuries in 2020 compared to a historical average. ITSA showed an 87% increase in the observed rate of firearm injuries above expected after the declaration of a nationwide emergency (p < 0.001). CONCLUSION The proportion of firearm injuries affecting children increased during the COVID-19 pandemic. The pandemic was associated with an increase in pediatric firearm injuries above expected rates based on historical patterns.
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Affiliation(s)
- Amelia T. Collings
- Department of Surgery, Indiana University, 545 Barnhill Dr., Emerson 125, Indianapolis, IN, United States,Corresponding author
| | | | | | - Mary E. Fallat
- Norton Children's Hospital, Louisville, KY, United States,Hiram C. Polk, Jr Department of Surgery, University of Louisville, KY, United States
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | | | - K. Elizabeth Speck
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, United States
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Richard A. Falcone Jr
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David S. Foley
- Norton Children's Hospital, Louisville, KY, United States,Hiram C. Polk, Jr Department of Surgery, University of Louisville, KY, United States
| | - Jason D. Fraser
- Children's Mercy Kansas City, Kansas City, MO, United States
| | - Samir K. Gadepalli
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, United States
| | - Martin S. Keller
- Division of Pediatric Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Matthew P. Landman
- Department of Surgery, Indiana University, 545 Barnhill Dr., Emerson 125, Indianapolis, IN, United States
| | - Charles M. Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI, United States
| | - Troy A. Markel
- Department of Surgery, Indiana University, 545 Barnhill Dr., Emerson 125, Indianapolis, IN, United States
| | - Nathan Rubalcava
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, United States
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10
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Collings AT, Farazi M, Van Arendonk K, Fallat ME, Minneci PC, Sato TT, Speck KE, Deans KJ, Falcone RA, Foley DS, Fraser JD, Keller MS, Kotagal M, Landman MP, Leys CM, Markel T, Rubalcava N, St Peter SD, Flynn-O'Brien KT. Impact of "Stay-at-Home" orders on non-accidental trauma: A multi-institutional study. J Pediatr Surg 2022; 57:1062-1066. [PMID: 35292165 PMCID: PMC8842346 DOI: 10.1016/j.jpedsurg.2022.01.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/31/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND It is unclear how Stay-at-Home Orders (SHO) of the COVID-19 pandemic impacted the welfare of children and rates of non-accidental trauma (NAT). We hypothesized that NAT would initially decrease during the SHO as children did not have access to mandatory reporters, and then increase as physicians' offices and schools reopened. METHODS A multicenter study evaluating patients <18 years with ICD-10 Diagnosis and/or External Cause of Injury codes meeting criteria for NAT. "Historical" controls from an averaged period of March-September 2016-2019 were compared to patients injured March-September 2020, after the implementation of SHO ("COVID" cohort). An interrupted time series analysis was utilized to evaluate the effects of SHO implementation. RESULTS Nine Level I pediatric trauma centers contributed 2064 patients meeting NAT criteria. During initial SHO, NAT rates dropped below what was expected based on historical trends; however, thereafter the rate increased above the expected. The COVID cohort experienced a significant increase in the proportion of NAT patients age ≥5 years, minority children, and least resourced as determined by social vulnerability index (SVI). CONCLUSIONS The COVID-19 pandemic affected the presentation of children with NAT to the hospital. In times of public health crisis, maintaining systems of protection for children remain essential. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Amelia T. Collings
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson 125, Indianapolis, IN 46203, United State,Corresponding author
| | - Manzur Farazi
- Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | | | - Mary E. Fallat
- Norton Children's Hospital, Louisville, KY, United States,Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, United State
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Thomas T. Sato
- Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - K. Elizabeth Speck
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, United States
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Richard A. Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David S. Foley
- Norton Children's Hospital, Louisville, KY, United States,Hiram C. Polk Jr, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, United State
| | - Jason D. Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - Martin S. Keller
- Division of Pediatric Surgery, Washington University School of Medicine, St Louis, MO, United States
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Matthew P. Landman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson 125, Indianapolis, IN 46203, United State
| | - Charles M. Leys
- Department of Surgery, Division of Pediatric Surgery, University of Wisconsin, Madison, WI, United States
| | - Troy Markel
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson 125, Indianapolis, IN 46203, United State
| | - Nathan Rubalcava
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, United States
| | - Shawn D. St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States
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11
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Gosalvez-Tejada A, Blank JJ, Flynn-O'Brien KT, Vo NN, Gourlay DM, Chugh AA. Paraduodenal Hernia: A Rare Cause of Small Bowel Obstruction. JPGN Rep 2022; 3:e170. [PMID: 37168754 PMCID: PMC10158419 DOI: 10.1097/pg9.0000000000000170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/10/2021] [Indexed: 05/13/2023]
Affiliation(s)
- Andrea Gosalvez-Tejada
- From the Division of Pediatrics Gastroenterology, Department of Pediatrics, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - Jacqueline J Blank
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - Katherine T Flynn-O'Brien
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - Nghia N Vo
- Division of Pediatric Radiology. Department of Radiology Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - David M Gourlay
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - Ankur A Chugh
- From the Division of Pediatrics Gastroenterology, Department of Pediatrics, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
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12
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Shah AC, Herstein AR, Flynn-O'Brien KT, Oh DC, Xue AH, Flanagan MR. Six Sigma Methodology and Postoperative Information Reporting: A Multidisciplinary Quality Improvement Study With Interrupted Time-Series Regression. J Surg Educ 2019; 76:1048-1067. [PMID: 30954426 DOI: 10.1016/j.jsurg.2018.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/22/2018] [Accepted: 12/26/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The postoperative handover is often compromised by reporting inconsistencies between different specialties. We describe a multidisciplinary quality improvement initiative to improve postoperative information reporting. DESIGN A quality improvement project with interrupted time-series data collection was undertaken in the postanesthesia care unit between January 2015 and August 2015. We utilized Six Sigma methodology to engage multispecialty stakeholders in identifying deficiencies in the existing postoperative handover process in January 2015. A standardized handover process including a checklist and electronic handover note was implemented within a postanesthesia care unit in June 2015. Direct observations of handovers were conducted to determine reporting accuracy, handover duration, and specialty representative attendance. Segmented linear and logistic regression analyses were used for interrupted time-series data. SETTING Single postanesthesia care unit at an academic tertiary referral center. PARTICIPANTS Physician trainees in anesthesia (n = 82) and surgical subspecialties (n = 139), certified registered nurse anesthetists (n = 57), and recovery room registered nurses (n = 139). RESULTS Cumulative handover scores increased by 18.3 points in the postimplementation period (n = 70) when compared to preimplementation handovers (n = 69), a finding which remained statistically significant after adjusting for preintervention time trends (difference 16 points; 95% confidence intervals 3-31; p = 0.021). No statistically significant difference in handover duration was seen between cohorts (6.8 minutes vs 6.1 minutes, difference 0.5 minutes; 95% confidence intervals -2.8 to 3.7; p = 0.78). Three years postimplementation, there was consistent use of a modified electronic handover note and surgical subspecialty attendance during handover. CONCLUSIONS A standardized handover process was associated with improved information reporting among different surgical disciplines without significantly lengthening handover duration.
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Affiliation(s)
- Aalap C Shah
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington; Independent Practice in Los Angeles, California.
| | - Andrew R Herstein
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | | | - Daniel C Oh
- University of Washington School of Medicine, Seattle, Washington
| | - Anna H Xue
- University of Washington School of Medicine, Seattle, Washington
| | - Meghan R Flanagan
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Department of Surgery, University of Washington Medical Center, Seattle, Washington
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13
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Flynn-O'Brien KT, Fallat ME, Rice TB, Gall CM, Nance ML, Upperman JS, Gourlay DM, Crow JP, Rivara FP. Pediatric Trauma Assessment and Management Database: Leveraging Existing Data Systems to Predict Mortality and Functional Status after Pediatric Injury. J Am Coll Surg 2017; 224:933-944.e5. [PMID: 28235647 DOI: 10.1016/j.jamcollsurg.2017.01.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/04/2017] [Accepted: 01/30/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Efforts to improve pediatric trauma outcomes need detailed data, optimally collected at lowest cost, to assess processes of care. We developed a novel database by merging 2 national data systems for 5 pediatric trauma centers to provide benchmarking metrics for mortality and non-mortality outcomes and to assess care provided throughout the care continuum. STUDY DESIGN Trauma registry and Virtual Pediatric Systems, LLC (VPS) from 5 pediatric trauma centers were merged for children younger than 18 years discharged in 2013 from a pediatric ICU after traumatic injury. For inpatient mortality, we compared risk-adjusted models for trauma registry only, VPS only, and a combination of trauma registry and VPS variables (trauma registry+VPS). To estimate risk-adjusted functional status, we created a prediction model de novo through purposeful covariate selection using dichotomized Pediatric Overall Performance Category scale. RESULTS Of 688 children included, 77.3% were discharged from the ICU with good performance or mild overall disability and 17.6% with moderate or severe overall disability or coma. Inpatient mortality was 5.1%. The combined dataset provided the best-performing risk-adjusted model for predicting mortality, as measured by the C-statistic, pseudo-R2, and Akaike Information Criterion, when compared with the trauma registry-only model. The final Pediatric Overall Performance Category model demonstrated adequate discrimination (C-statistic = 0.896) and calibration (Hosmer-Lemeshow goodness-of-fit p = 0.65). The probability of poor outcomes varied significantly by site (p < 0.0001). CONCLUSIONS Merging 2 data systems allowed for improved risk-adjusted modeling for mortality and functional status. The merged database allowed for patient evaluation throughout the care continuum on a multi-institutional level. Merging existing data is feasible, innovative, and has potential to impact care with minimal new resources.
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Affiliation(s)
- Katherine T Flynn-O'Brien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; Department of Surgery, Division of General Surgery, University of Washington, Seattle, WA.
| | - Mary E Fallat
- Hiram C Polk, Jr Department of Surgery, Division of Pediatric Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY
| | - Tom B Rice
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; Virtual Pediatric Systems, LLC, Los Angeles, CA
| | | | - Michael L Nance
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jeffrey S Upperman
- Department of Surgery, Division of General Pediatric Surgery, Children's Hospital of Los Angeles and USC Keck School of Medicine, Los Angeles, CA
| | - David M Gourlay
- Department of Surgery, Division of General Pediatric Surgery, Children's Hospital of Wisconsin, Milwaukee, WI
| | - John P Crow
- Department of Surgery, Division of General Pediatric Surgery, Akron Children's Hospital and Pediatric Surgery Center, Akron, OH
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA
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14
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Flynn-O'Brien KT, Thompson LL, Gall CM, Fallat ME, Rice TB, Rivara FP. Variability in the structure and care processes for critically injured children: A multicenter survey of trauma bay and intensive care units. J Pediatr Surg 2016; 51:490-8. [PMID: 26452704 DOI: 10.1016/j.jpedsurg.2015.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 09/04/2015] [Accepted: 09/07/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE Evaluate national variation in structure and care processes for critically injured children. METHODS Institutions with pediatric intensive care units (PICUs) that treat trauma patients were identified through the Virtual Pediatric Systems (n=72). Prospective survey data were obtained from PICU and Trauma Directors (n=69, 96% response). Inquiries related to structure and care processes in the PICU and emergency department included infrastructure, physician staffing, team composition, decision making, and protocol/checklist use. RESULTS About one-third of the 69 institutions were ACS-verified Level-1 Pediatric Trauma Centers (32%); 36 (52%) were state-designated Level 1. The surgeon was the primary decision maker in the trauma bay at 88% of sites, and in the PICU at 44%. The intensivist was primary in the PICU at 30% of sites and intensivist consultation was elective at 11%. Free-standing pediatric centers used checklists more often than adult/pediatric centers for DVT prophylaxis (75% vs. 50%, p=0.039), cervical spine clearance (75% vs. 44%, p=0.011), and pain control (63% vs. 34%, p=0.024). Otherwise, protocols/checklists were infrequently utilized by either center type. CONCLUSION Variability exists in structure and care processes for critically injured children. Further investigation of variation and its causal relationship to outcomes is warranted to provide optimal care.
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Affiliation(s)
- Katherine T Flynn-O'Brien
- Harborview Injury Prevention and Research Center, Box #359960, 325 Ninth Avenue, Seattle, WA 98104; Department of Surgery, University of Washington, Box # 356410, 1959 NE Pacific St, Seattle, WA 98195.
| | - Leah L Thompson
- Harborview Injury Prevention and Research Center, Box #359960, 325 Ninth Avenue, Seattle, WA 98104
| | - Christine M Gall
- Virtual Pediatric Systems, LLC, 470W Sunset Blvd #440, Los Angeles, CA 90027
| | - Mary E Fallat
- Department of Surgery, University of Louisville and Kosair Children's Hospital, 315 E. Broadway, Suite 565, Louisville, KY 40202
| | - Tom B Rice
- Virtual Pediatric Systems, LLC, 470W Sunset Blvd #440, Los Angeles, CA 90027; Department of Pediatrics, Medical College of Wisconsin, 9000W. Wisconsin Ave., MS #681, Milwaukee, WI 53226
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, Box #359960, 325 Ninth Avenue, Seattle, WA 98104; Department of Pediatrics, University of Washington, Box #359774, 325 Ninth Avenue, Seattle, WA 98104
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15
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Flynn-O'Brien KT, Stewart BT, Fallat ME, Maier RV, Arbabi S, Rivara FP, McIntyre LK. Mortality after emergency department thoracotomy for pediatric blunt trauma: Analysis of the National Trauma Data Bank 2007-2012. J Pediatr Surg 2016; 51:163-7. [PMID: 26577911 DOI: 10.1016/j.jpedsurg.2015.10.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to determine the proportion of children who survived after emergency department thoracotomy (EDT) for blunt trauma using a national database. METHODS A review of the National Trauma Data Bank was performed for years 2007-2012 to identify children <18 years of age who underwent EDT for blunt trauma. RESULTS Eighty-four children <18 years of age underwent EDT after blunt trauma. Every child died during their hospitalization. The median age was 15 (IQR 6-17) years. Mean injury severity score (ISS) was 34.2 (SD 20.8), and 56% had an ISS of 26-75. Data for "signs of life" were available for 21 children. Fifteen (71%) had signs of life upon ED arrival. Sixty percent of children died in the ED. Of those who survived to the operating room (OR), 66% died in the OR. Four children (5%) survived more than 24 hours in the intensive care unit, three of whom had a maximum head abbreviated injury score of 5. CONCLUSION There were no survivors after EDT for blunt trauma in the pediatric population in this national dataset. Usual indicators for EDT after blunt trauma in adults may not apply in children, and use should be discouraged without compelling evidence of a reversible cause of extremis.
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Affiliation(s)
- Katherine T Flynn-O'Brien
- Department of Surgery, University of Washington, Seattle, WA; Harborview Injury Prevention and Research Center, Seattle, WA.
| | | | - Mary E Fallat
- Division of Pediatric Surgery, Department of Surgery, Kosair Children's Hospital and University of Louisville, Louisville, KY
| | - Ronald V Maier
- Harborview Injury Prevention and Research Center, Seattle, WA; Department of Surgery, Harborview Medical Center and University of Washington, Seattle, WA
| | - Saman Arbabi
- Harborview Injury Prevention and Research Center, Seattle, WA; Department of Surgery, Harborview Medical Center and University of Washington, Seattle, WA
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, Seattle, WA; Department of Pediatrics, Harborview Medical Center and University of Washington, Seattle, WA
| | - Lisa K McIntyre
- Department of Surgery, Harborview Medical Center and University of Washington, Seattle, WA
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16
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Flynn-O'Brien KT, Rivara FP, Weiss NS, Lea VA, Marcelin LH, Vertefeuille J, Mercy JA. Prevalence of physical violence against children in Haiti: A national population-based cross-sectional survey. Child Abuse Negl 2016; 51:154-62. [PMID: 26612595 PMCID: PMC5928512 DOI: 10.1016/j.chiabu.2015.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 10/16/2015] [Accepted: 10/26/2015] [Indexed: 05/15/2023]
Abstract
Although physical violence against children is common worldwide, there are no national estimates in Haiti. To establish baseline national estimates, a three-stage clustered sampling design was utilized to administer a population-based household survey about victimization due to physical violence to 13-24 year old Haitians (n=2,916), including those residing in camps or settlements. Descriptive statistics and weighted analysis techniques were used to estimate national lifetime prevalence and characteristics of physical violence against children. About two-thirds of respondents reported having experienced physical violence during childhood (67.0%; 95% CI 63.4-70.4), the percentage being similar in males and females. More than one-third of 13-17 year old respondents were victimized in the 12 months prior to survey administration (37.8%; 95% CI 33.6-42.1). The majority of violence was committed by parents and teachers; and the perceived intent was often punishment or discipline. While virtually all (98.8%; 95% CI 98.0-99.3) victims of childhood physical violence were punched, kicked, whipped or beaten; 11.0% (95% CI 9.2-13.2) were subject to abuse by a knife or other weapon. Injuries sustained from violence varied by victim gender and perpetrator, with twice as many females (9.6%; 95% CI 7.1-12.7) than males (4.0%; 95% CI 2.6-6.1) sustaining permanent injury or disfigurement by a family member or caregiver (p-value<.001). Our findings suggest that physical violence against children in Haiti is common, and may lead to severe injury. Characterization of the frequency and nature of this violence provides baseline estimates to inform interventions.
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Affiliation(s)
- Katherine T Flynn-O'Brien
- Department of Surgery, University of Washington & Harborview Injury Prevention and Research Center, 325 Ninth Avenue, Box 359960, Seattle, WA 98104, USA
| | - Frederick P Rivara
- Department of Pediatrics, University of Washington & Harborview Injury Prevention and Research Center, 325 Ninth Avenue, Box 359960, Seattle, WA 98104, USA
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, 1959 NE Pacific St, Box 357236, Seattle, WA 98195, USA
| | - Veronica A Lea
- Division of Violence Prevention, National Center for Injury Prevention and Control Centers for Disease Control and Prevention, 4770 Buford Highway, NE (F64), Atlanta, GA 30341-3724, USA
| | - Louis H Marcelin
- Department of Anthropology and Department of Health Sciences, University of Miami, Chancellor, Interuniversity Institute for Research and Development (INURED), 8 Rue Eucalyptus, Delmas 83, Port-au-Prince, Haiti
| | - John Vertefeuille
- Division of Violence Prevention, National Center for Injury Prevention and Control Centers for Disease Control and Prevention, 4770 Buford Highway, NE (F64), Atlanta, GA 30341-3724, USA
| | - James A Mercy
- Division of Violence Prevention, National Center for Injury Prevention and Control Centers for Disease Control and Prevention, 4770 Buford Highway, NE (F64), Atlanta, GA 30341-3724, USA
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Flynn-O'Brien KT, Mandell SP, Eaton EV, Schleyer AM, McIntyre LK. Surgery and Medicine Residents' Perspectives of Morbidity and Mortality Conference: An Interdisciplinary Approach to Improve ACGME Core Competency Compliance. J Surg Educ 2015; 72:e258-66. [PMID: 26143516 DOI: 10.1016/j.jsurg.2015.05.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 05/17/2015] [Accepted: 05/27/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Morbidity and mortality conferences (MMCs) are often used to fulfill the Accreditation Council for Graduate Medical Education practice-based learning and improvement (PBLI) competency, but there is variation among institutions and disciplines in their approach to MMCs. The objective of this study is to examine the trainees' perspective and experience with MMCs and adverse patient event (APE) reporting across disciplines to help guide the future implementation of an institution-wide, workflow-embedded, quality improvement (QI) program for PBLI. DESIGN Between April 1, 2013, and May 8, 2013, surgical and medical residents were given a confidential survey about APE reporting practices and experience with and attitudes toward MMCs and other QI/patient safety initiatives. Descriptive statistics and univariate analyses using the chi-square test for independence were calculated for all variables. Logistic regression and ordered logistic regression were used for nominal and ordinal categorical dependent variables, respectively, to calculate odds of reporting APEs. Qualitative content analysis was used to code free-text responses. SETTING A large, multihospital, tertiary academic training program in the Pacific Northwest. PARTICIPANTS Residents in all years of training from the Accreditation Council for Graduate Medical Education-accredited programs in surgery and internal medicine. RESULTS Survey response rate was 46.2% (126/273). Although most respondents agreed or strongly agreed that knowledge of and involvement in QI/patient safety activities was important to their training (88.1%) and future career (91.3%), only 10.3% regularly or frequently reported APEs to the institution's established electronic incident reporting system. Senior-level residents in both surgery and medicine were more likely to report APEs than more junior-level residents were (odds ratio = 4.8, 95% CI: 3.1-7.5). Surgery residents had a 4.9 (95% CI: 2.3-10.5) times higher odds than medicine residents had to have reported an APE to their MMC or service, and a 2.5 (95% CI: 1.0-6.2) times higher odds to have ever reported an APE through any mechanism. The most commonly cited reason for not reporting APEs was "finding the reporting process cumbersome." Overall, 87% of respondents agreed or strongly agreed that MMCs were valuable, educational, and contributed to improving patient outcomes, but many cited opportunities for improvement. CONCLUSIONS Although the perceived value of MMCs is high among both surgical and medicine trainees, there is significant variability across disciplines and level of training in APE reporting and experience with MMCs. This study presents a multidisciplinary resident perspective on optimizing APE reporting, MMCs, and PBLI compliance.
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Affiliation(s)
- Katherine T Flynn-O'Brien
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Harborview Injury Prevention and Research Center, Seattle, Washington.
| | - Samuel P Mandell
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Harborview Injury Prevention and Research Center, Seattle, Washington; Division of Trauma and Burn Surgery, Harborview Medical Center, Seattle, Washington
| | - Erik Van Eaton
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Division of Trauma and Burn Surgery, Harborview Medical Center, Seattle, Washington
| | - Anneliese M Schleyer
- Department of Medicine, University of Washington, Seattle, Washington; Department of Medicine, Harborview Medical Center, Seattle, Washington
| | - Lisa K McIntyre
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Division of Trauma and Burn Surgery, Harborview Medical Center, Seattle, Washington
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Jelalian E, Hart CN, Mehlenbeck RS, Lloyd-Richardson EE, Kaplan JD, Flynn-O'Brien KT, Wing RR. Predictors of attrition and weight loss in an adolescent weight control program. Obesity (Silver Spring) 2008; 16:1318-23. [PMID: 18356834 DOI: 10.1038/oby.2008.51] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate demographic and psychosocial predictors of attrition and weight loss in a behaviorally based adolescent weight control trial. METHODS AND PROCEDURES Adolescents (N = 76) aged 13-16 years and 20-80% overweight (M = 60.56%, s.d. = 15.17%) received standard group-based behavioral treatment as part of a randomized trial comparing different activity interventions for overweight adolescents. Anthropometric and psychosocial measures were obtained at baseline and after the 16-week intervention. RESULTS Higher parent (P < 0.01) and adolescent BMI (P < 0.05) at baseline, as well as ethnic minority status (P < 0.05) were significantly associated with attrition in univariate analyses. Parent BMI remained the only significant predictor of attrition in multivariate analyses. BMI change for completers (N = 62) was highly variable, ranging from -6.09 to +1.62 BMI units. Male gender (P < 0.01) was a significant predictor of reduction in BMI, whereas not being from an ethnic minority group (P < 0.05) and attendance at group sessions (P = 0.05) were associated with > or = 5% absolute weight loss in multivariate analyses. Absolute weight loss during the first 4 weeks of the program was strongly associated with weight loss (pr = 0.44, P < 0.001) during the remainder of the intervention. Psychosocial variables were unrelated to attrition or treatment outcome. DISCUSSION These findings highlight the potential importance of attending to parental BMI in efforts to retain adolescent participants in treatment, as well as the need to develop weight control interventions that are more effective for ethnic minority youth.
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Affiliation(s)
- Elissa Jelalian
- Department of Psychiatry and Human Behavior, Bradley/Hasbro Children's Research Center, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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