Karen J. O'Connell

Family Presence During Pediatric Trauma Team Activation: An Assessment of a Structured Program

OBJECTIVE. When a child presents to a trauma center with a serious injury, family members are often excluded from the initial trauma team evaluation. The objective of this study was to evaluate the outcomes of a structured program of family presence during pediatric trauma team activations by measuring (1) the need for termination of family presence, (2) times to completion of key parts of the trauma evaluation, and (3) the opinions of staff surveyed immediately after conclusion of family presence. METHODS. This was a cross-sectional study that combined prospectively obtained data and surveys from trauma team evaluations in which family presence occurred, with retrospective chart review of all trauma activations during an 18-month study period. The study was conducted at a level 1 pediatric trauma center with a preestablished family presence program that assigns a staff member to screen family members for family presence, provide support, and record events. Times to completion of key components of the trauma evaluation were calculated and compared for cases with and without family presence. Cross-sectional surveys were performed immediately after each trauma team evaluation. RESULTS. A total of 197 family members participated in family presence. There were no cases of interference with medical care by family members. Seven family members were asked to leave the trauma area by staff after initiation of family presence for various reasons. Times to completion of key components of the trauma evaluation did not differ significantly between enrolled patients with family presence and those without family presence. Surveys were completed for 136 cases, and the majority of providers reported that family presence either had no effect on or improved medical decision-making (97%), institution of patient care (94%), communication among providers (92%), and communication with family members (98%). CONCLUSIONS. This prospective study suggests that there is an overall low prevalence of negative outcomes associated with family presence during pediatric trauma team evaluation after implementation of a structured family presence program. Excluding family members as a routine because of provider concerns about negative impact on clinical care does not seem to be indicated.

Validation of the modified Vesikari score in children with gastroenteritis in 5 US emergency departments.

Objectives: The burden of acute gastroenteritis (AGE) in US children is substantial. Research into outpatient treatment strategies has been hampered by the lack of easily used and validated gastroenteritis severity scales relevant to the populations studied. We sought to evaluate, in a US cohort, the reliability, construct validity, and generalizability of a gastroenteritis severity scale previously derived in a Canadian population, the modified Vesikari score (MVS). Methods: We conducted a prospective, cohort, clinical observational study of children 3 to 48 months of age with acute gastroenteritis presenting to 5 US emergency departments. A baseline MVS score was determined in the emergency department, and telephone follow-up 14 days after presentation was used to assign the follow-up MVS. We determined reliability using inter-item correlations; construct validity via principal component factor analysis; cross-sectional construct validity via correlations with the presence of dehydration, hospitalization, and day care and parental work absenteeism; and generalizability via score distribution among sites. Results: Two hundred eighteen of 274 patients (80%) were successfully contacted for follow-up. Cronbach &agr; was 0.63, indicating expectedly low internal reliability because of the multidimensional properties of the MVS. Factor analysis supported the appropriateness of retaining all variables in the score. Disease severity correlated with dehydration (P < 0.001), hospitalization (P < 0.001), and subsequent day care (P = 0.01) and work (P < 0.001) absenteeism. The MVS was normally distributed, and scores did not differ among sites. Conclusions: The MVS effectively measures global severity of disease and performs similarly in varying populations within the US health care system. Its characteristics support its use in multisite outpatient clinical trials.

Assessment of workload during pediatric trauma resuscitation.

BACKGROUND Trauma resuscitations are high-pressure, time-critical events during which health care providers form ad hoc teams to rapidly assess and treat injured patients. Trauma team members experience varying levels of workload during resuscitations resulting from the objective demands of their role-specific tasks, the circumstances surrounding the event, and their individual previous experiences. The goal of this study was to determine factors influencing workload experienced by trauma team members during pediatric trauma resuscitations. METHODS Workload was measured using the National Aeronautics and Space Administration Task Load Index (TLX). TLX surveys were administered to four trauma team roles: charge nurse, senior surgical resident (surgical coordinator), emergency medicine physician, and junior surgical resident or nurse practitioner (bedside clinician). A total of 217 surveys were completed. Univariate and multivariate statistical techniques were used to examine the relationship between workload and patient and clinical factors. RESULTS Bedside clinicians reported the highest total workload score (208.7), followed by emergency medicine physicians (156.3), surgical coordinators (144.1), and charge nurses (129.1). Workload was higher during higher-level activations (235.3), for events involving intubated patients (249.0), and for patients with an Injury Severity Score greater than 15 (230.4) (p, 0.001 for all). When controlling for potential confounders using multiple linear regression, workload was increased during higher level activations (79.0 points higher, p = 0.01) and events without previous notification (38.9 points higher, p = 0.03). Workload also remained significantly higher for the bedside clinician compared with the other three roles (p ⩽ 0.005 for all). CONCLUSION Workload during pediatric trauma resuscitations differed by team role and was increased for higher-level activations and events without previous notification. This study demonstrates the validity of the TLX as a tool to measure workload in trauma resuscitation. LEVEL OF EVIDENCE Prognostic study, level II.

National Survey of Pediatric Emergency Medicine Fellows on Debriefing After Medical Resuscitations

Background Medical resuscitations of critically ill children in the emergency department are stressful events requiring a coordinated team effort. Current guidelines recommend debriefing after such events to improve future performance. Debriefing practices within pediatric emergency departments by pediatric emergency medicine (PEM) fellows in the United States has not been studied. Objective The aim of this study was to describe the current debriefing experience of PEM fellows in the United States. Methods A 10-item, anonymous questionnaire regarding debriefing characteristics was distributed to fellows in US Accreditation Council for Graduate Medical Education–accredited PEM programs via e-mail and paper format from December 2011 to March 2012. Results were summarized using descriptive statistics. Results Of 393 eligible PEM fellows, 201 (51.1%) completed the survey. The 201 respondents included 82 first-year fellows (40.8%), 71 second-year fellows (35.3%), and 48 third-year fellows (23.9%). Ninety-nine percent had participated in medical resuscitations during their fellowship training, yet 88.0% reported no formal teaching on how to debrief. There was wide variability in the format and timing of debriefings. The majority of debriefings were led by PEM attending physicians (65.5%) and PEM fellows (19.6%). Most (91.5%) of the fellows indicated they would like further education about debriefing. Conclusions The majority of PEM fellows do not receive formal training on how to debrief after a critical event and may have limited experience in leading debriefings. Debriefing training should be considered part of the educational curriculum during PEM fellowship.

Laboratory Errors in a Pediatric Emergency Department Network: An Analysis of Incident Reports.

Objectives To describe the types and severity of reported laboratory errors in pediatric emergency departments. Methods Retrospective review of incident reports classified as laboratory errors from July 2007 to June 2008 within the Pediatric Emergency Care Applied Research Network. Laboratory testing errors recorded included: delayed results or lost specimen, unlabeled specimens, wrong patient, failure to label specimen correctly, and other. The severity of laboratory-related incidents was characterized using the National Coordinating Council for Medication Error Reporting and Prevention severity classification system. Contributing factors were classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems-based. Results A total of 335 (42.2%) laboratory reports were related to events in the preanalytic phase. Involved staff personnel were identified in 345 of the reports (43.5%). Nurses were identified in 179 (22.6%) and physicians in 38 (4.8%). The majority of laboratory errors [408 (51.5%)] were not associated with harm; 138 (17.4%) patients were harmed by the error; 136 (98.6%) patients were temporarily harmed and required treatment, and 1 (0.7%) patient was hospitalized or had their hospitalization prolonged with the event. Human factors 657 (82.8%) were the most common contributing factor. Conclusions Laboratory errors are a common cause of safety events in the pediatric ED. Most events are preanalytic and involve problems with specimens that are improperly collected, mislabeled, or lost. Although most events were not associated with harm, there is potential for significant injury.

Randomised controlled trial of Lactobacillus rhamnosus (LGG) versus placebo in children presenting to the emergency department with acute gastroenteritis: The PECARN probiotic study protocol

Introduction Acute gastroenteritis (AGE) is a common and burdensome condition that affects millions of children worldwide each year. Currently available strategies are limited to symptomatic management, treatment and prevention of dehydration and infection control; no disease-modifying interventions exist. Probiotics, defined as live microorganisms beneficial to the host, have shown promise in improving AGE outcomes, but existing studies have sufficient limitations such that the use of probiotics cannot currently be recommended with confidence. Here we present the methods of a large, rigorous, randomised, double-blind placebo-controlled study to assess the effectiveness and side effect profile of Lactobacillus rhamnosus GG (LGG) (ATCC 53103) in children with AGE. Methods and analysis The study is being conducted in 10 US paediatric emergency departments (EDs) within the federally funded Pediatric Emergency Care Applied Research Network, in accordance with current SPIRIT and CONSORT statement recommendations. We will randomise 970 children presenting to participating EDs with AGE to either 5 days of treatment with LGG (1010colony-forming unit twice a day) or placebo between July 2014 to December 2017. The main outcome is the occurrence of moderate-to-severe disease over time, as defined by the Modified Vesikari Scale. We also record adverse events and side effects related to the intervention. We will conduct intention-to-treat analyses and use an enrichment design to restore the statistical power in case the presence of a subpopulation with a substantially low treatment effect is identified. Ethics and dissemination Institutional review board approval has been obtained at all sites, and data and material use agreements have been established between the participating sites. The results of the trial will be published in peer-reviewed journals. A deidentified public data set will be made available after the completion of all study procedures. Trial registration number NCT01773967.

A Videographic Assessment of the Quality of EMS to ED Handoff Communication during Pediatric Resuscitations

Abstract Background: The National Association of Emergency Medical Services (EMS) Physicians emphasizes the importance of high quality communication between EMS providers and emergency department (ED) staff for providing safe, effective care. The Joint Commission has identified ineffective handoff communication as a contributing factor in 80% of serious medical errors. The quality of handoff communication from EMS to ED teams for critically ill pediatric patients needs further exploration. Objective: This study assessed the quality of handoff communication between EMS and ED staff during pediatric medical resuscitations. Methods/Design: We conducted a retrospective review of video recordings of pediatric patients who required critical care (“resuscitation”) in the ED between January 2014 and February 2016 at a Level 1 pediatric trauma center. Handoff quality between EMS and emergency department teams was assessed for completeness, timeliness, and efficiency. Institutional review board approval was obtained. Results: Sixty-eight resuscitations were reviewed; 28% presented in cardiac arrest, requiring cardiopulmonary resuscitation (CPR). Completeness of information communicated was variable and included chief complaint (88%), prehospital interventions (81%), physical exam findings (63%), medical history (59%), age (56%), and weight (20%). Completeness of specific vital sign reporting included: respiratory rate (53%), heart rate (43%), oxygen saturation (39%), and blood pressure (31%). Timeliness of communication included median patient handoff and report times of 50 seconds [IQR 30,74] and 108 seconds [IQR 62,252], respectively. Inefficient communication occurred in 87% of handoffs, including interruptions by ED staff (51%), questions from the ED physician team leader asking for information already communicated (40%), and questions by ED physician team leader requesting information not yet communicated (65%). When comparing non-CPR to CPR cases, only timeliness of patient handoff was significantly different for those patients receiving prehospital CPR. Conclusion: Handoff communication between EMS and ED teams during pediatric resuscitation was frequently incomplete and inefficient. Future educational and quality improvement interventions could aim to improve the quality of handoff communication for this patient population.

Effects of designated leadership and team-size on cardiopulmonary resuscitation: The Basel-Washington SIMulation (BaWaSim) trial

Objective: During cardiopulmonary resuscitation (CPR), it remains unclear whether designating an individual person as team leader compared with emergent leadership results in better team performance. Also, the effect of CPR team size on team performance remains understudied. Methods: This randomized‐controlled trial compared designated versus emergent leadership and size of rescue team (3 vs 6 rescuers) on resuscitation performance. Results: We included 90 teams with a total of 408 students. No difference in mean (±SD) hands‐on time (seconds) were observed between emergent leadership (106 ± 30) compared to designated leadership (103 ± 27) groups (adjusted difference − 2.97 (95%CI ‐15.75 to 9.80, p = 0.645), or between smaller (103 ± 30) and larger teams (106 ± 26, adjusted difference 3.53, 95%CI ‐8.47 to 15.53, p = 0.56). Emergent leadership groups had a shorter time to circulation check and first defibrillation, but the quality of CPR based on arm and shoulder position was lower. No differences in CPR quality measures were observed between smaller and larger teams. Conclusions: Within this international US/Swiss trial, leadership designation and larger team size did not improve hands‐on time, but emergent leadership teams initiated defibrillation earlier. Improvements in performance may be more likely to be achieved by optimization of emergent leadership than increasing the size of cardiac arrest teams.