Maryalice Nocera

Neurodevelopmental Consequences of Early Traumatic Brain Injury in 3-Year-Old Children

OBJECTIVES. The purpose of this work was to determine cognitive and adaptive behavioral outcomes of children with traumatic brain injury acquired before age 2 years and to compare outcomes between inflicted versus noninflicted brain injury. PATIENTS AND METHODS. All North Carolina children hospitalized in an ICU for a traumatic brain injury before age 2 years between the years 2000 and 2001 were eligible for study entry. A total of 112 surviving children were prospectively identified, 52 (46%) of whom had complete follow-up. Thirty-one control children were recruited from preschool settings. Control subjects were chosen to be demographically similar to case subjects. Child measures of cognition and adaptive behavior at age 3 years were measured and compared between children with and without traumatic brain injury and children with inflicted and noninflicted traumatic brain injury. RESULTS. Sixty percent of injured children were >1 SD below normal on cognitive testing. Forty percent of injured children scored >1 SD below normal on adaptive behavior testing. Children with inflicted traumatic brain injury performed more poorly on tests of cognition and adaptive behavior. Glasgow Coma Scale ≥13, absence of seizures, income above twice the poverty guidelines, and high social capital were associated with improved outcomes. Injured children had lower scores than uninjured control children after adjustment for socioeconomic status. CONCLUSIONS. Very young children with mild-to-severe traumatic brain injury as measured by the Glasgow Coma Scale are at risk for global cognitive deficits more than a year after the time of injury. Inflicted brain injury is associated with more severe injury and worse outcomes. This is less optimistic than findings in this same cohort 1 year after injury. Family characteristics seem to play a role in recovery after injury.

Child outcomes and family characteristics 1 year after severe inflicted or noninflicted traumatic brain injury

Objective. To assess outcomes 1 year after severe traumatic brain injury (TBI) among young children and to compare outcomes between children with inflicted versus noninflicted injuries. Study Design. Prospective cohort study. Methods. All North Carolina-resident children who were hospitalized between January 2000 and December 2001 in any of the states 9 PICUs and who survived a severe TBI that occurred on or before their second birthday were eligible to participate. Child health status, child use of ancillary medical resources, and family characteristics were determined through maternal caregiver interviews ∼1 year after injury. Comparisons were made between family characteristics and child outcomes according to injury type. Results. Seventy-two interviews of maternal caregivers were completed among 112 survivors (64.3%). Children with inflicted injuries (n = 41) had worse outcomes than did children with noninflicted injuries (n = 31), as measured with the Pediatric Outcome Performance Category and Stein-Jessup Functional Status II (Revised) tools. However, ∼50% of children with inflicted injuries had only mild deficits or better. Children with inflicted injuries had a higher use of ancillary medical resources. Families caring for the children did not differ substantively, with a large proportion of single, working, minority mothers. Conclusions. Children with inflicted TBIs had worse outcomes than did children with other TBIs 1 year after injury. However, outcomes for these children were better than those reported previously. Many families caring for children after severe TBI are socially disadvantaged. Interventions to improve child outcomes may include enhanced family support.

Frequency of intracranial pressure monitoring in infants and young toddlers with traumatic brain injury

Objective: To examine the use of intracranial pressure monitors and treatments for elevated intracranial pressure in brain-injured children of <2 yrs of age and compare them with the recently published management guidelines. Design: Prospective, population-based study. Setting: All pediatric intensive care units in the state of North Carolina. Patients: All patients of <24 months of age admitted to a pediatric intensive care unit with a traumatic brain injury between January 2000 and December 2001. Interventions: None. Measurements and Main Results: Use of intracranial pressure monitoring devices and treatments for elevated intracranial pressure were measured. There were 136 children admitted to a pediatric intensive care unit with brain injury. A total of 54 (39.7%) had an admission Glasgow Coma Score of ≤8, and 80% were infants. Thirty-three percent of children with a Glasgow Coma Score of ≤8 received monitoring. Hyperosmolar therapy was the most frequently used treatment (57.1%). Treatment for elevated intracranial pressure was more common in, but not limited to, children with monitors. Logistic-regression modeling showed that children of ≤12 months of age had an odds ratio of 0.2 (95% confidence interval, 0.1–0.6) of receiving a monitor compared with children aged 12–24 months. Conclusions: Brain injury in young children may lead to many years of lost quality of life. The utility of monitoring intracranial pressure in infants has not been well established, which may be a reason for its low use. As most infants with traumatic brain injury survive, high-quality studies with neurodevelopmental measures as the primary outcome are urgently needed to document best practice in this subpopulation.

Workplace violence prevention programs in hospital emergency departments

Objective: Hospital violence is a growing concern, yet little is known about existing programs. This study compared workplace violence programs in high-risk emergency departments among a representative sample of 116 hospitals in California and 50 hospitals in New Jersey. Methods: Information was collected through interviews, a facility walk-through, and review of written policies, procedures, and training material. Programs were scored on the components of training, policies and procedures, security, and environmental approaches. Results: California had significantly higher scores for training and policies and procedures, but there was no difference for security and environmental approaches. Program component scores were not highly correlated. For example, hospitals with a strong training program were not more likely to have strong policies and procedures. Conclusions: Most hospitals in California and New Jersey had implemented a workplace violence prevention program, but important gaps were found.

Longitudinal follow-up of families and young children with traumatic brain injury

OBJECTIVES. To examine the stability of functional outcomes 2 years after injury among children who sustained a traumatic brain injury (TBI) before 2 years of age and to examine the characteristics of the families caring for these children. METHODS. All North Carolina-resident children who were hospitalized between January 2000 and December 2001 in any of the states 9 PICUs and survived a TBI that occurred on or before their second birthday were eligible to participate in the prospective cohort study. Child health status, use of ancillary medical resources, and family characteristics were assessed through maternal caregiver interviews ∼2 years after injury. Comparisons were made among injury types (inflicted versus noninflicted). RESULTS. There were 112 children who survived a TBI during the 2-year study period. Fifty-seven (79%) of the 72 maternal caregivers who had completed an interview 1 year after the childs injury participated in the year 2 interview. Most children (67%) had an outcome of mild disability or better at year 2, with 45% functioning at an age-appropriate level. Childrens outcomes did not differ significantly at year 2 according to the mechanism of injury. The majority (67%) of children retained their Pediatric Overall Performance Category scores from year 1 to year 2. Children who changed were as likely to show improvement as deterioration. Children differed very little across time, as measured with the Stein-Jessup Functional Status II (Revised) scale. Families tended to have multiple environmental factors that could put their children at risk for poor developmental outcomes, including living below the poverty level (22%) and low social capital (39%). CONCLUSIONS. The children in this cohort had relatively stable functional outcomes from year 1 to year 2 after injury. This population of children remains very vulnerable to poor developmental outcomes secondary to the effects of their TBI and environmental factors.

Workplace Violence Prevention Programs in Psychiatric Units and Facilities

Psychiatric health care providers have high rates of workplace violence victimization, yet little is known about the strategies used by facilities to reduce violence. This study compared workplace violence prevention (WVP) programs in psychiatric units and facilities in California and New Jersey. Information was collected through interviews, a facility walk-through, and a review of written policies and training material. A similar proportion of hospitals in both states had WVP training programs. A higher proportion of hospitals in California had written WVP policies, and a higher proportion of New Jersey hospitals had implemented environmental and security modifications to reduce violence. Legislation is one of many potential approaches to increase workplace violence prevention programs in health care settings.

Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina

IMPORTANCE Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100,000 person-years in the first year of life. OBJECTIVE To assess the effectiveness of a statewide universal AHT prevention program. DESIGN, SETTING, AND PARTICIPANTS In total, 88.29% of parents of newborns (n = 405 060) in North Carolina received the intervention (June 1, 2009, to September 30, 2012). A comparison of preintervention and postintervention was performed using nurse advice line telephone calls regarding infant crying (January 1, 2005, to December 31, 2010). A difference-in-difference analysis compared AHT rates in the prevention program state with those of other states before and after the implementation of the program (January 1, 2000, to December 31, 2011). INTERVENTION The Period of PURPLE Crying intervention, developed by the National Center on Shaken Baby Syndrome, was delivered by nurse-provided education, a DVD, and a booklet, with reinforcement by primary care practices and a media campaign. MAIN OUTCOMES AND MEASURES Changes in proportions of telephone calls for crying concerns to a nurse advice line and in AHT rates per 100,000 infants after the intervention (June 1, 2009, to September 30, 2011) in the first year of life using hospital discharge data for January 1, 2000, to December 31, 2011. RESULTS In the 2 years after implementation of the intervention, parental telephone calls to the nurse advice line for crying declined by 20% for children younger than 3 months (rate ratio, 0.80; 95% CI, 0.73-0.87; P < .001) and by 12% for children 3 to 12 months old (rate ratio, 0.88; 95% CI, 0.78-0.99; P = .03). No reduction in state-level AHT rates was observed, with mean rates of 34.01 person-years before the intervention and 36.04 person-years after the intervention. A difference-in-difference analysis from January 1, 2000, to December 31, 2011, controlling for economic indicators, indicated that the intervention did not have a statistically significant effect on AHT rates (β coefficient, -1.42; 95% CI, -13.31 to 10.45). CONCLUSIONS AND RELEVANCE The Period of PURPLE Crying intervention was associated with a reduction in telephone calls to a nurse advice line. The study found no reduction in AHT rates over time in North Carolina relative to other states. Consequently, while this observational study was feasible and supported the program effectiveness in part, further programmatic efforts and evaluation are needed to demonstrate an effect on AHT rates.

Designing and Testing a Shaken Baby Syndrome Prevention Program—The Period of PURPLE Crying: Keeping Babies Safe in North Carolina

Each year infants die or are permanently disabled at the hands of their caregivers by abusive head trauma, more commonly known as Shaken Baby Syndrome (SBS). Current medical research confirms the central role of infant crying in triggering shaking by caregivers; anecdotally, inconsolable crying is the most common explanation given by abusers. Although SBS prevention efforts have been initiated, most remain unevaluated. This article provides an overview of a 5-year, evidence-based SBS-prevention program called The Period of PURPLE Crying: Keeping Babies Safe in North Carolina from a social marketing perspective. The project includes three components: (1) in-hospital education for parents of every newborn at all 86 hospitals/birthing centers in North Carolina; (2) reinforcement in community settings such as prenatal visits to health departments or well-child care visits to primary care providers; and (3) a media campaign.

Hospital Employee Assault Rates Before and After Enactment of the California Hospital Safety and Security Act

PURPOSE This study examines changes in violent event rates to hospital employees before and after enactment of the California Hospital Safety and Security Act in 1995. METHODS We compared pre- and post-initiative employee assault rates in California (n = 116) emergency departments and psychiatric units with those in New Jersey (n = 50), where statewide workplace violence initiatives do not exist. Poisson regression with generalized estimating equations was used to compare assault rates between a 3-year pre-enactment period (1993-1995) and a 6-year post-enactment period (1996-2001) using New Jersey hospitals as a temporal control. RESULTS Assault rates among emergency department employees decreased 48% in California post-enactment, compared with emergency department employee assault rates in New Jersey (rate ratio [RR] = 0.52, 95% confidence interval [CI]: 0.31, 0.90). Emergency department employee assault rates decreased in smaller facilities (RR = 0.46, 95% CI: 0.21, 0.96) and for-profit-controlled hospitals (RR = 0.39, 95% CI: 0.19, 0.79) post-enactment. Among psychiatric units, for-profit-controlled hospitals (RR = 0.41, 95% CI: 0.19, 0.85) and hospitals located in smaller communities (RR = 0.44, 95% CI: 0.21, 0.92) experienced decreased assault rates post-enactment. CONCLUSION Policy may be an effective method to increase safety to health care workers.

Parent Ratings of Behavioral Functioning After Traumatic Brain Injury in Very Young Children

OBJECTIVE The behavioral ratings of preschoolers who sustained traumatic brain injury (TBI) prior to the age of 2 years and a typically developing group were compared; predictors of behavioral functioning were examined. METHODS Eighty-two 3-year-olds comprised mild TBI (n = 31), moderate/severe TBI (n = 20), and typically developing (n = 31) groups, with Child Behavior Checklist (CBCL) as the primary outcome measure. RESULTS Groups differed on the CBCL Withdrawal Scale. No differences emerged in the proportion of children demonstrating clinical elevations, with average mean scores for each group. Exploratory analyses yielded no differences between inflicted, non-inflicted, and typical groups. Glasgow Coma Scale and Self-Report Family Inventory Leadership predicted Externalizing Problems; developmental level predicted Internalizing Problems. CONCLUSIONS After early TBI, preschoolers did not differ from one another or a matched comparison group in behavioral ratings; however, it may be premature to infer that preschoolers do not evidence behavioral dysfunction after early TBI.