Steven C. Rogers

Using Trauma Registry Data to Guide Injury Prevention Program Activities

BACKGROUND Injury prevention programs should be based on objective injury data. This study demonstrates how local injury data can be used to help guide injury prevention programs. METHODS We reviewed trauma registry data (2004-2006) from a Level I pediatric trauma center. Data included demographic information, anatomic location of injury, mechanism of injury, safety device utilization, Injury Severity Score (ISS), and temporal and geographic variables. The Injury Prevention Priority Score for each mechanism of injury was calculated. RESULTS There were 1,874 trauma patients. Most admissions were among white males, aged 11 years to 15 years (mean, 7.9 years ± 5.2 years). Most admissions occurred during summertime and on weekend evenings. Blunt injuries (92%) and fractures (56%) predominated (mean ISS, 5.9). A severe ISS >15 was highest among 11 year to 15 year and lowest among patients older than 15 years (p < 0.01). Falls, cut, or pierce, ATV, and off-road motorcycle ranked highest in the Injury Prevention Priority Score. Of the 134 motor vehicle occupants, 52% (n = 70) were restrained in car seats/seat belts. Only 15% of bicyclists, 24% of motorcyclists, and 58% of ATV riders wore helmets. CONCLUSION A significant percentage of injured children and adolescents were not using proven effective injury prevention devices at the time of their injury. These data identified areas for further study and will help guide community injury prevention programs at our institution.

Lights, camera, action… spotlight on trauma video review: an underutilized means of quality improvement and education.

Background: Trauma video review (TVR) is an effective method of quality improvement and education. The objective of this study was to determine TVR practices in the United States and use of TVR for quality improvement and education. Methods: Adult and pediatric trauma centers identified by the American College of Surgeons (n = 102) and the National Association of Childrens Hospitals and Related Institutions (n = 24) were surveyed by telephone. Surveys included questions regarding program demographics, residency information, and past/present TVR practices. Results: One hundred eight trauma centers (86%) were contacted, and 99% (107/108) completed surveys. Of the surveyed centers, 34% never used TVR; 37% previously used TVR and had discontinued at the time of the survey, with most reporting legal/privacy concerns; 20% were currently using TVR; and 9% were planning to use TVR in the future. Nineteen percent (14/73) of general trauma centers are using or planning to use TVR compared with 50% (17/34) of pediatric centers (P = 0.001). One hundred percent of current TVR programs report that TVR improves the trauma resuscitation process. Most pediatric emergency medicine (87%), emergency medicine (89%), and surgery (97%) trainees participate in trauma resuscitation at trauma centers. Fifty-two percent of centers using TVR report trainee attendance at TVR process/conference; 38% specifically use TVR for resident education. Conclusions: All current TVR programs report that it improves their trauma processes. More pediatric trauma centers report planning future TVR programs, but the implication of such plans remains unclear. Opportunities exist for expanded use of TVR for resident education.

Rapid Urine Drug Screens: Diphenhydramine and Methadone Cross-Reactivity

Background: Rapid urine screens to detect drugs of abuse are often used in pediatric emergency departments (PEDs). A positive result may lead to further clinical testing, social evaluation, and increased stress/inconvenience. A PED patient with suspected diphenhydramine (DPH) ingestion had a positive methadone result on the rapid urine drug screen, One Step Multi-Drug, Multi-Line Screen Test Device (ACON Laboratories, San Diego, Calif). There was no history of methadone exposure so the patient was admitted while confirmatory testing was performed. Gas chromatography/mass spectroscopy testing of the urine failed to confirm the presence of methadone. We present this unreported false-positive methadone result and evaluation of the kit for cross-reactivity of DPH and methadone. Methods: The same One Step urine drug screen was tested at an independent laboratory for cross-reactivity between methadone and DPH including the DPH metabolites. Drug-free urine was fortified with DPH, nordiphenhydramine, or dinordiphenhydramine at 0, 10, 25, 50, and 100 &mgr;g/mL for each analyte. One hundred microliters of the solutions were added to each of the 4 wells on test cassettes. Urine was allowed to migrate according to manufacturer instructions. Each cassette was interpreted by 2 analysts to ensure consistent interpretation and accurate data recording. Results: In vitro laboratory testing results showed cross-reactivity between methadone and DPH but not for nordiphenhydramine or dinordiphenhydramine. Conclusions: Rapid urine drug screens using immunoassays based on the principle of competitive binding may show false-positive methadone results for patients who have ingested DPH. Product information for urine drug screens may not include all cross-reacting agents and should be used with caution when interpreting drug screen results in PED patients.

Wishful thinking: Safe transportation of newborns at hospital discharge

BACKGROUND Motor vehicle occupant injury is a significant source of morbidity and mortality among children. Correctly used child safety seats (CSSs) substantially reduce injury morbidity and mortality. The objective of this study was to describe how parents learn to use and install CSS at newborn discharge. METHODS We prospectively enrolled maternal/newborn infant dyads at discharge from a large urban teaching hospital. Survey data included maternal demographics and parental knowledge on CSS installation. After survey completion, a certified child passenger safety technician observed and recorded CSS information, infant placement in CSS, and CSS placement in vehicle. Nine specific misuse categories were recorded. RESULTS A total of 101 mothers were enrolled, with mean age 29.4 years (15–45 years); 52% were white, 18% were black, and 27% were Hispanic; 50% had college degree or higher; and 41% were privately insured. We observed 254 CSS errors (range, 0–7; mean, 2.5). There were 52% infant placement in CSS misuse errors (range 0–4; mean, 1.3), and 48% CSS placement in vehicle misuse errors (range, 0–4; mean, 1.2). The CSS placement misuse included 29% CSS not attached to vehicle. More frequent misuse occurred among non-white, non–college-educated mothers (p < 0.01).There was no difference in misuse related to how, when, and where mothers learned about CSS installation. CONCLUSION Despite national, state, and hospital policies that require newborns to be transported in a CSS, we found a significant number of concerning CSS misuse in our study population. These results highlight the need for improved CSS education starting with the first ride home. LEVEL OF EVIDENCE Therapeutic study, level III.

Trampoline Park and Home Trampoline Injuries.

BACKGROUND AND OBJECTIVE: Trampoline parks, indoor recreational facilities with wall-to-wall trampolines, are increasing in number and popularity. The objective was to identify trends in emergency department visits for trampoline park injuries (TPIs) and compare TPI characteristics with home trampoline injuries (HTIs). METHODS: Data on trampoline injuries from the National Electronic Injury Surveillance System from 2010 to 2014 were analyzed. Sample weights were applied to estimate yearly national injury trends; unweighted cases were used for comparison of injury patterns. RESULTS: Estimated US emergency department visits for TPI increased significantly, from 581 in 2010 to 6932 in 2014 (P = .045), whereas HTIs did not increase (P = .13). Patients with TPI (n = 330) were older than patients with HTI (n = 7933) (mean 13.3 vs 9.5 years, respectively, P < .001) and predominantly male. Sprains and fractures were the most common injuries at trampoline parks and homes. Compared with HTIs, TPIs were less likely to involve head injury (odds ratio [OR] 0.64; 95% confidence interval [CI], 0.46–0.89), more likely to involve lower extremity injury (OR 2.39; 95% CI, 1.91–2.98), more likely to be a dislocation (OR 2.12; 95% CI, 1.10–4.09), and more likely to warrant admission (OR 1.76; 95% CI, 1.19–2.61). TPIs necessitating hospital admission included open fractures and spinal cord injuries. TPI mechanisms included falls, contact with other jumpers, and flips. CONCLUSIONS: TPI patterns differed significantly from HTIs. TPIs are an emerging concern; additional investigation and strategies are needed to prevent injury at trampoline parks.

Can nurse education in the postpartum period reduce car seat misuse among newborns

BACKGROUND Despite national, state, and hospital policies that require newborns to be transported in correctly used child safety seats (CSSs), significant CSS misuse frequently occurs among newborn infants. The objective of this study was to evaluate a comprehensive educational CSS training program for nurses and parents in a maternal/newborn unit. METHODS In the preintervention phase, we conducted a survey among maternal/newborn unit nurses in a large urban teaching hospital to measure CSS knowledge, attitude, and practice. We then enrolled 60 maternal-newborn dyads at discharge to survey maternal CSS knowledge and observe the CSS misuse rate. Our intervention phase included a 1-hour “mandatory” nurse CSS education classroom session, a nurse hands-on CSS demonstration and practice in a mother’s room. During the postintervention phase, we enrolled 70 maternal-newborn dyads at discharge to survey maternal CSS knowledge and observe change in CSS misuse rate. RESULTS In the preintervention phase, 43 (73%) of 59 eligible nurses completed the survey, and 47 (80%) of 59 completed the CSS education and training program. In the preintervention CSS survey, 23% of the nurses reported that education is part of their routine, 44% have CSS educational materials, 32% feel comfortable providing CSS education to parents, 12% feel CSS trained, 25% have time, 84% identify that CSS misuse is a problem, and 16% received CSS training. Enrolled mothers reflect maternal/newborn unit demographics as follows: maternal mean age of 29 years (range, 16–48 years), white (54%), black (11%), Hispanic origin (28%), English as primary language (83%), high school degree (31%), college degree (30%), Medicaid (23%), and private insurance (65%). Of 70 postintervention mothers, 44% reported receiving no nurse education, 21% reported receiving a brochure only, and 31% reported receiving nurse education. CSS misuse among mothers who received registered nurse education was not reduced compared with mother’s who received a brochure only and those who did not receive CSS education. Comparison of CSS misuse before (n = 60) and after (n = 70) observations revealed an increase in average misuse (1.8 vs. 3.0, p < 0.05) and a decreases or no significant change in appropriate use as follows: harness in lowest slot (95% vs. 87%), retainer clip at axilla level (63% vs. 33%, p < 0.01), harness snug (50% vs. 27%, p < 0.01), attached to the vehicle (80% vs. 80%), 45-degree angle (60% vs. 19%, p < 0.01), and CSS moves (32% vs. 27%). CONCLUSION Car safety seat misuse did not improve following implementation of a comprehensive nursing education and training program. CSS misuse in our study population was frequent and may increase injury risk in the event of a motor vehicle crash. Future work is needed to develop novel approaches and identify appropriate settings to reduce newborn CSS misuse. LEVEL OF EVIDENCE Therapeutic study, level V.

Restricting youth suicide: behavioral health patients in an urban pediatric emergency department

BACKGROUND Suicide is the third leading cause of death among individuals age 10 years to 19 years in the United States. Adolescents with suicidal behaviors are often cared for in emergency departments (EDs)/trauma centers and are at an increased risk for subsequent suicide. Many institutions do not have standard procedures to prevent future self-harm. Lethal means restriction (LMR) counseling is an evidence-based suicide prevention strategy that informs families to restrict access to potentially fatal items and has demonstrated efficacy in preventing suicide. The objectives of this study were to examine suicidal behavior among behavioral health patients in a pediatric ED and to assess the use of LMR by hospital staff. METHODS A sample of 298 pediatric patients was randomly selected from the population of behavioral health patients treated at the ED from January 1 through December 31, 2012 (n = 2,294). Descriptive data include demographics (age, sex, race/ethnicity, etc,), chief complaint, current and past psychiatric history, primary diagnosis, disposition, alcohol/drug abuse, and documentation of any LMR counseling provided in the ED. RESULTS Of the 298 patients, 52% were female, 47% were white, and 76% were in the custody of their parents. Behavior/out of control was the most common chief complaint (43%). The most common diagnoses were mood disorder (25%) and depression (20%). Thirty-four percent of the patients had suicidal ideation, 22% had a suicide plan, 32% had documented suicidal behavior, and 25% of the patients reported having access to lethal means. However, only 4% of the total patient population received any LMR counseling, and only 15% of those with access to lethal means had received LMR counseling. CONCLUSION Providing a safe environment for adolescents at risk for suicidal behaviors should be a priority for all families/caretakers and should be encouraged by health care providers. The ED is a key point of entry into services for suicidal youth and presents an opportunity to implement effective secondary prevention strategies. The low rate of LMR counseling found in this study suggests a need for improved LMR counseling for all at-risk youth. LEVEL OF EVIDENCE Epidemiologic study, level III.

Practical applications of injury surveillance: a brief 25-year history of the Connecticut Injury Prevention Center

Background: The mission of the Connecticut Injury Prevention Center (CIPC), jointly housed in Connecticut Childrens Medical Center and Hartford Hospital, is to reduce unintentional injury and violence among Connecticut residents, with a special focus on translating research into injury prevention programmes and policy. The CIPC engages in four core activities: research, education and training, community outreach programmes and public policy. As surveillance is an essential element of injury prevention, the CIPC has developed a robust statewide fatal and non-fatal injury surveillance system that has guided our prior work and continues to inform our current projects. Objective: The purpose of this article is to review the projects, programmes, and collaborative relationships that have made the CIPC successful in reducing unintentional injury and violence in Connecticut throughout the course of its 25 years history. Design, setting, participants: Retrospective review of the application of injury surveillance. Results/Conclusions: We believe that the application of our surveillance system can serve as a model for others who wish to engage in collaborative, community-based, data-driven injury prevention programmes in their own communities.

Current Pediatric Emergency Department Innovative Programs to Improve the Care of Psychiatric Patients

Emergency departments (EDs) across North America have become a safety net for patients seeking mental health (MH) services. The prevalence of families seeking treatment of children in MH crisis has become a national emergency. To address MH access and improve quality and efficient management of children with MH conditions, the authors describe ED projects targeting this vulnerable population. Five North American health care systems volunteered to feature projects that seek to reduce ED visits and/or improve the care of MH patients: Allina Health, Nationwide Childrens Hospital, Childrens Hospital of Eastern Ontario, Connecticut Childrens Medical Center, and Rhode Island Hospital.

Can a youth violence screening tool be used in a pediatric emergency department setting

BACKGROUND Youth violence is a significant public health concern. Many children and adolescents are treated in emergency departments (EDs), which may be a location to identify at-risk youth for interventions by administering a screening instrument. METHODS A prospective convenience study of youth (ages 8–17 years) presenting to the ED was conducted to evaluate a second-generation violence questionnaire. The 14 items of the Violence Prevention Emergency Tool 2 (VPET 2) was developed from a previously described tool (VPET 1). VPET 2 asked the frequency of physical or verbal violence events witnessed or experienced by the subject and was administered in the ED by research assistants. RESULTS Of the 211 youths, 200 were enrolled (95% participation rate); 3 were ineligible, and 8 declined (<4%). The youths had a mean age 13.3 years, 52.5% males, 39% Hispanic, and 17% black. Seventy-six percent of the legal guardians were mothers, 62.5% had at least a high school education, and 55% were working full time. Sixty-six percent of the subjects reported seeing a person slap another person “really hard;” 8.5% were threatened by someone with a weapon; 28% were physically harmed by another person; 10% reported drug/alcohol use; 32.5% had failed a class in the past year. Adolescents (13–17 years) compared with preadolescents (8–12 years) were more likely to report being threatened and/or physically harmed (p < 0.05). No significant sex differences were identified. CONCLUSION VPET 2 was administered in an ED with a high rate of enrollment and completion. This may be a feasible screening tool for use in the ED for determining which youth have the highest levels of violence exposure. A brief validated version of VPET 2 could be a valuable tool in ensuring that youth most at-risk are identified and provided appropriate referrals and services. LEVEL OF EVIDENCE Diagnostic study, level IV.