Susan Ziegfeld

Health care utilization and needs after pediatric traumatic brain injury.

OBJECTIVE. Children with moderate to severe traumatic brain injury (TBI) show early neurobehavioral deficits that can persist several years after injury. Despite the negative impact that TBI can have on a childs physical, cognitive, and psychosocial well-being, only 1 study to date has documented the receipt of health care services after acute care and the needs of children after TBI. The purpose of this study was to document the health care use and needs of children after a TBI and to identify factors that are associated with unmet or unrecognized health care needs during the first year after injury. METHODS. The health care use and needs of children who sustained a TBI were obtained via telephone interview with a primary caregiver at 2 and 12 months after injury. Of the 330 who enrolled in the study, 302 (92%) completed the 3-month and 288 (87%) completed the 12-month follow-up interviews. The health care needs of each child were categorized as no need, met need, unmet need, or unrecognized need on the basis of the childs use of post-acute services, the caregivers report of unmet need, and the caregivers report of the childs functioning as measured by the Pediatric Quality of Life Inventory (PedsQL). Regardless of the use of services or level of function, children of caregivers who reported an unmet need for a health care service were defined as having unmet need. Children who were categorized as having no needs were defined as those who did not receive services; whose caregiver did not report unmet need for a service; and the whose physical, socioemotional, and cognitive functioning was reported to be normal by the caregiver. Children with met needs were those who used services in a particular domain and whose caregivers did not report need for additional services. Finally, children with unrecognized needs were those whose caregiver reported cognitive, physical, or socioemotional dysfunction; who were not receiving services to address the dysfunction; and whose caregiver did not report unmet need for services. Polytomous logistic regression was used to model unmet and unrecognized need at 3 and 12 months after injury as a function of child, family, and injury characteristics. RESULTS. At 3 months after injury, 62% of the study sample reported receiving at least 1 outpatient health care service. Most frequently, children visited a doctor (56%) or a physical therapist (27%); however, 37% of caregivers reported that their child did not see a physician at all during the first year after injury. At 3 and 12 months after injury, 26% and 31% of children, respectively, had unmet/unrecognized health care needs. The most frequent type of unmet or unrecognized need was for cognitive services. The top 3 reasons for unmet need at 3 and 12 months were (1) not recommended by doctor (34% and 31%); (2) not recommended/provided by school (16% and 17%); and (3) cost too much (16% and 16%). Factors that were associated with unmet or unrecognized need changed over time. At 3 months after injury, the caregivers of children with a preexisting psychosocial condition were 3 times more likely to report unmet need compared with children who did not have one. Also, female caregivers were significantly more likely to report unmet need compared with male caregivers. Finally, the caregivers of children with Medicaid were almost 2 times more likely to report unmet need compared with children who were covered by commercial insurance. The only factor that was associated with unrecognized need at 3 months after injury was abnormal family functioning. At 12 months after injury, although TBI severity was not significant, children who sustained a major associated injury were 2 times more likely to report unmet need compared with children who did not. Consistent with the 3-month results, the caregivers of children with Medicaid were significantly more likely to report unmet needs at 1 year after injury. In addition to poor family functionings being associated with unrecognized need, nonwhite children were significantly more likely to have unrecognized needs at 1 year compared with white children. CONCLUSIONS. A substantial proportion of children with TBI had unmet or unrecognized health care needs during the first year after injury. It is recommended that pediatricians be involved in the post-acute care follow-up of children with TBI to ensure that the injured childs needs are being addressed in a timely and appropriate manner. One of the recommendations that trauma center providers should make on hospital discharge is that the parent/primary caregiver schedule a visit with the childs pediatrician regardless of the post-acute services that the child may be receiving. Because unmet and unrecognized need was highest for cognitive services, it is important to screen for cognitive dysfunction in the primary care setting. Finally, because the health care needs of children with TBI change over time, it is important for pediatricians to monitor their recovery to ensure that children with TBI receive the services that they need to restore their health after injury.

The tip of the iceberg for child abuse: the critical roles of the pediatric trauma service and its registry

BACKGROUND The incidence of child abuse is approximately 10% of all children presenting to an emergency department (ED), with a mortality rate less than 1%. By contrast, the characteristics of the subset of abused children presenting to a pediatric trauma service (PTS) is not well defined. METHODS This study was a retrospective evaluation of prospectively collected information from an urban Level I pediatric trauma registry from 1990 to 2002 (n = 11,919). Child abuse cases and their perpetrators were identified by E-codes. Patterns of injuries were examined by integer International Classification of Diseases, Ninth Revision codes, and diagnostic model was evaluated by discrimination and goodness-of-fit. RESULTS A total of 171 cases of child abuse (1.4%) were identified, and the majority were boys (59%, p > 0.05 vs. nonabuse cases). The median age of the abused cohort was younger than 1 year old, and the number of abuse cases did not differ over time (mean, 11 per year.) Abused children present with a higher median Injury Severity Score (10 vs. 4, p < 0.01), more severe injuries of the head and integument, longer hospital lengths of stay (4 vs. 1 day, p < 0.01), and a higher mortality rate (12% vs. 2%, p < 0.01). The following variables emerged with significant association to abuse: fracture of base or vault of skull, contusion of eye, rib fracture, intracranial bleeding, multiple burns, and age. A new Diagnostic Index for Physical Child Abuse was created. CONCLUSION Significant characteristics of the abused children in this pediatric trauma service include higher Injury Severity Score (especially in the head and integument), requirement for longer lengths of stay, and a nearly 10-times higher risk of death compared with the ED population. The Diagnostic Index for Physical Child Abuse is proposed as a new tool to assist in the identification of child abuse among pediatric trauma patients. An epidemiologic triangle for child abuse is described, with different prevalence and severity of child abuse seen at different levels of our health care system, starting with primary care providers, followed by the ED, the PTS, and ultimately the medical examiners. The number of cases decreases from the bottom to the top of the health care system, but the mortality rate increases as abuse escalates through the triangle. This establishes the PTS as possibly the final gatekeeper before an abused case becomes a fatality. These data emphasize the need for rigorous registry evaluation and subsequent evidence-based prevention initiatives.

The health-related quality of life of children with an extremity fracture: a one-year follow-up study.

Purpose: To document the health-related quality of life (HRQOL) of children with an extremity fracture at 3 and 12 months postinjury and to determine whether it varies significantly by fracture region and site. Methods: Children hospitalized for an extremity fracture at 4 pediatric trauma centers were studied. A baseline, 3-month, and 12-month telephone interview were completed by a primary caregiver to measure the childs HRQOL using the Pediatric Quality of Life Inventory (PedsQL). HRQOL was modeled as a function of injury, patient, and family characteristics using a longitudinal regression model. Result: Of the 100 children enrolled, 52 sustained a lower extremity fracture (LEF) and 48 an upper extremity fracture (UEF). Postinjury HRQOL scores were significantly poorer than preinjury scores for all subjects (P = 0.05). In addition, a significant proportion of subjects reported impaired physical and psychosocial HRQOL at 3 (44% and 46%, respectively) and 12 months (23% and 33%, respectively) postinjury. At 3 months postinjury, children with an LEF had significantly poorer HRQOL outcomes compared to children with a UEF. By 12 months postinjury, the physical function of children with a tibia and/or fibula fracture remained significantly lower than children with a UEF (P ≤ 0.05). Conclusions: Children hospitalized for an extremity fracture suffered dramatic declines in physical and psychosocial well-being during the first 3 months postinjury. By 1 year postinjury, most children recovered; however, children with a tibia and/or fibula fracture still reported significantly poorer physical functioning.

Diagnostic radiation exposure in pediatric trauma patients.

BACKGROUND The amount of imaging studies performed for disease diagnosis has been rapidly increasing. We examined the amount of radiation exposure that pediatric trauma patients receive because they are an at-risk population. Our hypothesis was that pediatric trauma patients are exposed to high levels of radiation during a single hospital visit. METHODS Retrospective review of children who presented to Johns Hopkins Pediatric Trauma Center from July 1, 2004, to June 30, 2005. Radiographic studies were recorded for each patient and doses were calculated to give a total effective dose of radiation. All radiographic studies that each child received during evaluation, including any associated hospital admission, were included. RESULTS A total of 945 children were evaluated during the study year. A total of 719 children were included in the analysis. Mean age was 7.8 (±4.6) years. Four thousand six hundred three radiographic studies were performed; 1,457 were computed tomography (CT) studies (31.7%). Average radiation dose was 12.8 (±12) mSv. We found that while CT accounted for only 31.7% of the radiologic studies performed, it accounted for 91% of the total radiation dose. Mean dose for admitted children was 17.9 (±13.8) mSv. Mean dose for discharged children was 8.4 (±7.8) mSv (p<0.0001). Burn injuries had the lowest radiation dose [1.2 (±2.6) mSv], whereas motor vehicle collision victims had the highest dose [18.8 (±14.7) mSv]. CONCLUSION When the use of radiologic imaging is considered essential, cumulative radiation exposure can be high. In young children with relatively long life spans, the benefit of each imaging study and the cumulative radiation dose should be weighed against the long-term risks of increased exposure.

The role of clinically significant venous thromboembolism and thromboprophylaxis in pediatric patients with pelvic or femoral fractures.

Background: In adults, pelvic and femoral fractures have a known association with venous thromboembolic disease and, thus, thromboprophylaxis is the standard of care. However, similar data for children are scarce, and recommendations for pediatric prophylaxis are less clear. Our goals were to: (1) analyze the predisposing risk factors, prevalence, and outcome (including mortality) of clinically significant venous thromboembolism; (2) investigate the use of thromboprophylaxis in pediatric trauma patients and ages at which it was given; and (3) determine the impact that central venous catheters had on the occurrence of venous thromboembolism. Methods: We reviewed the records of all pediatric patients with pelvic or femoral fracture admitted to our hospital from 1990 through 2009 for occurrence of venous thromboembolism and related mortality, use and effect of central venous catheters, use of thromboprophylaxis (heparin, warfarin, enoxaparin, or factor-X inhibitors), and patient age at administration. Of the 1782 patients, 948 had electronically searchable medication (and device) records. Ninety-five percent confidence intervals were found for all proportions with sample sizes >100, and an unpaired t test was used to compare the average age at which thromboprophylaxis was given with the average age of the total population. Results: Of the 1782 patients, there were 3 (0.17%) diagnoses of deep vein thrombosis and no diagnoses of pulmonary embolism; there was no related mortality. Of the medication subset (948 patients) only 83 (8.8%) received some type of thromboprophylaxis. The average age of patients given thromboprophylaxis was 14.65 years (SD, 2.34). No central venous catheter was associated with any of the patients who had a venous thromboembolic event. Conclusions: Thromboprophylaxis was used only occasionally at our institution; >91% of patients did not receive such treatment. No morbidity or mortality was reported related to venous thromboembolism in pediatric patients with femur or pelvic fracture for whom thromboprophylaxis was used. Level of Evidence: Level II, retrospective study.

Secondary overtriage in pediatric trauma: can unnecessary patient transfers be avoided?

BACKGROUND In an era of wide regionalization of pediatric trauma systems, interhospital patient transfer is common. Decisions regarding the location of definitive trauma care depend on prehospital destination criteria (primary triage) and interfacility transfers (secondary triage). Secondary overtriage can occur in any resource-limited setting but is not well characterized in pediatric trauma. METHODS The National Trauma Data Bank from 2008 to 2011 was queried to identify patients 15 years or younger who were transferred to pediatric trauma centers. Secondary overtriage was defined as meeting all 4 of the following criteria: injury severity score (ISS) less than 9, no need for surgical procedure, no critical care admission, and length of stay of less than 24 hours. All other transfers were deemed appropriate triage. RESULTS Our definition of secondary overtriage was met in 32,318 patients out of 144,420 transfers (22.4%). Within this group, 37.5% were discharged directly from the emergency department of the receiving hospital without hospital admission. Appropriately triaged patients required a therapeutic procedure in 43.5% of cases. Differences in age, sex, mechanism of injury, and payer status were modest. CONCLUSIONS Secondary overtriage is prevalent in pediatric trauma systems nationwide and is not associated with any particular patient characteristics. Because clinical outcomes and healthcare spending are increasingly scrutinized, secondary overtriage may reflect unnecessary patient transfer and a source of potential cost savings. Development of better guidelines for secondary triage of pediatric trauma patients may enable timely assessment and treatment of children who require a higher level of care while also preventing inefficient use of available resources.

Parent Distress Following Pediatric Burn Injuries

Parents commonly report elevated distress following a childs burn injury, yet limited research has identified child or injury characteristics that may explain parent distress. The main goal of the current study is to examine prevalence and predictors of parent distress following childrens burn injuries by evaluating distress symptoms in a clinic sample of parents whose children present for evaluation and treatment at a regional burn center. Participants included parents of 407 children who experienced a burn injury. Of this sample, follow-up data at a second time point was obtained for 130 children and their caregivers. Parents completed a measure of distress. Clinical and demographic variables were extracted retrospectively from the medical chart. Clinical and at risk levels of distress were reported by nearly 19% of parents at Time 1. Parent distress at Time 1 was associated with child minority race, fewer days since burn injury, and greater burn size. A propensity score was used to account for potential differences between parents with data at Time 1 only versus those with data at Time 2. Parents with Time 2 data tended to have higher levels of distress at Time 1. Of parents with Time 2 data, 17% continued to report elevated distress, and Time 1 distress was the best predictor of later distress. A proportion of parents report elevated distress following their childrens burn injuries. Our results suggest that best practices should include routine screening of parent distress following pediatric burn injuries to guide appropriate interventions.