Publications (27) View all
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Article: Role of Computed Tomography and Clinical Findings in Pediatric Blunt Intestinal Injury: A Multicenter Study.
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ABSTRACT: PURPOSE: Although computed tomographic (CT) scans are accurate in diagnosing solid-organ injuries, their ability to diagnose a blunt intestinal injury (BII) is limited, occasionally requiring repeated imaging. The purpose of this study was to evaluate the role of clinical findings as well as original and repeated CT imaging in the ultimate decision to operate for BII. METHODS: An 18-institution record review of children (≤15 years) diagnosed with a BII confirmed during surgery between 2002 and 2007 was conducted by the American Pediatric Surgery Association Trauma Committee. The incidence of imaging, repeated imaging, and final reported indications for operative exploration were evaluated. RESULTS: Among 331 patients identified with a BII, 292 (88%) underwent at least 1 abdominal CT scan. Sixty-two (19%) underwent at least 1 repeated scan before operation. Forty-seven percent of children who underwent a CT scan were taken to the operating room based primarily on clinical indications (fever, abdominal pain, shock or elevated white blood cell count), whereas 31% were operated on based on both a clinical and CT indication and 22% were operated on based on a CT indication alone (P < 0.001). Although free air was the most common radiographic indication for surgery, 13% of patients with a repeated scan had free air diagnosed on their first CT. Most children undergoing a repeated CT (84%) had findings on the original scan suggesting a BII. Among the 10 patients whose first CT scan result was normal, only 1 went to the operating room based only on radiographic findings. Children who had their first CT scan at a referring hospital were more likely to have a repeated study compared with those imaged at a trauma center (33% vs 13%, P < 0.0001). CONCLUSIONS: Although abdominal CT imaging may contribute to diagnosing intestinal injury after blunt trauma, most children undergo operation based on clinical findings. Repeated imaging should be limited to select patients with diagnostic uncertainty to avoid unneeded delay and radiation exposure.Pediatric emergency care 11/2012; · 0.92 Impact Factor -
Article: Assessment of factors associated with the delayed transfer of pediatric trauma patients: an emergency physician survey.
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ABSTRACT: The purpose of this study was to identify, among emergency department (ED) physicians, the potential barriers impacting the appropriate and timely transfer of injured children to pediatric trauma centers. Surveys assessed pediatric trauma knowledge and experience, transfer and imaging decisions, and perceived barriers to patient transfer. Two scenarios were created; one with a child meeting the state trauma triage criteria and one who did not. In April 2010, 936 surveys were mailed to randomly selected ED physicians. Respondents could answer by mail or online until June 30, 2010. A total of 486 surveys were returned, and 109 were excluded, leaving 377 included in the study. A majority reported limited experience in the care of the critically ill child, with 93%, 99%, 99%, and 100% respectively, having performed less than 5 intubations, intraosseous line, central line, or chest tube placements in the last year. In the scenario in which the child met criteria to be transferred, 74% appropriately transferred the patient, whereas in the other scenario, 34% transferred the patient. As much as 56% of the respondents reported they would perform a head computed tomography before transfer, mainly to avoid missed injuries and medicolegal concerns. Among those who would not transfer either patient, 27% reported not having an on-call surgeon at all times. Innovative measures should be developed so that ED physicians gain a greater understanding of the proper identification of pediatric patients requiring a timely transfer to a pediatric trauma center.Pediatric emergency care 08/2012; 28(8):758-63. · 0.92 Impact Factor -
Article: Use of a mild traumatic brain injury guideline to reduce inpatient hospital imaging and charges.
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ABSTRACT: In children, mild traumatic brain injuries (TBI) account for 70% to 90% of head injuries. Without clear guidelines, many of these children may be exposed to excess radiation owing to unnecessary imaging. The purpose of this study was to evaluate the impact of a mild TBI guideline in reducing hospital charges and repeated imaging of pediatric patients. Charts of all children who had at least one head computed tomography and were admitted to our level 1 trauma center with a blunt TBI and Glasgow Coma Scale of 13 to 15 were retrospectively reviewed. Patients were divided into 2 groups relative to the implementation of a TBI management guideline. A total of 742 patients were included, 389 preguideline and 353 postguideline. Implementation of the guideline was associated with reductions in the average number of head computed tomographies performed (1.6 vs 1.3, P = .006), length of stay (2.3 vs 1.7 days, P < .0001), and overall hospital charges ($21,760 vs $13,980, P = .006). No children were readmitted for missed injuries. Implementation of a simple guideline for the care of children with mild TBI can have significant impact on charges and length of stay while simultaneously reducing radiation exposure. Widespread implementation of such guidelines will improve efficiency without sacrificing quality of care in the management of mild TBI in the pediatric population.Journal of Pediatric Surgery 09/2011; 46(9):1777-83. · 1.45 Impact Factor -
Article: Unnecessary imaging, not hospital distance, or transportation mode impacts delays in the transfer of injured children.
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ABSTRACT: Timely transfer of injured children to pediatric trauma centers (PTCs) that can address their unique needs is important. This study was designed to understand the characteristics of transferred injured children. Data from our level I PTC over 5 years (2002-2006) were reviewed. Transferred patients were divided based on time from injury to arrival at our PTC: early (<2 hours) and late (>2 hours). Data collected included demographics, Injury Severity Scale score, Glasgow Coma Scale score, mode of transportation, referring hospital information including pretransfer imaging, and disposition from our emergency room. Seven hundred forty-eight patients were included. Eighty-two percent (n = 612) were in the late group and arrived, on average, 6 hours after those transferred early (420 vs 69.9 minutes, P < 0.05). Seventy-nine percent (n = 147) of transfers with severe injuries (Injury Severity Scale score >15) and 47% (n = 15) of those with severe head injuries (Glasgow Coma Scale score <8) arrived late. The disproportionate number of late transfers was consistent among all transferring hospitals regardless of distance and only slightly improved in the group transferred by air ambulance. In addition, those transferred late had significantly more pretransfer imaging (49% vs 23%, P = 0.0025). Despite the advantages of care in trauma centers, a significant number of severely injured children are transferred well beyond 2 hours after injury. This study has demonstrated that this pattern of delayed transfer is a systemic problem occurring among all transferring hospitals regardless of distance or mode of patient transfer and is associated with increased use of imaging before transfer.Pediatric emergency care 07/2010; 26(7):481-6. · 0.92 Impact Factor -
Article: Epidemiology of injury and the impact of health disparities.
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ABSTRACT: The purpose of this review is to highlight recent advances in understanding the epidemiology of pediatric trauma and the impact of health disparities on care of the injured child. Recent studies examining outcomes for injury in children consistently demonstrate worse clinical and functional outcomes for minority children compared with white children, with African-American race being an independent predictor of mortality. Despite controlling for injury severity and insurance status (as a surrogate of socioeconomic status), these disparities persist. Significant racial differences in mortality were also identified when national data were compared with local institutional data for children with traumatic brain injury. Studies examining the effect of insurance status on care of the injured child have similarly uncovered unsettling inequities. Disparities in delivery of pediatric trauma care have been identified based on access to pediatric trauma centers. Other studies have sought to reduce disparities by use of guidelines. Finally, prevention studies have demonstrated racial disparities in the use of motor vehicle restraints, with improved restraint use in minority populations after implementation of culturally tailored prevention programs. The cause of disparities in childhood trauma appears to be multifactorial and may include race, socioeconomic factors, insurance status, access, and healthcare provider biases. Multiple studies have confirmed that disparities exist, but it is difficult to tease out the reasons why they exist. Further work is necessary to identify causes of such disparities and formulate strategies to eliminate them.Current opinion in pediatrics 04/2010; 22(3):321-5. · 2.01 Impact Factor
