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AbstractObjectives:Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU.Methods:Retrospective review of clinical characteristics and outcomes of children (aged 0–21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation.Measurements and results:One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation.Conclusions:Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.

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AbstractObjective:Retrospectively apply criteria from Center to Advance Palliative Care to a cohort of children treated in a cardiac ICU and compare children who received a palliative care consultation to those who were eligible for but did not receive one.Methods:Medical records of children admitted to a cardiac ICU between January 2014 and June 2017 were reviewed. Selected criteria include cardiac ICU length of stay >14 days and/or ≥ 3 hospitalisations within a 6-month period.Measurements and Results:A consultation occurred in 17% (n = 48) of 288 eligible children. Children who received a consult had longer cardiac ICU (27 days versus 17 days; p < 0.001) and hospital (91 days versus 35 days; p < 0.001) lengths of stay, more complex chronic conditions at the end of first hospitalisation (3 versus1; p < 0.001) and the end of the study (4 vs.2; p < 0.001), and higher mortality (42% versus 7%; p < 0.001) when compared with the non-consulted group. Of the 142 pre-natally diagnosed children, only one received a pre-natal consult and 23 received it post-natally. Children who received a consultation (n = 48) were almost 2 months of age at the time of the consult.Conclusions:Less than a quarter of eligible children received a consultation. The consultation usually occurred in the context of medical complexity, high risk of mortality, and at an older age, suggesting potential opportunities for more and earlier paediatric palliative care involvement in the cardiac ICU. Screening criteria to identify patients for a consultation may increase the use of palliative care services in the cardiac ICU.

IMPORTANCE: The National Pediatric Readiness Project is a US initiative to improve emergency department (ED) readiness to care for acutely ill and injured children. However, it is unclear whether high ED pediatric readiness is associated with improved survival in US trauma centers. OBJECTIVE: To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centers. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 832 EDs in US trauma centers in 50 states and the District of Columbia was conducted using data from January 1, 2012, through December 31, 2017. Injured children younger than 18 years who were admitted, transferred, or with injury-related death in a participating trauma center were included in the analysis. Subgroups included children with an Injury Severity Score (ISS) of 16 or above, indicating overall seriously injured (accounting for all injuries); any Abbreviated Injury Scale (AIS) score of 3 or above, indicating at least 1 serious injury; a head AIS score of 3 or above, indicating serious brain injury; and need for early use of critical resources. EXPOSURES: Emergency department pediatric readiness for the initial ED visit, measured through the weighted Pediatric Readiness Score (range, 0-100) from the 2013 National Pediatric Readiness Project ED pediatric readiness assessment. MAIN OUTCOMES AND MEASURES: In-hospital mortality, with a secondary composite outcome of in-hospital mortality or complication. For the primary measurement tools used, the possible range of the AIS is 0 to 6, with 3 or higher indicating a serious injury; the possible range of the ISS is 0 to 75, with 16 or higher indicating serious overall injury. The weighted Pediatric Readiness Score examines and scores 6 domains; in this study, the lowest quartile included scores of 29 to 62 and the highest quartile included scores of 93 to 100. RESULTS: There were 372 004 injured children (239 273 [64.3%] boys; median age, 10 years [interquartile range, 4-15 years]), including 5700 (1.5%) who died in-hospital and 5018 (1.3%) who developed in-hospital complications. Subgroups included 50 440 children (13.6%) with an ISS of 16 or higher, 124 507 (33.5%) with any AIS score of 3 or higher, 57 368 (15.4%) with a head AIS score of 3 or higher, and 32 671 (8.8%) requiring early use of critical resources. Compared with EDs in the lowest weighted Pediatric Readiness Score quartile, children cared for in the highest ED quartile had lower in-hospital mortality (adjusted odds ratio [aOR], 0.58; 95% CI, 0.45-0.75), but not fewer complications (aOR for the composite outcome 0.88; 95% CI, 0.74-1.04). These findings were consistent across subgroups, strata, and multiple sensitivity analyses. If all children cared for in the lowest-readiness quartiles (1-3) were treated in an ED in the highest quartile of readiness, an additional 126 lives (95% CI, 97-154 lives) might be saved each year in these trauma centers. CONCLUSIONS AND RELEVANCE: In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centers that care for children.

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IMPORTANCE: Previous assessments of readiness of emergency departments (EDs) have not been comprehensive and have shown relatively poor pediatric readiness, with a reported weighted pediatric readiness score (WPRS) of 55. OBJECTIVES: To assess US EDs for pediatric readiness based on compliance with the 2009 guidelines for care of children in EDs; to evaluate the effect of physician/nurse pediatric emergency care coordinators (PECCs) on pediatric readiness; and to identify gaps for future quality initiatives by a national coalition. DESIGN, SETTING, AND PARTICIPANTS: Web-based assessment of US EDs (excluding specialty hospitals and hospitals without an ED open 24 hours per day, 7 days per week) for pediatric readiness. All 5017 ED nurse managers were sent a 55-question web-based assessment. Assessments were administered from January 1 through August 23, 2013. Data were analyzed from September 12, 2013, through January 11, 2015. MAIN OUTCOMES AND MEASURES: A modified Delphi process generated a WPRS. An adjusted WPRS was calculated excluding the points received for the presence of physician and nurse PECCs. RESULTS: Of the 5017 EDs contacted, 4149 (82.7%) responded, representing 24 million annual pediatric ED visits. Among the EDs entered in the analysis, 69.4% had low or medium pediatric volume and treated less than 14 children per day. The median WPRS was 68.9 (interquartile range [IQR] 56.1-83.6). The median WPRS increased by pediatric patient volume, from 61.4 (IQR, 49.5-73.6) for low-pediatric-volume EDs compared with 89.8 (IQR, 74.7-97.2) for high-pediatric-volume EDs (P &lt; .001). The median percentage of recommended pediatric equipment available was 91% (IQR, 81%-98%). The presence of physician and nurse PECCs was associated with a higher adjusted median WPRS (82.2 [IQR, 69.7-92.5]) compared with no PECC (66.5 [IQR, 56.0-76.9]) across all pediatric volume categories (P &lt; .001). The presence of PECCs increased the likelihood of having all the recommended components, including a pediatric quality improvement process (adjusted relative risk, 4.11 [95% CI, 3.37-5.02]). Barriers to guideline implementation were reported by 80.8% of responding EDs. CONCLUSIONS AND RELEVANCE: These data demonstrate improvement in pediatric readiness of EDs compared with previous reports. The physician and nurse PECCs play an important role in pediatric readiness of EDs, and their presence is associated with improved compliance with published guidelines. Barriers to implementation of guidelines may be targeted for future initiatives by a national coalition whose goal is to ensure day-to-day pediatric readiness of our nation’s EDs.

To describe parents’ experience of organ donation decision making in the case of donation after circulatory determination of death.

Objectives:To describe the epidemiology of repeat users of the emergency department (ED) using a statewide database. Methods:Probabilistic linkage was used to convert three years of statewide ED visit data into a longitudinal, patient‐based data set. Patients were classified as single, repeat (at least two visits within three years), or serial (four or more visits within a 365‐day period) users of the ED. Serial patients were further stratified by the number of EDs attended. Descriptive statistics were used to assess differences between patient types. Results:There were 1,370,607 separate visits associated with 780,074 patients from 1996 to 1998. While repeat and serial patients represented 33% of the patients, they accounted for 62% of the ED visits during the study period. Repeat and serial patients were younger and had smaller median ED charges per visit than single‐use patients. Serial patients attending five or more EDs were more likely to be coded as self‐pay than other serial patients. Diagnosis codes relating to sprains, back problems, and headaches were prevalent among serial patients who visited five or more EDs. Approximately 30% of serial patients during the first year remained serial patients in the second year. Conclusions:Due to the high turnover in serial patients, control groups in future studies are necessary to evaluate interventions aimed at decreasing serial ED use. The likelihood of serial ED users to use multiple EDs indicates that those studying serial ED use should collect data from multiple EDs.

Objectives:School injuries are a serious public health problem, yet classroom injuries have received little attention. The purpose of this study was to describe the epidemiology of classroom injuries in Utah public schools. Methods:Utah statewide school injury data on kindergarten through 12th grade students for 1996 through 1998 were used. The data were generated from a standardized Student Injury Report (SIR) form completed by school personnel for injuries that (1) caused loss of at least one half of a day of school or (2) warranted medical attention and treatment. Injuries occurring in laboratories, shop, and physical education classes were excluded. To determine the medical outcome and charges associated with classroom injuries, the authors probabilistically linked the SIR database to Utah statewide emergency department (ED) records and Utah statewide hospital inpatients discharge records for 1996 through 1998. Results:During the period 1996 through 1998, there were 1,366 classroom injuries. Nearly two thirds of the injuries occurred to male students. More than half the classroom injuries were related to equipment use. Weapon use was rare. Twenty percent of students injured in the classroom obtained treatment in an ED, where 71% of these injuries were determined to involve the head, neck, and upper extremity. Two incidents, one involving carbon monoxide and the other tear gas, accounted for 11% of the ED admissions. Conclusions:Classroom injuries are not sufficiently frequent, severe, or costly to justify special studies focused solely on acute injuries in standard classrooms. This does not negate the need for continued surveillance of classroom injuries along with other school injuries.

Objective:To describe the epidemiology of snowmobile injuries in Utah.

Abstract. Objective:To describe the epidemiology of school injuries resulting in emergency department (ED) visits, hospital admission, or death. Methods:Utah statewide school injuries from 1992 to 1996 were probabilistically linked to statewide ED records (1996 only), inpatient hospital records (1992‐1996), and death certificate records (1992‐1996). Results:There were 43,881 school injuries for the years 1992 through 1996. In 1996, 1,534 of 6,354 total school injuries (17.5%) resulted in ED evaluation. Between 1992 and 1996, 354 school injuries (0.8%) necessitated hospital admission. The overall rates of school injuries (per 1,000 students) of primary (kindergarten—grade 6) and secondary (grades 7‐12) school students requiring ED evaluation were 3.29 and 3.28, respectively; for hospital admission, 0.165 and 0.139. Abbreviated Injury Scale‐1990 (AIS‐90) regions identified in ED patients were the upper extremity (39.2%), face (20.8%), and lower extremity (17.1%), while AIS regions among inpatients were lower extremity (29.1%), upper extremity (26.6%), and head (22.6%). There were a total of 1,123 hospital days, and total charges of $2.16 million. The ED charges totaled $545,000. Median length of hospital stay was 1 day, and median hospital charge was $3,080. There were four fatalities. Conclusions:This study emphasizes the significance of school injuries and the need for interventions to prevent these injuries

Study Objective:We sought to compare the characteristics and medical outcomes of motor vehicle crashes for drivers 70 years and older with those of drivers between the ages of 30 and 39 years. Methods:We probabilistically linked statewide motor vehicle crash and hospital discharge data between the years of 1992 and 1995 for the state of Utah. We calculated the odds of older drivers exhibiting certain motor vehicle crash characteristics compared with younger drivers. Adjusting for nighttime crash, high-speed crash, and seatbelt use, we calculated the odds of an older driver being killed or hospitalized compared with those of a younger driver. Results:During the study years, there were 14,466 drivers older than 69 years and 68,706 drivers between the ages of 30 and 39 years involved in motor vehicle crashes in Utah. Older drivers were less likely to have crashes involving drug or alcohol use (odds ratio [OR] 0.1; 95% confidence interval [CI] 0.1 to 0.2) and less likely to have crashes at high speed (OR 0.6; 95% CI 0.6 to 0.7). Although older drivers were no more likely to have a crash involving a right-hand turn (OR 1.0; 95% CI 0.9 to 1.1) than younger drivers, they were over twice as likely to have a crash involving a left-hand turn (OR 2.3; 95% CI 2.2 to 2.5). Also, older drivers were more likely to be killed or hospitalized than younger drivers (OR, 3.5; P<.001). Among belted drivers, an older driver was nearly 7 times more likely to be killed or hospitalized than a younger driver (OR 6.9; 95% CI 5.4 to 8.9). Conclusion:Older drivers do have distinctive motor vehicle crash patterns. Interventions must be taken to reduce the number of left-hand turn crashes involving older drivers. In addition, further research is needed to design, implement, and evaluate countermeasures that may enable older drivers to continue driving while keeping public safety in the forefront. [Cook LJ, Knight S, Olson LM, Nechodom PJ, Dean JM. Motor vehicle crash characteristics and medical outcomes among older drivers in Utah, 1992-1995. Ann Emerg Med. June 2000;35:585-591.]

Objective: To compare pediatric ambulance patients transported for chief complaints of suicide, assault, alcohol, and drug intoxication (SAAD) with pediatric patients transported for all other chief complaints. Methods: An out‐of‐hospital database for the primary transporting service in an urban area was analyzed for patients 0‐20 years of age from 1992 to 1995. Chief complaints by age, gender, and billing status were analyzed. Results: There were 17,722 transports. The SAAD group comprised 14.9% of all transports (suicide attempt 1.6%, assault 5.9%, alcohol intoxication 3.2%, and drug abuse 4.2%). The proportion of transports due to SAAD increased with age: 0‐11‐year‐olds (4.2%); 11‐16‐year‐olds (17.5%); and 17‐20‐year‐olds (20.3%) (p = 0.0001). Genders were equally represented in the overall group, while males comprised 52.6% of the SAAD transports (p = 0.032). In the SAAD group, the majority of transports for assaults (55.9%) and alcohol (58.8%) involved males, while females were the majority in transports for suicide (52.3%) and drug abuse (66%) (p = 0.0001). Reimbursement sources differed, with those in the SAAD group less likely to be reimbursed by private or public (Medicaid, government) insurance (p < 0.0001) compared with the overall group. Conclusions: A substantial proportion of pediatric emergency medical services transports are for high‐risk conditions. This patient population differs from the overall group by age distribution and reimbursement source.

To compare and contrast retrospective versus concurrent quality of care review processes in a Level I Trauma Center, we conducted a retrospective chart review of all pediatric trauma admissions in 1990 (n113) and compared it to the concurrent trauma quality assurance program for the same time period. Twenty-four percent (24) of the patients reviewed in the retrospective study were identified by filters and reviewed through the concurrent process. In both the retrospective and concurrent review process problems in medical care problems, documentation, social and preventive elements of the case, and overall assessment of the patients' care were described. Overall, we found less than 50 agreement between the two reviews. The retrospective review identified medical care issues in 64 of cases, compared with a 44 error rate noted in the concurrent review (P< 0.07). Reviewers were more likely to note the absence of appropriate documentation, and overall assessment of the patients' care in the retrospective process (P< 0.0001). The retrospective review also highlighted issues related to the prevention of the injury and the patients' social situation, which were not considered by the concurrent review. Overall, we found the concurrent review appropriate for case by case medical management, while the retrospective review was relevant to a systems approach to the care of the injured child. To obtain a complete picture of the care of injured children, we recommend 1) a portion of charts be reviewed retrospectively in addition to ongoing concurrent review; or 2) the concurrent review add filters that are specific to pediatric issues and overall system issues.

Objective. To compare the initial emergency medical services (EMS) prehospital assessment of medical and traumatic cardiopulmonary arrest in the pediatric patient with that of the Office of the Medical Investigator (OMI) and assess differences and implications for EMS training and prevention.Design. Retrospective review of ambulance run forms with the OMI autopsy confirmations.Setting. An urban EMS system and the state Office of the Medical Investigator.Participants. Patients 15 years of age or less who were treated by prehospital personnel from November 1, 1990, to October 31, 1991, for a medical or traumatic arrest.Intervention. None. Measurements and Main Results. Ambulance runs were reported for 2,586 pediatric patients. Of these, 42 (1.6%) had suffered arrests, with 32 (76%) medical arrests and ten (24%) traumatic arrests. Children 1 year of age or less accounted for 75% of the medical arrests, while children more than 1 year of age accounted for 80% of the traumatic arrests (p = 0.003). Overall mortality was 81 %. When EMS prehospital assessments of medical and traumatic arrests were compared with autopsy reports, there was good agreement for sudden infant death syndrome (SIDS) (kappa = 0.70), but poor agreement for child abuse (kappa = 0.37).Conclusion. The authors found good agreement between EMS prehospital assessments and autopsy diagnoses for identifying pediatric SIDS, but child abuse was not well identified prior to autopsy.