1. Newgard CD, Babcock SR, Song X, Remick KE, Gausche-Hill M, Lin A, Malveau S, Mann NC, Nathens AB, Cook JNB, Jenkins PC, Burd RS, Hewes HA, Glass NE, Jensen AR, Fallat ME, Ames SG, Salvi A, McConnell KJ, Ford R, Auerbach M, Bailey J, Riddick TA, Xin HA, Kuppermann K. Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated with Survival. Ann Surg. (accepted 10/19/2022, In Press)
Objective: We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. Summary Background Data: Emergency department (ED) pediatric readiness is associated with improved short- and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. Methods: This was a retrospective cohort study of injured children <18 years treated in 458 trauma centers from 1/1/2012 through 12/31/2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED- and hospital-level variables. The primary outcome was in-hospital survival. Results: There were 274,756 injured children, including 4,585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0% to 2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the five highest-impact components were combined. Conclusion:
2. Newgard CD, Lin A, Goldhaber-Fiebert JD, Marin JR, Smith M, Cook JNB, Mohr NM, Zonfrillo MR, Puapong D, Papa L, Cloutier RL, Burd R. Association of Emergency Department Pediatric Readiness With Mortality To One Year Among Injured Children Treated At Trauma Centers. JAMA Surgery. 2022;157(4):e217419. Epub 2022 Apr 13. PMID: 35107579.
IMPORTANCE: There is substantial variability among emergency departments (EDs) in their readiness to care for acutely ill and injured children, including US trauma centers. While high ED pediatric readiness is associated with improved in-hospital survival among children treated at trauma centers, the association between high ED readiness and long-term outcomes is unknown. OBJECTIVE: To evaluate the association between ED pediatric readiness and 1-year survival among injured children presenting to 146 trauma centers. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, injured children younger than 18 years who were residents of 8 states with admission, transfer to, or injury-related death at one of 146 participating trauma centers were included. Children cared for in and outside their state of residence were included. Subgroups included those with an Injury Severity Score (ISS) of 16 or more; any Abbreviated Injury Scale (AIS) score of 3 or more; head AIS score of 3 or more; and need for early critical resources. Data were collected from January 2012 to December 2017, with follow-up to December 2018. Data were analyzed from January to July 2021. EXPOSURES: ED pediatric readiness for the initial ED, measured using the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES: Time to death within 365 days. RESULTS: Of 88 071 included children, 30 654 (34.8%) were female; 2114 (2.4%) were Asian, 16 730 (10.0%) were Black, and 49 496 (56.2%) were White; and the median (IQR) age was 11 (5-15) years. A total of 1974 (2.2%) died within 1 year of the initial ED visit, including 1768 (2.0%) during hospitalization and 206 (0.2%) following discharge. Subgroups included 12 752 (14.5%) with an ISS of 16 or more, 28 402 (32.2%) with any AIS score of 3 or more, 13 348 (15.2%) with a head AIS of 3 or more, and 9048 (10.3%) requiring early critical resources. Compared with EDs in the lowest wPRS quartile (32-69), children cared for in the highest wPRS quartile (95-100) had lower hazard of death to 1 year (adjusted hazard ratio [aHR], 0.70; 95% CI, 0.56-0.88). Supplemental analyses removing early deaths had similar results (aHR, 0.75; 95% CI, 0.56-0.996). Findings were consistent across subgroups and multiple sensitivity analyses. CONCLUSIONS AND RELEVANCE: Children treated in high-readiness trauma center EDs after injury had a lower risk of death that persisted to 1 year. High ED readiness is independently associated with long-term survival among injured children.
3. Newgard CD, Lin A, Olson LM, Cook JNB, Gausche-Hill M, Kuppermann N, Goldhaber-Fiebert JD, Malveau S, Smith M, Dai M, Nathens AB, Glass NE, Jenkins PC, McConnell KJ, Remick KE, Hewes H, Mann NC. Emergency Department Pediatric Readiness and Outcomes In US Trauma Centers. JAMA Pediatrics. 2021;175(9):947-956.
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.
4. Newgard CD, Malveau S, Mann NC, Hansen M, Lang B, Lin A, Carr BG, Berry C, Buchwalder K, Lerner EB, Hewes HA, Kusin S, Dai M, Wei R. A Geospatial Evaluation of 9-1-1 Ambulance Transports for Children and Emergency Department Pediatric Readiness. Prehospital Emergency Care. 2022 May 13:1-11. PMID: 35394855, Online ahead of print.
OBJECTIVE: Whether ambulance transport patterns are optimized to match children to high-readiness emergency departments (EDs) and the resulting effect on survival are unknown. We quantified the number of children transported by 9-1-1 emergency medical services (EMS) to high-readiness EDs, additional children within 30 minutes of a high-readiness ED, and the estimated effect on survival. METHODS: This was a cross-sectional study using data from the National EMS Information System for 5,461 EMS agencies in 28 states from 1/1/2012 through 12/31/2019, matched to the 2013 National Pediatric Readiness Project assessment of ED pediatric readiness. We performed a geospatial analysis of children 0 to 17 years requiring 9-1-1 EMS transport to acute care hospitals, including day-, time-, and traffic-adjusted estimates for driving times to all EDs within 30 minutes of the scene. We categorized receiving hospitals by quartile of ED pediatric readiness using the weighted Pediatric Readiness Score (wPRS, range 0-100) and defined a high-risk subgroup of children as a proxy for admission. We used published estimates for the survival benefit of high readiness EDs to estimate the number of lives saved. RESULTS: There were 808,536 children transported by EMS, of whom 253,541 (31.4%) were high-risk. Among the 2,261 receiving hospitals, the median wPRS was 70 (IQR 57-85, range 26-100) and the median number of receiving hospitals within 30 minutes was 4 per child (IQR 2-11, range 1 to 53). Among all children, 411,685 (50.9%) were taken to EDs in the highest quartile of pediatric readiness, and 180,547 (22.3%) children transported to lower readiness EDs were within 30 minutes of a high readiness ED. Findings were similar among high-risk children. Based on high-risk children, we estimated that 3,050 pediatric lives were saved by transport to high-readiness EDs and an additional 1,719 lives could have been saved by shifting transports to high readiness EDs within 30 minutes. CONCLUSIONS: Approximately half of children transported by EMS were taken to high-readiness EDs and an additional one quarter could have been transported to such an ED, with measurable effect on survival.
5. Remick K, Smith M, Newgard CD, Lin A, Hewes H, Jensen AR, Glass N, Ford R, Ames S, Cook J, Malveau S, Dai M, Auerbach M, Jenkins P, Gausche-Hill M, Fallat M, Kuppermann N, Mann NC. Impact of Individual Components of Emergency Department Pediatric Readiness on Pediatric Mortality in US Trauma Centers. J Trauma Acute Care Surg. (accepted 8/18/2022, In Press)
BACKGROUND: Injured children initially treated at trauma centers with high emergency department (ED) pediatric readiness have improved survival. Centers with limited resources may not be able to address all pediatric readiness deficiencies and there currently is no evidence-based guidance for prioritizing different components of readiness. The objective of this study was to identify individual components of ED pediatric readiness associated with better-than-expected survival in US trauma centers to aid in the allocation of resources targeted at improving pediatric readiness. METHODS: This cohort study of U.S. trauma centers used the National Trauma Data Bank (2012-2017) matched to the 2013 National Pediatric Readiness Project assessment. Adult and pediatric centers treating at least 50 injured children (age < 18 years) and recording at least one death during the 6-year study period were included. Using a standardized risk-adjustment model for trauma, we calculated the observed-to-expected (O/E) mortality ratio for each trauma center. We used bivariate analyses and multivariable linear regression to assess for associations between individual components of ED pediatric readiness and better-than-expected survival. RESULTS: Among 555 trauma centers, the O/E mortality ratios ranged from 0.07 to 4.17 (IQR 0.93, 1.14). Unadjusted analyses of 23 components of ED pediatric readiness showed that trauma centers with better-than-expected survival were more likely to have a validated pediatric triage tool, comprehensive quality improvement processes, a pediatric-specific disaster plan, and critical airway and resuscitation equipment (all p < 0.03). The multivariable analysis demonstrated that trauma centers with both a physician and a nurse pediatric emergency care coordinator had better-than-expected survival, but this association weakened after accounting for trauma center level. Child maltreatment policies were associated with lower-than-expected survival, particularly in Level III-V trauma centers. CONCLUSION: Specific components of ED pediatric readiness were associated with pediatric survival among US trauma centers. LEVEL OF EVIDENCE: Care management, level III.