Pediatric Quality Improvement Research Articles

Helmets Protect Pediatric Bicyclists From Head Injury and Do Not Increase Risk of Cervical Spine Injury.

Only 21 states have mandatory helmet laws for pediatric bicyclists. This study sought to determine the incidence of helmeted riders among pediatric bicyclists involved in a collision and hypothesized the risk of a serious head and cervical spine injuries to be higher in nonhelmeted bicyclists (NHBs) compared with helmeted bicyclists (HBs). The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for pediatric (age <16 years) bicyclists involved in a collision. Helmeted bicyclists were compared with NHBs. A serious injury was defined by an abbreviated injury scale grade of greater than 2. From 3693 bicyclists, 3039 (82.3%) were NHBs. Compared with HBs, NHBs were more often Black (21.6% vs 3.8%, P < 0.001), Hispanic (17.5% vs 9.3%, P < 0.001), without insurance (4.6% vs 2.4%, P = 0.012), and had a higher rate of a serious head injury (24.6% vs 9.3%, P < 0.001). Both groups had similar rates of complications and mortality (P > 0.05). The associated risk of a serious head (odds ratio = 3.17, P < 0.001) and spine injury (odds ratio = 0.41, P = 0.012) were higher and lower respectively in NHBs. Associated risks for cervical spine fracture or cord injury were similar (P > 0.05). Pediatric bicyclists involved in a collision infrequently wear helmets, and NHBs was associated with higher risks of serious head injury. However, the associated risk of serious spine injury among NHBs was lower. The associated risks for cervical spine fracture or cervical cord injuries were similar. Nonhelmeted bicyclists were more likely to lack insurance and to be Black or Hispanic. Targeted outreach programs may help decrease the risk of injury, especially in at-risk demographics.

Outcomes from wake up safe, the pediatric anesthesia quality improvement initiative.

Wake Up Safe, a Patient Safety Organization founded by the Society for Pediatric Anesthesia, collects data on serious adverse events along with demographic data from all pediatric patients receiving anesthesia care at participating institutions. This report reviews all events occurring between 2010 and 2015 and focuses on common adverse events that are anesthesia-related. Determine which adverse events were most common from 2010 to 2015 among participating Wake Up Safe institutions. Determine how many anesthesia-related events were deemed to be preventable. This is a descriptive report. The Wake Up Safe registry data were queried on September 29, 2017. Institutions were included if they had complete demographic data and at least 5 adverse events per year reported. At that time, 19 out of 29 institutions had complete demographic data for events from 2010 to 2015. This study describes demographic data and adverse events from these nineteen institutions. Descriptive data were extracted, and event rate was calculated for each adverse event category. In events that were assessed as primarily related to anesthesia, further detailed analysis was performed. Of all reported adverse events (2544 events), the most common were cardiac arrests (646, 31.6%), respiratory complications (598, 29.2%), and medication events (345, 16.9%). Of all anesthesia-related events (612 events), medication events were the most common (239, 31.9%), followed by respiratory complications (181, 24.1%), and cardiac arrests (139, 18.5%). Overall, 85% of anesthesia-related serious adverse events were deemed somewhat or almost certainly preventable. The majority of anesthesia-related serious adverse events reported to the Wake Up Safe database are preventable. Medication events are the most common anesthesia-related adverse events. Innovations aimed at decreasing medication events may be the most impactful.

Association of Risk of Mortality in Pediatric Patients Transferred From Scene by Helicopter With Major But Not Minor Injuries.

Helicopter emergency medical services (HEMS) are used for 16% of pediatric trauma. National HEMS guidelines advised that triage criteria be standardized for pediatric patients. A national report found pediatric HEMS associated with decreased mortality compared with ground emergency medical services (GEMS) but did not control for transport time. We hypothesized that the rate of HEMS has decreased nationally and the mortality risk for HEMS to be similar when adjusting for transport time compared with GEMS. The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years transported by HEMS or GEMS. A multivariable logistic regression was used. From 25,647 patients, 4527 (17.7%) underwent HEMS. The rate of HEMS from scene decreased from 21.2% in 2014 to 18.2% in 2016. The rate of HEMS for minor trauma (Injury Severity Score <15) decreased from 14.9% in 2014 to 13.5% in 2016 and major trauma (Injury Severity Score > 15) from 38.4% in 2014 to 35.9% in 2016. After controlling for predictors of mortality and transport time, HEMS was associated with decreased risk of mortality for only those with major injuries transferred from scene (odds ratio, 0.48; 95% confidence interval, 0.26-0.88; P = 0.01) compared with GEMS. The rate of HEMS in pediatric trauma has decreased. However, there is room for improvement as 14% of those with minor trauma are transported by HEMS. Given the similar risk of mortality compared with GEMS, further development of guidelines that avoid the unnecessary use of HEMS appears warranted. However, utilization of HEMS for transport of pediatric major trauma should continue.

Risk factors associated with splenectomy following a blunt splenic injury in pediatric patients.

The purpose of the study was to identify the factors associated with splenectomy in pediatric trauma patients. Pediatric Trauma quality improvement program (P-TQIP) database calendar year 2014-2016 was accessed for the study. All patients, age ≤ 18years old, who sustained splenic injury due to blunt mechanism, were included in the study. The primary outcome of the study was to identify the risk factors associated with splenectomy. Univariate followed by multivariate analyses were performed. A p value of < 0.05 was considered an indication of statistical significance. Of 1297 trauma victims, who fulfilled the inclusion criteria, 57 (4.4%) patients underwent total splenectomy. In Univariate analysis, there were significant differences found, in many variables, between the groups who underwent splenectomy versus those who did not have splenectomy. A multivariate logistic regression analysis showed use of blood transfusion within 4h and severity of splenic injury were the two variables associated with splenectomy. The area under the curve (AUC) value was 0.892 and the 95% confidence intervals were [0.859, 0.923]. Blood transfusion within 4h of patient's arrival to the hospital and high-grade splenic injury were main factors for splenectomy in the pediatric population.

Multidisciplinary Tracheostomy Quality Improvement in the COVID-19 Pandemic: Building a Global Learning Community.

Objectives:To report experience with a global multidisciplinary tracheostomy e-learning initiative.Methods:An international multidisciplinary panel of experts convened to build a virtual learning community for tracheostomy care, comprising a web-based platform, five distance learning (interactive webinar) sessions, and professional discourse over 12 months. Structured pre- and post-webinar surveys were disseminated to global participants including otolaryngologists, intensivists, nurses, allied health professionals, and patients/caregivers. Data were collected on audio-visual fidelity, demographics, and pre- and post-tutorial assessments regarding experience and skill acquisition. Participants reported confidence levels for NICU, pediatric, adult, and family care, as well as technical skills, communication, learning, assessment, and subdomains.Results:Participants from 197 institutions in 22 countries engaged in the virtual education platform, including otolaryngologists, speech pathologists, respiratory therapists, specialist nurses, patients, and caregivers. Significant improvements were reported in communication (P < .0001), clinical assessments (P < .0001), and clinical governance (P < .0001), with positive impact on pediatric decannulation (P = .0008), adult decannulation (P = .04), and quality improvement (P < .0001). Respondents reported enhanced readiness to integrate knowledge into practice. Barriers included time zones, internet bandwidth, and perceived difficulty of direct clinical translation of highly technical skills. Participants rated the implementation highly in terms of length, ability for discussion, satisfaction, applicability to professional practice, and expertise of discussants (median scores: 4, 4, 4, 4 and 5 out of 5).Conclusions:Virtual learning has dominated the education landscape during COVID-19 pandemic, but few data are available on its effectiveness. This study demonstrated feasibility of virtual learning for disseminating best practices in tracheostomy, engaging a diverse, multidisciplinary audience. Learning of complex technical skills proved a hurdle, however, suggesting need for hands-on experience for technical mastery. While interactive videoconferencing via webinar affords an engaging and scalable strategy for sharing knowledge, further investigation is needed on clinical outcomes to define effective strategies for experiential online learning and virtual in-service simulations.

The Value of Family Advisors as Coleaders in Pediatric Quality Improvement Efforts: A Qualitative Theme Analysis.

Engaging family advisors in pediatric quality improvement (QI) efforts is well-studied in intensive care but less understood in other settings. The purpose of this study was to assess the perceived impact of including a family advisor as a colead on a QI initiative that successfully improved the family-centered timing of routine morning blood tests performed on pediatric inpatients. Five structured written reflections from core QI team members were analyzed using inductive thematic analysis and 3 major themes were identified. The first found that a family advisor’s presence from the beginning of a QI initiative helps inform project design. The second determined that family partners working with residents fostered a better shared understanding of the role of trainees and caregivers in improving the quality of care. The third found that a family partner is an effective change agent to enact practice improvement, support professional development, and enhance resident education. Our qualitative analysis showed that engaging a family advisor as a colead influenced the design, implementation, and post-intervention impact of the initiative and improved family-centered outcomes.

Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement.

To protect children from harm, clinicians, educators, and patient safety champions need information to direct improvement efforts. Critical incident data could provide this but are often disregarded as a source of evidence because under-reporting makes them an inaccurate measure of error rates. Our aim was to identify key targets for pediatric healthcare quality improvement. The objective was to evaluate the types, characteristics, and areas of risk within reported medication errors in pediatric patients. We conducted a retrospective study of a large regional dataset of 1522 pediatric medication errors reported from secondary care between 2011 and 2015, including all hospitals and community pediatric settings in Northern Ireland. The following characteristics were included: error severity, patient age, drug involved, error type, and area of practice. Two academic pediatricians, a senior medicines governance pharmacist, a Reader in Pharmacy Practice, and a Professor of Medical Education analyzed the data. Validity checks included comparing the findings against key published literature and discussion by a practitioner panel representing five multidisciplinary stakeholder groups. Neonates, particularly in intensive care, were implicated in 19% of all errors. The medications most represented in risk were antimicrobials, paracetamol, vaccines, and intravenous fluids. The error types most implicated were dosing errors (32%) and omissions (21%). Incident reports identified neonates, a shortlist of drugs, and specific error types, associated with modifiable behaviors, as priority improvement targets. These findings direct further study and inform intervention development, such as specific training in calculations to prevent dosing errors. Involving experienced practitioners both endorsed the findings and engaged the practice community in their future implementation. The utility of incident reports to direct improvement efforts may offset the limitations in their representativeness.

Quality Improvement in a Pandemic.

Quality Improvement in a Pandemic.

Non-Accidental Trauma Associated with Withdrawal of Life-Sustaining Medical Treatment in Severe Pediatric Traumatic Brain Injury

In highly developed countries, as many as 16 percent of children are physically abused each year. Traumatic brain injury (TBI) is the most common injury in non-accidental trauma (NAT) and is responsible for 80 percent of fatal NAT cases, with most deaths occurring in children younger than three years old. Cases of abusers who refuse withdrawal of life-sustaining medical treatment (LSMT) to avoid criminal charges have previously been reported. Therefore, we hypothesized that NAT is associated with a lower risk for withdrawal LSMT in pediatric TBI. The pediatric Trauma Quality Improvement Program database was analyzed (2014 to 2016) for patients aged 16 and younger with TBI and Glasgow Coma Scale (GCS) of 8 and lower on admission. Patients with a head Abbreviated Injury Scale (AIS) of 2 or less or who died within 48 hours were excluded. A multivariable logistic regression model was used for analysis. Of 2,209 TBI patients, 92 (4.2 percent) had withdrawal of LSMT. Compared to those without withdrawal of LMST, those with LMST had statistically similar median age (three years of age versus seven years) and a higher rate of NAT (33.7 percent versus 13.5 percent). The most common specified perpetrator was a father/stepfather/male partner (70 percent). After adjusting for covariates, factors associated with higher risk for withdrawal of LSMT included age of less than three years (OR 2.38, CI 1.34-4.23) and NAT (OR 1.86, CI 1.02-3.41). NAT is associated with increased risk for withdrawal of LSMT in pediatric TBI. Age of less than three years is similarly associated with a higher risk for withdrawal of LSMT. Future research in this population is needed to determine what other factors predict withdrawal of LSMT and what resources, such as social workers and/or ethics consults, are utilized.

Variation in acute fluid resuscitation among pediatric burn centers

BackgroundAccurate resuscitation of pediatric patients with large thermal injury is critical to achieving optimal outcomes. The goal of this project was to describe the degree of variability in resuscitation guidelines among pediatric burn centers and the impact on fluid estimates. MethodsFive pediatric burn centers in the Pediatric Injury Quality Improvement Collaborative (PIQIC) contributed data from patients with ≥15% total body surface area (TBSA) burns treated from 2014 to 2018. Each center's resuscitation guidelines and guidelines from the American Burn Association were used to calculate estimated 24-h fluid requirements and compare these values to the actual fluid received. ResultsDifferences in the TBSA burn at which fluid resuscitation was initiated, coefficients related to the Parkland formula, criteria to initiate dextrose containing fluids, and urine output goals were observed. Three of the five centers’ resuscitation guidelines produced statistically significant lower mean fluid estimates when compared with the actual mean fluid received for all patients across centers (4.53 versus 6.35ml/kg/% TBSA, p<0.001), (4.90 versus 6.35ml/kg/TBSA, p=0.002) and (3.38 versus 6.35ml/kg/TBSA, p<0.0001). ConclusionsThis variation in practice patterns led to statistically significant differences in fluid estimates. One center chose to modify its resuscitation guidelines at the conclusion of this study.

Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma

Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P=not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P=0.04) and posterior tibial nerve injury (13.3% vs. 0%, P=0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P=0.008) and tibia/fibula (0% vs. 39.5%, P=0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI]=59.21-1,485.47, P<0.001), closed patella fracture/dislocation (OR 50.0, CI=24.22-103.23, P<0.001), open femur fracture/dislocation (OR 9.05, CI=3.56-22.99, P<0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI=3.81-14.55, P<0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI=1.80-11.59, P<0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI=13.22-541.70, P<0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI=24.50-110.31, P<0.001). A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.

Intracranial pressure monitoring associated with increased mortality in pediatric brain injuries.

BackgroundUtilization of ICP monitors for pediatric patients is low and varies between centers. We hypothesized that in more severely injured patients (GCS 3–4), there would be a decreased mortality associated with invasive monitoring devices.MethodsThe pediatric Trauma Quality Improvement Program (TQIP) was queried for patients aged ≤ 16 years meeting criteria for invasive monitors. Our primary outcome was mortality. Patients with ICP monitoring were compared to those without. A logistic regression was used to examine the risk of mortality.ResultsOf 3,808 patients, 685 (18.0%) underwent ICP monitoring. ICP monitors were associated with increased risk of mortality (OR 1.82, CI 1.36–2.44, p < 0.001). A secondary analysis including type of invasive ICP monitor and dividing GCS into 3 categories revealed both intraventricular drain (OR 1.89, CI 1.3–2.7, p = 0.001) and intraparenchymal pressure monitor (OR 1.86, CI 1.32–2.6, p < 0.001) to be independently associated with an increased likelihood of mortality regardless of GCS, while intraparenchymal oxygen monitoring was not (OR 0.47, CI 0.11–2.05, p = 0.316). The strongest effect was seen in those patients with a GCS of 5–6.ConclusionICP monitors are an independent risk factor for mortality, particularly with intraventricular drains and intraparenchymal monitors in patients with a GCS 5–6.

Managing Diagnostic Uncertainty in Pediatric Sepsis Quality Improvement with a Two-Tiered Approach.

A 2-tiered clinical pathway was implemented at 6 pediatric emergency departments and urgent care centers, incorporating order sets, education, paging. The Sepsis Stat pathway included 2 nurses, hand delivery of antibiotics, resuscitation room use. The Sepsis Yellow pathway included prioritized orders, standardized procedures, close monitoring, and evaluation of whether antibiotics were warranted. From April 2012 to December 2017, we treated 3,640 patients with suspected and confirmed sepsis. Among the 932 severe sepsis patients, the 30-day, in-hospital mortality was 0.9%. Arrival to recognition time improved from 50 to 4 minutes. Recognition to antibiotic time demonstrated an in-control process in our goal range with a median of 43 minutes for Sepsis Stat patients, 59 minutes for Sepsis Yellow patients. The proportion of severe sepsis patients requiring intensive care unit care declined from 45% to 34%. On the Sepsis Yellow pathway, 23% were de-escalated with discharge to home without antibiotics. This novel 2-tiered approach to pediatric sepsis quality improvement in varied emergency care settings improved process and outcome measures in severe sepsis while promoting stewardship and de-escalation where appropriate. Matching resources to the degree of illness was important in supporting quality care in potentially septic children.

Predictors and Outcomes of Laparoscopy in Pediatric Trauma Patients: A Retrospective Cohort Study.

Introduction: Laparoscopy has been shown to offer a safe alternative to laparotomy in hemodynamically stable pediatric trauma patients. Our purpose was to identify factors predictive of this approach and examine surgical outcomes. Methods: This is a retrospective cohort study using the ACS Pediatric Trauma Quality Improvement Program to examine pediatric patients who underwent exploration for blunt or penetrating abdominal trauma in 2014 and 2015. Patients with contraindications to laparoscopy were excluded. Multivariable modeling identified predictors of a laparoscopic approach. Secondary analysis assessed differences in outcomes and resource utilization between laparoscopy and laparotomy groups. Results: A total of 160 patients met inclusion criteria. Patients undergoing surgery in the northeastern (odds ratio [OR]: 2.25, 95% confidence interval [CI]: 1.26-4.03, P = .006) and western (OR: 2.03, 95% CI: 1.06-3.88, P = .032) U.S. regions had over two times greater odds of undergoing laparoscopy as those treated in the south. Patients injured by a firearm were significantly less likely to undergo laparoscopy than those suffering blunt injury (OR: 0.27, 95% CI: 0.13-0.55, P < .001). After adjustment, patients explored laparoscopically in comparison with those through laparotomy had decreased average length of stay (LOS) (mean difference [MD]: 2.55 days, 95% CI: 1.19-3.90, P < .001) and number of intensive care unit (ICU) days (MD: 1.13 days, 95% CI: 0.28-1.98, P = .01). Conclusion: Trauma laparoscopy may decrease LOS and ICU days in select pediatric patients requiring abdominal exploration; however, laparoscopy is not uniformly practiced in the United States. Targeted education and protocols for initial use of laparoscopy should be incorporated into hospitals treating this group to minimize morbidity and resource utilization.

Using Epidemiology and Pediatric Direction to Inform Air Medical Quality Improvement

IntroductionPediatric air transport research is limited, especially scene transport. Study purpose was to review transport epidemiology, outcomes, and documentation to inform development of a pediatric flight quality improvement (QI) program and outreach. MethodsStudy design was ongoing review and analysis of flight, ED, EMS and hospital records over 2 years from children ≤ 18 years transported by a regional flight program. Mission type included trauma, medical, scene and interfacility. Records were reviewed monthly by a pediatric medical director (PMD) with ongoing QI and educational initiatives. Peer review was added in year two. Demographic and outcome variables included weight, times, procedures, pain scales, Glasgow Coma Scale (GCS), medications, disposition, etc. Two QI focus areas were studied using QI Macros®: weight and pain documentation. ResultsChildren accounted for 8% of total flights (165/2076). Transport was 58% scene; 42% interfacility. Median dispatch to arrival time was 21 minutes. Saturday accounted for 24% of flights. Mean scene GCS was 12; 39 (24%) patients were intubated. Scene weight in kilograms improved 18% and pain documentation improved from 49% to 79% during the study. ConclusionAddition of PMD, peer and outcome review processes provided opportunities for improving pediatric transport QI initiatives and targeted outreach education.

Analysis of blunt cerebrovascular injury in pediatric trauma.

Blunt cerebrovascular injury (BCVI) occurs in <1% of pediatric patients. The two principal screening criteria for BCVI in children are the Utah and McGovern Score with motor vehicle accident (MVA) considered to be a predictor for BCVI. We sought to confirm previously reported risk factors and identify novel associations with BCVI in pediatric patients. The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years presenting after blunt trauma. A multivariable logistic regression was used to determine risk of BCVI. From 69,149 pediatric patients, 109 (<0.2%) had BCVI. The median age was 13 years, and the median Injury Severity Score was 25. More than half the patients were involved in MVAs (53.2%) and had a skull base fracture (53.2%). Factors independently associated with BCVI include skull base fracture (odds ratio [OR], 3.84; 95% confidence interval [CI], 2.40-6.14; p < 0.001), cervical spine fracture (OR, 3.15; 95% CI, 1.91-5.18; p < 0.001), intracranial hemorrhage (OR, 3.11; 95% CI, 1.89-5.14; p < 0.001), Glasgow Coma Scale score of 8 or less (OR, 2.11; 95% CI, 1.33-3.54; p = 0.003), and mandible fracture (OR, 1.99; 95% CI, 1.05-3.84; p = 0.04). Motor vehicle accident was not an independent predictor for BCVI (p = 0.07). In the largest analysis of pediatric BCVI to date, skull base fracture had the strongest association with BCVI. Other associations to pediatric BCVI included cervical spine and mandible fracture. Motor vehicle accident, previously identified to be associated with BCVI, was not an independent risk factor in our analysis. A future multicenter study incorporating newly identified variables in a scoring system to screen for BCVI is warranted. Level IV (Prognostic/Epidemiologic).

Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study

Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally. The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals. We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation. Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications). Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.

Publication Bias Among Conference Abstracts Reporting on Pediatric Quality Improvement Projects.

This study evaluated progress to publication of pediatric quality improvement (QI) projects initially presented as national conference abstracts, according to project findings and other characteristics. QI abstracts were identified among presentations at the 2010-2015 American Academy of Pediatrics National Conference & Exhibition, and publications were tracked through June 2018. Positive findings (improvement on at least 1 quantitative project outcome), interventions, and analyses were correlated with journal publication. Of 142 abstracts, 128 (90%) reported positive findings. Forty-nine positive abstracts and 3 abstracts reporting negative results resulted in publication (38% vs 21%, respectively; P = .256). Median time to publication was 1.2 years for projects with positive findings, compared to >3 years for abstracts with negative findings (P = .029). Ninety percent of abstracts reported positive findings, and these abstracts progressed to publication more quickly. Overcoming publication bias for pediatric QI projects may enhance selection of promising interventions as new projects are designed.

Early Tracheostomy for Severe Pediatric Traumatic Brain Injury is Associated with Reduced Intensive Care Unit Length of Stay and Total Ventilator Days.

To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. Retrospective cohort analysis. The Pediatric Trauma Quality Improvement Program (TQIP) database. One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016. Not applicable. The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups. Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings. Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.

Nonaccidental Trauma Is an Independent Risk Factor for Mortality Among Injured Infants.

The Centers for Disease Control disclosed over 600,000 cases of child abuse or neglect in 2016. Single-institution studies have shown that nonaccidental trauma (NAT) has higher complication rates than accidental trauma (AT). Nonaccidental trauma is disproportionately represented in infants. We hypothesized that NAT would increase the risk of mortality in infants. This study aims to provide a contemporary descriptive analysis for infant trauma patients and determine the association between NAT and mortality. Infants (<1 year of age) within the Pediatric Trauma Quality Improvement Program database (2014-2016) were identified. Descriptive statistics (χ2 and t test) were used to compare NAT infants to AT infants. A multivariable logistic regression was used to determine the risk of mortality associated with select variables including NAT. From 14,965 infant traumas, most presented to a level I pediatric trauma center (53.5%) with a median injury severity score of 9. The most common mechanism was falls (48.6%), followed by NAT (14.5%). Overall mortality was 2.1%. Although most NAT infants were white (60.2%), black infants were overrepresented (23.6% vs 18.3%; P < 0.0001) compared with AT infants. The incidence of mortality was higher in NAT infants (41.6% vs 13.9%; P < 0.0001), and they were more likely to have traumatic brain injury (TBI) (63.1% vs 50.6%; P < 0.001). Nonaccidental trauma [odds ratio (OR), 2.48; P < 0.001], hypotension within 24 hours (OR, 8.93; P < 0.001), injury severity score (OR, 1.12; P < 0.001), and severe abbreviated injury scale-head (OR 1.62, P = 0.014) had the highest association with mortality. This study confirms the incidence of TBI and NAT in infants. Although providers should be vigilant for NAT, suspicion of NAT should prompt close surveillance, as there is a 2-fold increased risk of mortality independent of injury or TBI.