IMPORTANCEThe 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 PARTICIPANTSA 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 MEASURESIn-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 RELEVANCEIn this cohort st...

BACKGROUND Interfacility transfer of patients from Level III/IV to Level I/II (tertiary) trauma centers has been associated with improved outcomes. However, little data are available classifying the specific subsets of patients that derive maximal benefit from transfer to a tertiary trauma center. Drawbacks to transfer include increased secondary overtriage. Here, we ask which injury patterns are associated with improved survival following interfacility transfer. METHODS Data from the National Trauma Data Bank was utilized. Inclusion criteria were adults (≥16 years). Patients with Injury Severity Score of 10 or less or those who arrived with no signs of life were excluded. Patients were divided into two cohorts: those admitted to a Level III/IV trauma center versus those transferred into a tertiary trauma center. Multiple imputation was performed for missing values, and propensity scores were generated based on demographics, injury patterns, and disease severity. Using propensity score–stratified Cox proportional hazards regression, the hazard ratio for time to death was estimated. RESULTS Twelve thousand five hundred thirty-four (5.2%) were admitted to Level III/IV trauma centers, and 227,315 (94.8%) were transferred to a tertiary trauma center. Patients transferred to a tertiary trauma center had reduced mortality (hazard ratio, 0.69; p < 0.001). We identified that patients with traumatic brain injury with Glasgow Coma Scale score less than 13, pelvic fracture, penetrating mechanism, solid organ injury, great vessel injury, respiratory distress, and tachycardia benefited from interfacility transfer to a tertiary trauma center. In this sample, 56.8% of the patients benefitted from transfer. Among those not transferred, 49.5% would have benefited from being transferred. CONCLUSION Interfacility transfer is associated with a survival benefit for specific patients. These data support implementation of minimum evidence-based criteria for interfacility transfer. LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.

ImportanceEmergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown.ObjectiveTo evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states.Design, Setting, and ParticipantsThis is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022.ExposureED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment.Main Outcomes and MeasuresThe primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states.ResultsThere were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented.Conclusions and RelevanceThese findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.

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Rationale:The presentation of sepsis and bacteremia in cutaneous and cavitary myiasis is uncommon. We present a patient, residing in a temperate region of the United States, with myiasis and sepsis from the emerging human pathogens Wohlfahrtiimonas chitiniclastica and Ignatzschineria indica.Patient concerns:A 37-year-old male patient with an 8-month history of chronic lymphedema and ulcers of the lower left extremity presented with myiasis of the left foot and leg. The patient was initially seen by his family practitioner many times and was prescribed antibiotics which he could not afford. Debridement of the myiasis was not conducted by the family practitioner due to the belief that the patient's current state of myiasis would effectively debride and eventually heal the chronic ulcers along with multiple antibiotic regimens. Over the 8-month period, the patient developed a progressive, painful, necrotizing infection of his lower left extremity.Diagnoses:Physical examination clearly showed myiasis of the patient's lower left extremity, believed to be caused by Lucilia sericata (green bottle fly). Blood cultures revealed the presence of Providencia stuartii, W chitiniclastica, and I indica to be the underlying cause of sepsis and bacteremia.Interventions:All visible maggots were extracted, debridement of devitalized tissue was performed, and the leg ulcers were wrapped in pH neutral bleach. The patient was initially treated with a broad-spectrum antibiotic regimen of vancomycin, clindamycin, piperacillin, and tazobactam which, following clinical improvement, was de-escalated to cefepime.Outcomes:The fly larvae and maggots were removed from the extremity by scrubbing, pulse lavage, and filing away the callused tissue. Additionally, the patient's sepsis and bacteremia, caused by W chitiniclastica and I indica, were successfully treated through antibiotic intervention. Amputation was avoided.Lessons:The use of pulse lavage and chlorhexidine-soaked brushes for the removal of cavitary myiasis is an effective and minimally invasive procedure which does not cause additional damage to surrounding tissue. W chitiniclastica and I indica are emerging bacteria that have known association to parasitic fly myiasis in humans and are capable of causing sepsis and/or bacteremia if not accurately identified and treated promptly.

Differential mortality on off-hours is not seen at our Level I trauma center. Outcomes that are independent of time of day and day of week may be because of the explicit requirements for trauma centers to be fully staffed and operational at all times. There are implications for staffing and systems solutions for other time-sensitive disease including ST elevation myocardial infarction, stroke, and cardiac arrest. Interventions may include the development of a categorization system based on emergency care capabilities, development of explicit staffing requirements, and requiring an emergency care-specific quality improvement program.

for the Pediatric Readiness Study Group 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 PARTICIPANTSIn 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. RESULTSOf 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 RELEVANCEChildren 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.

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