A consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation

Lerner, E. Brooke; Drendel, Amy L.; Falcone, Richard A.; Weitze, Keith C.; Badawy, Mohamed; Cooper, Arthur; Cushman, Jeremy T.; Drayna, Patrick C.; Gourlay, David M.; Gray, Matthew P.; Shah, Manish I.; Shah, Manish N.

doi:10.1097/ta.0000000000000543

Cited by 38 publications

(45 citation statements)

References 30 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…A sensitivity analysis was performed using a consensus based definition for pediatric patients requiring the highest level of trauma activation as the outcome. 18 Pediatric patients were considered to require full trauma activation if they had any one of the following criteria: 1. Definitive airway placement prehospital or in the emergency department (ED); 2.…”

Section: Methodsmentioning

confidence: 99%

The value of the injury severity score in pediatric trauma

Brown

Gestring

Leeper

et al. 2017

Journal of Trauma and Acute Care Surgery

109

View full text Add to dashboard Cite

Background The Injury Severity Score (ISS) is the most commonly used injury scoring system in trauma research and benchmarking. An ISS>15 conventionally defines severe injury; however, no studies evaluate whether ISS performs similarly between adults and children. Our objective was to evaluate ISS and AIS to predict mortality and define optimal thresholds of severe injury in pediatric trauma. Methods Patients from the Pennsylvania trauma registry 2000–2013 were included. Children were defined as age<16years. Logistic regression predicted mortality from ISS for children and adults. The optimal ISS cut-off for mortality that maximized diagnostic characteristics was determined in children. Regression also evaluated association between mortality and maximum AIS in each body-region, controlling for age, mechanism, and non-accidental trauma. Analysis was performed in single and multisystem injuries. Sensitivity analyses with alternative outcomes were performed. Results There were 352,127 adults and 50,579 children included. Children had similar predicted mortality at ISS of 25 as adults at ISS of 15 (5%). The optimal ISS cut-off in children was ISS>25 and had a positive predictive value (PPV) of 19% and negative predictive value (NPV) of 99% compared to PPV of 7% and NPV of 99% for ISS>15 to predict mortality. In single-system injured children, mortality was associated with head (OR 4.80; 95%CI 2.61–8.84, p<0.01) and chest AIS (OR 3.55; 95%CI 1.81–6.97, p<0.01), but not abdomen, face, neck, spine, or extremity AIS (p>0.05). For multisystem injury, all body region AIS were associated with mortality except extremities. Sensitivity analysis demonstrated ISS>23 to predict need for full trauma activation, and ISS>26 to predict impaired functional independence were optimal. Conclusions ISS>25 may be a more appropriate definition of severe injury in children. Pattern of injury is important, as only head and chest injury drive mortality in single-system injured children. These findings should be considered in benchmarking and performance improvement efforts. Level of Evidence III, epidemiologic

show abstract

Section: Methodsmentioning

confidence: 99%

The value of the injury severity score in pediatric trauma

Brown

Gestring

Leeper

et al. 2017

Journal of Trauma and Acute Care Surgery

109

View full text Add to dashboard Cite

show abstract

“…6, 11–16 Some suggest biomarkers such as lactate may augment standard triage criteria for predicting severe injury. 17 Lactate is a biomarker indicative of hypoperfusion, and may identify patients requiring trauma center resources.…”

Section: Introductionmentioning

confidence: 99%

Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level

Brown

Lerner

Sperry

et al. 2016

Journal of Trauma and Acute Care Surgery

Self Cite

View full text Add to dashboard Cite

Background Trauma activation level is determined by prehospital criteria. The American College of Surgeons (ACS) recommends trauma activation criteria; however, their accuracy may be limited. Prehospital lactate has shown promise in predicting trauma center resource requirements. Our objective was to investigate the added value of incorporating prehospital lactate in an algorithm to designate trauma activation level. Methods Air medical trauma patients undergoing prehospital lactate measurement were included. Algorithms using ACS activation criteria (ACS) and ACS activation criteria plus prehospital lactate (ACS+LAC) to designate trauma activation level were compared. Test characteristics and net reclassification improvement (NRI), which evaluates reclassification of patients among risk categories with additional predictive variables, were calculated. Algorithms were compared to predict trauma center need (TCN) defined as >1unit of blood in the ED; spinal cord injury; advanced airway; thoracotomy or pericardiocentesis; ICP monitoring; emergent operative or interventional radiology procedure; or death. Results There were 6,347 patients included. Twenty-eight percent had TCN. The ACS+LAC algorithm upgraded 256 patients and downgraded 548 patients compared to the ACS algorithm. The ACS+LAC algorithm versus ACS algorithm had a NRI of 0.058 (95%CI 0.044, 0.071; p<0.01), with an event NRI of −0.5% and non-event NRI of 6.2%. When weighted to favor changes in under-triage, the ACS+LAC still had a favorable overall reclassification (wNRI 0.041; 95%CI 0.028, 0.054; p=0.01). The ACS+LAC algorithm increased PPV, NPV, and accuracy. Over-triage was reduced 7.2%, while under-triage only increased 0.7%. The area under the curve (AUC) was significantly higher for the ACS+LAC algorithm (0.79 vs. 0.76, p<0.01). Conclusions The ACS+LAC algorithm reclassified patients to more appropriate levels of trauma activation when compared to the ACS algorithm. This overall benefit is achieved by significant reduction in over-triage relative to very small increase in under-triage. In the context of trauma team activation, this trade-off may be acceptable, especially in the current healthcare environment. Level of Evidence Diagnostic study, Level IV

show abstract

“…This study replicated the methods used in three prior projects that developed criterion standard definitions for various triage tools in the prehospital setting using a modified‐Delphi technique . This project was conducted by the Charlotte, Houston, and Milwaukee Prehospital (CHaMP) Node of the Pediatric Emergency Care Applied Research Network (PECARN).…”

Section: Methodsmentioning

confidence: 86%

“…Two authors (JRS and EBL) reviewed the responses to each survey, but they did not participate in the voting. The methods described below for assessing consensus were determined a priori by the two authors responsible for reviewing each survey, following methodologies set forth in prior studies conducted in the prehospital setting . If an individual criterion received fewer than 50% of the panelists’ votes during a voting round, it was removed from consideration in subsequent voting rounds.…”

Section: Methodsmentioning

confidence: 99%

Consensus‐based Criterion Standard for the Identification of Pediatric Patients Who Need Emergency Medical Services Transport to a Hospital with Higher‐level Pediatric Resources

Studnek

Lerner

Shah

et al. 2018

Academic Emergency Medicine

Self Cite

View full text Add to dashboard Cite

Background: Emergency medical services (EMS) providers must be able to identify the most appropriate destination facility when treating children with potentially severe medical illnesses. Currently, no validated tool exists to assist EMS providers in identifying children who need transport to a hospital with higher-level pediatric care. For such a tool to be developed, a criterion standard needs to be defined that identifies children who received higher-level pediatric medical care.Objective: The objective was to develop a consensus-based criterion standard for children with a medical complaint who need a hospital with higher-level pediatric resources.Methods: Eleven local and national experts in EMS, emergency medicine (EM), and pediatric EM were recruited.Initial discussions identified themes for potential criteria. These themes were used to develop specific criteria that were included in a modified Delphi survey, which was electronically delivered. The criteria were refined iteratively based on participant responses. To be included, a criterion required at least 80% agreement among participants. If an item had less than 50% agreement, it was removed. A criterion with 50% to 79% agreement was modified based on participant suggestions and included on the next survey, along with any new suggested criteria. Voting continued until no new criteria were suggested and all criteria received at least 80% agreement.

show abstract

A consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation

Cited by 38 publications

References 30 publications

The value of the injury severity score in pediatric trauma

The value of the injury severity score in pediatric trauma

Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level

Consensus‐based Criterion Standard for the Identification of Pediatric Patients Who Need Emergency Medical Services Transport to a Hospital with Higher‐level Pediatric Resources

Contact Info

Product

Resources

About