Evaluation of developmental metrics for utilization in a pediatric advanced automatic crash notification algorithm

Objective: Appropriate treatment at designated trauma centers (TCs) improves outcomes among injured children after motor vehicle crashes (MVCs). Advanced Automatic Crash Notification (AACN) has shown promise in improving triage to appropriate TCs. Pediatric-specific AACN algorithms have not yet been created. To create such an algorithm, it will be necessary to include some metric of development (age, height, or weight) as a covariate in the injury risk algorithm. This study sought to determine which marker of development should serve as a covariate in such an algorithm and to quantify injury risk at different levels of this metric.

Methods: A retrospective review of occupants age < 19 years within the MVC data set NASS-CDS 2000–2011 was performed. R² values of logistic regression models using age, height, or weight to predict 18 key injury types were compared to determine which metric should be used as a covariate in a pediatric AACN algorithm. Clinical judgment, literature review, and chi-square analysis were used to create groupings of the chosen metric that would discriminate injury patterns. Adjusted odds of particular injury types at the different levels of this metric were calculated from logistic regression while controlling for gender, vehicle velocity change (delta V), belted status (optimal, suboptimal, or unrestrained), and crash mode (rollover, rear, frontal, near-side, or far-side).

Results: NASS-CDS analysis produced 11,541 occupants age < 19 years with nonmissing data. Age, height, and weight were correlated with one another and with injury patterns. Age demonstrated the best predictive power in injury patterns and was categorized into bins of 0–4 years, 5–9 years, 10–14 years, and 15–18 years. Age was a significant predictor of all 18 injury types evaluated even when controlling for all other confounders and when controlling for age- and gender-specific body mass index (BMI) classifications. Adjusted odds of key injury types with respect to these age categorizations revealed that younger children were at increased odds of sustaining Abbreviated Injury Scale (AIS) 2+ and 3+ head injuries and AIS 3+ spinal injuries, whereas older children were at increased odds of sustaining thoracic fractures, AIS 3+ abdominal injuries, and AIS 2+ upper and lower extremity injuries.

Conclusions: The injury patterns observed across developmental metrics in this study mirror those previously described among children with blunt trauma. This study identifies age as the metric best suited for use in a pediatric AACN algorithm and utilizes 12 years of data to provide quantifiable risks of particular injuries at different levels of this metric. This risk quantification will have important predictive purposes in a pediatric-specific AACN algorithm.     

Long‐term effects of Hurricane Katrina on the psychological well‐being of evacuees

Hurricane Katrina of August 2005 forced more than one million people to evacuate the Gulf Coast of the United States. This study examines the psychological health and well‐being of a subset of evacuees to determine the prevalence of ongoing mental health problems. Interviews were conducted with 101 adults who evacuated to Louisville, Kentucky, and were living in the state at the one‐year anniversary of the event or had recently returned to the Gulf Coast. The psychological health and well‐being of respondents was evaluated using several well‐validated measures. More than one‐half met the criteria for post‐traumatic stress disorder and a majority were suffering from depression and anxiety. The mean quality of life score was 0.6 on a scale from 0–1, suggesting that adaptation and return to pre‐hurricane well‐being had not occurred 12 months after the storm. The potential for long‐term psychological damage exists in this sample of Hurricane Katrina evacuees. Results suggest other evacuees may also be at heightened risk.     

Nationwide risk factors for hospital readmission for subsequent injury after motor vehicle crashes

Abstract

Objective: Some drivers involved in motor vehicle crashes across the United States may be identified as at risk of subsequent injury by a similar mechanism. The purpose of this study was to perform a national review of the risk factors for hospitalization for a new injury due to a subsequent motor vehicle crash. It was hypothesized that presenting to a different hospital after subsequent injury would result in worse patient outcomes when compared to presentation at the same hospital.

Methods: The Nationwide Readmissions Database for 2010–2014 was queried for all inpatient hospitalizations with injury related to motor vehicle traffic. The primary patient outcome of interest was subsequent motor vehicle crash–related injury within 1 year. The secondary patient outcomes were different hospital subsequent injury presentation, higher Injury Severity Score (ISS), longer length of stay (LOS), and in-hospital death after subsequent injury. The analysis of secondary patient outcomes was performed only on patients who were reinjured. Univariable analysis was performed for each outcome using all variables during the index admission. Multivariable logistic regression was performed using all significant (P < .05) variables on univariate analysis. Results were weighted for national estimates.

Results: During the study period, 1,008,991 patients were admitted for motor vehicle–related injury; 12,474 patients (1.2%) suffered a subsequent injury within 1 year. From the reinjured patients, 32.9% presented to a different hospital, 48.9% had a higher ISS, and 22.1% had a longer LOS. The in-hospital mortality rate after subsequent injury was 1.1%. Presentation to a different hospital for subsequent injury was associated with a longer LOS (odds ratio [OR]?=?1.32; 95% confidence interval [CI], 1.20–1.45; P < .01) and a higher ISS (OR?=?1.38; 95% CI, 1.27–1.49; P < .01). Motorcyclists were more likely to suffer subsequent injury (OR?=?1.39; 95% CI, 1.32–1.46; P < .01) and motorcycle passengers were more likely to present to a different hospital with a subsequent injury (OR?=?2.49; 95% CI, 1.73–3.59; P < .01). Alcohol abuse was associated with subsequent injury (OR?=?1.12; 95% CI, 1.07–1.18; P < .01).

Conclusions: Nearly a third of patients suffering subsequent motor vehicle crash–related injury after an initial motor vehicle crash in the United States present to a different hospital. These patients are more likely to suffer more severe injuries and longer hospitalizations due to their subsequent injury. Future efforts to prevent these injuries must consider the impact of this fragmentation of care and the implications for quality and cost improvements.     

Comparison of recidivism rates for a teenage trauma prevention program after the addition of high-fidelity patient simulation

Objectives: We evaluated the benefits of adding high-fidelity simulation to a teenage trauma prevention program to decrease recidivism rates and encourage teens to discuss actionable steps toward safe driving.

Methods: A simulated pediatric trauma scenario was integrated into an established trauma prevention program. Participants were recruited because they were court-ordered to attend this program after misdemeanor convictions for moving violations. The teenage participants viewed this simulation from the emergency medical services (EMS) handoff to complete trauma care. Participants completed a postsimulation knowledge assessment and care evaluation, which included narrative data about the experience. Qualitative analysis of color-coded responses identified common themes and experiences in participants' answers. Court records were reviewed 6 years after course completion to determine short- and long-term recidivism rates, which were then compared to our program's historical rate.

Results: One hundred twenty-four students aged 16–20 years participated over a 2-year study period. Narrative responses included general reflection, impressions, and thoughts about what they might change as a result of the course. Participants reported that they would decrease speed (30%), wear seat belts (15%), decrease cell phone use (11%), and increase caution (28%). The recidivism rate was 55% within 6 years. At 6 months it was 8.4%, at 1 year it was 20%, and it increased approximately 5–8% per year after the first year. Compared with our programs, for historical 6-month and 2-year recidivism rates, no significant difference was seen with or without simulation.

Conclusions: Adding simulation is well received by participants and leads to positive reflections regarding changes in risk-taking behaviors but resulted in no changes to the high recidivism rates This may be due to the often ineffectiveness of fear appeals.     

Ocean waves and roadside spirits: Thai health service providers' post-tsunami psychosocial health

A massive earthquake off the west coast of Sumatra in Indonesia triggered a tsunami on 26 December 2004. At least five million people around the world were affected, and the total number of deaths exceeded 280,000. In Thailand, the tsunami struck six southern provinces, where the disaster's immediate impact was catastrophic. Based on ethnographic fieldwork in Phang Nga Province (2007), this paper provides an overview of the disaster's psychosocial consequences for Thai health service providers, the vast majority of whom were bypassed by regional post-tsunami mental health initiatives. The available tsunami literature only briefly attends to health providers' experience of professional 'burn-out', rather than explores the tsunami's wide spectrum of psychosocial effects. This research aims to remedy such oversights through 'critical medical' and 'interpretive phenomenological' analysis of the diverse and culturally-situated ways in which health providers' experienced the tsunami. The paper concludes by arguing for disaster-related psychosocial interventions to involve health providers explicitly.     

Functional outcomes of motor vehicle crash thoracic injuries in pediatric and adult occupants

Objective: Characterization of the severity of injury should account for both mortality and disability. The objective of this study was to develop a disability metric for thoracic injuries in motor vehicle crashes (MVCs) and compare the functional outcomes between the pediatric and adult populations.

Methods: Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank for the most frequently occurring Abbreviated Injury Scale (AIS) 2–5 thoracic injuries. Occupants with thoracic injury were classified as disabled or not disabled based on the FIM scale, and comparisons were made between the following age groups: pediatric, adult, middle-aged, and older occupants (ages 7–18, 19–45, 46–65, and 66+, respectively). For each age group, DR was calculated by dividing the number of patients who were disabled and sustained a given injury by the number of patients who sustained a given injury. To account for the effect of higher severity co-injuries, a maximum AIS adjusted DR (DR_MAIS) was also calculated for each injury. DR and DR_MAIS could range from 0 to 100% disability risk.

Results: The mean DR_MAIS for MVC thoracic injuries was 20% for pediatric occupants, 22% for adults, 29% for middle-aged adults, and 43% for older adults. Older adults possessed higher DR_MAIS values for diaphragm laceration/rupture, heart laceration, hemo/pneumothorax, lung contusion/laceration, and rib and sternum fracture compared to the other age groups. The pediatric population possessed a higher DR_MAIS value for flail chest compared to the other age groups.

Conclusion: Older adults had significantly greater overall disability than each of the other age groups for thoracic injuries. The developed disability metrics are important in quantifying the significant burden of injuries and loss of quality life years. Such metrics can be used to better characterize severity of injury and further the understanding of age-related differences in injury outcomes, which can influence future age-specific modifications to AIS.     

The effect of correct cross-chest clip use on injury outcomes in young children during motor vehicle crashes

Objective: Traffic crashes have high mortality and morbidity for young children. Though many specialized child restraint systems improve injury outcomes, no large-scale studies have investigated the cross-chest clip's role during a crash, despite concerns in some jurisdictions about the potential for neck contact injuries from the clips. This study aimed to investigate the relationship between cross-chest clip use and injury outcomes in children between 0 and 4 years of age.

Methods: Child passengers between 0 and 4 years of age were selected from the NASS-CDS data sets (2003–2014). Multiple regression analysis was used to model injury outcomes while controlling for age, crash severity, crash direction, and restraint type. The primary outcomes were overall Abbreviated Injury Score (AIS) 2+ injury, and the presence of any neck injury.

Results: Across all children aged 0–4 years, correct chest clip use was associated with decreased Abbreviated Injury Scale (AIS) 2+ injury (odds ratio [OR] = 0.44, 95% confidence interval [CI], 0.21–0.91) and was not associated with neck injury. However, outcomes varied by age. In children <12 months old, chest clip use was associated with decreased AIS 2+ injury (OR = 0.09, 95% CI, 0.02–0.44). Neck injury (n = 7, all AIS 1) for this age group only occurred with correct cross-chest clip use. For 1- to 4-year-old children, cross-chest clip use had no association with AIS 2+ injury, and correct use significantly decreased the odds of neck injury (OR = 0.49; 95% CI, 0.27–0.87) compared to an incorrectly used or absent cross-chest clip. No serious injuries were directly caused by the chest clips.

Conclusions: Correct cross-chest clip use appeared to reduce injury in crashes, and there was no evidence of serious clip-induced injury in children in 5-point harness restraints.     

The significance of a small, level-3 'semi evacuation' hospital in a terrorist attack in a nearby town

Terrorist attacks can occur in remote areas causing mass-casualty incidents MCIs far away from level-1 trauma centres. This study draws lessons from an MCI pertaining to the management of primary and secondary evacuation and the operational mode practiced. Data was collected from formal debriefings during and after the event, and the medical response, interactions and main outcomes analysed using Disastrous Incidents Systematic Analysis through Components, Interactions and Results (DISAST-CIR) methodology. A total of 112 people were evacuated from the scene-66 to the nearby level 3 Laniado hospital, including the eight critically and severely injured patients. Laniado hospital was instructed to act as an evacuation hospital but the flow of patients ended rapidly and it was decided to admit moderately injured victims. We introduce a novel concept of a 'semi-evacuation hospital'. This mode of operation should be selected for small-scale events in which the evacuation hospital has hospitalization capacity and is not geographically isolated. We suggest that level-3 hospitals in remote areas should be prepared and drilled to work in semi-evacuation mode during MCIs.     

‘You fix my community,you have fixed my life’: the disruption and rebuilding of ontological security in New Orleans

Using the concept of ontological security, this paper examines the physical and psychological loss of home and community following Hurricane Katrina. This qualitative longitudinal study includes 40 heads of households with school‐age children who lived in New Orleans during Hurricane Katrina. Participants describe a breakdown in their social fabric at the individual and structural/community levels that contributes to a sense of community loss and social displacement, disrupting their ontological security—their notion of safety, routine and trust in a stable environment. Three interrelated reactions were common: 1) experiencing nostalgia for their old neighbourhoods specifically and New Orleans in general; 2) experiencing a sense of loss of people and things that represented a level of security or constancy; 3) initiation of a process for re‐establishing ontological security whether or not they returned to New Orleans. The paper concludes that intangible losses have an important psychological effect on community redevelopment and recovery from trauma.