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Background: Efficient transfer of adult trauma patients to the intensive care unit (ICU) is associated with decreased emergency department (ED) length of stay (ED LOS) and improved patient outcomes. While well studied in adults, quality improvement (QI) initiatives focused on the rapid transfer of pediatric trauma patients are lacking. We report the effect of institutional system changes directed at expediting the transfer of pediatric trauma patients to the pediatric ICU (PICU)., Methods: This initiative commenced in 2013. Preliminary data regarding ED LOS for pediatric trauma patients were collected from January through December 2012 as the pre-implementation cohort. Using the plan-do-study-act (PDSA) framework of QI, the first PDSA cycle was implemented in January 2013. In subsequent PDSA cycles, we implemented the mandatory attendance of the PICU charge nurse and the PICU attending physician to all highest-level pediatric trauma activations. Throughout, ED LOS was collected and mapped on a run chart. ED LOS and variance were compared between all cycles of implementation., Results: One hundred and fifty-one pediatric patients arrived or were upgraded to the highest-level pediatric trauma activation and admitted to the PICU from 2012 through 2019. We observed a decrease in median ED LOS of 105 minutes between the pre- and post-implementation groups. With each PDSA cycle, we observed a decrease in median ED LOS and variation., Conclusion: The inclusion of the PICU charge nurse and attending physician at highest-level pediatric trauma activations facilitated more rapid access to the PICU with decreased ED LOS., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We studied pediatric bicycle accident victims (age ≤ 15 years) who were treated at our pediatric Level I trauma center during a 10-year period. Demographic data, injury severity, hospital course, and hospital cost data were collected. We compared the children who were helmeted to those who were unhelmeted. Our study cohort consisted of 516 patients. Patients were mostly male (70.2%) and white (84.7%); the median age was nine years. There were 101 children in the helmet group and 415 children in the unhelmeted group. Helmeted children were more likely to have private insurance (68.3% vs 35.9%, P < 0.001). Unhelmeted children were more likely to sustain multiple injuries (40% vs 25.7%, P = 0.008), meet our trauma activation criteria (45.5% vs 16.8%, P < 0.001), and be admitted to the hospital (42.4% vs 14.9%, P < 0.001). Helmeted children were less likely to sustain brain injuries (15.8% vs 25.8%, P = 0.037), skull fractures (1% vs 10.8%, P = 0.001), and facial fractures (1% vs 6%, P = 0.040). Median hospital costs were more expensive in the unhelmeted group. Helmet usage was suboptimal. Although most children sustained relatively minor injuries, the unhelmeted children had more injuries and higher costs than those who used helmets. Injury prevention programs are warranted.

We initiated a multidisciplinary Child Protection Team (CPT) as a subgroup of our pediatric multidisciplinary trauma peer review committee. Meetings are held monthly. Nonaccidental trauma (NAT) patients from the preceding month are reviewed. The meeting has two parts. During the open part, detectives and child protective services (CPS) workers are invited to discuss specific cases. The closed part focuses on improvement of specific processes and future outcomes. Attendance is recorded and minutes are kept. We sought to review accomplishments of this group. We retrospectively reviewed the minutes from our CPT meetings conducted between February 2014 and April 2015. We tracked attendance, cases reviewed, process improvement projects, and corrective action plans. Meeting attendance was very good-78 per cent. During the 15-month study period, we had 141 suspected NAT patients; 96 were reviewed at our meetings. CPS workers attended 53 per cent of the meetings; 13 investigations were discussed. We established a clinical practice guideline for the evaluation of NAT patients. We created a mechanism to improve compliance with follow-up skeletal surveys. Six corrective letters were sent to individuals notifying them of care concerns and opportunities for improvement. Equipment needs were identified, and we obtained a digital camera and speaker phone. We have conducted multiple educational sessions to increase awareness. Our CPT meeting has improved the care of our NAT patients and provided better communication between our hospital staff and CPS workers. We have improved inhospital processes for our NAT patients. We have provided educational opportunities to outside care providers.

Non-accidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. We sought to better understand the injury patterns and outcomes of NAT victims who were treated at our level I pediatric trauma center. Trauma registry data were used to identify NAT victims between January 2008 and December 2012. Demographic data, injury severity, hospital course, and outcomes were evaluated. One hundred and eighty-eight cases of suspected NAT were identified. Children were mostly male and white. The median age was 1.1 years; the median Injury Severity Score was 9. Traumatic brain injuries, lower extremity fractures, and skull fractures were the most common injuries. Twenty-seven per cent required medical procedures; most were performed by orthopedic surgery. Twenty-four per cent required admission to the pediatric intensive care unit. The median length of stay was two days. The mortality rate was 9.6 per cent. We generated a hot spot map of our catchment area and identified areas of our state where NAT occurs at increased rates. NAT victims sustain significant morbidity and mortality. Due to the severity of injuries, pediatric trauma surgeons should be involved in the evaluation and management of these children. Much work is needed to prevent the death and disability incurred by victims of child abuse.

Therapeutic reduction of intussusception by air or contrast enema may require surgery if the bowel is irreducible or perforates. There is no standard for the involvement of a pediatric surgeon in the workup of the condition. A regional survey of clinical practices was therefore undertaken to attempt to establish a consensus as to when the presence of a pediatric surgeon is required. Distributed to pediatric surgeons at 32 institutions, a questionnaire asked the process of imaging and reduction of infants with intussusception and the extent of pediatric surgical involvement. Surgeons at 29 institutions responded (91%). Ultrasound was used in diagnosis in 16 (55%), 13 (45%) requiring a positive ultrasound diagnosis of intussusception before attempting reduction. Three-fourths (22 [76%]) required surgeon notification that enema reduction was taking place, and one-fourth (seven [24%]) required prior surgical consultation. Only three (10%) required the presence of a surgery team member. Most (21 [72%]) did not demand one, and five (18%) indicated that surgical presence was desirable but not a necessity. There is no consensus for pediatric surgical involvement before and during reduction of an intussusception.

Complicated necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are major causes of mortality. We hypothesized that peritoneal drainage (PD) is more efficacious in SIP. Newborn infants with intestinal perforation treated with PD at our institution between 2007 and 2012 were divided into two groups: Group 1, infants with complicated NEC (n = 19), and Group 2, infants with SIP (n = 15). In Group 1, median birth weight was 705 g; median gestational age was 25.9 weeks. Median age at PD was 24 days. Six required laparotomy. Median time from PD to enteral feeds was 22.5 days. In Group 2, median birth weight was 685 g; median gestational age was 25.3 weeks. Median age at PD was 5 days. Two required laparotomy. Median time from PD to enteral feeds was 16 days. In Group 1, eight patients survived to discharge; median length of hospital stay (LOS) was 104.5 days. In Group 2, eight survived; median LOS was 109.5 days. Neither outcome was statistically significant (P = 0.73 and 0.878, respectively). Management of premature infants with intestinal perforation remains challenging. Mortality is high. Between our cohorts, there were no differences in regard to PD as definitive therapy, survival, and LOS.

Our objective was to determine the accuracy of laparoscopic evaluation to detect a contralateral patent processus vaginalis (CPPV) at initial presentation for inguinal hernia (IH) repair and the rate of CPPV relative to age, sex, and initial hernia side. We performed a 5-year retrospective review of 1580 pediatric patients with unilateral IH in which surgeons selectively used laparoscopy to evaluate for a CPPV. There were 1205 boys and 303 girls; 980 (65%) presented with right IH (RIH) and 528 (35%) with left IH (LIH). Laparoscopic evaluation was performed in 459 (47%) patients presenting with RIH and 225 (43%) patients presenting with LIH. Laparoscopic evaluation was positive for CPPV in 32 per cent of patients with RIH and 42 per cent of patients with LIH (P = 0.0168). CPPV was associated with prematurity (P = 0.0003) and age younger than 6 months (P = 0.0001) but not with sex (P = 0.55). The future contralateral occurrence rate was 1.6 per cent and recurrence rate 0.2 per cent. This study supports the accuracy of CPPV evaluation by laparoscopy. Although the rate of CPPV decreases after 6 months of age, girls older than 2 years of age have a significantly higher rate of CPPV than boys, supporting laparoscopic evaluation in older girls.

The management of intestinal malrotation without midgut volvulus is controversial. Some advocate the Ladd procedure in all patients with malrotation, whereas others propose a more selective approach. We attempted the laparoscopic Ladd procedure on nine patients who were diagnosed with intestinal malrotation without volvulus. Patient records were retrospectively reviewed. Data were collected on patient presentation, operative procedure, hospital course, and outcome. The laparoscopic Ladd procedure was successfully completed in eight patients (aged 10 weeks to 25 years). One patient required conversion to an open procedure. Operative time averaged 111 minutes (range, 77-176 minutes). Hospital stay ranged from 3 to 5 days (average, 3.6 days). All patients were discharged home on a regular diet. There was one complication and no deaths. Eight patients had complete resolution of their symptoms. The laparoscopic Ladd procedure is a safe and effective procedure for infants, children, and adults who have intestinal malrotation without midgut volvulus. The operative times, hospital stay, and clinical outcomes were acceptable. We recommend that laparoscopic intervention be considered in patients with intestinal malrotation without volvulus. Intestinal malrotation occurs along a wide spectrum of anatomic variants and clinical presentations. The management of malrotation without midgut volvulus remains controversial. Most advocate performing the Ladd procedure on all patients found to have malrotation because there is no way to know which of these patients will develop catastrophic midgut volvulus. Some propose a more selective approach because of the morbidity associated with operative intervention. There have been a number of small series and case reports describing the use of laparoscopy to diagnose and correct malrotation. Proponents of this method point out its minimally invasiveness, patients' quick recoveries, and successful outcomes. We describe our experience with the laparoscopic Ladd procedure and its long-term results.