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Browsing by Author "Hewes, Hilary A."
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Item Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care(American Medical Association, 2023-01-03) Newgard, Craig D.; Lin, Amber; Malveau, Susan; Cook, Jennifer N. B.; Smith, McKenna; Kuppermann, Nathan; Remick, Katherine E.; Gausche-Hill, Marianne; Goldhaber-Fiebert, Jeremy; Burd, Randall S.; Hewes, Hilary A.; Salvi, Apoorva; Xin, Haichang; Ames, Stefanie G.; Jenkins, Peter C.; Marin, Jennifer; Hansen, Matthew; Glass, Nina E.; Nathens, Avery B.; McConnell, K. John; Dai, Mengtao; Carr, Brendan; Ford, Rachel; Yanez, Davis; Babcock, Sean R.; Lang, Benjamin; Mann, N. Clay; Pediatric Readiness Study Group; Surgery, School of MedicineImportance: Emergency 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. Objective: To 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 participants: This 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. Exposure: ED 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 measures: The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. Results: There 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 relevance: These 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.Item Life-Threatening Bleeding in Children: A Prospective Observational Study(Wolters Kluwer, 2021) Leonard, Julie C.; Josephson, Cassandra D.; Luther, James F.; Wisniewski, Stephen R.; Allen, Christine; Chiusolo, Fabrizio; Davis, Adrienne L.; Finkelstein, Robert A.; Fitzgerald, Julie C.; Gaines, Barbara A.; Goobie, Susan M.; Hanson, Sheila J.; Hewes, Hilary A.; Johnson, Laurie H.; McCollum, Mark O.; Muszynski, Jennifer A.; Nair, Alison B.; Rosenberg, Robert B.; Rouse, Thomas M.; Sikavitsas, Athina; Singleton, Marcy N.; Steiner, Marie E.; Upperman, Jeffrey S.; Vogel, Adam M.; Wills, Hale; Winkler, Margaret K.; Spinella, Philip C.; Surgery, School of MedicineObjectives: The purpose of our study was to describe children with life-threatening bleeding. Design: We conducted a prospective observational study of children with life-threatening bleeding events. Setting: Twenty-four childrens hospitals in the United States, Canada, and Italy participated. Subjects: Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included. Interventions: Children were compared according bleeding etiology: trauma, operative, or medical. Measurements and main results: Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours. Conclusions: Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.