Easter Traditions Around the World

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Issue 63 @vvrmc April 2, 2018 Easter Traditions Around the World Hungary Sweden “Sprinkling” is a popular Hungarian Easter Easter in Sweden sounds a lot like Monday tradition, in which boys playfully Halloween to me, with the children dressing sprinkle perfume, cologne or water over a up as Easter witches wearing long skirts, young women’s head, and ask for a kiss. colorful head scarves and painted red cheeks, and go from home to home in their neighbor- hoods trading paintings and drawings in the hope of receiving sweets.

Corfu, Greece The traditional of “Pot Throwing” takes place on the morning of Holy Saturday. People throw pots, pans and other earthenware out of their windows, smashing them on the street. Some say the custom of throwing of pots welcomes spring, symbol- France izing the new crops that will be gathered In the town of Haux, a giant omelet made in new pots. Others say it derives from the with 4,500 eggs that feeds 1,000 people Venetians, who on New Year’s Day used to is served up in the town’s main square. throw out all of their old items. The story goes, when Napoleon and his Czech Republic army were traveling through the south of On Easter Monday there’s a tradition in France, they stopped in a small town and which men spank women with handmade ate omelets. Napoleon liked his so much whips made of willow and decorated with that he ordered the townspeople to gather ribbons. According to legend, the willow their eggs and make a giant omelet for his is the first tree to bloom in the spring, so army the next day. the branches are supposed to transfer the tree’s vitality and fertility to the women. Brazil This is meant to be playful spanking all in Besides being crazy football fans, there’s good fun and not to cause pain. a crazy tradition of creating straw dolls to represent Judas (the apostle known for betraying Christ) and hanging them in the streets and beating them up. And many times politicians involved in scan- dals become Judas. But, it’s not all ag- gression, and on Easter Saturday, called ‘Sábado de Aleluia,’ inspires mini versions of Carnaval in many small towns to celebrate the end of Lent. VVRMC’s Family Easter Egg Hunt

Hospital Happenings

Many Hands Make Light the Load It was all hands on deck when VVRMC’s washing machine was down. You can imagine how quickly laundry would pile up here! Laura Caldelas, Director of Risk Management and Maricela Areola, Admin. Asst.helped EVS catch up. Way to exhibit UNITY!

World Down Syndrome Day Recognized with Crazy Socks

HIM The Future is Coming from SFDRCISD

Monday the Del Rio High School EMS CTE Program showed off their new Ambulance that was donated to the program by VVRMC District Board and Administration. We are proud to partner with SFDRCISD to prepare the next leaders with the tools for success. What a wonderful program SFDRCISD has created. A Premier Experience for All

The lab at our clinic came up with some Easter fun for the kids. They provided a coloring page and crayons. While kids waited in the waiting area, they colored the page. They then turned in their works of art and were given a little prize (purchased by lab staff from their own funds). The colorful masterpieces were prominently displayed. What a fun and festive way to deliver a great experience for kids and their parents.

We deliver a premier experience to every person, every time! Good Rewards

Maricela Maltos from Case Management received recognition for Unity, Quality, Accountability and Consistency from Marisol Musquiz. She consistently goes above and beyond to ensure patients are assessed in a timely fashion and authorizations/UR are completed!

Daniel Herrera was outside fulfilling his Security duties by checking stickers and disabled placards on parked cars near the main entrance. Out came Elizabeth carrying three bags filled with stuff that needed to go to a meeting. Not only did he offer to carry some bags, he INSISTED on it! He toted the bags all the way out to overflow parking. Not his job, but he was willing to help when he saw a need. Unity! Nena De la Cerda consistently shows unity by helping Elizabeth Rockey when she has a Spanish speaker on the phone. It is certainly not her job to provide translation services for Marketing but she is always willing to lend a hand to help. Unity!

Thank you to those departments who participated and wore their Doctors Day Stickers. Those who participated were eligible for a prize. Albert Lattimier, Balde Briones and Jureza Moselina.

From Gloria Ziegler General Good Stuff

MVL has reached all the way to Ormoc Leyte, Philippines! Pictured are Eugenio and Luzviminda Salangsang family of Mario Guerra EVS at VVRMC. Are we going viral????

Our very own Bernadine Peter, Population Health Coordinator and Registered Dietitian, has received a prestigious award from her Alma Mater. She got the Margaret F. Gloninger Service Award in honor of organizing an annual Asthma and Allergy Fair, annual medical missions to Belize and recognizing serious medical conditions of patients in Belize and arranging for treatment in the US. She also organized fund raisers; the largest of which was an International Food Festival held each year, and raising tens of thousands of dollars. She also ran a free medical clinic at her church which provided care to migrant workers. We are lucky to have her here! Financial Services received a heart felt thank you for the work they do to help patients find avenues to pay for healthcare! OR Kudos

On Thursday a patient had a procedure done in the OR. She left and rather than recuperating at home, she returned with flowers and gifts for everyone who attended to her before, during and after the procedure. Way to provide a premier experience OR team!!!

Pictured are Kayla Bruno, Edna Ortiz and Chelsea Gurley. In the second picture are Lulu Rodriguez and Dana Zamora. The CRNA was Howard Freeman and the surgeon was Dr. Otazo. The Institute for Therapeutic Medicine Offers a Pie Challenge to bring Awareness to Autism in Del Rio

The Institute held a Pie in the Face relay and challenge on Friday to bring awareness to Autism. They challenged VVRMC Senior Staff and two local banks to do their own pie challenge. If you want to see it live, check our facebook page.

April 2nd is nationally recognized as “World Autism Awareness Day” Help us bring awareness to Autism by wearing blue!

What is Autism Spectrum Disorder (ASD)? Autism, or autism spectrum disorder, refers to a range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication, as well as by unique strengths and differences.

Facts about Autism: 1. The Centers for Disease Control and Prevention (CDC) estimates autism’s prevalence as 1 in 68 children in the United States.

2. It is estimated that around one third of people with autism remain nonverbal.

3. Certain medical and mental health issues frequently accompany autism. They include gastrointestinal (GI) disorders, seizures, sleep disturbances, attention deficit and hyperactivity disorder (ADHD), anxiety and phobias. Information obtained from Autism Speaks Website Journal of Pediatric Surgery xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Prehospital education in triage for pediatric and pregnant patients in a regional trauma system without collocated pediatric and adult trauma centers

Sarah B. Cairo a,⁎, Malachi Fisher b, Brian Clemency c, Charlotte Cipparone d, Evelyn Quist d, Kathryn D. Bass a,e a John R Oshei Children's Hospital, Department of Pediatric Surgery, Buffalo, NY 14202, United States b Women and Children's Hospital of Buffalo, Trauma Injury Prevention and Education, Buffalo, NY 14222, United States c Erie County Medical Center, Department of Emergency Medicine, Buffalo, NY 14215, United States d Jacobs School of Medicine State University of New York at Buffalo, University at Buffalo, Buffalo, New York 14214, United States e Jacobs School of Medicine State University of New York at Buffalo, Department of Surgery, University at Buffalo, Buffalo, New York 14214, United States article info abstract

Article history: Purpose: Patient triage to the appropriate destination is critical to prehospital trauma care. Triage decisions are Received 7 January 2018 challenging in a region without collocated pediatric and adult trauma centers. Accepted 1 February 2018 Methods: A regional survey was administered to emergency medical response units identifying variability and Available online xxxx confusion regarding factors inﬂuencing patient disposition. A course was developed to guide the triage of pediatric and pregnant trauma patients. Pre- and posttests were administered to address course principles, including Key words: decision making and triage. Pediatric trauma Results: A total of 445 participants completed the course at 22 sites representing 88 different prehospital provider Trauma in pregnancy Prehospital provider education agencies. Pre- and posttests were administered to 62% of participants with an average score improvement of Quality improvement 53.4% (pretest range 30% to 56.6%; posttest range 85% to 100%). Improvements were seen in all categories includ- Trauma triage ing major and minor trauma in pregnancy, major trauma in adolescence, and knowledge of age limits and triage protocols. Conclusion: Education on triage guidelines and principles of pediatric resuscitation is essential for appropriate prehospital trauma management. Pre- and posttests may be used to demonstrate short term efﬁcacy, while ongoing evaluations of practice patterns and follow-up surveys are needed to demonstrate longevity of acquired knowledge and identify areas of persistent confusion. Level of Evidence: Level IV, Case Series without Standardized. © 2018 Elsevier Inc. All rights reserved.

1. Background Through state and nationwide initiatives to improve the care of all trauma patients, the American College of Surgeons recognized regional Trauma is a significant cause of morbidity and mortality, especially pediatric trauma centers (PTCs) to provide optimal care to injured pedi- amongst adolescent patients, with up to 89.3 per 100,000 pedestrian atric patients, defined as less than 15 years of age [5,6]. traffic injuries in the United States alone [1]. With increased awareness While early reports showed inconsistent results for pediatric and ad- of the burden of pediatric and adolescent trauma, injury prevention pro- olescent patients treated at PTCs compared to adult trauma centers grams and regional pediatric trauma centers have been established (ATCs), data from the National Trauma Data Bank demonstrate im- [2,3]. Trauma systems in the United States have evolved to include tri- proved outcomes and decreased imaging and invasive procedures with- age and management principles lowering the mortality of injured pa- out additional mortality risk for severely injured adolescent patients tients treated at trauma centers compared to nontrauma centers [4]. treated at PTCs [7]. When both adult and pediatric trauma centers are available in a given region, prehospital providers report significant confusion as to the optimal location for injured adolescent and pregnant pa- Abbreviations: PTC, Pediatric Trauma Center; ATC, Adult Trauma Center; MTC, Mixed tients [7–9]. In the U.S. there are more than 1150 trauma centers with Trauma Center; NTDB, National Trauma Database; EMT, Emergency Medical Technician; rising numbers of centers with level I designation (the highest acuity CDC, Center for Disease Control; ACS-COT, American College of Surgeons Committee on designated by the American College of Surgeons) [10]. In a 2000 review Trauma; WREMAC, Western Region Emergency Medical Advisory Committee. ⁎ Corresponding author. of the Kids' Inpatient Database, for example, 89% of injured children re- E-mail address: [email protected] (S.B. Cairo). ceived care outside of children's hospitals [11,12]. https://doi.org/10.1016/j.jpedsurg.2018.02.033 0022-3468/© 2018 Elsevier Inc. All rights reserved.

Similar confusion exists for pregnant trauma patients with physical guidelines for triage of pregnant trauma patients; (6) specific trauma trauma affecting 1 in 12 pregnant women [13]. In a system with collo- care and considerations; and (7) standardized trauma reports. The cated pediatric and adult trauma centers, there has been a movement course included several open-ended questions geared at engaging the towards over triage and over admission because of a pregnant state participants and assessing knowledge prior to institution of pre- and [14]. While some centers have reported use of gestational age as criteria posttest quizzes (Appendix 1, Pre- and posttest). The pre- and posttest for trauma team activation, there are limited data on appropriate triage quizzes included five questions each to address five topics covered in if the women's hospital is not collocated within the level I trauma center the course through multiple choice questions. Topics included case- [15]. Furthermore, research and trauma guidelines support maternal re- based scenarios to review (1) major trauma in pregnancy; (2) minor suscitation and care in order to keep the fetus alive but only rarely men- trauma in pregnancy; and (3) penetrating trauma in adolescent pa- tion trauma center designation in triage decision making [16–19]. tients. The remaining two questions were recall based to address the In this study we sought to describe regional efforts to evaluate (4) lower age limit for adult trauma center and (5) major triage factors existing knowledge of trauma triage among prehospital providers. A and decision making for adult vs. pediatric trauma centers. program was then designed to educate providers on appropriate care Course and instructor evaluations were also administered to assess abil- and implement regional protocols to introduce standardized practices ity of the course to adequately accomplish teaching goals and identify and improve patient outcomes. areas for improvement. The instructor was evaluated on (1) knowledge of subject matter; (2) preparation for class; (3) effective communication 2. Methods of material; (4) adequate response to students' questions and (5) estab- lishment of positive rapport with students, respectively. The course was An educational intervention was performed to clarify appropriate assessed for (1) its ability to meet learner's needs; (2) whether or not triage of pediatric, adolescent and pregnant trauma patients. Surveys the course offering matching the descripting in course guide; (3) the and tests were used to design and measure the effectiveness of an edu- pace of the class; (4) the use of materials and handouts and (5) class location intervention. cation and equipment (Appendix 1, course and instructor evaluation).

2.1. Study setting 2.4. Follow-up survey

There is one PTC serving all eight counties of Western New York and A follow-up survey was administered using SurveyMonkey®. The sur- treating an average of 9100 injured patients annually. The PTC has 24/7 vey was distributed through existing list serve by the Trauma Injury house obstetrical care and is the region's only level 1 NICU. The region's Prevention and Educational Outreach Coordinator. All emergency med- only designated level 1 ATC, located less than 5 miles from the PTC, has ical response providers that participated in the initial course were in- extensive resources and specialty trauma care but no pediatric specific cluded and questions were designed to assess whether or not the services. There is no labor and delivery unit at the ATC but obstetrical individuals had attended the course and whether they had acquired consultants are available 24/7 on an on-call basis. There are no other knowledge from their peers if they did not attend the course. The survey trauma centers serving the eight counties of Western New York. In also contained a brief knowledge assessment of triage protocols covered this region there are approximately 270 responding emergency medical in the course such as age of patient and other factors influencing trauma agencies (transporting and non-transporting) including a variety of first triage (Appendix 2, Follow-up Survey). responders, Emergency Medical Technician (EMT) Basic, EMT Ad- vanced, and EMT paramedics. In 2015 an active Emergency Medical Ser- 2.5. Statistical analysis vice provider was hired as the PTC Coordinator of Trauma Injury Prevention and Educational Outreach within the department of pediat- Descriptive statistics were performed using Microsoft Excel 2010 to ric surgery and trauma. describe the course participants and region served. Pre- and postopera- tive test scores were compared along with pre- and postintervention 2.2. Preliminary (formative) survey rates of adolescent trauma presentations to the regional pediatric and adult trauma centers using Microsoft Excel 2010. Confidence intervals As part of an initiative to enhance delivery of care to pediatric and means were calculated and a p valueb0.05 was used for statistical trauma patients, a regional survey was administered to emergency significance using chi-squared to compare pre- and posttest scores. medical response units regarding opportunities for EMS outreach and process improvement. The WCHOB Trauma Injury Prevention Coordi- 2.6. IRB review nator visited multiple EMS provider facilities, hospitals, and ambulance bays to administer survey at the end of 2015. Several different levels and The study protocol was reviewed by the Institutional Review Board organizations of EMS providers were included in the survey which was of the University of Buffalo and determined to be exempt from formal collected in a voluntary, anonymous fashion as part of ongoing quality review based on incorporation of existing quality improvement initia- improvement initiatives. Providers were asked open-ended questions tives and nonhuman research. regarding how to better facilitate communication and coordination of services with WCHOB. 3. Results

2.3. Outreach program 3.1. Preliminary (formative) survey

Based on the results of the initial survey, a course was developed by the 59 surveys were completed by all levels of EMS providers with the Trauma Injury Prevention and Educational Outreach team as a guide to exception of Certified First Responders at the end of 2015. With regard the triage and management of pediatric and pregnant trauma patients. to areas for improvement in pediatric trauma services participants re- The lecture, as part of the pediatric trauma and injury prevention educa- quested improvement in communication during triage, increased Con- tional outreach program, covered several topics including (1) keys to tinuing Medical Education (CME) opportunities for pediatric care, successful pediatric trauma resuscitation; (2) Center for Disease Control clearer age guidelines, feedback on critical patients, and decreased clut- Trauma Triage Guidelines; (3) review of preliminary survey of EMS pro- ter in the ED (Table 1). The survey identified areas of confusion with re- viders; (4) review of region specific age guidelines; (5) discussion and gard to factors influencing patient disposition.

Table 1 be taken into consideration when deciding on triage location for an ad- Regional outreach survey, requested areas for improvement, n (%). olescent patient while 98.4% accurately selected age alone on the post- Better communication during triage 15 (26.3) test for an average improvement of 87.6%. Increased opportunities for CME in pediatric care 9 (15.8) A course evaluation was completed by 239 (53.7%) participants to Increased clarity of age guidelines 6 (10.5) address participant satisfaction with the instructor as well as course Feedback on critical patients 5 (8.8) content. Overall, a high level of satisfaction was reported. No difference Less clutter in the Emergency Department 1 (1.8) No response 25 (43.9) was seen in scores over time though no evaluations were administered in the ﬁrst 8 sessions.

3.3. Follow-up survey Regarding familiarity with the Center for Disease Control Trauma Triage guidelines, participants reported an average score of 5 out of 10 (Appen- A follow-up survey administered via SurveyMonkey® approxi- dix 3, CDC Trauma Triage Guidelines). The majority of respondents mately 9 months after course completion was distributed to all emer- (57.9%) appropriately identi ed age as a factor affecting decision re- fi gency medical personnel from agencies identified through active EMS garding triage to ATC or PTC. In response to open ended questions on list serve. 15 organizations were represented by the responders ranging factors affecting transport decision, participants reported using severity from 1 to 13 respondents per site. 64.5% of respondents had not of injury (29.8%), size/weight (15.8%), medical direction (14.0%), preg- attended the education course on the approach to pediatric trauma nancy (10.5%), protocol (7.0%) and signs of puberty (5.3%) for decision and triage for pediatric and pregnant trauma patients. When asked making. about criteria most important in determining appropriate triage for a pediatric trauma patient, only 19% of respondents correctly identified age as the most important factor. The majority of respondents, 73%, 3.2. Trauma triage and pediatric trauma patients: EMS outreach course responded that age, height and weight, and signs of puberty should all be used. In contrast, 85% of respondents correctly identified an adult 445 EMS professionals participated in the trauma outreach course trauma center as the appropriate trauma center for a pregnant female addressing pediatric trauma triage in a total of 22 lectures. Pre- and with major trauma. In response to open ended question on the course, posttest assessment quizzes were included in the final 15 courses, ac- respondents who participated in the course reported overall satisfac- counting for 62.2% of all participants. Overall, the average pretest tion. Respondents who did not take the course acknowledged the im- score was 40.3% (standard deviation 7.7%) compared to 93.7% (standard portance of the content and desire for additional educational materials. deviation 4.8%) on the posttest for an average improvement of 53.4% (standard deviation 8.1%). The first three questions, as noted, involved case scenarios to address triage rules taught in the course. The first 4. Discussion question on major trauma in pregnancy had the highest pretest score at 65.8%. Following the course, there was some improvement with an Recent literature supports the triage of pediatric trauma patients average score of 97.4% as most participants correctly identified the preferentially to pediatric trauma centers. Recommendations for ado- need to transport a patient with major trauma to an adult trauma center lescent trauma patients, however, have been less clearly defined. This (Table 2). The second question, which addressed minor trauma in preg- appears to be in large part because of variable definitions of adolescent nancy scored slightly lower on pre- and posttest at 44.6% and 80.4% cor- trauma patients and varying criteria for triage to an adult versus a pedi- rect, respectively. While the largest proportion of participants correctly atric trauma center. This study served to evaluate the use of community triaged the patient with minor or no trauma and concerns regarding her outreach to disseminate knowledge to emergency medical personnel fetus to the facility where her obstetrician was located, several partici- and participating in a regional emergency medical advisory committee pants preferred an adult trauma center. The third and final case based to establish a standardized approach and set of guidelines for patient tri- question involved penetrating trauma in an adolescent male who is de- age. While this study supports this method of education and community scribed as being large in size and with secondary sexual characteristics. engagement, it also validates the need for ongoing exposure to educa- Despite low scores initially, a significant improvement was seen in tional materials to reinforce and solidify knowledge. scores from 47.3% correct to 95.7% as participants correctly identified Injured children represent an estimated 25% of all injured patients in age as the factor affecting triage decision rather than secondary sexual the United States with unique needs that may require treatment at a pe- characteristics or size alone (p b 0.001). diatric trauma center [8]. In 1999, the American College of Surgeons The final two questions were recall based and addressed issues in Committee on Trauma (ACS-COT) issued a statement that care for in- the course. Specifically, participants were asked to identify the lower jured children is, “optimally provided in the environment of a children's age limit for transporting a patient to the adult trauma center in the re- hospital with a demonstrated commitment to trauma care.” [20] This gion. A large proportion of participants incorrectly selected 18 years of notion has been evaluated more recently with reproducible findings of age initially (the upper age limit for transporting a patient to a pediatric improved outcomes for younger and more seriously injured children trauma center). 94.1% correctly selected 15 years of age following the in children's hospitals [11]. Though discrepancies can be identified in course. Similarly, participants most frequently responded incorrectly the literature, most prominent assessments of children (with and with- prior to the course that size and weight, age, and signs of puberty should out adolescent patients included) demonstrate equivalent and lower

Table 2 Pre- and posttest score by topic assessed in individual questions.

Pretest score Posttest score Percent CHANGE Chi-squared (p-value)

p b 0.001 Major trauma in pregnancy 65.8% 97.4% 31.6% Minor trauma in pregnancy 44.6% 80.4% 35.8% Penetrating trauma, adolescent 47.3% 95.7% 48.4% Lower age limit for ATCa 36.0% 94.1% 58.1% Major triage factor: ATC vs. PTCa 10.8% 98.4% 87.6%

a ATC: Adult Trauma Center, PTC: Pediatric Trauma Center.

Please cite this article as: Cairo SB, et al, Prehospital education in triage for pediatric and pregnant patients in a regional trauma system without collocated pediatric and a..., J Pediatr Surg (2018), https://doi.org/10.1016/j.jpedsurg.2018.02.033 4 S.B. Cairo et al. / Journal of Pediatric Surgery xxx (2018) xxx–xxx mortality for patients treated at pediatric centers in comparison to adult knowledge from course participants to other providers, this was not centers [21–25]. well established with the follow-up survey. Pregnant patients, the other specialty group addressed in this educa- WREMAC, the Western Region Emergency Medical Advisory Com- tion program, were also identified as a group in need of guidelines for mittee, functions as a regional advisory committee to develop policies, appropriate triage in a system without collocation of adult trauma ser- procedures, and protocols consistent with the standards of the State vices and a women and children's hospital. Though the obstetricians Emergency Medical Advisory Committee. One of the key roles of in this system are not based in the ATC, they are available for consulta- WREMAC is to establish standards for physicians to operate as tion 24/7. With approximately 8% of pregnancies complicated by trau- prehospital medical directors and to provide oversight in quality im- matic injury, trauma is a major contributor to poor maternal and fetal provement initiatives addressing system wide concerns [34]. As part outcomes [26]. Improved maternal and neonatal outcomes have been of this course roll out and in response to the high level of provider turn- reported in trauma centers compared to nontrauma centers [19]. over, a push has been made to include standardized triage protocols in While these studies do not specifically address the presence of an obste- the WREMAC handbook available to all emergency medical personnel trician and pediatric team, a trauma system with refined protocols for (Fig. 1). Studies on learning theory report that the greatest retention evaluation and management improves maternal resuscitation even in comes from teaching others and the least comes from lecture and inde- the absence of obstetricians [27,28]. A combined system is often pre- pendent reading. Repetitive exposure to standardized protocols and use ferred for these patients because of the high risk of preterm labor or of multimodal teaching methods will enhance knowledge retention and fetal loss in addition to the complex alterations in maternal physiology use in the field [35–37]. secondary to pregnancy [14]. Further work is needed to address the gap in the literature comparing pregnant patients managed at an ATC 4.1. Limitations and pregnant patients managed at the women's hospital or nontrauma facility equivalent in this region. As a regional, hospital based education initiative, this study has a few Across the field of trauma, including adults and pediatrics, triage de- inherent limitations. Though more than 400 providers participated in cisions are known to have a significant impact on patient outcomes [29]. the course, not all were given a pre- and posttest to assess knowledge Appropriate triage procedures have been the focus of attention for the acquisition. While this may have helped adjust course objectives or Center for Disease Control, the National Highway Traffic Safety Admin- teaching methods, the added benefit of pre- and posttests lies in identi- istration, and the ACS-COT for more than a decade after emerging evi- fying areas of weakness and opportunities for improvement. Further- dence that appropriate utilization of Level I trauma centers had the more, the follow-up survey and test were administered nearly potential for cost-savings in addition to improved patient outcomes 9 months after course completion. Only a small percentage of the [30,31]. In a review of triage decision making by emergency medical ser- providers who took the follow-up survey had participated in the vice personnel, specifically paramedics and emergency physicians, sig- educational course. This is likely because of the suboptimal response nificant differences in outcome were found in the assessment and rate and differing methods utilized to identify providers for course classification of emergent, urgent, and nonemergent/nonurgent patient enrollment and providers on the list serve utilized for distribution of categories [32]. These findings, in child, adolescent and pregnant follow-up survey. Assessing knowledge retention at decreased time trauma patients, support the need for further research defining the eti- intervals would provide useful data to the trauma outreach team and ology of differences in mortality as well as the need for standardized ap- help solidify persistent deficits in the knowledge base. While policy proaches to patient triage. updates will be issued in the coming months, the long time period The initial survey administered by the injury prevention coordinator between course completion and distribution of written, formalized identified an area of confusion with regard to appropriate triage proto- policies, is not ideal for knowledge acquisition. cols within our trauma system. Across the country, multiple governing Additionally, while this course positively impacted the individuals bodies participate in the regulation and standardization of protocols who participated, many of the providers evaluated in the follow-up sur- for triage and initial resuscitation of trauma patients. Evidence supports vey had not taken the course. As a growing trauma injury prevention standardization and use of specialized teams for transport of pediatric program, this will be addressed through repetition of the course and in- patients [33]. Most providers assessed in this study were unaware of troduction of train-the-trainer modalities. The latter method will utilize existing guidelines for triage of pediatric and pregnant trauma patients the WREMAC handbook provided to all EMS personnel and scenarios and incorrectly identified the appropriate disposition in given scenarios. employed in the course and pre- and posttest to reinforce the lessons While questions were aimed at identifying the dissemination of learned on a more regular basis. By engaging the students in the education process we anticipate improved adherence to the education points and improved longevity of knowledge.

Pediatric Triage Addendum for WREMAC/Collaborative Protocols Trauma education programs are essential in all communities and all trauma center types. This study, however, is unique to the region of Western New York with a stand-alone pediatric trauma center and a Patients who meet the NYS major trauma or CDC Guidelines for Field Triage of Injured Patients criteria should be taken to an age-appropriate trauma center, provided the total stand-alone adult trauma center located just less than 5 miles apart. time from injury to arrival at the trauma center is <60 minutes. If the time from injury to No other trauma centers are located in this region. Differences in the re- arrival at a trauma center is <60 minutes, proceed directly to the trauma center and pre- notify the trauma center as soon as possible. If the time from injury to arrival at the trauma gional trauma system may also contribute to regional differences in center is likely to be >60 minutes, contact MC to determine the appropriate destination. trauma activation and triage criteria. For example, if a provider had pre- viously worked in a region with a collocated adult and pediatric trauma To clarify hospital capabilities for adolescent trauma patients meeting the above major trauma criteria: center and 24/7 in house obstetricians at the trauma center, they may choose to send the pregnant patient with minor or no trauma to a Patients who are or who appear to be 15 years or older may be taken to Erie trauma center; a decision that would be less well supported in our re- County Medical Center (ECMC). Patients who are or appear to be 18 years or younger may be taken to Women & gional trauma system. For pediatric trauma patients, inconsistent con- Children’s Hospital of Buffalo (WCHOB). clusions regarding mortality and impact of trauma center type make it Adolescent patients (15 to 18 years old) may be transported to ECMC or WCHOB at the discretion of the EMS provider and patient/family request. essential to understand the characteristics of a trauma system and ca- EMS providers should call the expected destination facility for Medical Control if pacity for managing pediatric trauma patients prior to generalizing the they have any questions regarding the appropriate destination. results of trauma triage and disposition related studies [38]. On most recent review, only 57% of children in the United States live within Fig. 1. Pediatric triage addendum for WREMAC/collaborative protocols. 30 miles of a pediatric trauma center and nearly 45% are treated at

Please cite this article as: Cairo SB, et al, Prehospital education in triage for pediatric and pregnant patients in a regional trauma system without collocated pediatric and a..., J Pediatr Surg (2018), https://doi.org/10.1016/j.jpedsurg.2018.02.033 S.B. Cairo et al. / Journal of Pediatric Surgery xxx (2018) xxx–xxx 5 nontrauma centers making practices specific to a stand-alone PTC less [13] Jain V, Chari R, Maslovitz S, et al. Guidelines for the management of a pregnant trauma patient. J Obstet Gynaecol Can 2015;37(6):553–74. generalizable [37]. [14] Einav S, Sela HY, Weiniger CF. Management and outcomes of trauma during preg- While the education tool and survey utilized were developed inter- nancy. Anesthesiol Clin 2013;31(1):141–56. nally, they include principals of education and assessment which have [15] Sasser SM, Hunt RC, Faul M, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm been validated by long standing education programs such as Advanced Rep 2012;61(RR-1):1–20. Trauma Life Support (ATLS), Pediatric Advanced Life Support (PALS), [16] Weiner E, Gluck O, Levy M, et al. Obstetric and neonatal outcome following minor and Advanced Cardiac Life Support (ACLS). Further validation of these trauma in pregnancy. Is hospitalization warranted? Eur J Obstet Gynecol Reprod tools and collaboration with additional trauma programs on curriculum Biol 2016;203:78–81. [17] Battaloglu E, McDonnell D, Chu J, et al. Epidemiology and outcomes of pregnancy development will enhance their utility moving forward. and obstetric complications in trauma in the United Kingdom. Injury 2016;47(1): 184–7. [18] Lucia A, Dantoni SE. Trauma management of the pregnant patient. Crit Care Clin 4.2. Conclusions 2016;32(1):109–17. [19] Distelhorst JT, Krishnamoorthy V, Schiff MA. Association between hospital trauma Education on triage guidelines and principles of pediatric resuscitation designation and maternal and neonatal outcomes after injury among pregnant women in Washington state. J Am Coll Surg 2016;222(3):296–302. are essential for appropriate prehospital trauma management. Outreach [20] Bensard DD, McIntyre RC, Moore EE, et al. A critical analysis of acutely injured programming and collaboration between trauma facilities will ensure de- children managed in an adult level I trauma center. J Pediatr Surg 1994;29(1): livery of a uniform message with the support of regional advisory com- 11–8. [21] Miyata S, Haltmeier T, Inaba K, et al. Should all severely injured pediatric patients be mittees. Further research is needed to assess knowledge acquisition and treated at pediatric level I trauma centers? A national trauma data bank study. Am retention. 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VVRMC’s EMS

Del Rio Police & Bike Rodeo Department a time to celebrate kids, prevent injuries and save lives.

Del Rio Fire MAY 19, 2018 Department

9:00 AM - 12:00 PM AirEvac Life Team/ Methodist AirCare Bike Rodeo Register your child for our bike rodeo so they may take a ride on our bike track and earn a free US Customs and bicycle helmet! All children registered will be Border Protection entered into a drawing for a chance to win a new bike!!! (Must bring bike to participate.) and more! Safe Kids Day Safe Kids Day is a time to celebrate kids, prevent injuries and save lives. Join us, along with first VVRMC responders of our community, to learn how to RURAL HEALTH CLINIC prevent injuries and take steps towards making your kids safer. 1801 N. Bedell Ave. Del Rio

Call (830) 778-3632 to register your (830) 778-3632 child today! vvrmc.org/safe-kids/ BE THE VOICE 5K

Family Fun Walk/Run Del Rio Community Health Improvement Coalition Saturday, April 21, 2018

7:30-8:00am Check-in and on-site registration 8:30 am Start Start/Finish at Buena Vista Park – Bill Jewell Memorial Softball Field Parking Lot For more information or to register on line please visit www.chicdelrio.org

I am registering for the ☐5K

Registration Fee: ☐ $15* (By April 13) ☐ $20 (After April 13) ☐ $15* Youth 13-17 ☐ Children 12 and under Registration are free but must (By April 13) register** ☐ $15* All active duty military and their dependents, including on race day (with valid ID)

*Pre-Registrants will receive a commemorative souvenir. ** Souvenir may be purchased

First Name: ______Last Name: ______Gender: ☐ M ☐ F

Mailing Address: ______

Phone: ______Age at Time of Event: _____ Birth Date: ______

Email: ______

Current Base Affiliation: ☐ AD ☐ Civ Serv ☐ Contract ☐ Dep Ret ☐ N/A

Please make checks payable to CHIC. Mail registration form & fee to BCFS Health and Human Services-Del Rio, 712 E. Gibbs Suite 200, Del Rio, TX, 78840. For more information, contact Delia Ramos @ (830) 768-2755 or [email protected].

I, the undersigned voluntarily waive, discharge and release CHIC and all agencies whose property and/or personnel are used, and other sponsoring or co-sponsoring company(ies), agency(ies), or individual(s) from responsibility for any injuries or damages I may suffer as a result of my participation. I hereby certify that I am in good physical condition and an able to safely participate in this event. I will additionally permit the use of my name and pictures in broadcasts, telecasts, newspapers, brochures, etc. And I also understand that the entry fee is non-refundable and non-transferable. As a participant I certify that all information provided in this form is true and complete. Bib numbers are non-transferable and must be worn on the front of shirt to help insure accuracy of time results. Failure to return the electronic chip transponder will result in a $30 charge. I have read the entry information provided for the event and certify my compliance by my signature below.

Participant’s Signature______Date______Parent’s signature if under 18

If participant is under 18: This is to certify that my son/daughter has my permission to participate in CHIC’s 5K and related events, is in good physical condition, and that the event officials have my permission to authorize emergency treatment if necessary.

Running in an event other than the registered event will result in unofficial times and a disqualification for awards. Course limit 90 minutes

FOR USE BY RACE ORGANIZERS ONLY: PAID: ______Category: ______BIB #: ______FREE Val Verde Regional Medical Center is now eligible offering InSure FIT colorectal cancer COLORECTAL CANCER IS THE SECOND MOST COMMON CANCER KILLER, BUT IF CAUGHTscreening EARLY testsIT CAN BEfor PREVENTED, TRE patients!ATED, AND CURED. Who is eligible?

 If you are over the age of 50  If you DO NOT have a history of colorectal cancer in you or your immediate family  If you have NOT had a colonoscopy in the last 10 years  If you have NOT had a sigmoidoscopy in the last 5 years  If you have NOT had an Fecal Occult Blood Test screening in the last 12 months You could be eligible for a FREE InSure FIT screening kit!!! Just stop by one of the screening locations for more information!!!

Val Verde Regional Medical Center Val Verde Regional Medical Center Walk-in clinic FluFIT on the Frontera Office Located at 1801 N Bedell Ave. Located at 801 N Bedell Ave. (830)(830) 768-778-37269200 (830) 778 - 3735 (830) 778 - 3745