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Pediatric General Trauma Care

Date Last Search Run: Feb 01, 2022
Table last updated: May 02, 2021
Data last added: Feb 14, 2022

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)    
2 (fair evidence exists)
3 (weak evidence exists)    


Interventions

Blood transfusion
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Safety Patient PH-MD & CCT Fahy AS., Thiels CA., Polites SF., Parker M., Ishitani MB., Moir CR., et al. Prehospital blood transfusions in pediatric trauma and nontrauma patients a single-center review of safety and outcomes. Pediatr Surg Int 2017; 33(7) 787-92 Medline

BVM
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Mortality rate Patient PH-Paramedic Cooper A., DiScala C., Foltin G., Tunik M., Markenson D., Welborn C. Prehospital ETI for severe head injury in children: A reappraisal. Sem Ped Surg 2001;10:3-6. Medline

Cervical Collar
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Cervical spine flexion Patient ED-MD Treloar DJ., Nypaver M. Angulation of the pediatric cervicalspine with and without cervical collar. Pediatr Emerg Care 1997; 13:5-8.41. Medline

Crystalloid Infusion
Level Direction Primary Outcome Patient/Process Setting Reference

C-Spine Clearance
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Agreement b/w EMS and ED MD risk of CSI. Process ED-Paramedic & MD Browne LR., Schwartz H., Ahmad FA., Wallendorf M., Kuppermann N., Lerner EB., et al. Interobserver Agreement in Pediatric Cervical Spine Injury Assessment Between Prehospital and Emergency Department Providers. Academic emergency medicine 2017; 24(12) 1501-10. Medline
II Supportive (Green) Safety Patient PH-Paramedic Muhr MD., Seabrook DL., Wittwer LK. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp Emerg Care 1999; 3:1-6. Medline
II Supportive (Green) Safety Patient Pieretti-Vanmarke R., et al. Clinical clearance of the c-spine in blunt trauma patients younger than 3 years: a multi-centre study of the American Assoc for the Surgery of Trauma. J Trauma 2009; 67:543-50. Medline
II Neutral (Yellow) Identification of spinal injury Patient PH-Paramedic Domeier RM., Evans RW., Swor RA., et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp Emerg Care 1999; 3:332-7. Medline
II Neutral (Yellow) Kappa Process PH-Paramedic Meldon SW., Brant TA., Cydulka RK., et al. Out-of-hospital cervical spine clearance: Agreement between emergency medical technicians and emergency physicians. J Trauma: Inj, Infec and Crit Care 1998; 45(6):1058-61. Medline
II Neutral (Yellow) Kappa Patient SIM Sahni R., Menegazzi JJ., Mosesso VN. Paramedic evaluation of clinical indicators of cervical spinal injury. Prehosp Emerg Care 1997; 1(1):16-8. Medline
III Supportive (Green) C-spine injury on radiography Patient ED-MD Viccellio P., Simon H., Pressman BD., Shah MN., Mower WR., Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001; 108:e20. Medline
III Neutral (Yellow) Identification of spinal injury Patient PH-Paramedic Domeier RM., Evans RW., Swor RA., et al. Prehospital clinical findings associated with spinal injury. Prehosp Emerg Care 1997; 1:11-5. Medline

Fentanyl
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Analgesia Patient ED-MD Borland M., Jacobs I., King B., O'Brien D. A RCT comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the ED. Ann Emerg Med 2007; 49:335-40. Medline
I Supportive (Green) Pain scores at time zero and every 10 min until 30 min Patient ED-MD Borland M., Milsom S., Esson A. Equivalency of two concentrations of fentanyl administered by the intranasal route for acute analgesia in children in a paediatric emergency department: A randomized controlled trial. Emerg Med Australas 2011; 23(2):202-8. Medline
I Supportive (Green) Reduction in pain Patient ED-MD Furyk JS., Grabowski WJ., Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: A randomized controlled trial. Emerg Med Australas 2009; 21(3):203-9. Medline
I Supportive (Green) Rates of adverse events within 60 minutes Patient ED-MD Reynolds SL., Bryant KK., Studnek JR., Hogg M., Dunn C., Templin MA., et al. Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures. Academic emergency medicine 2017; 24(12) 1430-40. Medline
II Supportive (Green) Effective analgesia Patient PH-Paramedic Bendall JC, Simpson PM, Middleton PM. Effectiveness of prehospital morphine, fentanyl, and methoxyflurane in pediatric patients. Prehosp Emerg Care 2011; 15(2):158-65. Medline
II Supportive (Green) Analgesia Patient PH-Paramedic Harris MI, Adelgais KM, Linakis SW, Magill CF, Brazauskas R, Shah MI, Nishijima DK, Lowe GS, Chadha K, Chang TP, Lerner EB, Leonard JC, Schwartz HP, Gaither JB, Studnek JR, Browne LR. Impact of Prehospital Pain Management on Emergency Department Management of Injured Children. Prehosp Emerg Care. 2021 Dec 22:1-9. doi: 10.1080/10903127.2021.2000683. Epub ahead of print. PMID: 34734787. Medline
II Supportive (Green) Pain at 0, 10, 20 and 30 minutes. Patient ED-MD Miner JR., Kletti C., Herold M., Hubbard D., Biros MH. Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med 2007; 14(10):895-8. Medline
II Supportive (Green) Pain reduction Patient PH-Paramedic Samuel N., Steiner IP., Shavit I. Prehospital pain management of injured children: A systematic review of current evidence. Am J Emerg Med 2015; 33(3):451-4. Medline
III Supportive (Green) Decrease Pain Patient ED-MD Cole J., Shepherd M., Young P. Intranasal fentanyl in 1-3-year-olds: A prospective study of the effectiveness of intranasal fentanyl as acute analgesia. Emerg Med Australas 2009; 21(5):395-400. Medline
III Supportive (Green) Pain reduction Patient PH-Paramedic Murphy AP., Hughes M., Mccoy S., Crispino G., Wakai A., O'Sullivan R. Intranasal fentanyl for the prehospital management of acute pain in children. European journal of emergency medicine 2017; 24(6) 450-4. Medline
X Not Yet Graded (White) - Abebe Y, Hetmann F, Sumera K, Holland M, Staff T. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29(1):170. Medline

HEMS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) In-hospital Survival Patient Brown JB., Leeper CM., Sperry JL., et al. Helicopters and injured kids: Improved survival with scene air medical transport in the pediatric trauma population. The journal of trauma and acute care surgery. 2016;80(5):702-10. Medline
II Supportive (Green) In-hospital mortality Patient PH-Paramedic & CCT Englum BR., Rialon KL., Kim J., et al. Current use and outcomes of helicopter transport in pediatric trauma: A review of 18,291 transports. J Pediatr Surg. 2017;52(1):140-144. Medline
II Supportive (Green) PTS Process Other Patel SC., Murphy S., Penfil S., Romeo D., Hertzog JH. Impact of Interfacility Transport Method and Specialty Teams on Outcomes of Pediatric Trauma Patients. Pediatr Emerg Care 2018; 34(7) 467-72. Medline
II Neutral (Yellow) Need for time-sensitive intervention Patient Meyer MT., Gourlay DM., Weitze KC., et al. Helicopter interfacility transport of pediatric trauma patients: Are we overusing a costly resource? The journal of trauma and acute care surgery. 2016;80(2):313-7. Medline
II Neutral (Yellow) Factors influencing GEMS vs HEMS for rural pediatric trauma patients. Process Other Starnes AB., Oluborode B., Knoles C., Burns B., McGinnis H., Stewart K. Direct Air Versus Ground Transport Predictors for Rural Pediatric Trauma. Air Med J; 37(3) 165-9. Medline
II Opposes (Red) Hospital length of stay Patient Other Farach SM., Walford NE., Bendure L., Amankwah EK., Danielson PD., Chandler NM. Helicopter Transport From the Scene of Injury Are There Improved Outcomes for Pediatric Trauma Patients? Pediatr Emerg Care 2018; 34(5) 344-8. Medline
X Not Yet Graded (White) - Duffens A, Grigorian A, de Virgilio C, Chin T, Kim D, Lekawa M, Schubl SD, Nahmias J. Association of Risk of Mortality in Pediatric Patients Transferred From Scene by Helicopter With Major But Not Minor Injuries. Pediatr Emerg Care 2022; 38(1):e287–91. Medline

Hypertonic Saline
Level Direction Primary Outcome Patient/Process Setting Reference

Intubation
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Mortality rate Patient PH-Paramedic Cooper A., DiScala C., Foltin G., Tunik M., Markenson D., Welborn C. Prehospital ETI for severe head injury in children: A reappraisal. Sem Ped Surg 2001;10:3-6. Medline

Intubation with in-line stabilization
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Time to success Process Madziala M., Smereka J., Dabrowski M., Leung S., Ruetzler K., Szarpak L. A comparison of McGrath MAC® and standard direct laryngoscopy in simulated immobilized cervical spine pediatric intubation: a manikin study. Eur J Pediatr 2017; 176(6):779-786. Medline
III Supportive (Green) Time to intubation Process SIM Nishisaki A., Scrattish L., Boulet J., Kalsi M., Maltese M., Castner T., et al. Effect of cervical spine immobilization technique on pediatric advanced airway management: a high-fidelity infant simulation model. Pediatr Emerg Care 2008; 24(11):749-56. Medline
III Neutral (Yellow) First pass success Process Madziala M., Smereka J., Dabrowski M., Leung S., Ruetzler K., Szarpak L. A comparison of McGrath MAC and standard direct laryngoscopy in simulated immobilized cervical spine pediatric intubation: A manikin study. Eur J Pediatr. 2017;176(6):779-786. Medline

Ketamine
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Tolerance to procedure Patient ED-MD Qureshi FA., Mellis PT., McFadden MA. Efficacy of oral ketamine for providing sedation and analgesia to children requiring laceration repair. Pediatr Emerg Care 1995; 11(2):93-7. Medline
I Supportive (Green) Rates of adverse events within 60 minutes Patient ED-MD Reynolds SL., Bryant KK., Studnek JR., Hogg M., Dunn C., Templin MA., et al. Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures. Academic emergency medicine 2017; 24(12) 1430-40. Medline
I Neutral (Yellow) VAS Patient ED-MD Rubinstein O., Barkan S., Breitbart R., et al. Efficacy of oral ketamine compared to midazolam for sedation of children undergoing laceration repair: A double-blind, randomized, controlled trial. Medicine. 2016;95(26):e3984. Medline
II Supportive (Green) Pain reduction Patient PH-Paramedic Samuel N., Steiner IP., Shavit I. Prehospital pain management of injured children: A systematic review of current evidence. Am J Emerg Med 2015; 33(3):451-4. Medline
X Not Yet Graded (White) - Abebe Y, Hetmann F, Sumera K, Holland M, Staff T. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29(1):170. Medline
X Not Yet Graded (White) - Bredmose P., Grier G., Davies G., Lockey D. Pre-hospital use of ketamine in paediatric trauma. Acta Anaesthesiol Scand 2009; 53:543–5. Medline
X Not Yet Graded (White) - Guthrie AM, Baum RA, Carter C, Dugan A, Jones L, Tackett T, et al. Use of Intranasal Ketamine in Pediatric Patients in the Emergency Department. Pediatr Emerg Care 2021; 37(12):e1001–7. Medline

Long Spinal Immobilization Devices
Level Direction Primary Outcome Patient/Process Setting Reference
II Opposes (Red) Self-reported pain Patient PH-Paramedic Leonard J., Mao J., Jaffe D. Potential Adverse Effects of Spinal Immobilization on Children. PEC 2012; 16:513-518. Medine

Manual Intraosseous Insertion
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) First attempt success Patient Sunde G., Heradstveit B., Vikenes B., HeltneJ. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Trauma, Resus and Emerg Med 2010; 18:52. Medline
III Supportive (Green) Insertion time Process Hartholt KA., van Lieshout EM., Thies WC., Patka P., Schipper IB. Intraosseous devices: A randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care 2010; 14(1):6-13. Medline
III Supportive (Green) In-hospital mortality Patient ICU Olaussen A., Williams B. Intraosseous access in the prehospital setting: Literature review. Prehosp Disaster Med 2012; 27(5):468-72. Medline
III Neutral (Yellow) Time to ED treatment Process Fiorito BA., Mirza F., Doran TM., et al. Intraosseous access in the setting of pediatric critical care transport. Pediatr Crit Care Med 2005; 6(1):50-3. Medline
III Neutral (Yellow) Success rate Process SIM Shavit I., Hoffmann Y., Galbraith R., Waisman Y. Comparison of two mechanical intraosseous infusion devices: A pilot, randomized crossover trial. Resuscitation 2009; 80(9):1029-1033. Medline

Mechanical Intraosseous Insertion
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) First attempt success Patient Sunde G., Heradstveit B., Vikenes B., HeltneJ. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Trauma, Resus and Emerg Med 2010; 18:52. Medline
III Supportive (Green) Success rate on first attempt Process Gazin N., Auger H., Jabre P., et al. Efficacy and safety of the EZ-IO intraosseous device: Out-of-hospital implementation of a management algorithm for difficult vascular access. Resuscitation 2011; 82(1):126-9. Medline
III Supportive (Green) Insertion time Patient Hartholt KA., van Lieshout EM., Thies WC., Patka P., Schipper IB. Intraosseous devices: A randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care 2010; 14(1):6-13. Medline
III Supportive (Green) Predictive value Process PH-Paramedic Horton MA., Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatr Emerg Care 2008; 24(6):347-50. Medline
III Supportive (Green) Prediction Process ED-MD Olaussen A., Williams B. Intraosseous access in the prehospital setting: Literature review. Prehosp Disaster Med 2012; 27(5):468-72. Medline
III Supportive (Green) Neurologic recovery Patient PH-Paramedic Santos D., Carron PN., Yersin B., Pasquier M. EZ-IO(®) intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature. Resuscitation 2013; 84(4):440-5. Medline
III Supportive (Green) Time to view Process SIM Shavit I., Hoffmann Y., Galbraith R., Waisman Y. Comparison of two mechanical intraosseous infusion devices: A pilot, randomized crossover trial. Resuscitation 2009; 80(9):1029-1033. Medline

Methoxyflurane (Penthrox)
Level Direction Primary Outcome Patient/Process Setting Reference
X Not Yet Graded (White) - Abebe Y, Hetmann F, Sumera K, Holland M, Staff T. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29(1):170. Medline

Morphine
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Analgesia Patient ED-MD Borland M., Jacobs I., King B., O'Brien D. A RCT comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the ED. Ann Emerg Med 2007; 49:335-40. Medline
II Supportive (Green) Effective analgesia Patient PH-Paramedic Bendall JC, Simpson PM, Middleton PM. Effectiveness of prehospital morphine, fentanyl, and methoxyflurane in pediatric patients. Prehosp Emerg Care 2011; 15(2):158-65. Medline
II Supportive (Green) Analgesia Patient PH-Paramedic Harris MI, Adelgais KM, Linakis SW, Magill CF, Brazauskas R, Shah MI, Nishijima DK, Lowe GS, Chadha K, Chang TP, Lerner EB, Leonard JC, Schwartz HP, Gaither JB, Studnek JR, Browne LR. Impact of Prehospital Pain Management on Emergency Department Management of Injured Children. Prehosp Emerg Care. 2021 Dec 22:1-9. doi: 10.1080/10903127.2021.2000683. Epub ahead of print. PMID: 34734787. Medline
II Supportive (Green) Pain reduction Patient PH-Paramedic Samuel N., Steiner IP., Shavit I. Prehospital pain management of injured children: A systematic review of current evidence. Am J Emerg Med 2015; 33(3):451-4. Medline
III Neutral (Yellow) Rate of missed appendicitis Process ED-MD Green R., Bulloch B., Kabani A., Hancock BJ., Tenenbein M. Early analgesia for children with acute abdominal pain. Pediatrics 2005; 116(4):978-83. Medline
X Not Yet Graded (White) - Abebe Y, Hetmann F, Sumera K, Holland M, Staff T. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29(1):170. Medline

Nitrous Oxide
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Analgesia Patient PH-Paramedic McKinnon KDL. Prehospital analgesia with nitrous oxide/oxygen. CMA Journal 1981; 125:836-40. Medline
III Supportive (Green) Depth of sedation Process ED-MD Babl FE., et al. High-concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation. Pediatrics 2007:121-e528-32. Pediatrics
III Supportive (Green) Pain behaviour Patient ED-MD Gamis AS., Knapp JF., Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med 1989; 18(2):177-81. Medline

Optimal Trip Destination
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Neurologic outcome Patient PH-Paramedic Anders JF., Adelgais K., Hoyle JD. Jr., et al. Comparison of outcomes for children with cervical spine injury based on destination hospital from scene of injury. Acad Emerg Med 2014; 21(1):55-64. Medline
II Supportive (Green) Risk adjusted in-hospital mortality Patient In-Patient Elkbuli A., Lopez JR., Villarroel PP., Ang D., Liu H., Boneva D., et al. Comparison of Outcomes for Pediatric Trauma at Different Types of Trauma Centers The Unresolved Mystery. Am Surg 2018; 84(6) 1054-7. Medline
II Supportive (Green) In-hospital mortality Patient ED-MD Mitchell RJ., Curtis K., Testa L., Holland AJ., Sv SS, Adams S. Differences in survival outcome for severely injured paediatric trauma by type of trauma centre. J Paediatr Child Health 2017; 53(8) 808-13. Medline
II Supportive (Green) Mortality Patient ED-MD Miyata S., Cho J., Park H., Matsushima K., Bliss DW. Comparison of outcomes in severe pediatric trauma at adult trauma centers with different trauma case volumes. J Pediatr Surg 2017; 52(11) 1831-5. Medline
II Supportive (Green) Mortality Process ED-MD Miyata S., Haltmeier T., Inaba K., Matsushima K., Goodhue C., Bliss DW. Should all severely injured pediatric patients be treated at pediatric level I trauma centers? A national trauma data bank study. Am Surg 2015; 81(10):927-31. Medline
II Supportive (Green) Mortality Patient Rogers AT, Gross BW, Cook AD, Rinehart CD, Lynch CA, Bradburn EH, et al. Outcome differences in adolescent blunt severe polytrauma patients managed at pediatric versus adult trauma centers. The journal of trauma and acute care surgery 2017; 83(6):1082-7. Medline
II Neutral (Yellow) Secondary transport Process PH-Paramedic Fishe JN, Psoter KJ, Klein BL, Anders JF. Retrospective Evaluation of Risk Factors for Pediatric Secondary Transport. Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors; 22(1):41-9. Medline
II Neutral (Yellow) Time to first clinician review Process Other Lin YC., Lee YT., Feng JXY., Chiang LW., Nah SA. Prehospital Transport for Pediatric Trauma A Comparison of Private Transport and Emergency Medical Services. Pediatr Emerg Care 2017; 33(12) 781-3. Medline
III Neutral (Yellow) Transport destination Process PH-Paramedic Lerner EB., Studnek JR., Fumo N., Banerjee A., Arapi I., Browne LR., et al. Multicenter Analysis of Transport Destinations for Pediatric Prehospital Patients. Academic emergency medicine 2018. Medline
X Not Yet Graded (White) - Larson JT., Dietrich AM., Abdessalam SF., Werman HA. Effective use of the air ambulance for pediatric trauma. J Trauma 2004; 56(1):89-93. Medline

Sedation
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Safety Patient McGlone RG., Howes MC., Joshi M. The lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis. Emerg Med J 2004; 21(3):290-5. Medline
II Neutral (Yellow) Adverse events Patient Migita RT., Klein EJ., Garrison MM. Sedation and analgesia for pediatric fracture reduction in the emergency department: A systematic review. Arch Pediatr Adolesc Med 2006; 160(1):46-51. Medline
III Neutral (Yellow) Adverse events Patient Bellolio MF., Puls HA., Anderson JL., Gilani WI., Murad MH., Barrionuevo P., et al. Incidence of adverse events in paediatric procedural sedation in the emergency department: A systematic review and meta-analysis. BMJ open 2016; 6(6):e011384. Medline
X Not Yet Graded (White) - Acworth JP., Purdie D., Clark RC. Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation. Emerg Med J 2001; 18(1):39-45. Medline

Shock Prediction Tool
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Mortality Process In-Patient Vandewalle RJ, Peceny JK, Dolejs SC, Raymond JL, Rouse TM. Trends in pediatric adjusted shock index predict morbidity and mortality in children with severe blunt injuries. J Pediatr Surg 2018; 53(2):362-6. Medline

Spinal Precautions
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Proportion of patients receiving spinal imaging Process ED-Paramedic & MD Ward CE., Badolato GM., Breslin K., Brown K., Simpson JN. Evaluation of a Selective Prehospital Pediatric Spinal Protection Protocol. PEC 2019 1-12. Medline

Thermostasis
Level Direction Primary Outcome Patient/Process Setting Reference

Trauma Team Activation
Level Direction Primary Outcome Patient/Process Setting Reference


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