Retrospective review of intervention for traumatic blunt spleen injuries in adolescents by trauma center type

Persistent disparities between trauma center types in the management of children with high-grade blunt splenic injuries

BACKGROUND

In the early 2000s, substantial variations were reported in the management of pediatric patients with blunt splenic injury (BSI). The purpose of this study was to assess the recent trends and disparities between different types of trauma centers. We hypothesized that there would be persistent disparities despite decreased trends in the rate of splenectomy.

METHODS

This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database. We included patients (age ≤18 years) with high-grade BSI (Abbreviated Injury Scale 3-5) between 2014 and 2021. The patients were divided into three groups based on trauma center types (adult trauma centers [ATCs], mixed trauma centers [MTCs], and pediatric trauma centers [PTCs]). The primary outcome was the splenectomy rate. Logistic regression was performed to evaluate the association between trauma center types and clinical outcomes. Additionally, the trends in the rate of splenectomy at ATCs, MTCs, and PTCs were evaluated.

RESULTS

A total of 6601 patients with high-grade BSI were included in the analysis. Overall splenectomy rates were 524 (17.5%), 448 (16.3%), and 32 (3.7%) in the ATC, MTC, and PTC groups, respectively. ATCs and MTCs had significantly higher splenectomy rates compared to PTCs (ATCs: OR = 5.72, 95%CI = 3.78-8.67, and p < 0.001 and MTCs: OR = 4.50, 95%CI = 2.97-6.81, and p < 0.001), while decreased trends in the splenectomy rates were observed in ATCs and MTCs (ATCs: OR = 0.92, 95%CI = 0.87-0.97, and p = 0.003 and MTCs: OR = 0.92, 95%CI = 0.87-0.98, and p = 0.013).

CONCLUSIONS

This study suggested persistent disparities between different trauma center types in the management of children with high-grade BSI.

Facility Size and Risk Factors for Mortality in Pediatric Trauma

BACKGROUND

Pediatric trauma outcomes can vary across facilities, yet evidence on the relationship between facility bed size and pediatric trauma outcomes has been mixed. We aimed to identify how facility bed size might modify the impact of patient-level risk factors on mortality in pediatric trauma. We hypothesized that patient-level risk factors would have a stronger association with mortality at smaller trauma centers, and a weaker association with mortality at larger centers.

METHODS

We used deidentified data obtained from the 2017-2018 Trauma Quality Programs registry, including patients ages 0-18 years of age who were admitted to the hospital. The primary outcome was in-hospital mortality. Facility bed size was dichotomized as large (>600 beds) vs small/medium (≤600 beds). Sensitivity analyses used 200 and 400 beds as alternative cutoffs. Interaction between facility bed size and patient characteristics was assessed using unadjusted logistic regression, with statistically significant interactions entered in a final, fully adjusted model.

RESULTS

The analysis included 171 810 patients (mean age 10 ± 5 years; 65%/35% male/female), including 28% treated in a large hospital and 1.2% who died during the hospitalization. Controlling for trauma center level (or subsetting to pediatric trauma centers only), larger bed size did not reduce mortality risk associated with patient characteristics such as injury mechanism, injury severity, or patient demographics.

CONCLUSIONS

Contrary to our hypothesis, greater facility bed size was not associated with reduced mortality risk associated with patient characteristics. Future studies are needed to identify hospital practices or characteristics that can attenuate the excess risk of known patient-level risk factors.

Between paradigms: Comparing experiences for adolescents treated at pediatric and adult trauma centres

INTRODUCTION

Injured adolescents may be treated at pediatric trauma centres (PTCs) or adult trauma centres (ATCs). Patient and parent experiences are an integral component of high-quality health care and can influence patient clinical trajectory. Despite this knowledge, there is little research on differences between PTCs and ATCs with respect to patient and caregiver-reported experience. We sought to identify differences in patient and parent-reported experiences between the regional PTC and ATC using a recently developed Patient and Parent-Reported Experience Measure.

METHODS

We prospectively enrolled patients (caregivers) aged 15-17 (inclusive), admitted to the local PTC and ATC for injury management (01/01/2020 - 31/05/2021) We provided a survey 8-weeks post-discharge to query acute care and follow-up experience. Patient and parent experiences were compared between the PTC and ATC using descriptive statistics, chi-square tests for categorical and independent t-tests for continuous variables.

RESULTS

We identified 90 patients for inclusion (51 PTC, and 39 ATC). From this population, we had 77 surveys (32 patient and 35 caregiver) completed at the PTC, and 41 (20 patient and 21 caregiver) at the ATC. ATC patients tended to be more severely injured. We identified few differences in reported experience on the patient measure but identified lower ratings from caregivers of adolescents treated in ATCs for the domains of information and communication, follow-up care, and overall hospital scores. Patients and parents reported poorer family accommodation at the ATC.

CONCLUSION

Patient experiences were similar between centres. However, caregivers report poorer experiences at the ATC in several domains. These differences are multifaceted, and may reflect differing patient volumes, effects of COVID-19, and healthcare paradigms. However, further work should target information and communication improvement in adult paradigms given its impact on other domains of care.