Trauma experts versus pediatric experts: comparison of outcomes in pediatric penetrating injuries

Does Trauma Center Volume Account for the Association Between Trauma Center Verification Level and In-Hospital Mortality among Children Injured by Firearms in California?

BACKGROUND

Heterogeneity in trauma center designation and injury volume offer possible explanations for inconsistencies in pediatric trauma center designation's association with lower mortality among children. We hypothesized that rigorous trauma center verification, regardless of volume, would be associated with lower firearm injury-associated mortality in children.

STUDY DESIGN

This retrospective cohort study leveraged the California Office of Statewide Health Planning and Development patient discharge data. Data from children aged 0 to 14 years in California from 2005 to 2018 directly transported with firearm injuries were analyzed. American College of Surgeons (ACS) trauma center verification level was the primary predictor of in-hospital mortality. Centers' annual firearm injury volume data were analyzed as a mediator of the association between center verification level and in-hospital mortality. Two mixed-effects multivariable logistic regressions modeled in-hospital mortality and the estimated association with center verification while adjusting for patient demographic and clinical characteristics. One model included the center's firearm injury volume and one did not.

RESULTS

The cohort included 2,409 children with a mortality rate of 8.6% (n = 206). Adjusted odds of mortality were lower for children at adult level I (adjusted odds ratio [aOR] 0.38, 95% CI 0.19 to 0.80), pediatric (aOR 0.17, 95% CI 0.05 to 0.61), and dual (aOR 0.48, 95% CI 0.25 to 0.93) trauma centers compared to nontrauma/level III/IV centers. Firearm injury volume did not mediate the association between ACS trauma center verification and mortality (aOR/10 patient increase in volume 1.01, 95% CI 0.99 to 1.03).

CONCLUSIONS

Trauma center verification level, regardless of firearm injury volume, was associated with lower firearm injury-associated mortality, suggesting that the ACS verification process is contributing to achieving optimal outcomes.

Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis

Importance

Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking.

Objective

To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma.

Data Sources

MEDLINE, Embase, and Web of Science through March 2023.

Study Selection

Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years).

Data Extraction and Synthesis

This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence.

Main Outcome(s) and Measure(s)

Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI).

Results

A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes.

Conclusions and Relevance

In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.

Pediatric trauma center vs. adult trauma center: which is better?

PURPOSE OF REVIEW

Pediatric trauma centers (PTCs) have been championed as multidisciplinary facilities specializing in the care of pediatric trauma, the leading cause of childhood mortality in the United States. 1 However, the vast majority of pediatric trauma is still seen in trauma centers focused on treating adults. This article reviews the latest evidence comparing the relative strengths of PTCs and adult trauma centers (ATCs) in treating childhood injury.

RECENT FINDINGS

Recent multicenter studies comparing outcomes of pediatric injury in PTCs and ATCs have found no differences in mortality or hospital length of stay, contradicting earlier findings. However, fewer invasive procedures and CT scans were performed at PTCs, and more children were discharged back to their homes.

SUMMARY

It is difficult to demonstrate a difference in outcomes for children treated at PTCs vs. ATCs. However, PTCs do offer a multidisciplinary, nuanced approach to pediatric trauma care, which may result in long term benefits and offer opportunities for regional collaboration.

Racial disparities in triage of adolescent patients after bullet injury

BACKGROUND

While pediatric trauma centers (PTCs) and adult trauma centers (ATCs) exhibit equivalent trauma mortality, the optimal care environment for traumatically injured adolescents remains controversial. Race has been shown to effect triage within emergency departments (EDs) with people of color receiving lower acuity triage scores. We hypothesized that African-American adolescents were more likely triaged to an ATC than a PTC compared with their White peers.

METHODS

Institutional trauma databases from a neighboring, urban Level I PTC and ATC were queried for gunshot wounds in adolescents (15-18 years) presenting to the ED from 2015 to 2017. The PTC and ATC were compared in terms of demographics, services, and outcomes. Results were analyzed using univariate analysis and logistic regression.

RESULTS

Among 316 included adolescents, 184 were treated in an ATC versus 132 in a PTC. Patients at the PTC were significantly more likely to be younger (16.1 vs. 17.5 years; p < 0.001), White (16% vs. 5%; p = 0.001), and privately insured (41% vs. 30%; p = 0.002). At each age, the proportion of Whites treated at the PTC exceeded the proportion of African-Americans. At the PTC, patients were more likely to receive inpatient and outpatient social work follow-up (89% vs. 1%, p < 0.001). Adolescents treated at the PTC were less likely to receive opioids (75% vs. 56%, p = 0.001) at discharge and to return to ED within 6 months (25% vs. 11%, p = 0.005). On multivariate logistic regression, African-American adolescents were less likely to be treated at a PTC (odds ratio, 0.30; 95% confidence interval, 0.10-0.85; p = 0.02) after controlling for age and Injury Severity Score.

CONCLUSION

Disparities in triage of African-American and White adolescents after bullet injury lead to unequal care. African-Americans were more likely to be treated at the ATC, which was associated with increased opioid prescription, decreased social work support, and increased return to ED.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Pediatric traumatic brain injury: Resource utilization and outcomes at adult versus pediatric trauma centers

INTRODUCTION

Traumatic brain injury is the leading cause of trauma-related death in children. We hypothesized that children with isolated traumatic brain injury would experience differential outcomes when treated at pediatric versus adult or combined trauma centers.

METHODS

After institutional review board approval, the 2015 National Trauma Data Bank was queried for children up to age 16 years with isolated traumatic brain injury. Demographics and clinical outcomes were collected. Univariable and multivariable analyses were conducted to assess for predictors of in-hospital mortality and complications. Kaplan-Meier survival analysis was conducted.

RESULTS

A total of 3,766 children with isolated traumatic brain injury were identified; 1,060 (28%) were treated at pediatric trauma centers, 1,909 (51%) at adult trauma centers, and 797 (21%) at combined trauma centers. Subjects were 5 years old (median, interquartile range 1-12 years), 63% male, and 64% white. Higher blood pressure and lower injury severity score were associated with reduced mortality (P < .05). Increasing injury severity score was associated with higher mortality by multivariable logistic regression (odds ratio 1.57, P < .0001). There were no survival differences among hospital types (P = .88).

CONCLUSION

Outcomes for children with isolated traumatic brain injury appear equal across different types of designated trauma centers. These findings may have implications for prehospital transport and triage guidelines.

Pediatric Mortality at Pediatric versus Adult Trauma Centers

Introduction:

Pediatric trauma centers (PTCs) were created to address the unique needs of injured children with the expectation that outcomes would be improved. However, prior studies to evaluate the impact of PTCs have had conflicting results. Our study was conducted to further clarify this question. We hypothesize that severely injured children ≤ 14 years of age have better outcomes at PTCs and that better survival may be due to higher emergency department (ED) survival rates than at adult trauma centers (ATCs).

Methods:

A retrospective analysis of severely injured children (ISS>15) ≤18 years of age entered into the National Trauma Data Bank (NTDB) between 2011 and 2012 was performed. Subjects were stratified into 2 age cohorts; young children (0-14 years) and adolescents (15-18 years). Primary outcomes were emergency department (ED) and in-patient (IP) mortality. Secondary outcomes included in-hospital complications, hospital and ICU length of stay, and ventilator days. Outcome differences were assessed using multilevel logistic and negative binomial regression analyses.

Results:

A total of 10,028 children were included. Median ISS was 22 (Interquartile range 17-29). Adjusting for confounders on multivariate analysis, children ≤ 14 had lower odds of ED (0.42[CI 0.25-0.71], p=0.001) and IP mortality (0.73[CI 0.5-0.9], p=0.02) at PTCs. There were no differences in odds of ED mortality (0.81 [CI 0.5-1.3], p=0.4) or IP mortality (1.01 [CI 0.8-1.2], p=0.88) for adolescents between centers. There were no differences in complication rates between PTCs and ATCs (OR 0.86 [CI 0.69-1.06], p=1.7) but children were more likely to be discharged to home and have more ICU and ventilator free days if treated at a PTC.

Conclusion:

Young children but not adolescents have better ED survival at PTCs compared to ATCs.

Level of Evidence: Level IV, Therapeutic

Mortality in adolescent trauma: a comparison of children's, mixed and adult major trauma centres

OBJECTIVE

We aimed to compare adolescent mortality rates between different types of major trauma centre (MTC or level 1; adult, children's and mixed).

METHODS

Data were obtained from TARN (Trauma Audit Research Network) from English sites over a 6-year period (2012-2018), with adolescence defined as 10-24.99 years. Results are presented using descriptive statistics. Patient characteristics were compared using the Kruskal-Wallis test with Dunn's post-hoc analysis for pairwise comparison and χ2 test for categorical variables.

RESULTS

21 033 cases met inclusion criteria. Trauma-related 30-day crude mortality rates by MTC type were 2.5% (children's), 4.4% (mixed) and 4.9% (adult). Logistic regression accounting for injury severity, mechanism of injury, physiological parameters and 'hospital ID', resulted in adjusted odds of mortality of 2.41 (95% CI 1.31 to 4.43; p=0.005) and 1.85 (95% CI 1.03 to 3.35; p=0.041) in adult and mixed MTCs, respectively when compared with children's MTCs. In three subgroup analyses the same trend was noted. In adolescents aged 14-17.99 years old, those managed in a children's MTC had the lowest mortality rate at 2.5%, compared with 4.9% in adult MTCs and 4.4% in mixed MTCs (no statistical difference between children's and mixed). In cases of major trauma (Injury Severity Score >15) the adjusted odds of mortality were also greater in the mixed and adult MTC groups when compared with the children's MTC. Median length of stay (LoS) and intensive care unit LoS were comparable for all MTC types. Patients managed in children's MTCs were less likely to have a CT scan (46.2% vs 62.8% mixed vs 64% adult).

CONCLUSIONS

Children's MTC have lower crude and adjusted 30-day mortality rates for adolescent trauma. Further research is required in this field to identify the factors that may have influenced these findings.

Mortality After Adolescent Firearm Injury: Effect of Trauma Center Designation

PURPOSE

To determine the incidence and outcomes of firearm injuries in adolescents and the effect of trauma center (TC) designation on their mortality.

METHODS

The National Trauma Data Bank (2010-2016) was queried for all encounters involving adolescents aged 13-16 years with firearm injuries. Multivariable logistic regression was employed to determine the association of covariates with mortality (α = .05). Propensity score matching was also used to explore the relationship between TC designation and mortality.

RESULTS

A total of 9,029 adolescents met inclusion criteria. Patients aged 15 and 16 years compromised 77.8% of the cohort and were more often male (87.9% vs. 80.6%, p < .001), black (63.8% vs. 56.1%, p < .001), injured in the abdomen (25.4% vs. 22.4%, p = .007) or extremities (62.3% vs. 56.7%, p < .001), and incurred severe injuries (54.5% vs. 50.9%, p = .004) versus 13- and 14-year-old patients. Younger patients were more often injured in the head/neck (23.8% vs. 20.5%, p = .001). Multivariable logistic regression demonstrated no difference in mortality between age groups. Poor neurologic presentation, severe injury, abdominal, chest, and head injuries were all associated with an increased odds of death. Odds of mortality were 2.88 times higher at adult TCs compared to pediatric TCs (CI: 1.55-5.36, p = .001). However, using a 1:1 propensity score matching model, no difference in mortality was found between TC types (p = NS).

CONCLUSIONS

Variability exists in outcomes for adolescents after firearm injuries. Understanding and identifying the potential differences between pediatric and adult TCs managing adolescent firearm victims may improve survival in all treatment venues, but these data support patients being treated at the closest available TC.

Suicide Attempts and Adolescents: The Need for Specialized Resources at Adult Trauma Centers

Background:

Suicide is the second leading cause of adolescent death and suicide attempts outnumber deaths 50:1 for adolescents 15 to 19 years of age. This study examines differences in outcomes between adolescents and adults treated at an adult trauma center in an effort to guide recovery and prevention strategies following an adolescent suicide attempt.

Methods:

Retrospective review of patients aged ≥14 years treated at an urban, Level 1 trauma center for self-inflicted injuries between 2009 and 2018 was performed. The cohort was divided into adolescents (14-19 years) and adults (≥20 years) and into group A (economically distressed) and group B (non-distressed). Demographics, injury, outcomes, and geospatial analysis were compared.

Results:

Among 723 patients, 60 (8%) were adolescents of which 92% were male, 55% black, 47% blunt injuries, and 53% penetrating. In adults, 76% were male, 41% black, 28% blunt injuries, and 72% penetrating. Mortality estimates for adolescents and adults were 35% and 24%, respectively (p=0.09). Most adolescent deaths occurred within 3 days after admission, while adult deaths occurred further into hospitalization (p<0.01). Cox regression analysis found higher mortality with self-pay compared to private insurance (HR 2.6; p<0.001), and penetrating vs. blunt/other injuries (HR 2.4; p<0.001). Psychiatric care was administered in 64% of adolescents (n=39) and 84% of adults (p< 0.01).

Conclusions:

Inpatient psychiatric care for adolescents who attempted suicide was limited at an adult trauma center. The high incidence of suicide attempts and community-level distress in adolescents require immediate attention and resources.

A comparison of adolescent penetrating trauma patients managed at pediatric versus adult trauma centers in a mature trauma system

BACKGROUND

While there is little debate that pediatric trauma centers (PTC) are uniquely equipped to manage pediatric trauma patients, the extent to which adolescents benefit from treatment there remains controversial. We sought to elucidate differences in management approach and outcome between PTC and adult trauma centers (ATC) for the adolescent penetrating trauma population. We hypothesized that improved mortality would be observed at ATC for this subset of patients.

METHODS

Adolescent patients (age, 15-18 years), presenting to Pennsylvania-accredited trauma centers between 2003 and 2017 with penetrating injury, were queried from the Pennsylvania Trauma Outcome Study database. Dead on arrival, transfer patients, and those admitted to a Level III or Level IV trauma center were excluded from analysis. Patient length of stay, number of complications, surgical intervention, and mortality were compared between ATC and PTC. Multilevel mixed effects logistic regression models with trauma center as the clustering variable were used to assess the impact of center type (ATC/PTC) on management approach and mortality adjusted for appropriate covariates.

RESULTS

A total of 2,630 adolescent patients met inclusion criteria (PTC: n = 428 [16.3%]; ATC: n = 2,202 [83.7%]). Pediatric trauma centers had a lower adjusted odds of mortality (adjusted odds ratio [AOR], 0.35; 95% confidence interval [CI], 0.17-0.74; p = 0.006) and a lower adjusted odds of surgery (AOR, 0.67; 95% CI, 0.0.48-0.93; p = 0.016) than their ATC counterparts. There were no differences in complication rates (AOR, 0.94; 95% CI, 0.57-1.55; p = 0.793) or length of stay longer than 4 days (AOR, 0.95; 95% CI, 0.61-1.48; p = 0.812) between the PTCs and ATCs. There were also differences in penetrating injury type between PTC and ATC.

CONCLUSION

The adolescent penetrating trauma patient population treated at PTC had less surgery performed with improved mortality compared with ATC.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Pediatric firearm injuries: Racial disparities and predictors of healthcare outcomes

BACKGROUND/PURPOSE

The U.S. has an alarming rate of firearm injuries. Racial disparities among victims and predictors of outcomes are not well established. Our objective was to assess costs, length of stay (LOS), and inpatient mortality among nonfatal and fatal pediatric firearm injuries that required hospitalization.

METHODS

Pediatric (≤18 years of age) hospitalizations with a firearm injury discharge diagnosis were identified from the national Kids' Inpatient Databases (KID) for 2006 through 2012. Firearm injury intent, weapon type, and hospitalization rates by racial groups were examined. Inpatient mortality, costs, and length of stay were examined using regression models.

RESULTS

Of 15,211 hospitalizations, the majority of injuries were due to assault (60%) and the intentions of firearm injury differed by race (p < 0.001). The median cost per hospitalization was $10,159 (interquartile range: $5071 to $20,565), totaling more than a quarter of a billion dollars. On regression analysis, Black (OR: 0.41; CI: 0.30-0.55) and Hispanic (OR: 0.47; CI: 0.34-0.66) patients were less likely to die than White patients.

CONCLUSION

Pediatric firearm injury circumstances and survival vary by race with Whites being more likely to experience unintentional injury and suicide, while Blacks and Hispanics are more likely to experience inflicted injury.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Clinical Research Study.

Analysis of pediatric gunshot wounds in Houston, Texas: A social perspective

BACKGROUND

This study sought to determine the role of social factors in pediatric gunshot wounds (GSW).

METHODS

We identified medical records of victims aged 0-15 years who presented to our Level 1 pediatric trauma center from 2001 to 2016.

RESULTS

Three hundred fifty-eight children were treated between 2001 and 2016. Patients ranged from 2.5 months to 15 years old (mean = 10.8 years). Two hundred ninety-two patients (81.6%) were male, and 66 (18.4%) were female. The most common anatomic injury location was the head, face, neck, and/or spine (n = 168; 36.2%). 38.3% of injuries (n = 137) were caused by handguns, 25.1% (n = 90) by BB guns, and 12.6% (n = 45) by shotguns/rifles. 45.5% of incidents (n = 163) were intentional; 17 of these (4.7%) were suicide attempts. 48.9% of incidents (n = 175) were accidental. The majority (n = 229) of incidents (64.0%) occurred in a family residence. An adult supervised the victim in only 26.3% of cases (N = 94). Criminal charges were filed in 36 cases (10.1%). Fifteen victims (4.2%) were placed in CPS custody. 12.0% of charts (N = 43) mentioned gun safety education being provided to the family.

CONCLUSION

Analysis of social factors associated with pediatric GSW suggests that many of these injuries could have been prevented with safe firearm storage, increased community education efforts, and other safety measures.

LEVELS OF EVIDENCE

Level III- Retrospective Comparative Study.

State-level geographic variation in prompt access to care for children after motor vehicle crashes

BACKGROUND

Motor vehicle crashes (MVCs) are a principal cause of death in children; fatal MVCs and pediatric trauma resources vary by state. We sought to examine state-level variability in and predictors of prompt access to care for children in MVCs.

MATERIALS AND METHODS

Using the 2010-2014 Fatality Analysis Reporting System, we identified passengers aged <15 y involved in fatal MVCs (crashes on US public roads with ≥1 death, adult or pediatric, within 30 d). We included children requiring transport for medical care from the crash scene with documented time of hospital arrival. Our primary outcome was transport time to first hospital, defined as >1 or ≤1 h. We used multivariable logistic regression to establish state-level variability in the percentage of children with transport time >1 h, adjusting for injury severity (no injury, possible injury, suspected minor injury, suspected severe injury, fatal injury, and unknown severity), mode of transport (emergency medical services [EMS] air, EMS ground, and non-EMS), and rural roads.

RESULTS

We identified 18,116 children involved in fatal MVCs from 2010 to 2014; 10,407 (57%) required transport for medical care. Median transport time was 1 h (interquartile range: [1, 1]; range: [0, 23]). The percent of children with transport time >1 h varied significantly by state, from 0% in several states to 69% in New Mexico. Children with no injuries identified at the scene and crashes on rural roads were more likely to have transport times >1 h.

CONCLUSIONS

Transport times for children after fatal MVCs varied substantially across states. These results may inform state-level pediatric trauma response planning.