Effect of emergency department care on outcomes in pediatric trauma: what approaches make a difference in quality of care?

Variability in the structure and care processes for critically injured children: A multicenter survey of trauma bay and intensive care units

PURPOSE

Evaluate national variation in structure and care processes for critically injured children.

METHODS

Institutions with pediatric intensive care units (PICUs) that treat trauma patients were identified through the Virtual Pediatric Systems (n=72). Prospective survey data were obtained from PICU and Trauma Directors (n=69, 96% response). Inquiries related to structure and care processes in the PICU and emergency department included infrastructure, physician staffing, team composition, decision making, and protocol/checklist use.

RESULTS

About one-third of the 69 institutions were ACS-verified Level-1 Pediatric Trauma Centers (32%); 36 (52%) were state-designated Level 1. The surgeon was the primary decision maker in the trauma bay at 88% of sites, and in the PICU at 44%. The intensivist was primary in the PICU at 30% of sites and intensivist consultation was elective at 11%. Free-standing pediatric centers used checklists more often than adult/pediatric centers for DVT prophylaxis (75% vs. 50%, p=0.039), cervical spine clearance (75% vs. 44%, p=0.011), and pain control (63% vs. 34%, p=0.024). Otherwise, protocols/checklists were infrequently utilized by either center type.

CONCLUSION

Variability exists in structure and care processes for critically injured children. Further investigation of variation and its causal relationship to outcomes is warranted to provide optimal care.

Does young age merit increased emergency department trauma team response?

Introduction:

To determine if increased trauma team response results in alterations in resource use in a population of children <6 years, especially in those least injured.

Methods:

We conducted a retrospective before and after study of children <6 years sustaining blunt trauma and meeting defined prehospital criteria. We compared hospitalization rates and missed injuries (injuries identified after discharge from the emergency department/hospital) among patients with and without an upgraded trauma team response. We compared the computed tomography (CT) rate and laboratory testing rate among minimally injured patients (Injury Severity Score [ISS] 6).

Results:

We enrolled 352 patients with 180 (mean age 2.7 ± 1.5 years) in the upgrade cohort and 172 (mean age 2.6 ± 1.5 years) in the no-upgrade cohort. Independent predictors of hospital admission in a regression analysis included: Glasgow Coma Scale <14 (odds ratio [OR]=11.4, 95% confidence interval [CI] 2.3, 56), ISS (OR=1.55, 95% CI 1.33, 1.81), and evaluation by the upgrade trauma team (OR=5.66, 95% CI 3.14, 10.2). In the 275 patients with ISS <6, CT (relative risk=1.34, 95% CI 1.09, 1.64) and laboratory tests (relative risk=1.71, 95% CI 1.39, 2.11) were more likely to be obtained in the upgrade cohort as compared to the no-upgrade cohort. We identified no cases of a missed diagnosis.

Conclusion:

Increasing the trauma team response based upon young age results in increased resource use without altering the rate of missed injuries. In hospitals with emergency department physicians capable of evaluating and treating injured children, increasing ED trauma team resources solely for young age of the patient is not recommended.

Pediatric Polytrauma Management

Caring for pediatric trauma patients requires an understanding of the distinct anatomy and pathophysiology of the pediatric population compared to adult trauma patients. Initial evaluation, management, and resuscitation are performed as a multidisciplinary approach including pediatric physicians, trauma surgeons, and pediatric intensive care physicians. Head injury severity is the principle determinant of outcome and mortality in polytraumatized children. Abdominal injuries rarely require surgery in contrast to adults, but need to be detected. Spine and pelvic injuries as well as injuries of the extremities require age-adapted surgical procedures. However, the degree of recovery in polytraumatized children is often remarkable, even after apparently devastating injuries. Maximal care should, therefore, be rendered under the assumption that a complete recovery will be made.

[Multiple trauma in pediatric patients]

Important prerequisites to adequately treat pediatric patients with multiple trauma are a profound knowledge of the underlying mechanisms of injury, common injury patterns and the associated mortality. The younger the child the more injury patterns as well as organ-specific injury severity differ in comparison to adult trauma patients. Traumatic brain and thorax injuries are the key to the prognosis of the injured child. Abdominal injuries rarely require surgery in contrast to adults. Spine and pelvic injuries as well as injuries of the extremities make age-adapted surgical procedures mandatory. The present article describes the established primary diagnostic evaluation after admittance to the emergency room as well as specific treatment options for particular organ systems with respect to age-specific anatomical characteristics and pitfalls in children.

Outcomes in Pediatric Trauma Care in the Stockholm Region

BACKGROUND

Although trauma is a leading cause of pediatric mortality and morbidity in Sweden, few studies have examined the outcome of pediatric trauma.

OBJECTIVE

Here, we describe the age and gender distribution, injury mechanisms, injury severity, and outcome of pediatric trauma in the Stockholm region.

METHODS

This retrospective study comprises all trauma patients (age ≤ 15 years) admitted to a regional pediatric trauma center and all pediatric deaths due to trauma in Stockholm in 2002. Data from the trauma registry database were verified by comparison with medical records and autopsy reports. Outcome was measured by mortality and length of stay in a pediatric intensive care unit (PICU) and acute care hospital.

RESULTS

In all, 432 injured children were included. The median age was 10 years and 59% were males. The median injury severity score was 4 (interquartile range [IQR] 1-9) and 50% sustained head injuries. Mortality was low (1%) and the median length of hospital stay was 2 days (IQR 1-3); 19% stayed in a PICU and, of those, 89% stayed for one day. Comparison with medical records showed that much information in the trauma registry database was either incorrect or missing.

CONCLUSIONS

Many injuries were minor and half of the children were discharged home from the emergency department.Head injurieswere themost common injury in all age groups. The most severe head injuries were seen in the youngest group and were caused by falls. Trauma team activation criteria should be improved to avoid overutilization. The quality and completeness of data in the trauma registry must be enhanced.