Outcomes and delivery of care in pediatric injury

Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
Journal of Pediatric Surgery (Impact Factor: 1.39). 02/2006; 41(1):92-8; discussion 92-8. DOI: 10.1016/j.jpedsurg.2005.10.013
Source: PubMed


To design effective pediatric trauma care delivery systems, it is important to correlate site of care with corresponding outcomes. Using a multistate administrative database, we describe recent patient allocation and outcomes in pediatric injury.
The 2000 Kids' Inpatient Database, containing 2,516,833 inpatient discharge records from 27 states, was filtered by E-code to yield pediatric injury cases. Injury Severity Scores (ISSs) were derived for each discharge using ICDMAP-90 (Tri-Analytics, Inc, Forest Hill, MD). After weighting to estimate national trends, cases were grouped by age (0-10, >10-20 years), ISS (< or =15, >15), and National Association of Children's Hospitals and Related Institutions-designated site of care. Measured outcomes included mortality, length of stay, and total charges. Analysis was completed using Student's t test and chi2.
Among 79,673 injury cases, mean age was 12.2 +/- 6.2 years and ISS was 7.4 +/- 7.6. Eighty-nine percent of injured children received care outside of children's hospitals. In the subgroup of patients aged 0 to 10 years with ISS of greater than 15, the mean ISS for adult hospitals and children's hospitals was not significantly different (18.9 +/- 9.1 vs. 19.4 +/- 9.3, P = .08). However, in-hospital mortality, length of stay, and charges were all significantly higher in adult hospitals (P < .0001).
Younger and more seriously injured children have improved outcomes in children's hospitals. Appropriate triage may improve outcomes in pediatric trauma.

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Available from: John C Densmore
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    • "It is well known that populations at extremes of age are much more likely to suffer morbidity from traumatic injuries and benefit from early transfer to designated trauma centers242526272829. Pediatric trauma patients have been shown to have higher inhospital mortality, length of stay, and cost of care in adult hospitals than pediatric-centered hospitals[25]. Additionally, increased age (>65 years old) is also a risk factor for the development of multiple organ failure morbidity from traumatic brain injury and overall morbidity and mortality293031. "
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    ABSTRACT: The regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status. We queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared. 5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06). These data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated.
    Full-text · Article · Dec 2016 · Journal of Trauma Management & Outcomes
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    • "Similarly, after the regionalisation of a paediatric trauma system in the Netherlands, mortality rates improved among adolescents (13 to 18 years), however no changes were found for younger children (0 to 12 years) [64]. This contradicts other studies that found mortality benefit in younger, more severely injured children treated at PTCs or ATC AQ [41,45]. In a national review of PTCs in the US an attending surgeon reduced mortality in the older severely injured child, other variables measured had no significant impact on mortality rates [63]. "
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    ABSTRACT: Background: Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear. Aims: This research aims to identify the impact of trauma systems on the health outcomes of children following severe injury. Methods: Integrative review with data sourced from Medline, Embase, CINAHL, Scopus and hand searched references. Abstracts were screened for inclusion/exclusion criteria with fifty nine articles appraised for quality, analysed and synthesised into 3 main categories. Results: The key findings from this review include: (1) a lack of consistency of prehospital and inhospital triage criteria for severely injured children leading to missed injuries, secondary transfer and poor utilisation of finite resources; (2) severely injured children treated at paediatric trauma centres had improved outcomes when compared to those treated at adult trauma centres, particularly younger children; (3) major causes of delays to secondary transfer are unnecessary imaging and failure to recognise the need for transfer; (4) a lack of functional or long term outcomes measurements identified in the literature. Conclusions: Research designed to identify the best processes of care and describe the impacts of trauma systems on the long term health outcomes of severely injured children is required. Ideally all phases of care including prehospital, paediatric triage trauma criteria, hospital type and interfacility transfer should be included, focusing on timeliness and appropriateness of care. Outcome measures should include long term functional outcomes in addition to mortality.
    Full-text · Article · Jan 2016 · Injury
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    • "On the other hand, pediatric trauma centers (PTCs) are specifically equipped and staffed with specialty-trained caregivers to provide optimal care for injured children (American College of Surgeons Committee on Trauma 2006). While some authors dispute outcome differences between ATCs and PTCs (Fortune et al. 1992; Jubelirer et al. 1990; Kaufmann et al. 1989; Knudson et al. 1992; Osler et al. 2001; Rhodes et al. 1993), other studies have demonstrated improvement in morbidity and mortality when pediatric trauma patients are treated at PTCs (Densmore et al. 2006; Mooney et al. 2006; Potoka et al. 2001; Pracht et al. 2008). Due to the shortage of PTCs as well as geographic distributions limiting access to care at PTCs in many areas of the country (Nance et al. 2009), the majority of pediatric trauma patients in the U.S. receive care at ATCs (Segui-Gomez et al. 2003). "

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