Association Between Trauma Center Type and Mortality Among Injured Adolescent Patients. Webman RB, Carter EA, Mittal S, Wang J, Sathya C, Nathens AB, Nance ML, Madigan D, Burd RS. JAMA Pediatr. 2016 Aug 1; 170(8): 780-6.
Injured adolescents are treated in a variety of settings including adult trauma centers (ATCs), pediatric trauma centers (PTCs) and mixed trauma centers (MTCs). Previous studies have shown improved outcomes for children treated at PTCs, however differences in mortality have not been consistently shown for adolescents based on treatment center type.
The purpose of this study was to utilize the 2010 National Trauma Data Bank to compare the association of trauma center type with mortality and final discharge disposition of injured adolescents (age 15 to 19 years). Multilevel logistic regression was used to determine the effect of trauma center level and type on overall mortality and disposition. The model accounted for sex, injury mechanism, injury type and severity, initial systolic BP and GCS. Multiple imputations were used to manage missing data. Among 29613 injured adolescents, most were treated at ATCs (68.9%) as compared with PTCs (5.5%) or MTCs (25.6%). Adolescents at PTCs were more likely injured by blunt mechanism (91.4%) as compared with ATCs (80.4%). Mortality was higher among adolescents treated at ATCs (3.2%) and MTCs (3.5%) as compared to PTCs (0.4%, p< 0.01). The odds ratio of mortality was higher at ATCs (OR = 4.19) and MTCs (OR = 6.68) compared to PTCs even when adjusting for patient and center variables, but was not different between level 1 and level 2 centers.
Mortality among injured adolescents was lower among those treated at PTCs as compared with MTCs and ATCs, even when adjusting for injury type, mechanism of injury, severity of injury, and demographics. Defining resource and patient features or treatment practices that account for the observed differences is needed to optimize outcomes in injured adolescents.
This study shows differences in outcomes in adolescents based on treatment center type and highlights the importance of optimizing resources and care practices for injured adolescents.
Preventable Transfers in Pediatric Trauma: A 10-year Experience at a Level I Pediatric Trauma Center. Fenton SJ, Lee JH, Stevens AM, Kimbal KC, Zhang C, Presson AP, Metzger RR, Scaife ER
J Pediatr Surg. 2016 Apr; 51(4): 645-8.
Injured children are often transferred to pediatric trauma centers better equipped to meet their unique physiologic and developmental needs. Interfacility transfer, however, is associated with additional cost and resource utilization. The purpose of the study was to identify and characterize preventable transfer, defined as a transferred patient who is discharged from the hospital within 36 hours without surgical intervention or additional advanced imaging studies.
This study is a single center retrospective review of all interfacility transfers to a level-I, free-standing children’s hospital over a 10-year period. 1699 of 6380 (26.6%) transferred injured children were classified as preventable. These children were younger (median age of 5 vs. 7 years; p < 0.001) and less severely injured (ISS of 5 vs. 9; p < 0.001). The most common injury was TBI (64% vs. 51%l p < 0.001), with the most common mechanism of injury being fall (62% vs. 44%; p <0.001). Preventable transfers underwent more head CTs performed at the referring hospital (74% vs. 57%; p < 0.001). 29% of preventable transfers were discharged directly form the emergency room with 27% discharged directly from a 24-hour ED observation unit. Overall, 87% of preventable transfers were admitted for less than 24 hours with 6% admitted to the ICU (median ICU length of stay of 14 hours). Multivariate analysis showed that referring hospital CT scans (OR: 3.84; 3.15-4.69) and thoracic trauma (OR 1.56; 1.14-2.14) were predictors of preventable transfer where ISS, abdominal trauma, facial injury, orthopedic injury, spinal injury, injury from a vehicular cause, and injury from assault or child abuse were not. Total estimated transfer charges for preventable transfer patients were $8,857,246 with a mean of $5,204.
Preventable transfers are common and are associated with cost in terms of hospital charges and resources, particularly time and transportation services. Limitations of the study include its retrospective design and the lack of specific clinical details leading to the decision to transfer.
This study highlights the importance of consultation and improved communication amongst providers to optimize the care of injured children and resource utilization.
Outcomes of Pediatric Patients with Persistent Midline Cervical Spine Tenderness and Negative Imaging Result after Trauma. Dorney K, Kimia A, Hannon M, Hennelly K, Meehan WP 3rd, Proctor M, Mooney DP, Glotzbecker M, Mannix R. J Trauma Acute Care Surg. 2015 Nov; 79(5): 822-7.
Midline cervical spine tenderness after trauma raises the suspicion for important cervical spine injury in children. Responses to this finding may include advanced imaging, consultation with specialist spine physicians, or extended use of a cervical collar until the pain resolves. This retrospective cohort study examined the outcomes of 307 children with midline neck tenderness that were evaluated in the ED following injury. They were evaluated with imaging in the ED, which was plain radiography in >90% of patients. Other ED imaging included CT (20.8%), MRI (8.3%) and flexion-extension radiographs (2.1%). Specialist spine consultation was obtained in 45.3% of patients. Fewer than 2% of patients had additional injuries that could be distracting. All patients were discharged from the ED with scheduled follow-up in outpatient spine clinic 1-2 weeks later.
Outcomes were documented by chart review or phone call, with 6% missing data. Only 65% of children followed up in spine clinic. Of those that came to spine clinic, at least half received additional imaging, and 84% were “cleared” of the collar at the first visit. Only 2% of patients were found to have injuries, and these were managed nonoperatively. In light of the low incidence of injuries, the authors conclude that these patients can be safely managed as outpatients, perhaps even in the primary care setting. It is worth noting that the use of advanced imaging and early spine specialty consultation was heterogeneous in this population.
In otherwise uninjured children with midline cervical spine tenderness and negative imaging, significant injury is rare, and discharge in a cervical collar with outpatient follow-up is appropriate.
Acute traumatic coagulopathy in a critically injured pediatric population: Definition, trend over time, and outcomes. Leeper ML, Kutcher M, Nasr I, McKenna C, Billiar T, Neal M, Speery J, Gaines BA.
J Trauma Acute Care Surg. 2016 Jul; 81(1): 34-41.
Acute trauma coagulopathy (ATC) is well described in adults and has been recognized in children, but not clearly understood. International Normalized Ratio (INR) has been used in the adult population to detect ATC. The aim of this paper was determine appropriate INR levels to define ATC in the pediatric population.
This was a 10-year retrospective review in level 1 trauma patients age 0 to 17 years. INR at admission and at 24 hours served as markers of coagulopathy, with attention to variables of mortality, transfusion, injuries, vital signs, and other laboratory studies.
A total of 776 children were studied. Mean age 8.4 yrs., 67% male, 82% blunt, 6.5% penetrating, and median GCS 5. Patients with a normal admission INR of less the 1.2 had a mortality of 2% compared to 10% for INR 1.3 – 1.4, 36% for INR 1.5 – 1.7, and 64% for INR greater than 1.8. Multiple statistical models demonstrated an INR cutoff of 1.3 as the most predictive of increased mortality with an odds ratio of 3.77.
444 patients had INR tested at 24 hours. Pts with an INR >1.3 at this time point more significantly more likely to die (59% vs 2.6%). The group with the highest mortality had an increased INR at admission and again at 24 hours (69%). Age was not found to be a significant factor for mortality.
An INR >1.3 demonstrated acute traumatic coagulopathy in a pediatric population and was associated with a significantly higher mortality. Patients whose INR did not normalize after 24 hours had higher mortality that those whose INR did normalize. This effect was independent of transfusion, suggesting that INR is a late marker of coagulopathy and perhaps not an appropriate early measure for transfusion decisions and response.
Even mild elevation of INR (>1.3) is a marker for significant mortality in pediatric trauma, but this is likely a late coagulation finding and not a “real time” transfusion target.