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Published on: February 7, 2025
Pediatric traumatic brain injury is inconsistently regionalized in the United States
Mary Hartman1, Robert Scott Watson, Walter Linde-Zwirble
1Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Durham, North Carolina, USA.
Insights
Many children with severe traumatic brain injury (TBI) do not receive care at recommended high-level trauma centers. This study reveals significant gaps in regionalized pediatric TBI care, impacting outcomes.
Area of Science:
- Pediatric Traumatology
- Public Health Policy
- Emergency Medicine
Background:
- Traumatic brain injury (TBI) is a primary cause of pediatric mortality.
- Evidence supports superior outcomes for severe TBI patients treated at high-level trauma centers.
- The American College of Surgery Committee on Trauma recommends specialized care for severe pediatric TBI.
Purpose of the Study:
- To evaluate adherence to recommendations for severe pediatric TBI care at high-level trauma centers.
- To identify factors influencing adherence to these critical care guidelines.
- To assess the degree of regionalization for pediatric TBI care across multiple US states.
Main Methods:
- Analysis of 2001 population and hospital discharge data from 6 US states.
- Identification of severe pediatric TBI cases using ICD-9-CM codes and ACS-COT criteria.
- Definition of high-level centers (Level I or pediatric trauma centers) and 'well-regionalized' areas (>90% admissions in high-level centers).
Main Results:
- Only 67.3% of severe pediatric TBI admissions occurred in high-level centers; 87.3% were in high-level or Level II centers.
- Only 2 of 6 states and 19.1% of 68 health care referral regions met the 'well-regionalized' criteria.
- Weak correlation between distance to care and regionalization; no link to trauma system age.
Conclusions:
- A significant proportion of children with severe TBI do not receive care at recommended high-level trauma centers.
- Current pediatric trauma care exhibits substantial regionalization deficits, impacting access to specialized treatment.
- Findings underscore the need for improved healthcare policy and further research to optimize pediatric TBI management.
Objectives:
Traumatic brain injury is a leading cause of death in children. On the basis of evidence of better outcomes, the American College of Surgery Committee on Trauma recommends that children with severe traumatic brain injury receive care at high-level trauma centers. We assessed rates of adherence to these recommendations and factors associated with adherence.
Methods:
We studied population and hospital discharge data from 2001 from all of the health care referral regions (n = 68) in 6 US states (Florida, Massachusetts, New Jersey, New York, Texas, and Virginia). We identified children with severe traumatic brain injury by using International Classification of Diseases, Ninth Revision, Clinical Modification, codes and American College of Surgery Committee on Trauma criteria. We defined "high-level centers" as either level I or pediatric trauma centers. We considered an area to be well regionalized if >or=90% of severe traumatic brain injury hospitalizations were in high-level centers. We also explored how use of level II trauma centers affected rates of care at high-level centers.
Results:
Of 2117 admissions for severe pediatric traumatic brain injury, 67.3% were in high-level centers, and 87.3% were in either high-level or level II centers. Among states, 56.4% to 93.6% of severe traumatic brain injury admissions were in high-level centers. Only 2 states, Massachusetts and Virginia, were well regionalized. Across health care referral regions, 0% to 100% of severe traumatic brain injury admissions were in high-level centers, and only 19.1% of health care referral regions were well regionalized. Only a weak relationship existed between the distance to the nearest high-level center and regionalization. The age of statewide trauma systems had no relationship to the extent of regionalization.
Conclusions:
Despite evidence for improved outcomes of severely injured children admitted to high-level trauma centers, we found that almost one third of the children with severe traumatic brain injury failed to receive care in such centers. Only 2 of 6 states and less than one fifth of 68 health care referral regions were well regionalized. This study highlights problems with current pediatric trauma care that can serve as a basis for additional research and health care policy.
