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Mortality Among Injured Children Treated at Different Trauma Center Types
Chethan Sathya1, Aziz S Alali2, Paul W Wales3
1Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
Insights
Injured children treated at adult or mixed trauma centers face higher mortality risks than those at pediatric trauma centers. This is particularly true for younger and severely injured children, highlighting a need for improved care at non-pediatric facilities.
Area of Science:
- Pediatric Trauma Care
- Healthcare Quality Improvement
- Public Health Outcomes
Background:
- Trauma is the leading cause of death in US children.
- The optimal trauma care environment for pediatric patients remains debated.
- Comparing outcomes across pediatric, mixed, and adult trauma centers is crucial for quality improvement.
Purpose of the Study:
- To assess the association between trauma center type (pediatric, mixed, or adult) and in-hospital mortality in children.
- To stratify analyses by age groups: young children (≤5 years), older children (6-11 years), and adolescents (12-18 years).
- To evaluate outcomes for severely injured children (Injury Severity Score ≥25).
Main Methods:
- Retrospective cohort study of 175,585 injured children (≤18 years) hospitalized between 2010-2013.
- Inclusion criteria: Abbreviated Injury Score ≥2 in at least one body region.
- Analysis used random-intercept multilevel regression, with stratified analyses by age and injury severity.
Main Results:
- Crude mortality rates were 2.3% (ATCs), 1.8% (MTCs), and 0.6% (PTCs).
- Adjusted analyses showed higher mortality odds at ATCs (OR, 1.57) and MTCs (OR, 1.45) compared to PTCs.
- Young children treated at ATCs had significantly higher mortality (OR, 1.78); similar trends observed for severely injured patients.
Conclusions:
- Injured children treated at adult and mixed trauma centers experience higher in-hospital mortality than at pediatric trauma centers.
- This disparity is most pronounced in younger children and those with severe injuries.
- Quality improvement initiatives are essential for ATCs and MTCs to enhance care for injured children.
Importance:
Trauma is the leading cause of death among US children. Whether pediatric trauma centers (PTCs), mixed trauma centers (MTCs), or adult trauma centers (ATCs) offer a survival benefit compared with one another when treating injured children is controversial. Ascertaining the optimal care environment will better inform quality improvement initiatives and accreditation standards.
Objective:
To evaluate the association between type of trauma center (PTC, MTC, or ATC) and in-hospital mortality among young children (5 years and younger), older children (aged 6-11 years), and adolescents (aged 12-18 years).
Design, Setting, And Participants:
In this retrospective cohort study, injured children aged 18 years or younger who were hospitalized in the United States from January 1, 2010, to December 31, 2013, were observed for the duration of their admission until discharge or death. We included patients with an Abbreviated Injury Score of 2 or greater in at least 1 body region. Random-intercept multilevel regression was used to evaluate the association between center type and in-hospital mortality after adjusting for confounders. Stratified analyses in young children, older children, and adolescents were performed. We conducted secondary analyses limited to patients with severe injuries (Injury Severity Score ≥25). Both analyses were performed between January 1 and August 31, 2014. Data were derived from 252 US level I and II trauma centers voluntarily participating in the American College of Surgeons adult or pediatric Trauma Quality Improvement Program.
Main Outcome And Measure:
In-hospital mortality.
Results:
We identified 175 585 injured children. Crude mortality rates were 2.3% for children treated at ATCs, 1.8% for children treated at MTCs, and 0.6% for children treated at PTCs. After adjustment, children had higher odds of dying when treated at ATCs (odds ratio [OR], 1.57; 95% CI, 1.15-2.14) and MTCs (OR, 1.45; 95% CI, 1.05-2.01) compared with those treated at PTCs. In stratified analyses, young children had higher odds of death when treated at ATCs vs PTCs (OR, 1.78; 95% CI, 1.05-3.40), but there was no association between center type and mortality among older children (OR, 1.17; 95% CI, 0.65-2.11) and adolescents (OR, 1.23; 95% CI, 0.82-1.85). Results were similar in analyses of severely injured children: those treated at ATCs (OR, 1.75; 95% CI, 1.25-2.44) and MTCs (OR, 1.62; 95% CI, 1.15-2.29) had higher odds of death when compared with those treated at PTCs.
Conclusions And Relevance:
Injured children treated at ATCs and MTCs had higher in-hospital mortality compared with those treated at PTCs. This association was most evident in younger children and remained significant in severely injured children. Quality improvement initiatives geared toward ATCs and MTCs are required to provide optimal care to injured children.
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