Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children's hospital

Perspectives of health professionals on the best care settings for pediatric trauma casualties: a qualitative study

BACKGROUND

Critically-injured children are frequently treated by providers who lack specialty pediatric training in facilities that have not been modified for the care of children. We set out to understand the attitudes and perspectives of policy makers, and senior nursing and medical managers in the Israeli healthcare system, concerning the provision of medical care to pediatric trauma casualties in emergency departments.

METHODS

We conducted semi-structured interviews with 17 health professionals from medical centers across Israel and the Ministry of Health. The interviews were analyzed by qualitative methods.

RESULTS

There was lack of clarity and uniformity concerning the definition of a pediatric trauma casualty. All of the participants attributed extreme importance to the professional level of the care team manager, and most suggested that this should be a pediatric emergency medicine specialist. They emphasized the importance of around-the-clock availability of pediatric medical teams to care for young trauma casualties, and the crucial need for caregivers to be equipped with a wide variety of professional skills for the adequate treatment of a broad spectrum of injuries. All participants described significant variability in pediatric-care training and experience among physicians and nurses working in emergency departments. Most participants believe that pediatric trauma casualties should be treated in designated pediatric emergency departments, in a limited number of medical centers across the country.

CONCLUSIONS

Our findings indicate that specialized pediatric EDs would constitute the best location for intake of children with major traumatic injuries. Pediatric emergency medicine specialists should manage trauma cases using pediatric surgeons as ad-hoc consultants. The term 'pediatric patient' should be defined to allow trauma patients to be referred to the most appropriate ED. Teams working at these EDs should undergo specialized pediatric emergency medicine training. Finally, to regulate the key aspects of trauma care, clear statutory guidelines should be formulated at national and local levels.

Management of severe traumatic brain injury (first 24hours)

The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade^® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.

Treatment provider is most predictive of ED dismissal in minimally-injured trauma patients: a retrospective review

Background

Secondary triage protocols have been described in the literature as physiologic (first-tier) criteria and mechanism-related (second-tier) criteria to determine the level of trauma activation. There is debate as to the efficiency of triage decisions based on mechanism of injury which may result in overtriage and overuse of limited trauma resources. Our institution developed and implemented an advanced three-tier trauma alert system in which stable patients presenting with blunt traumatic mechanism of injury would be evaluated by the emergency department (ED) physician rather than the trauma surgeon. The American College of Surgeons Committee on Trauma (ACSCOT) requires that operational changes be monitored and evaluated for patient safety and performance. The primary aim of this study was to evaluate the process, as well as outcomes, of patient care pre and post implementation of the new triage protocol. The secondary aim was to determine predictor variables that were associated with ED dismissal.

Methods

A retrospective blinded pre/post process change implementation explicit chart review was conducted to compare process and outcomes of minimally injured trauma patients who were field triaged by mechanism of injury. Generalized linear modeling was performed to determine which predictor variables were associated with ED dismissal.

Results

There were no significant differences in minutes to physician evaluation, CT scan, OR/ICU disposition, readmission rates, safety or quality. Significant differences only occurred in time to chest x-ray, length of stay in ED, and ED dismissal rates. Trauma surgeon and ED physician patient groups did not differ on ISS, age, or sex. The only significant predictor for ED dismissal was treatment provider, with ED physicians 3.6 times more likely to dismiss the patient from the emergency department.

Conclusions

ED physicians provided compble care as measured by safety, timeliness, and quality in minimally-injured patients triaged to our trauma center based only on mechanism of injury. Moreover, ED physicians were more likely to dismiss patients from the ED. A three-tiered internal triaging protocol can redirect resource usage to reduce the burden on the trauma service. This may be increasingly beneficial in trauma models in which the trauma surgeons also serve as critical care intensivists.

Trauma surgery: discipline in crisis

Throughout the past quarter century, there have been slow but dramatic changes in the nature and practice of trauma surgery, and this field increasingly faces potent economic, logistic, political, and workforce challenges. Patients and emergency physicians have much to lose by this budding crisis in our partner discipline. This article reviews the specific issues confronting trauma surgery, their historical context, and the potential directions available to this discipline. Implications of these issues for emergency physicians and for trauma care overall are discussed.

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

Deriving evidence-based best practice for each phase or setting of trauma care is necessary to maximize best outcomes. There is a paucity of studies examining the association of provider training on pediatric trauma outcomes. Pivotal decisions (whether and where to transfer, diagnostic workup, and initial resuscitation) occur in this setting, yet there is little evidence relating to best practices in those areas. Classic process-performance measures such as time intervals during care (e.g., time to computerized tomography scan, time to operating room, etc.) or utilization measures (American College of Surgeons designation) are commonly used in the trauma center certification process, yet process-outcome links relevant to children are lacking. Although great advances have been made in the trauma care delivered to children, scientific proof is lacking and much more needs to be done to establish the evidence-based need to deliver the highest quality of pediatric trauma care.

Role of the pediatric intensivist in the management of pediatric trauma

There is a substantial body of evidence supporting the importance of the intensivist, and the importance of active involvement of the intensivist in day-to-day management of patients, although there are much fewer data for pediatric trauma. Postoperative management of the pediatric trauma patient is complex and includes many nonsurgical areas of expertise, such as management of respiratory and renal failure, nutritional support, metabolic support, prevention and management of infection, and sepsis. Collaborative multidisciplinary care of these children should include the active and officially acknowledged involvement of pediatric intensivists side by side with their surgical colleagues.

Is There Evidence to Support the Need for Routine Surgeon Presence on Trauma Patient Arrival?

The trauma center certification requirements of the American College of Surgeons include the expectation that, whenever possible, general surgeons be routinely present at the emergency department arrival of seriously injured patients. The 2 historical factors that originally prompted this requirement, frequent exploratory laparotomies and emergency physicians without trauma training, no longer exist in most modern trauma centers. Research from multiple centers and in multiple varying formats has not identified improvement in patient-oriented outcomes from early surgeon involvement. Surgeons are not routinely present during the resuscitative phase of Canadian and European trauma care, with no demonstrated or perceived decrease in the quality of care. American trauma surgeons themselves do not consistently believe that their use in this capacity is either necessary or an efficient distribution of resources. There is not compelling evidence to support the assumption that trauma outcomes are improved by the routine presence of surgeons on patient arrival. Research is necessary to clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Individual trauma centers should be permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria.

Clinical decision rules for secondary trauma triage: predictors of emergency operative management

STUDY OBJECTIVE

Most injured patients taken by ambulance to hospital emergency departments do not require emergency surgery, yet most US trauma centers require a surgeon to be present on their arrival. If a clinical decision rule could be developed to accurately identify which injured patients require emergency operative intervention, then such "secondary triage" criteria could permit a trauma center to more efficiently use their surgeons' time.

METHODS

We analyzed 7.5 years of data (8,289 consecutive trauma activations) in our prospectively maintained Level I trauma center registry. We used classification and regression tree analyses to generate clinical decision rules using standard out-of-hospital variables to identify emergency operative intervention (within 1 hour) by a general surgeon (for adults) or a pediatric surgeon (if < or =14 years).

RESULTS

Emergency operative intervention occurred in 3.0% of adults and 0.35% of children. For adults, summoning a surgeon for any one of 3 criteria (penetrating mechanism, systolic blood pressure <96 mm Hg, pulse rate >104 beats/min) could reduce surgeon calls by 51.2% while failing to identify emergency operative intervention in only 0.08% (rule sensitivity 97.2% and specificity 48.6%). For children, no rule at all (ie, never automatically summoning a surgeon) would fail to identify emergency operative intervention in only 0.35% of patients, and use of a single criterion (penetrating mechanism) would reduce surgeon calls by 96.2% while failing to identify emergency operative intervention in only 0.09% (rule sensitivity 75.0% and specificity 96.5%).

CONCLUSION

We have derived simple decision rules for trauma centers that, if validated, could substantially reduce the need for routine surgeon presence on trauma patient arrival. These rules demonstrate low false-negative rates.

Outcomes and delivery of care in pediatric injury

PURPOSE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

Younger and more seriously injured children have improved outcomes in children's hospitals. Appropriate triage may improve outcomes in pediatric trauma.