Pediatric trauma patients are more likely to be discharged from the emergency department after arrival by helicopter emergency medical services

Pediatric trauma center vs. adult trauma center: which is better?

PURPOSE OF REVIEW

Pediatric trauma centers (PTCs) have been championed as multidisciplinary facilities specializing in the care of pediatric trauma, the leading cause of childhood mortality in the United States. 1 However, the vast majority of pediatric trauma is still seen in trauma centers focused on treating adults. This article reviews the latest evidence comparing the relative strengths of PTCs and adult trauma centers (ATCs) in treating childhood injury.

RECENT FINDINGS

Recent multicenter studies comparing outcomes of pediatric injury in PTCs and ATCs have found no differences in mortality or hospital length of stay, contradicting earlier findings. However, fewer invasive procedures and CT scans were performed at PTCs, and more children were discharged back to their homes.

SUMMARY

It is difficult to demonstrate a difference in outcomes for children treated at PTCs vs. ATCs. However, PTCs do offer a multidisciplinary, nuanced approach to pediatric trauma care, which may result in long term benefits and offer opportunities for regional collaboration.

Interfacility helicopter transport to a tertiary pediatric trauma center

BACKGROUND

Helicopter emergency medical services (HEMS) are intended to expedite care to definitive management. Studies are inconclusive in demonstrating appropriate use. We aimed to examine emergent interventions after interfacility helicopter transport (IHT) to our pediatric trauma center.

METHODS

Trauma patients 0-18 years undergoing IHT or interfacility ground transport (IGT) to our institution from January 2011-December 2020 were studied. We evaluated the rate of IHT patients undergoing emergent (1 h), urgent (6 h), and semi urgent (48 h) operating room (OR) intervention compared to IGT as a measure of appropriate transport.

RESULTS

Inclusion was met by 1003 IHT and 7829 IGT patients. OR intervention was required in 29.6% of IHT patients, emergent in 1.3%, urgent in 12.6%, and semi urgent in 10.6%. Overall, IHT patients had higher mean injury severity score (ISS; IHT:14.5; SD:11.0 vs. IGT:6.0; SD:5.0; p < 0.01) and lower GCS (IHT:12.0; SD:4.9 vs. IGT:14.8; SD:1.4; p < 0.01), though over triage (ISS ≤ 15) occurred in 67.9% of patients.

CONCLUSION

More interfacility helicopter transport patients underwent emergent and urgent procedures compared to interfacility ground transport patients; however, emergent intervention was not required in 98.7% of interfacility helicopter transport patients and over two thirds had ISS ≤ 15, possibly suggesting overutilization of interfacility helicopter transport for pediatric trauma patients at our center.

LEVEL OF EVIDENCE

Level III.

Rethinking pediatric trauma triage

Despite advances in the delivery of trauma care, trauma remains the leading cause of death amongst the pediatric population within the United States and is one of the leading causes of death in children worldwide.  Accurately triaging pediatric trauma patients is essential to minimize preventable mortality without burdening the system by utilizing unnecessary resources.  This article will review the accuracy of current pediatric trauma triage practices and how it will evolve in the future including moving away from mechanism of injury towards physiologic scoring tools such as the pediatric age-adjust shock index, and intervention-based systems including. Need for Surgeon Presence and Need For Trauma Intervention. This paper will also present evidence regarding over-utilization of air transport for pediatric trauma patients and the associated unnecessary costs placed on the trauma system.

Air Rescue for Pediatric Trauma in a Metropolitan Region of Brazil: Profiles, Outcomes, and Overtriage Rates

Besides ensuring a quick response and transport of trauma victims, helicopter support also involves risks to patients and professionals and has higher operational costs. Studying prehospital triage criteria and their relationship with patient overtriage and outcomes is important, particularly in newly established services and in developing countries with limited health budgets. This could help improve the use of the helicopter rescue and provide better management of the costs and risks related to it. The objective of this study was to determine the epidemiologic and severity profiles of pediatric victims of trauma attended by helicopter in a Brazilian Metropolitan Area to evaluate the outcomes and overtriage rates related to pediatric air rescue in the region. We conducted an observational and retrospective study using 49 hospital and prehospital records from victims of trauma aged <18 years old (yo) assisted by helicopter and then transferred to a tertiary University Hospital. Of the 49 patients, 39 (79.6%) individuals were male, and the mean age was 11.3 yo. Vehicular collisions accounted for 15 (30.6%) of the traumas, and traumatic brain injuries occurred in 28 (57.1%) cases. A total of 29 (59.1%) individuals had severe trauma (Injury Severity Score; ISS >15), and 34 (69.4%) required admission to the intensive care unit. Overtriage varied from 18.4 to 40.8% depending on the criteria used for its definition, being more frequent in individuals aged between 1 and 5 yo. Death occurred in 10 (20.4%) patients. On prehospital evaluation, we classified 29/32 (90.6%) patients with severe trauma according to the Pediatric Trauma Score (PTS ≤8) and 18/25 (72%) according to the Revised Trauma Score (RTS ≤11). Of these, 7/29 (24.1%) and 6/18 (33.3%), respectively, presented ISS <15 at in-hospital evaluation. None of the patients with PTS >8 and 3/7 (42.8%) of those with RTS >11 presented ISS >15. In conclusion, air rescue of pediatric trauma victims was used mainly for critically ill individuals, resulting in rates of overtriage compatible with that found in the literature. PTS showed the lowest rates of overtriage within excellent rates of undertriage.

Association of Risk of Mortality in Pediatric Patients Transferred From Scene by Helicopter With Major But Not Minor Injuries

OBJECTIVES

Helicopter emergency medical services (HEMS) are used for 16% of pediatric trauma. National HEMS guidelines advised that triage criteria be standardized for pediatric patients. A national report found pediatric HEMS associated with decreased mortality compared with ground emergency medical services (GEMS) but did not control for transport time. We hypothesized that the rate of HEMS has decreased nationally and the mortality risk for HEMS to be similar when adjusting for transport time compared with GEMS.

METHODS

The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years transported by HEMS or GEMS. A multivariable logistic regression was used.

RESULTS

From 25,647 patients, 4527 (17.7%) underwent HEMS. The rate of HEMS from scene decreased from 21.2% in 2014 to 18.2% in 2016. The rate of HEMS for minor trauma (Injury Severity Score <15) decreased from 14.9% in 2014 to 13.5% in 2016 and major trauma (Injury Severity Score > 15) from 38.4% in 2014 to 35.9% in 2016. After controlling for predictors of mortality and transport time, HEMS was associated with decreased risk of mortality for only those with major injuries transferred from scene (odds ratio, 0.48; 95% confidence interval, 0.26-0.88; P = 0.01) compared with GEMS.

CONCLUSIONS

The rate of HEMS in pediatric trauma has decreased. However, there is room for improvement as 14% of those with minor trauma are transported by HEMS. Given the similar risk of mortality compared with GEMS, further development of guidelines that avoid the unnecessary use of HEMS appears warranted. However, utilization of HEMS for transport of pediatric major trauma should continue.

Characteristics of Children Cared for by a Physician-Staffed Helicopter Emergency Medical Service

OBJECTIVES

The effectiveness of Japanese helicopter emergency medical services (HEMS) and interventions at the scene is not clear as regard children. For effective use of HEMS at the clinical scene, we need to clarify the characteristics of pediatric patients cared for by HEMS. Therefore, the objective of this study was to describe the characteristics of pediatric scene flights and to describe the procedures performed on the patients.

METHODS

This was a retrospective cohort study based on the database for children aged younger than 18 years who were cared for by physician-staffed HEMS of Ibaraki prefecture, in Japan. We reviewed the database for air medical transports conducted at our institution from July 2010 to December 2016.

RESULTS

During the 6.5-year period, the Ibaraki HEMS attended to 288 children. The median age of the children was 11 (interquartile range, 5-14) years. Of the total, 196 (68.1%) of the children had trauma-related injuries. The head was the most common site of significant injuries (12.4%). The most common cause of nontrauma incidents was seizure (9.0%). In 65.9% of the patients, the injury or illness was of mild or moderate severity at the scene. An intervention was applied at the scene in 76.0% of the cases: 75.1%, intravenous route; 6.9%, intubation; and 13.4%, drug administration. Of those patients, 29.1% were discharged from the emergency department. In-hospital mortality accounted for 1.5% (n = 2) of the cases.

CONCLUSIONS

Although the condition at the scene of most of the pediatric patients transported by the physician-staffed HEMS was not severe, an intervention was frequently applied from the scene. Improving the dispatch criteria and monitoring compliance are needed for appropriate use of HEMS.

Air transportation over-utilization in pediatric trauma patients

BACKGROUND

Air transportation can be a life-saving transfer modality for trauma patients. However, it is also costly and carries risk for air-crews and patients. We sought to examine the incidence of air transportation among pediatric trauma patients as well as the rate of over-triage in utilizing this intervention.

METHODS

We conducted a single-institution retrospective review of all pediatric trauma patients who utilized air transportation, either from scene to hospital or hospital to hospital Emergency Department (ED) transfers, between 2013 and 2018.

RESULTS

There were 348 pediatric trauma patients who utilized air transport. More than half of all patients (n = 186, 55.9%) were discharged from the hospital within 48 h, 121 (36.3%) were discharged within 24 h, and 34 (10.2%) were discharged home from the ED. The mean ISS was 11.2 ± 0.5 while only 31% had an ISS ≥15. There were 97 patients (27.9%) with elevated age adjusted shock index, and 101 patients (29.0%) who required time sensitive interventions. More than half of patients (59.3%) were initially taken to an outside hospital (OSH) and were then transferred to our facility by air while 40.4% were transported directly from scene to our institution by air. Patients who were transferred from an OSH were younger (6.8 ± 0.4 vs 11.2 ± 0.4, p < 0.01) and had a higher incidence of an elevated age-adjusted shock index (32.4% vs 19.1%, p = 0.006) as well as mortality (6.3% vs 1.4%, p = 0.03). However, ultimately there were no differences in ISS, rates of operative intervention, PICU utilization, or time sensitive intervention. Both groups had similarly high rates of discharge within 48 h, 24 h, and from the ED.

CONCLUSIONS

Air transportation among pediatric trauma patients from scene to hospital and hospital to hospital is over-utilized based on multiple metrics including low rates of ISS ≥15, elevated age-adjusted shock indexes, low rates of time sensitive intervention, as well as high rates of discharge within 24 and 48 h.

LEVEL OF EVIDENCE

III TYPE OF STUDY: Clinical Research-retrospective review.

Characteristics, management and outcome of prehospital pediatric emergencies by a Dutch HEMS

Background

In prehospital care, the Helicopter Emergency Medical Service (HEMS) can be dispatched for critically injured or ill children. However, little detail is known about dispatches for children, in terms of the incidence of prehospital interventions and overall mortality. The primary objective of this study is to provide an overview of pediatric patient characteristics and incidence of interventions.

Methods

A retrospective chart review of all patients ≤ 17 years who received medical care by Rotterdam HEMS from 2012 until 2017 was carried out.

Results

During the study period, 1905 pediatric patients were included. 59.1% of patients were male and mean age was 6.1 years with 53.2% of patients aged ≤ 3 years. 53.6% were traumatic patients and 49.7% were non-traumatic patients. 18.8% of patients were intubated. Surgical procedures were performed in 0.9%. Medication was administered in 58.1% of patients. Cardiopulmonary resuscitation (CPR) was necessary in 12.9% of patients, 19.9% were admitted to the intensive care unit and 14.0% needed mechanical ventilation. Overall mortality was 9.5%. Mortality in trauma patients was 5.5% and in non-trauma group 15.3%. 3.9% of patients died at the scene.

Conclusions

Patients attended by HEMS are at high risk of prehospital interventions like CPR or intubation. EMS has little exposure to critically ill or injured children. Hence, HEMS expertise is required to perform critical procedures. Trauma patients had higher survival rates than non-traumatic patients. This may be explained by underlying illnesses in non-traumatic patients and CPR as reason for dispatch. Further research is needed to identify options for improving prehospital care in the non trauma pediatric patients.

Early Hospital Discharge After Helicopter Transport of Pediatric Trauma Patients: Analysis of Rates of Over and Undertriage

OBJECTIVES

Helicopter air ambulance (HAA) of pediatric trauma patients is a life-saving intervention. Triage remains a challenge for both scene transport and interhospital transfer of injured children. We aimed to understand whether overtriage or undertriage was a feature of scene or interhospital transfer and how in or out of state transfers affected these rates.

METHODS

Children (<18 years) who underwent trauma activation at a level I trauma center between 2011 and 2013 were identified and reviewed. Patients transported by HAA were compared with those transported by ground ambulance (GA).

RESULTS

Of 399 pediatric patients (median age, 10.4 years; range, 0.1-17 years; 264 male [66%]), 71 (18%) were transported by HAA. Seventy-two percent of HAA patients went to the intensive care unit or the operating room from the trauma bay or suffered in-hospital mortality (vs 42% GA, P < 0.001). More patients were overtriaged (HAA with injury severity score [ISS] of <15) from interhospital transfers than from the scene (25% vs 3%, P = 0.002). Undertriage (GA with ISS >15) was acceptable at 5% from the scene and 14% from interhospital transfers (P = 0.08). Overtriage of patients with ISS less than 15 to HAA was significantly lower from in-state hospitals (22%) than out-of-state hospitals (45%) (P = 0.02). Undertriage of patients with ISS greater than 15 to GA was also lower from in-state hospitals (20%) versus out-of-state hospitals (38%) (P = 0.03).

CONCLUSIONS

Triage of pediatric trauma patients to HAA remains difficult. There remains potential for improvement, particularly as regards interhospital HAA overtriage, but well developed transfer protocols (such in-state protocols) may help.

Association between physician-staffed helicopter versus ground emergency medical services and mortality for pediatric trauma patients: A retrospective nationwide cohort study

Background

Helicopter emergency medical services’ (HEMS) effectiveness for pediatric trauma patients remains unclear. We aimed to examine the relation between HEMS and reduced mortality in pediatric trauma patients.

Methods

This retrospective cohort study utilized data from the Japan Trauma Data Bank, a national multicenter clinical trauma database. Participants were aged <18 years, admitted between 2004 and 2015, and transported from the scene to the hospital by HEMS or ground emergency medical services (GEMS). We used a standardized mortality ratio (SMR) weight method, and fitted a marginal structural model to adjust for measured confounders. The SMR weight was calculated using the estimation of the propensity scores. A logistic regression model was used with the baseline independent variables to estimate the propensity score.

Results

Overall, 5,947 patients were identified in our study: 453 were transported by HEMS and 5,494 by GEMS. The mean injury severity score in the HEMS group was significantly higher than that in the GEMS group17.0 (Standard deviation = 11.0) vs 12.2 (Standard deviation = 9.2), p < .001. In-hospital mortality was higher in the HEMS group than that in the GEMS group in the unadjusted analysis (3.8% vs 1.3%, respectively; p < .001). After adjusting for covariates, HEMS transport was not associated with reduced hospital mortality. (odds ratio = 0.82, 95% confidence interval = 0.42–1.58).

Conclusions

HEMS was not associated with reduced mortality among pediatric trauma patients compared with GEMS in this nationwide study. Further investigation is necessary to determine who clearly benefits from HEMS as compared to GEMS.

Critical Care Helicopter Overtriage: A Failure Mode and Effects Analysis

OBJECTIVE

Overtriage (OT) of helicopter emergency medical services (HEMS) poses significant burden to multiple stakeholders. The project aims were to identify the following: 1) associated factors, 2) downstream effects, and 3) focus areas for change.

METHODS

We undertook a failure mode and effects analysis (FMEA) to evaluate our HEMS interfacility transport process. Data were collected from organizational finances and 3 key stakeholder groups: 1) interfacility patients transferred by HEMS in 2017 who were discharged from the receiving facility within 24 hours (n = 149), 2) flight registered nurses (n = 19), and 3) referring emergency medicine providers (EMPs) (n = 30) from the top HEMS users of 2017. The completed FMEA identified failure modes, the frequency and severity of effects, and unique risk profile numbers (RPNs).

RESULTS

Twelve failure modes were identified with 30 potential causes. Leading failure modes included inappropriate HEMS requests by EMPs (RPN = 343), inappropriate activation by EMS for interfacility transport (RPN = 343), and minimizing patient/family involvement in decision making (RPN = 315). Significant burdens to organizational finances and flight registered nurse satisfaction were identified.

CONCLUSION

Associated factors for interfacility HEMS OT, downstream effects, and areas for change were identified. EMP and emergency medical services practices, HEMS processes, and shared decision making may affect regional OT rates.

Resource utilization and indications for helicopter transport of head-injured children

INTRODUCTION

Helicopter emergency medical services (HEMS) have provided benefit for severely injured patients. However, HEMS are likely overused for the transportation of both adult and pediatric trauma patients. In this study, we aim to evaluate the degree of overuse of helicopter as a mode of transport for head-injured children. In addition, we propose criteria that can be used to determine if a particular patient is suitable for air versus ground transport.

MATERIALS AND METHODS

We identified patients who were transported to our facility for head injuries. We included only those patients who were transported from another facility and who were seen by the neurosurgical service. We recorded a number of data points including age, gender, race, Glasgow Coma Score (GCS), and intubation status. We also collected data on a number of imaging findings such as mass effect, edema, intracranial hemorrhage, and skull fractures. Patients undergoing emergent nonneurosurgical intervention were excluded.

RESULTS

Of the 373 patients meeting inclusion criteria, 116 (31.1%) underwent a neurosurgical procedure or died and were deemed appropriate for helicopter transport. The remaining 68.9% of patients survived their injuries without neurosurgical intervention and were deemed nonappropriate for helicopter transport. Multivariable logistic regression identified GCS 3-8 and/or presence of mass effect, edema, epidural hematoma (EDH), and open-depressed skull fracture as appropriate indications for helicopter transport.

CONCLUSIONS

The majority of patients transported to our facility by helicopter survived their head injury without need for neurosurgical intervention. Only those patients meeting clinical (GCS 3-8) or radiographic (mass effect, edema, EDH, open-depressed skull fracture) criteria should be transported by air.

LEVEL OF EVIDENCE

Level III (Diagnostic Study).

Direct Air Versus Ground Transport Predictors for Rural Pediatric Trauma

OBJECTIVE

Traumatic injury is the leading cause of mortality in children and the most common cause of emergency medical services transport in pediatric populations. We aimed to identify what factors are currently associated with selection for helicopter transport (HEMS) over ground ambulance (GEMS) in a primarily rural state.

METHODS

We performed a retrospective case-control study of trauma patients younger than 18 years old reported to the Oklahoma State Trauma Registry between 2005 and 2014 who received direct transport from the scene of injury to a tertiary trauma center within the state. Factors associated with HEMS transport over GEMS were identified by multivariate regression analysis.

RESULTS

Of the 1,700 patients in the study group, 50.8% were transported by HEMS. Increased distance (odds ratio [OR] = 6.1-18.6), lower Glasgow Coma Scale (OR = 2.5), multisystem injury (OR = 1.5), intubation (OR = 2.7), motor vehicle collision-related injuries (OR = 2.1), and elevated heart rate (OR = 1.8) were all associated with increased odds of HEMS transport, with distance being the strongest factor.

CONCLUSION

This study found that the principal determinants of triage to HEMS transport in the case of pediatric trauma in a rural state were primarily distance to a major trauma center and clinical factors relating to the type and severity of injury.

Helicopter Transport From the Scene of Injury: Are There Improved Outcomes for Pediatric Trauma Patients?

BACKGROUND

There is conflicting data to support the routine use of helicopter transport (HT) for the transfer of trauma patients. The purpose of this study was to evaluate outcomes for trauma patients transported via helicopter from the scene of injury to a regional pediatric trauma center.

METHODS

The institutional trauma registry was queried for trauma patients presenting from January 2000 through March 2012. Of 9119 patients, 1709 patients who presented from the scene were selected for further evaluation. This cohort was stratified into HT and ground transport (GT) for analysis. Associations between mode of transport and outcomes were estimated using odds ratios and 95% confidence intervals from multivariable logistic regression models.

RESULTS

Seven hundred twenty-five patients (42.4%) presented via HT, whereas 984 (57.6%) presented via GT. Patients arriving by HT had a higher Injury Severity Score, lower Glasgow Coma Scale, were less likely to undergo surgery within 3 hours, more likely to present after motorized trauma, and had longer intensive care unit (ICU) and hospital length of stay (LOS). Multivariate analysis controlling for Injury Severity Score, Glasgow Coma Scale, mechanism of injury, scene distance, and time to arrive to the hospital revealed that patients arriving by HT were more likely to have longer hospital LOS compared with those arriving by GT (odds ratios = 2.3, 95% confidence interval = 1.00-5.28, P = 0.049). However, no statistically significant association was observed for prehospital intubation, surgery within 3 hours, ICU admissions, or ICU LOS.

CONCLUSIONS

Although patients arriving by helicopter are more severely injured and arrive from greater distances, when controlling for injuries, scene distance, and time to hospital arrival, only hospital LOS was significantly affected by HT.

Mortality following helicopter versus ground transport of injured children

INTRODUCTION

Injured children may be transported to trauma centers by helicopter air ambulance (HAA); however, a benefit in outcomes to this expensive resource has not been consistently shown in the literature and there is concern that HAA is over-utilized. A study that adequately controls for selection biases in transport mode is needed to determine which injured children benefit from HAA. The purpose of this study was to determine if HAA impacts mortality differently in minimally and severely injured children and if there are predictors of over-triage of HAA in children that can be identified.

METHODS

Children ≤18 years of age transported by HAA or ground ambulance (GA) from scene to a trauma center were identified from the 2010-2011 National Trauma Data Bank. Analysis was stratified by Injury Severity Score (ISS) into low ISS (≤15) and high ISS (>15) groups. Following propensity score matching of HAA to GA patients, conditional multivariable logistic regression was performed to determine if transport mode independently impacted mortality in each stratum. Rates and predictors of over-triage of HAA were also determined.

RESULTS

Transport by HAA occurred in 8218 children (5574 low ISS, 2644 high ISS) and by GA in 35305 (30506 low ISS, 4799 high ISS). Overall mortality was greater in HAA patients (4.0 vs 1.4%, p<0.001). After propensity score matching, mortality was equivalent between HAA and GA for low ISS patients (0.2 vs 0.2%, p=0.82) but, for high ISS patients, mortality was lower in HAA (9.0 vs 11.1% p=0.014). On multivariable analysis, HAA was associated with decreased mortality in high ISS patients (OR=0.66, p=0.017) but not in low ISS patients (OR=1.13, p=0.73). Discharge within 24h of HAA transport occurred in 36.5% of low ISS patients versus 7.4% high ISS patients (p<0.001).

CONCLUSIONS

Based on a national cohort adjusted for nonrandom assignment of transport mode, a survival benefit to HAA transport exists only for severely injured children with ISS >15. Many children with minor injuries are transported by helicopter despite frequent dismissal within 24h and no mortality benefit.

Current use and outcomes of helicopter transport in pediatric trauma: a review of 18,291 transports

PURPOSE

The role of helicopter emergency medical services (HEMS) in pediatric trauma remains controversial. We examined its use in pediatric trauma and its effectiveness in children with moderate/severe injuries.

METHODS

All blunt/penetrating trauma patients ≤18years old in the National Trauma Data Bank were evaluated for use of HEMS and in-hospital mortality. In a comparative effectiveness study, only patients treated at level I/II pediatric centers with injury severity score (ISS)≥9 were included.

RESULTS

Of 127,489 included patients, 18,291 (14%) arrived via HEMS, compared to 56% by ground ambulance and 29% by private vehicle/walk-in. HEMS patients had more severe injuries (ISS≥25; 28% vs. 14%) and altered mental status (GCS≤8; 29% vs. 11%), but also contained many patients with only minor injuries or no major physiologic derangements. In unadjusted analysis, HEMS was associated with increased mortality (OR: 1.6; 95% CI: 1.4-1.7). However, it had decreased mortality by regression (0.5; 0.4-0.6) and propensity analysis (0.7; 0.6-0.8) to adjust for confounders.

CONCLUSION

We found multiple indicators for overuse of HEMS, with nearly 40% of children having only minor injuries. In moderate/severe injuries, HEMS is associated with decreased mortality, potentially saving one life for every 47 flights. Research is needed to determine appropriate criteria for helicopter triage.

COMPARATIVE STUDY/LEVEL OF EVIDENCE

III.

Helicopters and injured kids: Improved survival with scene air medical transport in the pediatric trauma population

BACKGROUND

Helicopter emergency medical services (HEMS) are frequently used to transport injured children, despite unclear evidence of benefit. The study objective was to evaluate the association of HEMS compared with ground emergency medical services (GEMS) transport with outcomes in a national sample of pediatric trauma patients.

METHODS

Patients 15 years or younger undergoing scene transport by HEMS or GEMS in the National Trauma Data Bank from 2007 to 2012 were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS transport based on demographics, prehospital physiology and time, injury severity, and geographic region. Absolute standardized differences of less than 0.1 indicated adequate covariate balance between groups after matching. The primary outcome was in-hospital survival, while the secondary outcome was discharge disposition in survivors. Conditional logistic regression determined the association between HEMS versus GEMS transport with outcomes while controlling for demographics, admission physiology, injury severity, nonaccidental trauma, and in-hospital complications not accounted for in the propensity score. Subgroup analysis was performed in patients with a transport time of greater than 15 minutes to capture patients with the potential for HEMS transport.

RESULTS

A total of 25,700 HEMS/GEMS pairs were matched from 166,594 patients. Groups were well matched, with all propensity score variables having absolute standardized differences of less than 0.1. In matched patients, HEMS was associated with a 72% increase in odds of survival compared with GEMS (adjusted odds ratio, 1.72; 95% confidence interval, 1.26-2.36; p < 0.01). Transport mode was not associated with discharge disposition (p = 0.47). Subgroup analysis included 17,657 HEMS/GEMS pairs. HEMS was again associated with a significant increase in odds of survival (adjusted odds ratio, 1.81; 95% confidence interval, 1.24-2.65; p < 0.01), while transport mode was not associated with discharge disposition (p = 0.58).

CONCLUSION

Scene transport by HEMS was associated with improved odds of survival compared with GEMS in pediatric trauma patients. Further study is warranted to understand the underlying mechanisms and develop specific triage criteria for HEMS transport in this population.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: protocol for a mixed methods cohort study

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. The objective of this study is to review the processes of care and describe the impacts of a regionalised trauma system on the outcomes of severely injured children.

METHODS

This article describes the design of a mixed methods cohort study evaluating the paediatric trauma system in New South Wales (NSW), the most populous state in Australia. Recommendations and an implementation strategy will be developed for aspects of the paediatric trauma care system that require change. All injured children (aged <16 years) requiring intensive care, or with an Injury Severity Score (ISS) ≥ 9 treated in NSW, or who died following injury in NSW in the 2015-16 financial year, will be eligible for participation. Injury treatment and processes will be examined via retrospective medical record review. Quality of care will be measured via peer review and staff interviews, utilising a human factors framework. Health service and cost outcomes will be calculated using activity based funding data provided by the Ministry of Health. Health-related quality of life (HRQoL) proxy measures will occur at baseline, 6 and 12 months to measure child HRQoL and functional outcomes.

DISCUSSION

This will be the first comprehensive analysis undertaken in Australia of the processes and systems of care for severe paediatric injury. The collaborative research method will encourage clinician, consumer and clinical networks to lead the clinical reform process and will ultimately enable policy makers and service providers to ensure that children seriously injured in Australia have the best opportunity for survival, improved functional outcome and long-term quality of life.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: An integrative review

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.

Helicopter versus ground emergency medical services for the transportation of traumatically injured children

BACKGROUND

Helicopter emergency medical services (HEMS) are a common mode of transportation for pediatric trauma patients. We hypothesized that HEMS improve outcomes for traumatically injured children compared to ground emergency medical services (GEMS).

METHODS

We queried trauma registries of two level 1 pediatric trauma centers for children 0-17 years, treated from 2003 to 2013, transported by HEMS or GEMS, with known transport starting location and outcome. A geocoding service estimated travel distance and time. Multivariate regression analyses were performed to adjust for injury severity variables and travel distance/time.

RESULTS

We identified 14,405 traumatically injured children; 3870 (26.9%) transported by HEMS and 10,535 (73.1%) transported by GEMS. Transport type was not significantly associated with survival, ICU length of stay, or discharge disposition. Transport by GEMS was associated with a 68.6%-53.1% decrease in hospital length of stay, depending on adjustment for distance/time. Results were similar for children with severe injuries, and with propensity score matched cohorts. Of note, 862/3850 (22.3%) of HEMS transports had an ISS<10 and hospitalization<1 day.

CONCLUSIONS

HEMS do not independently improve outcomes for traumatically injured children, and 22.3% of children transported by HEMS are not significantly injured. These factors should be considered when requesting HEMS for transport of traumatically injured children.

Do prehospital criteria optimally assign injured children to the appropriate level of trauma team activation and emergency department disposition at a level I pediatric trauma center?

PURPOSE

To examine the association of prehospital criteria with the appropriate level of trauma team activation (TTA) and emergency department (ED) disposition among injured children at a level I pediatric trauma center.

METHODS

Injured children younger than 15 years and transported by emergency medical services (EMS) from the scene of injury between January 1, 2008 and December 31, 2011 were identified using the institution's trauma registry. Logistic regression was used to study the main outcomes of interest, full TTA (FTTA) and ED disposition.

RESULTS

Out of 3,213 children, 1,991 were eligible and analyzed. Only 279 children initiated the FTTA and 73.9% were admitted. Having a chest injury, abnormal heart rate or Glasgow Coma Scale less than 9 (GCSLT9) in the field was associated with higher odds of initiating the FTTA (odds ratio [OR] = 3.33, 95% confidence interval [CI] 1.54-7.20; OR = 2.59, CI 1.15-5.79 and OR = 2.67, CI 1.14-6.22, respectively). Children with the criteria above in addition to abdominal injury were more likely to be discharged to the ICU, OR or morgue compared to those without them.

CONCLUSION

Children with GCSLT9, abnormal heart rate, chest and abdominal injury showed a strong association with FTTA and higher resource utilization.

Helicopter overtriage in pediatric trauma

BACKGROUND

Helicopter Emergency Medical Services (HEMS) have been designed to provide faster access to trauma center care in cases of life-threatening injury. However, the ideal recipient population is not fully characterized, and indications for helicopter transport in pediatric trauma vary dramatically by county, state, and region. Overtriage, or unnecessary utilization, can lead to additional patient risk and expense. In this study we perform a nationwide descriptive analysis of HEMS for pediatric trauma and assess the incidence of overtriage in this group.

METHODS

We reviewed records from the American College of Surgeons National Trauma Data Bank (2008-11) and included patients less than 16 years of age who were transferred from the scene of injury to a trauma center via HEMS. Overtriage was defined as patients meeting all of the following criteria: Glasgow Coma Scale (GCS) equal to 15, absence of hypotension, an Injury Severity Score (ISS) less than 9, no need for procedure or critical care, and a hospital length of stay of less than 24 hours.

RESULTS

A total of 19,725 patients were identified with a mean age of 10.5 years. The majority of injuries were blunt (95.6%) and resulted from motor vehicle crashes (48%) and falls (15%). HEMS transported patients were predominately normotensive (96%), had a GCS of 15 (67%), and presented with minor injuries (ISS<9, 41%). Overall, 28 % of patients stayed in the hospital for less than 24 hours, and the incidence of overtriage was 17%.

CONCLUSIONS

Helicopter overtriage is prevalent among pediatric trauma patients nationwide. The ideal model to predict need for HEMS must consider clinical outcomes in the context of judicious resource utilization. The development of guidelines for HEMS use in pediatric trauma could potentially limit unnecessary transfers while still identifying children who require trauma center care in a timely fashion.

Is paediatric trauma severity overestimated at triage? An observational follow-up study

BACKGROUND

Severe paediatric trauma is rare, and pre-hospital and local hospital personnel experience with injured children is often limited. We hypothesised that a higher proportion of paediatric trauma victims were taken to the regional trauma centre (TC).

METHODS

This is an observational follow-up study that involves one level I TC and seven local hospitals. We included paediatric (< 16 years) and adult (≥ 16-≤ 79 years) trauma patients with a driving distance to the TC > 30 minutes. The primary end-point was the proportion of trauma patients arriving in the TC.

RESULTS

We included 1934 trauma patients, 238 children and 1696 adults. A total of 33/238 children (13.9%) vs. 304/1696 adults (17.9%) were transported to the TC post-injury (P = 0.14). Among these, children were significantly less injured than adults [median Injury Severity Score (ISS) 9 vs. 14, P < 0.01]. There was no significant difference between the groups in the proportion of seriously injured trauma victims (ISS > 15) taken to the TC [8/11 (72.7%) vs. 139/182 (76.4%)]. The corresponding figures for ISS < 15 were 25/227 (11.0%) and 164/1509 (10.9%), respectively. No significant difference was found in intensive care unit length of stay or time to TC arrival. No paediatric vs. 36/1671 (2.2%) adult deaths were observed at 30-day follow-up (P = 0.03).

CONCLUSIONS

There was no difference in the proportion of paediatric and adult trauma patients transported to the TC, neither overall nor among severely injured patients. Paediatric trauma patients admitted to the TC were, however, significantly less injured than adults.

Effect of a checklist on advanced trauma life support workflow deviations during trauma resuscitations without pre-arrival notification

BACKGROUND

Trauma resuscitations without pre-arrival notification are often initially chaotic, which can potentially compromise patient care. We hypothesized that trauma resuscitations without pre-arrival notification are performed with more variable adherence to ATLS protocol and that implementation of a checklist would improve performance.

STUDY DESIGN

We analyzed event logs of trauma resuscitations from two 4-month periods before (n = 222) and after (n = 215) checklist implementation. Using process mining techniques, individual resuscitations were compared with an ideal workflow model of 6 ATLS primary survey tasks performed by the bedside evaluator and given model fitness scores (range 0 to 1). Mean fitness scores and frequency of conformance (fitness = 1) were compared (using Student's t-test or chi-square test, as appropriate) for activations with and without notification both before and after checklist implementation. Multivariable linear regression, controlling for patient and resuscitation characteristics, was also performed to assess the association between pre-arrival notification and model fitness before and after checklist implementation.

RESULTS

Fifty-five (12.6%) resuscitations lacked pre-arrival notification (23 pre-implementation and 32 post-implementation; p = 0.15). Before checklist implementation, resuscitations without notification had lower fitness (0.80 vs 0.90; p < 0.001) and conformance (26.1% vs 50.8%; p = 0.03) than those with notification. After checklist implementation, the fitness (0.80 vs 0.91; p = 0.007) and conformance (26.1% vs 59.4%; p = 0.01) improved for resuscitations without notification, but still remained lower than activations with notification. In multivariable analysis, activations without notification had lower fitness both before (b = -0.11, p < 0.001) and after checklist implementation (b = -0.04, p = 0.02).

CONCLUSIONS

Trauma resuscitations without pre-arrival notification are associated with a decreased adherence to key components of the ATLS primary survey protocol. The addition of a checklist improves protocol adherence and reduces the effect of notification on task performance.