C. Schlegel1, A. Greeno1, K. F. Collins1, H. N. Lovvorn1 1Vanderbilt University Medical Center,Nashville, TN, USA
Introduction: Trauma is the leading cause of mortality among children. While much is written about improved outcomes among pediatric trauma patients treated by a pediatric specialist, either at a pediatric trauma center (PTC) or an adult trauma center with pediatric qualifications (ATC), little has been written comparing outcomes after transition from an ATC to PTC at a single institution. Additionally, as more PTC’s are established, a significant knowledge gap exists in understanding the evolution in patient population and outcomes at these new centers. Over the last decade at our medical center, pediatric trauma care has transitioned from an ATC Level 1 facility to a stand alone PTC. The aim of this study was to evaluate the impact of this transition on our single-center outcomes, specifically focusing on mechanism of injury, utilization of resources, and mortality.
Methods: A retrospective analysis of 1,188 children who presented as Level 1 traumas to our institution between 2005-2016 was performed. Patients were divided into those treated at our adult hospital preceding the transition (ATC), early at the initiation of a Level 1 PTC (E-PTC), and later following ACS review (L-PTC). Comparisons were made using Pearson’s Chi-2, Wilcoxon rank sum, and Kruskal-Wallis tests.
Results: Of the 1,188 pediatric trauma patients, 245 were treated at ATC, 672 during E-PTC, and 271 during L-PTC periods. No differences were detected in age, gender, or injury severity. The predominant mechanism of injury for all groups was motor vehicle collisions, with increases in assaults (2.5% ATC vs 10.7% L-PTC) and other blunt mechanisms of trauma (4.5% ATC vs 9.6% L-PTC) (p<0.006), while an increasing trend was observed in violent firearm injuries (6.4% ATC vs 11.8% L-PTC). A significant decrease in ICU admissions was observed during L-PTC in comparison to E-PTC and ATC (51.3% vs 62.4% vs 66.5%, p<0.001). Transition to a PTC correlated with a significant increase in earlier operative intervention following arrival to the ED compared to ATC (20.7% vs 11.4%, p<0.005). Overall mortality trended down in the L-PTC group (12.2%), compared to either E-PTC (13.7%) or ATC (13.0%). This decrease was most notable in children<5 years of age, with mortality decreasing significantly from 22.2% at ATC and 20.7% at E-PTC to 15.7% at L-PTC (p<0.002).
Conclusion: Changes in the mechanism of trauma presentation occurred following transition to a pediatric Level 1 trauma center, with notable increases in blunt trauma, including assault/NAT. Improvements in mortality and decreases in ICU admission occurred following the creation of an independent PTC when compared to our ATC or during the early evolution of our PTC, with the most drastic differences noted in younger age groups. Transition to a PTC is not only safe, with minimal changes in mortality during early evolution compared to ATC, but also ultimately results in improved pediatric trauma care.