Injured Children Fare Better at Specialized Centers : Investigator calls for greater effort to triage most severely injured children to pediatric trauma centers.

PHOENIX — Pediatric trauma patients are not usually brought to pediatric trauma centers and receive less than optimal treatment as a result, according to two studies presented at the annual meeting of the American Pediatric Surgical Association.

John C. Densmore, M.D., and his colleagues analyzed nearly 80,000 pediatric trauma cases from the year 2000 in the 27-state Kids' Inpatient Database maintained by the Agency for Healthcare Research and Quality.

Nearly 90% were treated at adult hospitals, reported Dr. Densmore of the Children's Hospital of Wisconsin in Milwaukee. The 10.7% treated at children's hospitals had significantly better mortality rates, length of stay, and charges.

Mortality rates ranged from 0.9% in children's hospitals to 1.4% in adult hospitals and 2.4% in children's units within adult hospitals. Length of stay greater than the 90th percentile occurred least often in the children's hospitals (8.9%), somewhat more often in adult hospitals (9.7%), and most often in children's units (17.2%). Charges greater than the 50th percentile followed the same pattern: 20.2%, 22.2%, and 32.4%, respectively.

A larger proportion (26.8%) of children ages 0–10 years with injury severity scores greater than 15 were treated at children's hospitals. Subgroup analysis revealed that their mortality rate, length of stay, and charges were higher, but they also fared better in children's hospitals, compared with the adult centers. “The youngest and most severely injured subgroup shows the largest disparity in outcomes among sites,” Dr. Densmore said.

In the second study, Steven Stylianos, M.D., and his colleagues identified 3,232 children with spleen injuries in health department data sets from California, Florida, New Jersey, and New York for 2000–2002.

Dr. Stylianos, who conducted the study while at the Children's Hospital of New York in New York City, said spleen injuries follow a predictable course. Yet he reported that the odds of splenectomy varied widely based on who treated the child and where care was given.

Nontrauma centers were significantly more likely to perform surgery, with an 18.8% rate of operation, compared with 12.2% in trauma centers; the adjusted odds ratio was 2.12. The adjusted odds ratios for splenectomy were also higher for general hospitals vs. children's hospitals (2.8), general surgeons vs. pediatric surgeons (4.1), and adult or nontrauma centers vs. pediatric trauma centers (6.2).

Nearly half the children were treated in nontrauma centers. For children with multiple injuries, the rates of splenectomy were 15.3% in trauma centers and 19.3% in nontrauma centers. When the injury was isolated, 9.2% of children in trauma centers and 18.5% in nontrauma centers underwent splenectomy.

Dr. Stylianos, now at Miami Children's Hospital, said the consensus guidelines and benchmarks of the American Pediatric Surgical Association recommended splenectomy for 10%–17% of the patients with multiple injuries, 0%–3% with isolated injuries, and 5%–10% of the total population. “I think this is an unacceptable risk of splenectomy that the children of America are being subjected to,” he said.

Both investigators noted that there are not enough children's hospitals or pediatric surgeons to serve all sick and injured children. Dr. Stylianos urged pediatric surgeons to do more to disseminate the American Pediatric Surgical Association's consensus guidelines and benchmarks for treatment of pediatric spleen injury to both trauma and nontrauma centers.

“Pediatric surgeons and pediatric trauma centers treat the minority of patients,” he said. “State [and] regional trauma systems may be the most practical and effective targets for dissemination of benchmarks.”

Dr. Densmore called for greater efforts to triage severely injured children to children's hospitals. His study found pediatric trauma patients in the children's units had higher injury severity scores on average than those in the children's hospitals or adult hospital care. The researchers noted they corrected for injury severity in outcome measures.

“Outcomes data like these should be taken into consideration when we think about where to build children's hospitals and how to refer appropriately injured children to that facility,” Dr. Densmore said in an interview at the meeting. “Right now there are state-based systems, and there needs to be perhaps a more national view on how we triage and care for injured children.”

PHOENIX — Pediatric trauma patients are not usually brought to pediatric trauma centers and receive less than optimal treatment as a result, according to two studies presented at the annual meeting of the American Pediatric Surgical Association.

John C. Densmore, M.D., and his colleagues analyzed nearly 80,000 pediatric trauma cases from the year 2000 in the 27-state Kids' Inpatient Database maintained by the Agency for Healthcare Research and Quality.

Nearly 90% were treated at adult hospitals, reported Dr. Densmore of the Children's Hospital of Wisconsin in Milwaukee. The 10.7% treated at children's hospitals had significantly better mortality rates, length of stay, and charges.

Mortality rates ranged from 0.9% in children's hospitals to 1.4% in adult hospitals and 2.4% in children's units within adult hospitals. Length of stay greater than the 90th percentile occurred least often in the children's hospitals (8.9%), somewhat more often in adult hospitals (9.7%), and most often in children's units (17.2%). Charges greater than the 50th percentile followed the same pattern: 20.2%, 22.2%, and 32.4%, respectively.

A larger proportion (26.8%) of children ages 0–10 years with injury severity scores greater than 15 were treated at children's hospitals. Subgroup analysis revealed that their mortality rate, length of stay, and charges were higher, but they also fared better in children's hospitals, compared with the adult centers. “The youngest and most severely injured subgroup shows the largest disparity in outcomes among sites,” Dr. Densmore said.

In the second study, Steven Stylianos, M.D., and his colleagues identified 3,232 children with spleen injuries in health department data sets from California, Florida, New Jersey, and New York for 2000–2002.

Dr. Stylianos, who conducted the study while at the Children's Hospital of New York in New York City, said spleen injuries follow a predictable course. Yet he reported that the odds of splenectomy varied widely based on who treated the child and where care was given.

Nontrauma centers were significantly more likely to perform surgery, with an 18.8% rate of operation, compared with 12.2% in trauma centers; the adjusted odds ratio was 2.12. The adjusted odds ratios for splenectomy were also higher for general hospitals vs. children's hospitals (2.8), general surgeons vs. pediatric surgeons (4.1), and adult or nontrauma centers vs. pediatric trauma centers (6.2).

Nearly half the children were treated in nontrauma centers. For children with multiple injuries, the rates of splenectomy were 15.3% in trauma centers and 19.3% in nontrauma centers. When the injury was isolated, 9.2% of children in trauma centers and 18.5% in nontrauma centers underwent splenectomy.

Dr. Stylianos, now at Miami Children's Hospital, said the consensus guidelines and benchmarks of the American Pediatric Surgical Association recommended splenectomy for 10%–17% of the patients with multiple injuries, 0%–3% with isolated injuries, and 5%–10% of the total population. “I think this is an unacceptable risk of splenectomy that the children of America are being subjected to,” he said.

Both investigators noted that there are not enough children's hospitals or pediatric surgeons to serve all sick and injured children. Dr. Stylianos urged pediatric surgeons to do more to disseminate the American Pediatric Surgical Association's consensus guidelines and benchmarks for treatment of pediatric spleen injury to both trauma and nontrauma centers.

“Pediatric surgeons and pediatric trauma centers treat the minority of patients,” he said. “State [and] regional trauma systems may be the most practical and effective targets for dissemination of benchmarks.”

Dr. Densmore called for greater efforts to triage severely injured children to children's hospitals. His study found pediatric trauma patients in the children's units had higher injury severity scores on average than those in the children's hospitals or adult hospital care. The researchers noted they corrected for injury severity in outcome measures.

“Outcomes data like these should be taken into consideration when we think about where to build children's hospitals and how to refer appropriately injured children to that facility,” Dr. Densmore said in an interview at the meeting. “Right now there are state-based systems, and there needs to be perhaps a more national view on how we triage and care for injured children.”

PHOENIX — Pediatric trauma patients are not usually brought to pediatric trauma centers and receive less than optimal treatment as a result, according to two studies presented at the annual meeting of the American Pediatric Surgical Association.

John C. Densmore, M.D., and his colleagues analyzed nearly 80,000 pediatric trauma cases from the year 2000 in the 27-state Kids' Inpatient Database maintained by the Agency for Healthcare Research and Quality.

Nearly 90% were treated at adult hospitals, reported Dr. Densmore of the Children's Hospital of Wisconsin in Milwaukee. The 10.7% treated at children's hospitals had significantly better mortality rates, length of stay, and charges.

Mortality rates ranged from 0.9% in children's hospitals to 1.4% in adult hospitals and 2.4% in children's units within adult hospitals. Length of stay greater than the 90th percentile occurred least often in the children's hospitals (8.9%), somewhat more often in adult hospitals (9.7%), and most often in children's units (17.2%). Charges greater than the 50th percentile followed the same pattern: 20.2%, 22.2%, and 32.4%, respectively.

A larger proportion (26.8%) of children ages 0–10 years with injury severity scores greater than 15 were treated at children's hospitals. Subgroup analysis revealed that their mortality rate, length of stay, and charges were higher, but they also fared better in children's hospitals, compared with the adult centers. “The youngest and most severely injured subgroup shows the largest disparity in outcomes among sites,” Dr. Densmore said.

In the second study, Steven Stylianos, M.D., and his colleagues identified 3,232 children with spleen injuries in health department data sets from California, Florida, New Jersey, and New York for 2000–2002.

Dr. Stylianos, who conducted the study while at the Children's Hospital of New York in New York City, said spleen injuries follow a predictable course. Yet he reported that the odds of splenectomy varied widely based on who treated the child and where care was given.

Nontrauma centers were significantly more likely to perform surgery, with an 18.8% rate of operation, compared with 12.2% in trauma centers; the adjusted odds ratio was 2.12. The adjusted odds ratios for splenectomy were also higher for general hospitals vs. children's hospitals (2.8), general surgeons vs. pediatric surgeons (4.1), and adult or nontrauma centers vs. pediatric trauma centers (6.2).

Nearly half the children were treated in nontrauma centers. For children with multiple injuries, the rates of splenectomy were 15.3% in trauma centers and 19.3% in nontrauma centers. When the injury was isolated, 9.2% of children in trauma centers and 18.5% in nontrauma centers underwent splenectomy.

Dr. Stylianos, now at Miami Children's Hospital, said the consensus guidelines and benchmarks of the American Pediatric Surgical Association recommended splenectomy for 10%–17% of the patients with multiple injuries, 0%–3% with isolated injuries, and 5%–10% of the total population. “I think this is an unacceptable risk of splenectomy that the children of America are being subjected to,” he said.

Both investigators noted that there are not enough children's hospitals or pediatric surgeons to serve all sick and injured children. Dr. Stylianos urged pediatric surgeons to do more to disseminate the American Pediatric Surgical Association's consensus guidelines and benchmarks for treatment of pediatric spleen injury to both trauma and nontrauma centers.

“Pediatric surgeons and pediatric trauma centers treat the minority of patients,” he said. “State [and] regional trauma systems may be the most practical and effective targets for dissemination of benchmarks.”

Dr. Densmore called for greater efforts to triage severely injured children to children's hospitals. His study found pediatric trauma patients in the children's units had higher injury severity scores on average than those in the children's hospitals or adult hospital care. The researchers noted they corrected for injury severity in outcome measures.

“Outcomes data like these should be taken into consideration when we think about where to build children's hospitals and how to refer appropriately injured children to that facility,” Dr. Densmore said in an interview at the meeting. “Right now there are state-based systems, and there needs to be perhaps a more national view on how we triage and care for injured children.”