Emergency Medicine

Treating injured adolescents at pediatric trauma centers associated with lower mortality

Swanson Russell photo shoot trauma emergency department Brand Photos FY13

As children mature into adolescence, they also transition from being cared for by pediatric healthcare providers to being cared for by health professionals who primarily treat adults. Controversy remains about whether a primarily pediatric or adult treatment location is optimal to meet the needs of injured adolescents. For this reason, the cutoff age for triaging children to pediatric versus adult trauma hospitals varies in different settings. A research team led by Randall S. Burd, MD, PhD, Chief of the Children’s National Health System Division of Trauma and Burn Surgery, found that injured adolescents treated at pediatric trauma centers (PTCs) had a lower mortality rate than injured adolescents treated at adult trauma centers (ATCs) or mixed trauma centers (MTCs), facilities that treat both adults and children, even when controlling for differences in patients.Trauma is a leading cause of death and acquired disability among adolescents. To determine any potential association between the type of trauma center and mortality rates, the research team examined 29,613  records for patients aged 15 to 19 years old drawn from the 2010 National Trauma Data Bank.“Trauma centers dedicated to the treatment of pediatric patients see a different adolescent population than do ATCs and MTCs,” Dr. Burd and colleagues write in an article published June 27 by JAMA Pediatrics. “After controlling for these differences, we observed that adolescent trauma patients have lower overall and in-hospital mortality when treated at PTCs.”

These findings, bolstered by additional research, have the potential to change the approach for triaging injured adolescents, says Dr. Burd, the paper’s senior author. The study findings suggest that commonly used age thresholds of 14 or 15 years might be safely adjusted higher.

Because the data were obtained from a large dataset, making that case will require closer examination – perhaps chart-by-chart analysis for each patient – to tease out nuances that differentiate care adolescents receive at different types of trauma hospitals, Dr. Burd says. “Are there differences in the process of care – or availability of specific resources – that account for the differences in outcome? Or, do the patients treated at each hospital type have differences in their injuries that we have not yet identified?”

Most adolescents (68.9 percent) included in the study were treated at an adult trauma center. In addition to being older, these youths were more likely to be severely injured and more frequently suffered severe injuries to the head, chest, and upper extremities. The most common traumatic injuries seen at adult centers resulted from children being passengers in motor vehicles (32.6 percent). Penetrating injuries from firearms (12 percent) and cutting or piercing (7.1 percent) were more common at adult centers.

Some 1,636 patients (5.5 percent) were treated at a pediatric trauma center, with many being transferred there from another hospital. Adolescents treated at pediatric trauma centers were more likely to be injured by a blunt rather than penetrating mechanism. The most common injuries seen at pediatric centers were injuries from a fall (25.9 percent) or injuries that resulted from being struck (26.1 percent).

“Because adolescents straddle the gap between pediatric and adult medicine, identifying differences in care among PTCs, ATCs, and MTCs will help determine the most appropriate triage strategies or identify practice strategies that can optimize the outcome for patients in this age group,” the authors conclude.

Related resources: Research at a Glance 

Association Seen Between Trauma Center Type and Mortality Risk for Injured Youths

Swanson Russell photo shoot trauma emergency department Brand Photos FY13

What’s Known
Trauma is the leading cause of death among children and young adults in the United States, but controversy remains about which treatment location is optimal to meet the needs of injured adolescent patients. Pediatric trauma centers tailor care to children’s unique physiological,anatomical, and social needs. Yet, there are variations in the cutoff age used to triage children to either pediatric or adult trauma centers, with the usual decision to triage children to pediatric facilities if they are younger than 14 or 15 and to transport them to adult systems if they are older. A 2015 study found that injured children aged 18 or younger treated at pediatric trauma centers had lower in-hospital mortality.

What’s New
A team led by Children’s National Health System researchers examined 29,613 de-identified records for patients aged 15 to 19 years old drawn from the 2010 National Trauma Data Bank to determine associations between the type of trauma center and youths’ mortality rates. Some 68.9 percent of injured youths were treated at adult trauma centers (ATCs), while 25.6 percent were seen at mixed trauma centers (MTCs), and 5.5 percent at pediatric trauma centers (PTCs). Mortality was higher among youths treated at ATCs (3.2 percent) and MTCs (3.5 percent) than for adolescents seen at PTCs (0.4 percent), P < .001. The adjusted odds of mortality were higher at ATCs (4.19) and MTCs (6.68 ) compared with PTCs (0.76). While the research team saw differences in mortality between trauma center type, the study does not provide information about what may account for these differences.

Questions for Future Research

  • What is the best method to determine differences in treatment practices between trauma center types to better explain differences in the mortality rates of injured adolescents?
  • Which specific qualities are common to trauma centers that provide optimal outcomes to children, and can quality-improvement initiatives help to identify and replicate those attributes elsewhere?

Source: “Association Between Trauma Center Type and Mortality Among Injured Adolescent Patients. R.B. Webman, E.A. Carter, S. Mittal, J. Wang, C. Sathya, A. Nathens, M. Nance, D. Madigan, and R. Burd. Published online by JAMA Pediatrics June 27, 2016.