Impact of Adult Trauma Center Certification on Pediatric Emergency Trauma

Abstract

Background

There is currently no information regarding the impact of adult trauma center certification as a level 1 trauma center on pediatric trauma in the same institution.

Objective

To examine the impact of adult trauma certification on pediatric trauma.

Design/Methods

We identified a time period before and after state trauma level 1 certification (pre-certification = August 2000 – March 2001, post-certification = August 2001 – March 2002) for an adult emergency department and compared these two periods of time with respect to the type of trauma seen in the Pediatric Emergency Department located in the same hospital. The Pediatric Emergency Department is not certified as a level 1 trauma center. The Adult and Pediatric Emergency Departments are located in a large inner-city teaching hospital with a physically separate Pediatric Emergency Department with greater than 25,000 visits in children less than 18 years of age. Trauma patients prior to state certification were identified through ICD coding while trauma patients who presented post state trauma certification were identified through the trauma registry. Pediatric trauma post certification was defined as those patients < 18 years of age who fit ACSCOT criteria for trauma team activation.

Results

The number of pediatric trauma patients increased from 45 in the pre-certification period to 99 in the post-certification period (an increase of 120%). The most common mechanism of trauma in both groups was a pedestrian struck by a vehicle. There was no significant difference in the Injury Severity Score between pre-certification (3.44±2.4) and post-certification (3.68±4.5). However, 90% of patients with an ISS > or = to 9 were in the post certification group (p=.17). All cases of penetrating assault were found the post-certification group.

Conclusion

This study suggests that following adult level 1 trauma state certification, the volume and severity of pediatric trauma may increase – even when the pediatric emergency facility is not a state certified trauma facility. These data underscore the need to anticipate such increases in both volume and severity and prepare appropriately. This may include training in trauma for all personnel, administrative systems review, adequate staffing and preparation of new policies and procedures.

Injury is the leading cause of death in children older than 1 year of age. In 2001, more than 5,500 children younger than 15 years if age died of causes related to trauma; another 1,000 died secondary to homicide or suicide. In 2002, more than 100,000 children were hospitalized and over 6 million children were evaluated in emergency departments due to trauma related causes. ^{1 2}

As of August 2001, there were 18 Regional Trauma Centers and 2 Pediatric Regional Trauma Centers in the New York City area. The Pediatric Trauma Centers were located at Children’s Hospital of New York, and Schneider Children’s Hospital/Long Island Jewish Medical Center.  A third Pediatric Regional Trauma Center was located in Buffalo, New York at the Women and Children’s Hospital. Clearly most of the pediatric trauma in New York State is managed by either one of the 18 regional trauma centers and not necessarily a New York State certified pediatric trauma center.

There is currently no information regarding the impact of certification of an adult trauma center on pediatric trauma in the same institution. This is especially important in the majority of those institutions where pediatric trauma cases are managed (i.e. where there is no New York State certified pediatric trauma center). The aim of this study, therefore, was to examine the impact of adult emergency department trauma certification on pediatric trauma.

Design/Methods

The Adult and Pediatric Emergency Departments of St. Barnabas Hospital are located in a large inner-city teaching hospital with a physically separate Pediatric Emergency Department reporting an annual census greater than 25,000 visits in children less than 18 years of age. The Pediatric Emergency Department is not state certified as a Pediatric Trauma Center. Trauma patients prior to state certification of Level I Adult Trauma Center status were identified through ICD coding while trauma patients who presented post state trauma certification were identified through the trauma registry. Pediatric trauma post certification was defined as those patients < 18 years of age who fit ACSCOT criteria for trauma team activation.

A retrospective study of pediatric patients with trauma-related injuries that were evaluated in the St. Barnabas Hospital Emergency Department was conducted. Two similar 8 month time periods were compared with respect to the number and severity of pediatric trauma cases seen in the Pediatric Emergency Department. The period from August 2000 – March 2001 was the period prior to adult trauma certification and was defined as “Pre-Certification.” The period from August 2001-March 2002 was the period after adult trauma certification and was defined as “Post-Certification.” Patients were identified through ICD codes pre-certification and through the trauma registry post-certification. An Injury Severity Score (ISS) was assigned to all patients. Severe trauma was defined as those patients with an ISS of > 9.

Results

230 patients were included in the study; 54 were from the pre-certification group and 175 from the post-certification group. Variables examined included demographic parameters (age, ethnicity, sex and location of injury), Injury Severity Score (ISS) and volume of pediatric trauma patients per month. A significant increase of 225% was noted in the number of pediatric trauma patients evaluated post-certification.  By comparison, there was only an 18% increase in the overall pediatric ED population post-certification.  Evaluation of the monthly number of pediatric trauma patients revealed a significant difference between the two groups (p=0.02).  There were no significant differences in the ISS scores, age, gender, ethnicity or location of trauma in the two groups (3.44 pre-certification compared to 3.67 post-certification, Tables 1 and 2).

Discussion

Unintentional injuries (accidents) are the leading cause of death and disability for those under 35 years of age; more patients are affected than those with cancer and heart disease combined. According to the 1994-1998 Special Report on Pediatric Trauma in New York State, pediatric patients were defined as 0-19 years of age and represented 19.9% of all patients who qualified for inclusion in the New York State Trauma Registry. ³ Data collected during this time revealed a total of 20,306 pediatric patients, with the largest age group between 15-19 years (39.7%). Males represented 72.1% of this group.

The most common mechanisms of injury (MOI) statewide were falls (21.5%), motor vehicle crashes (20.7%), assaults (14.7%), pedestrian struck (13.4%), sports/recreation (7.2%), bicycle crash (7.2%), other (14.6%) and unknown (0.8%). Regional distribution showed that 30.1% of pediatric patients in the New York State Trauma Registry were in New York City.  The number of pediatric trauma patients in NYC is estimated to be higher since NYC does not collect non-center data.  Statewide, regional trauma centers treated 66.2% of pediatric trauma patients.

As of August 2001, there were 18 Regional Trauma Centers and 2 Pediatric Regional Trauma Centers in the New York City area, which includes Children’s Hospital of New York, located in Columbia Presbyterian Medical Center in Manhattan and Schneider Children’s Hospital in Long Island Jewish Hospital Medical Center in New Hyde Park, N.Y.  A third Pediatric Regional Trauma Center located in Buffalo, New York is Women and Children’s Hospital.

The number and distribution of Pediatric Trauma Centers in New York State may not be proportional to the incidence of pediatric trauma.  Multiple factors influence why large portions of pediatric trauma patients are often transported to Adult instead of Pediatric Trauma Centers. Distance and transport times, as well as severity of injury may necessitate transport to the nearest trauma center. Emergency Medical Service personnel or by-standers may consider adolescents as adults, either due to body proportion or secondary to the mechanism of injury such as stab or gun shot wounds.  Family members or caretakers do not differentiate for appropriateness of emergency departments.

In urban settings, parents or caretakers rely on an ambulance, public transportation or simply walk to the local emergency department when injured. They often are transported by the Emergency Medical Service to a local trauma center or emergency department and do not have an alternative method of transportation to a Pediatric Center even if they so desired.  In an attempt not to separate parents from their children when involved in motor vehicle crashes or incidents, pediatric patients are often transported along with their parents to adult trauma centers.  As a result, pediatric trauma patients frequently are not transported directly to a designated Pediatric Trauma Center.

Considering this reality, Adult Trauma Centers must be prepared to manage pediatric trauma victims regardless of their original designation. Our study underscores the need for trauma centers to consider applying for dual adult and pediatric trauma center certification.  To meet the tremendous challenge of caring for pediatric trauma patients, adult trauma centers need to thoroughly review equipment, management, and staffing protocols developed by a variety of certifying agencies. Development of standards, evaluation and certification of trauma centers applying for pediatric designation could be conducted by the State Department of Health or the American College of Surgeons similar to the same application process used to obtain Adult Trauma Certification. ^{6 7}

In August 2001, St. Barnabas Hospital was designated as a Regional Trauma Center by the New York State Department of Health.  Although the hospital had not applied for and was not certified as a pediatric trauma center, the trauma service and emergency department were designed to accommodate both pediatric and adult patients.  As anticipated, an increase in pediatric trauma patients to our center occurred after Level I Trauma Certification.

In view of the results of this study, we conclude that despite certification, trauma centers should anticipate to evaluate and manage a significant number of pediatric trauma patients solely as a result of their adult trauma certification and should acquire necessary resources appropriate for this population.  A standardized dual trauma certification (adult/pediatric) would assist with improving and monitoring the delivery of pediatric trauma care in New York State.  Centers who do are not eligible for dual certification should insure that adequate pediatric resources are available for initial trauma stabilization, transfer polices and procedures are in place and that transport by properly trained personnel equipped with specialized equipment is arranged.

Conclusion

These data suggest a significant increase in volume and severity of pediatric patients following adult trauma center certification.  Pediatric trauma patients usually require specialized resources, equipment, staffing and expertise from the pediatric emergency department which needs to be addressed prior to adult trauma certification.

Following adult trauma center certification, educational programs may need to be instituted regarding the parameters of care offered by the adult trauma center to pre-hospital personnel, staff and patients. Transfer procedures should be in place for patients who need advanced treatment. Pediatric surgeons or appropriately credentialed trauma surgeons must be prepared to manage patients who may need emergency surgery prior to transfer. Finally, when considering adult trauma center certification application, simultaneous application for pediatric trauma center certification should be considered.