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Where Pediatric Trauma Fits into a Trauma System

R. Todd Maxson, MD, FACSTrauma Medical Director

Arkansas Children’s HospitalTrauma Consultant

Arkansas Dept. of Health

Something more to it

ACS verification improves outcomes

Level matters

Pediatric centers improve outcomes

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American Medical Association

Arkansas ranked 50th in the United States for timely trauma center accessibility for its citizens.

Pre-hospital times are long leading to preventable mortality

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AMA 293:2633-2633, 2005

National Report Card of the State of Emergency Medicine

Arkansas’ emergency care system is the worst in the nation.

Receiving a “ D-”

Only state without a designated / verified trauma center.

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American College of Emergency PhysiciansDecember 2008

American College of Surgeons Committee on Trauma

Overall injury fatality is 50% higher than the national average

CDC Data puts mortality for children involved in motor vehicle crashes at almost three times the national average.

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Michael Rotondo, MDChair COTNov. 2008

Motor Vehicle Crash Mortality Rates Arkansas vs. U.S., 2007-2009, All Ages

Source: CDC WISQARS 6

AR deaths, age 1-14, 1999-2007

1.28% mortality rate at Arkansas Children’s Hospital

Why would Mortality at Arkansas Children’s Hospital be so much better than the National Average ?

A. ACH just kick’s butt!

B. Helicopter transport services based at Children’s Hospitals lead to improved outcomes

C. The pre-hospital services are efficient and decrease preventable mortality

D. Most patient’s died prior to reaching the facility

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A. B. C. D.

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AR deaths, age 1-14, 1999-2007

1.28% mortality rate

791 injury deaths in the state; only 97 (12%) at Arkansas Children’s Hospital

% ISS > 16 below the national average

AR deaths, age 1-14, 1999-2007

1.28% mortality rate

791 injury deaths in the state; only 97 (12%) at Arkansas Children’s Hospital

Vast majority of Arkansas pediatric trauma deaths occur outside ACH

Contribution of Mortality

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Are we really doing the best we can to care for injured children?

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What happened in Arkansas

2008 – ACS, ACEP and CDC all publicized the highest mortality rates in the Country.

The Med was going broke

Momentum for a trauma bill

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2009 Legislature Established a funded mandate for the

creation of a trauma system

Infra-structure within the ADH Call center for rapid transportation Designation of Trauma Centers Establishment State-wide education Establish triage and care guidelines State-wide trauma registry Develop quality indicators

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What’s Different about Pediatric Trauma Patients?

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Well…Nothing and Plenty!

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Vehicles and equipment Environment

Behavioral Avoidance Design Avoidance Design

Factors

Phase Human

Pre-Event

Behavioral Response Systems Response SystemsEvent

Post-Event Treatment Tools System

Haddon Matrix

Pre-Hospital Skills Paramedics in busy urban areas intubate

children 1.5 times per year and children < 5 yrs once every three years. CJEM Jan 2006

Multiple ETI attempts are associated with significant morbidity. J. Ped. Surg. Sept 2004

Pre-hospital care of children is suboptimal because of lack of ETI, PIV and fluid resuscitation skills Ped. Crit. Care Med. Aug 2010

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Scary Mary

Pre-hospital

Triage Criteria

Education – Mandated Foundation

Equipment – Mandated ACEP / AAP Braslow

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First Receiving Hospitals

Few critically injured children seen Few practitioners with significant

pediatric resuscitation skills

Causes of preventable death Airway management IV access and fluid resuscitation Ability to transfer to definitive care

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Community Hospital Education – Mandated Equipment - Mandated Clinical Practice Guidelines

Imaging, Fluid resuscitation Communications Center Trauma Image Repository Performance Improvement

Regional State-wide

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) ) )

) )

) )

) ) )

) )

) ) ) ) ) ) ) ) ) ) ) )

Hub SiteRemote Site

T-1

Transfer

Specialized transport services

All others****

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Tertiary Hospital

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ACS may not be the best way to provide care in a pediatric hospital Collaborative Outcome based Continuously ready Benchmarked

Psycho-social

Defining Quality Care

Collaborative Research PECARN ATOMAC

Benchmark TQIP NTDB – State-wide comparisons ACS verification

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Rehabilitation

Must have a place to go

Care should be specific

Must have funding for patients to get care

Demonstrate value

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Drinking and Driving

Caregiver behavior that contributes to pediatric injury

Behaviors are socially normative

Social psychology and marketing

Pursuit all available avenues04/21/23 29

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No Helmet

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Gunshot wound

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No Booster Seat

Disaster preparedness Rare

No “pop off”

Drill deep into the facility Identify weaknesses and solutions

Medical Society, Legal, Credentialing, liability, financial

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Influencing Policy There should NOT be a Pediatric

Committee

Pediatric issues should be considered in Every discussion

Sit at the table with the policy makers

Inform the electorate

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Back at Arkansas Children’s

Volume has gone up Transfers have gone down Scene runs have gone up Mortality at ACH

2007 - 1.28% 2012 – 1.6%

Mortality in the State is down

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There is something more to it

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Pediatric centers improve outcomes

What are the roles and responsibilities of a Pediatric Trauma Center?

A. Educate pre-hospital and receiving hospital personnel

B. Define guidelines for care and provide benchmarked outcome data

C. Advocate for regulatory and legislative changes that positively impact injured children

D. All of the above

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What are the roles and responsibilities of a Pediatric Trauma Center?

A. Educate pre-hospital and receiving hospital personnel

B. Define guidelines for care and provide benchmarked outcome data

C. Advocate for regulatory and legislative changes that positively impact injured children

D. All of the above04/21/23 38

A. B. C. D.

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Role of the Pediatric Trauma Center in a Region

Educate

Protocols

24/7 support – Telemedicine Where are the mistakes made?

Regional Peer Review

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Role of the Pediatric Trauma Center in a Region

Define and provide care

Rehabilitate – family

Injury Control

Advocacy

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Thank you

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