Wang N Ewen, Chan Jia, Mahlow Pamela, Wise Paul H
Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
Acad Emerg Med. 2007 Apr;14(4):309-15. doi: 10.1197/j.aem.2006.11.012. Epub 2007 Feb 12.
While it is known that trauma systems improve the outcome of injury in children, there is a paucity of information regarding trauma system function amid changes in policies and health care financing that affect emergency medical systems for children.
To describe the trends in the proportion of pediatric trauma patients acutely hospitalized in trauma-designated versus non-trauma-designated hospitals.
This was a retrospective observational study of a population-based cohort obtained by secondary analysis of a publicly available data set: the California Office of Statewide Health Planning and Development Patient Discharge Database from 1998 to 2004. Patients were included in the analysis if they were 0-19 years old, had International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes and E-codes indicative of trauma, had an unscheduled admission, and were discharged from a general acute care hospital (N = 111,566). Proportions of patients hospitalized in trauma-designated hospitals versus non-trauma-designated hospitals were calculated for Injury Severity Score and death. Injury Severity Scores were calculated from ICD-9 codes. Primary outcomes were hospitalization in a trauma center and death two or more days after hospitalization.
Over the study period, the proportion of children aged 0-14 years with acute trauma requiring hospitalization and who were cared for in trauma-designated hospitals increased from 55% (95% confidence interval [CI] = 54% to 56%) in 1998 to 66% (95% CI = 65% to 67%) in 2004 (p < 0.01). For children aged 15-19 years, the proportion increased from 55% (95% CI = 54% to 57%) in 1998 to 74% (95% CI = 72% to 75%) in 2004 (p < 0.0001). When trauma discharges were stratified by injury severity, the proportion of children with severe injury who were hospitalized in trauma-designated hospitals increased from 69% (95% CI = 66% to 72%) in 1998 to 84% (95% CI = 82% to 87%) in 2004, a rate higher than in children with moderate injury (59% [95% CI = 58% to 61%] in 1998 and 75% [95% CI = 74% to 76%] in 2004) and mild injury (51% [95% CI = 50% to 52%] in 1998 and 63% [95% CI = 62% to 64%] in 2004) (p < 0.0001 for each injury severity category and both age groups). Of the hospitalized children who died two or more days after injury (n = 502), 18.1% died in non-trauma-designated hospitals (p < 0.002 for children aged 0-14 years; p = 0.346 for children aged 15-19 years).
An increasing majority of children with trauma were cared for in trauma-designated hospitals over the study period. However, 23% of children with severe injuries, and 18.1% of pediatric deaths more than two days after injury, were cared for in non-trauma-designated hospitals. These findings demonstrate an important opportunity for improvement. If we can characterize those children who do not access the trauma system despite severe injury or death, we will be able to design clinical protocols and implement policies that ensure access to appropriate regional trauma care for all children in need.
虽然已知创伤系统可改善儿童损伤的预后，但关于在影响儿童急诊医疗系统的政策和医疗保健融资变化中创伤系统功能的信息却很少。
描述在指定创伤医院与非指定创伤医院急性住院的儿科创伤患者比例的趋势。
这是一项基于人群队列的回顾性观察研究，通过对一个公开可用数据集进行二次分析获得：1998年至2004年加利福尼亚州全州卫生规划与发展办公室患者出院数据库。纳入分析的患者年龄在0至19岁之间，具有国际疾病分类第九版（ICD - 9）诊断代码和表明创伤的E代码，有非计划入院情况，且从综合急性护理医院出院（N = 111,566）。计算了指定创伤医院与非指定创伤医院住院患者的损伤严重程度评分和死亡比例。损伤严重程度评分根据ICD - 9代码计算。主要结局是在创伤中心住院以及住院两天或更长时间后死亡。
在研究期间，0至14岁因急性创伤需要住院且在指定创伤医院接受治疗的儿童比例从1998年的55%（95%置信区间[CI] = 54%至56%）增至2004年的66%（95% CI = 65%至67%）（p < 0.01）。对于15至19岁的儿童，该比例从1998年的55%（95% CI = 54%至57%）增至2004年的74%（95% CI = 72%至75%）（p < 0.0001）。当按损伤严重程度对创伤出院病例进行分层时，在指定创伤医院住院的重伤儿童比例从1998年的69%（95% CI = 66%至72%）增至2004年的84%（95% CI = 82%至87%），这一比例高于中度损伤儿童（1998年为59% [95% CI = 58%至61%]，2004年为75% [95% CI = 74%至76%]）和轻伤儿童（1998年为51% [95% CI = 50%至52%]，2004年为63% [95% CI = 62%至64%]）（每个损伤严重程度类别和两个年龄组的p均< 0.0001）。在受伤两天或更长时间后死亡的住院儿童（n = 502）中，18.1%在非指定创伤医院死亡（0至14岁儿童的p < 0.002；15至19岁儿童的p = 0.346）。
在研究期间，越来越多的创伤儿童在指定创伤医院接受治疗。然而，23%的重伤儿童以及18.1%在受伤两天多后死亡的儿科患者在非指定创伤医院接受治疗。这些发现表明有一个重要的改进机会。如果我们能够确定那些尽管受重伤或死亡却未进入创伤系统的儿童的特征，我们将能够设计临床方案并实施政策，以确保所有有需要的儿童都能获得适当的区域创伤护理。
