Myers Sage R, Branas Charles C, French Benjamin, Nance Michael L, Carr Brendan G
Department of Biostatistics and Epidemiology, University of Pennsylvania.
Pediatr Emerg Care. 2019 Jan;35(1):1-7. doi: 10.1097/PEC.0000000000000902.
More childhood deaths are attributed to trauma than all other causes combined. Our objectives were to provide the first national description of the proportion of injured children treated at pediatric trauma centers (TCs), and to provide clarity to the presumed benefit of pediatric TC verification by comparing injury mortality across hospital types.
We performed a population-based cohort study using the 2006 Healthcare Cost and Utilization Project Kids Inpatient Database combined with national TC inventories. We included pediatric discharges (≤16 y) with the International Classification of Diseases, Ninth Revision code(s) for injury. Descriptive analyses were performed evaluating proportions of injured children cared for by TC level. Multivariable logistic regression models were used to estimate differences in in-hospital mortality by TC type (among level-1 TCs only). Analyses were survey-weighted using Healthcare Cost and Utilization Project sampling weights.
Of 153,380 injured children, 22.3% were admitted to pediatric TCs, 45.2% to general TCs, and 32.6% to non-TCs. Overall mortality was 0.9%. Among level-1 TCs, raw mortality was 1.0% pediatric TC, 1.4% dual TC, and 2.1% general TC. In adjusted analyses, treatment at level-1 pediatric TCs was associated with a significant mortality decrease compared to level-1 general TCs (adjusted odds ratio, 0.6; 95% confidence intervals, 0.4-0.9).
Our results provide the first national evidence that treatment at verified pediatric TCs may improve outcomes, supporting a survival benefit with pediatric trauma verification. Given lack of similar survival advantage found for level-1 dual TCs (both general/pediatric verified), we highlight the need for further investigation to understand factors responsible for the survival advantage at pediatric-only TCs, refine pediatric accreditation guidelines, and disseminate best practices.
儿童期因创伤导致的死亡比其他所有原因导致的死亡总和还要多。我们的目标是首次在全国范围内描述在儿科创伤中心（TCs）接受治疗的受伤儿童的比例，并通过比较不同类型医院的损伤死亡率，明确儿科TC认证的假定益处。
我们进行了一项基于人群的队列研究，使用2006年医疗保健成本和利用项目儿童住院数据库以及全国TC清单。我们纳入了患有国际疾病分类第九版损伤编码的儿科出院患者（≤16岁）。进行描述性分析以评估不同TC级别所护理的受伤儿童比例。多变量逻辑回归模型用于估计不同类型TC（仅在一级TC中）的住院死亡率差异。分析使用医疗保健成本和利用项目抽样权重进行调查加权。
在153,380名受伤儿童中，22.3%被收治到儿科TCs，45.2%被收治到综合TCs，32.6%被收治到非TCs。总体死亡率为0.9%。在一级TCs中，儿科TC的原始死亡率为1.0%，双重认证TC为1.4%，综合TC为2.1%。在调整分析中，与一级综合TC相比，一级儿科TC的治疗与显著降低的死亡率相关（调整后的优势比为0.6；95%置信区间为0.4 - 0.9）。
我们的结果首次在全国范围内证明，在经过认证的儿科TCs接受治疗可能会改善预后，支持儿科创伤认证具有生存益处。鉴于在一级双重认证TCs（同时具有综合/儿科认证）中未发现类似的生存优势，我们强调需要进一步调查，以了解仅儿科TCs具有生存优势的因素，完善儿科认证指南，并推广最佳实践。
