From the Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL (Sullivan, Reiter, Zeineddin, Hu, Kabre, Raval).
Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL (Sullivan).
J Am Coll Surg. 2023 Nov 1;237(5):738-749. doi: 10.1097/XCS.0000000000000818. Epub 2023 Aug 15.
Heterogeneity in trauma center designation and injury volume offer possible explanations for inconsistencies in pediatric trauma center designation's association with lower mortality among children. We hypothesized that rigorous trauma center verification, regardless of volume, would be associated with lower firearm injury-associated mortality in children.
This retrospective cohort study leveraged the California Office of Statewide Health Planning and Development patient discharge data. Data from children aged 0 to 14 years in California from 2005 to 2018 directly transported with firearm injuries were analyzed. American College of Surgeons (ACS) trauma center verification level was the primary predictor of in-hospital mortality. Centers' annual firearm injury volume data were analyzed as a mediator of the association between center verification level and in-hospital mortality. Two mixed-effects multivariable logistic regressions modeled in-hospital mortality and the estimated association with center verification while adjusting for patient demographic and clinical characteristics. One model included the center's firearm injury volume and one did not.
The cohort included 2,409 children with a mortality rate of 8.6% (n = 206). Adjusted odds of mortality were lower for children at adult level I (adjusted odds ratio [aOR] 0.38, 95% CI 0.19 to 0.80), pediatric (aOR 0.17, 95% CI 0.05 to 0.61), and dual (aOR 0.48, 95% CI 0.25 to 0.93) trauma centers compared to nontrauma/level III/IV centers. Firearm injury volume did not mediate the association between ACS trauma center verification and mortality (aOR/10 patient increase in volume 1.01, 95% CI 0.99 to 1.03).
Trauma center verification level, regardless of firearm injury volume, was associated with lower firearm injury-associated mortality, suggesting that the ACS verification process is contributing to achieving optimal outcomes.
创伤中心的指定和受伤量的异质性为儿科创伤中心指定与儿童死亡率降低之间的不一致提供了可能的解释。我们假设，无论容量大小，严格的创伤中心验证都与儿童枪支伤害相关死亡率降低相关。
这项回顾性队列研究利用了加利福尼亚州卫生规划和发展办公室的患者出院数据。分析了 2005 年至 2018 年期间加利福尼亚州年龄在 0 至 14 岁之间直接因枪支伤害而接受治疗的儿童的数据。美国外科医师学院 (ACS) 创伤中心验证级别是院内死亡率的主要预测指标。分析中心每年枪支伤害量数据，作为中心验证级别与院内死亡率之间关联的中介因素。两个混合效应多变量逻辑回归模型分别对院内死亡率和与中心验证的估计关联进行建模，同时调整了患者人口统计学和临床特征。一个模型包含中心的枪支伤害量，另一个则没有。
该队列包括 2409 名儿童，死亡率为 8.6%（n=206）。与非创伤/三级/四级中心相比，成人一级（校正优势比 [aOR] 0.38，95%置信区间 [CI] 0.19 至 0.80）、儿科（aOR 0.17，95% CI 0.05 至 0.61）和双重（aOR 0.48，95% CI 0.25 至 0.93）创伤中心的死亡几率较低。ACS 创伤中心验证与死亡率之间的关联并未通过枪支伤害量来介导（每增加 10 名患者的 aOR 为 1.01，95% CI 0.99 至 1.03）。
无论枪支伤害量大小，创伤中心的验证级别均与枪支伤害相关死亡率降低相关，这表明 ACS 验证过程有助于实现最佳结果。
