The first responder has a critical decision to make as she loads a severely injured child into an ambulance. Take the child to the nearest hospital emergency department (ED) to be seen and stabilized as soon as possible, or go another three miles farther to a hospital with specialized trauma care facilities? Or 20 minutes farther still to a specialized children’s hospital?
Little evidence exists to help her make the tradeoff between expediting care and the facility’s capabilities to manage a critically injured child. A team of researchers from The Children’s Hospital of Philadelphia, Thomas Jefferson University, and the University of Pennsylvania, is working to change that and build a useful knowledge base that can shape policy and guidelines in order to improve the outcomes of injured children in the U.S.
“One way we can optimize their outcomes is by improving the matching of the child’s needs to the care they can receive at the hospital,” said Scott Lorch, MD, MSCE, a neonatologist and director of the Center for Perinatal and Pediatric Health Disparities at CHOP, and an associate professor of Pediatrics at the Perelman School of Medicine at Penn. Dr. Lorch is co-principal investigator of the new four-year project, which is funded with a grant from the Agency for Healthcare Research and Quality.
U.S. hospitals’ trauma care capabilities vary widely — from community EDs with no trauma or pediatric specialty designation, to designated trauma centers for adults that may lack specialized personnel and equipment for pediatrics, to trauma centers with pediatric capabilities, and specialty designated children’s trauma centers including children’s hospitals — and even within each type of facility, the specific capabilities and strengths can vary. The study team will conduct a national survey of these EDs and trauma centers to fill in the largely unknown landscape of what structures and processes of care are available to pediatric trauma patients at each facility. Structures, for example, include staffing level, types of available specialists, ED capacity, and pediatric-specific equipment, while processes include round-the-clock availability of various pediatric and adult specialists, protocols for events such as triage and transfer, and the department’s research and education activities.
The team next aims to build on that new knowledge of what structures and care processes exist in the pediatric trauma system, to answer a far more complex question of which ones deliver the best outcomes for children with injuries of various types and levels of severity.
“More severely injured patients tend to be taken to more specialized centers, so it is hard to compare facilities — and even harder to determine which structures and practices are most likely to improve outcomes,” said Brendan Carr, MD, associate professor of Emergency Medicine and associate dean at Thomas Jefferson University, who is co-principal investigator of the study with Dr. Lorch.
Dr. Carr has studied trauma care systems in adults and children and run into these challenges in comparing different types of facilities. The current collaboration began when he and other colleagues in trauma and emergency care at Penn and CHOP took notice of research Dr. Lorch had done that applied a novel approach to a similar challenge in neonatology.
Women with high-risk pregnancies whose babies are likely to need immediate care in the neonatal intensive care unit (NICU) have to make a choice about their hospital for delivery similar to the choice facing an emergency medical technician transporting an injured child. In both cases, the closest hospital might ordinarily be a compelling option, but a more specialized, better-equipped, or better-staffed center could lead to better outcomes for the child.
Even after adjusting for the fact that the more specialized NICUs tend to treat a higher proportion of the most severely ill infants, earlier research did not initially bear out the idea that babies had better outcomes there. Dr. Lorch then applied a statistical method from economics called an instrumental variables approach that better controlled for differences in the patient population. He found that mortality was as much as 50 to 60 percent lower when severely ill infants received care at better-equipped and better-staffed NICUs.
“The Instrumental Variable approach is an important tool that we believe will help us to build a better system,” Dr. Carr said, of the team’s plan to adapt this method to understanding and improving pediatric trauma care.
The team will correlate structures and processes of trauma care to children’s outcomes using population-based data from ED and inpatient hospital records in 13 states. The primary outcomes they will measure include mortality, prolonged hospital stay and complications, and other care utilization factors.
“We want to look at a variety of injury types and a variety of variables to try to understand, are there different patients who may benefit more from coming to the most specialized centers?” Dr. Lorch said. “And we need to sort out what practices can be exported to centers that aren’t focused on children in order to improve outcomes.”
Additional collaborators on the team are CHOP pediatric emergency medicine physician and Penn Assistant Professor Sage Myers, MD, MSCE; Michael Nance, MD, director of the Pediatric Trauma Program at CHOP and professor of Surgery at Penn; and M. Kit Delgado, MD, MS, an assistant professor of Emergency Medicine and Epidemiology at Penn.