Do Adult Trauma Centers Harm Children?

Transcription

1 Do Adult Trauma Centers Harm Children? Western Pediatric Trauma Conference David P. Mooney, M.D., M.P.H. Trauma Center Director Boston Children s Hospital

2 Primary Children s Medical Center Children s Hospital Colorado Phoenix Children s Hospital

3 Alternate Titles Why are the idiots killing children? How did the axe-murderers get a medical license in this state? Where are the malpractice lawyers when you need them? Thanks for covering pedi trauma call.

4 Faculty Disclaimer I wish there was enough commercial interest and money in pediatric injury for me to become corrupt. However, there s not, and in the past 20 years, I have had no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. If you hear of money, don t me, catch me outside

5 Boston Marathon 2013

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7 Hospital Response Trauma Stat team assembled IV s obtained OR ready Vascular/reimplant on standby Blood ready Family comforted

8 Outcome Limb saved Wounds closed Discharged Acute stress response Playing baseball

9 Boston Marathon 2013 Bully pulpit No one knows we exist Policymakers Public Medical community

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11 Adult Trauma Center Outcome MacKenzie NEJM 2006 Prospective study 69 hospitals in 14 states Nearly 5,200 patients followed for a year 25% reduction in mortality

12 Is Mortality Improved at Pediatric Trauma Centers? Holy Grail of outcomes Very hard to prove Big data

13 Some Nomenclature PTC = pediatric trauma center ATC = adult trauma center ATC-AQ = adult trauma center with added qualifications in pediatric trauma care NTC = non-trauma center

14 Potoka J Trauma 2000 Pennsylvania Trauma Outcome Study >13,000 children over 5 years Better survival at PTC than ATC in PA Brain/solid organ: PTC better than ATC-AQ More neuro interventions, fewer solid organ

15 Osler J Trauma 2001 National Pedi Trauma Registry >32,000 children Adjusted PTC and ATC mortality the same ACS verified centers better

16 Densmore J Ped Surg 2006 KID database in ,856 injured kids in 27 states Age 0-10 with ISS > 15 and TBI ATC 5.0%, Unit 8.1%, Pedi 1.6% 73% received care in non PTC

17 Tepas J Ped Surg 2007 Florida discharge data from 1995 to 2004 >27,000 kids 0 to 15 years of age Brain, spine, torso, vascular and burns TC 1.6% lower mortality than NTC PTC 4.5% lower than TC (6.1% than NTC)

18 Oyetunji Am J Surg 2011 NTDB > 53,000 kids ATC versus ATC-AQ ISS >=9, no burns, < 18 years old Overall mortality 3.9% 20% lower at ATC-AQ Younger kids, GCS < 8 and ISS> 25

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20 Mortality and Pediatric Centers Lower mortality rate Methodologic problems No prospective study Enroll ~50,000 children Limit to a sliver of patients

21 Functional Outcomes Potoka J Trauma 2001 PTOS ISS > 15 and brain injury PTC versus ATC and ATC-AQ Improved function at PTC

22 Outcome measures-spleen Lippert J Surg Research 2013 Compared local ATC with PTC 14 to 17 year olds from PTC do better: lower spleen op rate Multivariable regression: hospital strong independent predictor

23 Matsushima J Surg Res PTOS Solid organ injury procedures 13 to 18 year olds Spleen: ATC 16.1% versus 3.2% PTC Liver: ATC 5.9% versus 0 PTC higher ISS

24 Adult process differences Imaging Labs Mental health Follow-up

25 Mannix Acad Emerg Med 2011 MA ED patients discharged home 1.3% underwent c-spine CT Non-PTC twice as likely as PTC ATC-AQ 4 times as likely to CT One of them 18 times

26 Hartin J Surg Research 2013 Ratio of CT s done during trauma eval 7:3 PTS versus referring hospital 18% of the scans repeated

27 Calvert J Ped Surg children referred after abdominal CT Half received excess radiation dose Range 0.17 to 5.07 times

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30 Triage of injured children Care for all kids in pediatric centers Centers in every mid-sized town Convince every pediatric surgeon

31 Segui-Gomez J Ped Surg 2003 Administrative data 18 states: pediatric only trauma centers (1%) 26 adult/pediatric trauma centers (2%) 53% in any trauma center 13% in PTC Generous definition

32 Wang Ann Emerg Med 2008 CA discharge database Children 1-14 years, ISS > 15 HMO: 55% to TC Private: 68% MediCal: 77% No county TC: 39%

33 Kernic J Neurotrauma July, , 2006 and 2009 KID ~39,000 kids with severe TBI NTC: 16%, ATC 43% ATC-AQ 22%, PTC 19% 53% of 0 to 4 year olds with moderate to severe TBI at ATC or NTC

34 Nance Curr Opin in Peds 2010

35 Sorenson JAMA Surg June 2013 Overtriage at a rural trauma center 49% of children ISS < 15 LOS less than 48 hours

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37 Pedi care in an adult center Fortune J Trauma kids over 4 years Outcomes similar to pediatric centers PICU

38 Our job We re the experts in this mini-niche We won t get all of the patients It may get worse-financial triage Many adult surgeons don t want it Educate our competitors 5 things

39 1. Ban the Pan Scan Head CT Neck CT Chest CT Abdominal CT Pelvic CT

40 Average Dose per CT Study

41 CT Radiation Dose per Patient

42 Radiation Risk

43 2. Get along with others-pecarn Kupperman, Lancet 374, , ,412 children 25 pediatric emergency departments

44 Brain CT decision rule-out Under 2: no scalp hematoma except frontal Loss of consciousness for less than 5 seconds Non-severe injury mechanism, no palpable skull fracture acting normally Negative predictive value 100% Over 2: normal mental status, no loss of consciousness No vomiting, non-severe injury mechanism, no signs of basilar skull fracture, no severe headache Negative predictive value 99.95%,

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46 3. Disseminate guidelines Trauma Association of Canada Pediatric Cervical Spine Guidelines

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49 4. Share our data Solid organ injury Normal vital signs Decrease fear factor

50 Injury Grade vs. Hemodynamics

51 Pulse Grade 4 Spleen Injury Pulse ED Time after Injury (hrs)

52 Pulse after spleen injury Bowel 95th Mean 5th

53 5. Educate about PTSD Parents in the room Evaluate children prior to discharge Train providers to recognize trouble Make help available

54 Function after Injury

55 Conclusions Pediatric trauma centers have best outcomes Adult trauma centers have good outcomes It s our responsibility to help them 5 things: Pan Scan, play with others, spread guidelines, share data and educate about PTSD

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