England & Wales SEVERE INJURY IN CHILDREN

Transcription

1 England & Wales SEVERE INJURY IN CHILDREN 2012

2 THE TRAUMA AUDIT AND RESEARCH NETWORK

3 The TARNlet Committee Mr Ross Fisher Co-chairman of TARNlet Consultant in Paediatric Surgery Sheffi eld Children s NHS Foundation Trust Dr Ian Maconochie Co-chairman of TARNlet Consultant in Paediatric Emergency Medicine Imperial College Healthcare NHS Trust Dr Derek Burke Consultant in Paediatric Emergency Medicine Sheffi eld Children s NHS Foundation Trust Professor Tim Coats Professor of Emergency Medicine University of Leicester Dr Lorcan Duane Consultant in Emergency Medicine Central Manchester University Hospitals NHS Foundation Trust Julie Flaherty Paediatric Nurse Consultant Salford Royal NHS Foundation Trust Dr Muhuntha Gnanalingham Consultant in Paediatric Intensive Care Central Manchester University Hospitals NHS Foundation Trust Professor Fiona Lecky Professor of Emergency Medicine University of Sheffield Mr Roberto Ramirez Consultant in Paediatric Neurosurgery Central Manchester University Hospitals NHS Foundation Trust Maralyn Woodford Executive Director The Trauma Audit & Research Network Acknowledgements We would like to thank the staff at each trauma receiving hospital and Mr Thomas Lawrence, Data Analyst at the Trauma Audit & Research Network. SEVERE INJURY IN CHILDREN

4 Contents 3 Introduction 4 Summary 5 Data completeness 6 Demographics 7 Injury mechanism 8 Injury type 9 Time of arrival at hospital 10 Month of arrival at hospital 11 Mode of arrival at hospital 12 Type of first admitting hospital 13 Transfer between hospitals 14 ICU / HDU admissions, intubation & length of stay in hospital 15 Mortality rates 16 Injuries associated with death 17 Grade of most senior clinician in the ED 18 Grade of most senior clinician involved in surgery 19 Time to first surgery from arrival 20 Glossary 2 THE TRAUMA AUDIT AND RESEARCH NETWORK

5 Introduction Children are different but, remarkably, very little work has been published which permits an analysis of paediatric trauma care. The Trauma Audit and Research Network (TARN) registry contains information on over 4700 children under the age of 16 injured in Data from previous years has been a valuable asset in demonstrating improvements in outcome*. The TARNlet committee, consisting of clinicians, managers and academics that focus on injured children was established to address specific questions relating to paediatric trauma care and this is its first annual report. This report is based on data reported to TARN from England & Wales for Those that died at the incident scene and were not transported to hospital are not reported to TARN. Further information about the data methodology can be found at ISS > 15 n = 737 All children in the TARN database n = 4720 All children attending ED with injury Figure 1 (2012 data) Injury produces a significant health burden for children, being a leading cause of both death and disability, with the numbers of different severities being shown in Figure 1. This report concentrates on the 737 children in 2012 who sustained the most serious injuries - an injury severity score (ISS) greater than 15. This report gives an overview of when and where injured children present in the healthcare system, along with some measures of the process of care. Future reports will look in more detail at specific aspects of injury management in children. *Reducing accident rates in children and young adults: the contribution of hospital care. SEVERE INJURY IN CHILDREN

6 Severe Injury in Children Summary During 2012 there were 737 severely injured children treated in England & Wales. Road traffic collisions and resulting head injuries predominate as the major causes of severe injury and mortality. The peak incidence in infants is often caused by nonaccidental injury. A significant proportion of severely injured children were not conveyed to hospital by ambulance so the pre-hospital triage system will not have been applied. Trauma systems need to anticipate that children will continue to arrive at trauma units or non-designated hospitals and have systems to ensure that children are not disadvantaged by initially presenting to the wrong hospital. Staff in all hospitals need sufficient continuing training to enable them to provide initial care until either a specialist team arrives or an inter-hospital transfer is carried out. The data showed that most severely injured children are moved to a specialist Trauma Centre, which emphasises the need for a prompt inter-hospital transfer system. Time to surgery is related to outcome therefore an efficient transport and transfer system that minimises delays is important. The pattern of arrival of severely injured children implies that staffing for paediatric trauma needs to be matched to a pattern that includes high rates of arrival outside the conventional working day (especially in the evening and at weekends), and low rates of arrival after midnight. As trauma systems evolve and mature there will be changes in the way in which the healthcare system responds to severely injured children. The TARNlet annual reports will aim to present the best information that is available about our care of children and young people and strive to produce data that will improve the delivery of trauma services. 4 THE TRAUMA AUDIT AND RESEARCH NETWORK

7 Trauma in children Data Completeness All Submissions Deaths Trust n HES Completion % n HES Completion % England & Wales This is displayed as a percentage and represents the number of patients submitted to TARN compared to the number of patients expected based on the 2012 Hospital Episode Statistics (HES) dataset. The HES dataset is used as a general baseline and the TARN fraction may be more than 100% as deaths in the ED are not recorded in HES. This data refers to submissions to TARN, however the same patient may be submitted more than once if they undergo an inter-hospital transfer. Reducing the dataset to individual cases results in 2360 children who met the TARN entry criteria admitted to hospitals in the area covered by this report. 737 children had severe injuries that were assigned an injury severity score (ISS) of more than 15 and 56 died of those injuries. SEVERE INJURY IN CHILDREN

8 Demographics Number (%) Total 737 age < 1 year 171 (23.2%) age 1-2 years 60 (8.1%) age 3-5 years 96 (13%) age 6-10 years 142 (19.3%) age years 146 (19.8%) age years 122 (16.6%) Median Age (IQR) 7.7 ( ) Male (percentage) 65.8 Median ISS (IQR) 22 (16-26) Percentage of patients age <1 year age 1-2 years age 3-5 years age 6-10 years age years age years Two thirds of injured children are male. There is a bimodal distribution of age with a peak in the first year of life followed by another from 6 years old. 6 THE TRAUMA AUDIT AND RESEARCH NETWORK

9 Injury Mechanism Number (%) Road Traffic Collision 284 (38.5%) Fall < 2m 164 (22.3%) Fall > 2m 110 (14.9%) NAI under 2 years 74 (10%) Penetrating 10 (1.4%) Blows 46 (6.2%) Other (eg. sport/drowning) 49 (6.6%) Percentage of patients Road Traffic Fall > 2m Fall < 2m NAI under 2 years Penetrating Blows Other (eg. Collision sport/drowning) Analysis of injury mechanism data shows a preponderance of road traffic collisions and falls of less than 2 metres. 10.1% of the patients are aged under 2 and were injured intentionally (recorded as Non-Accidental Injury). SEVERE INJURY IN CHILDREN

10 Injury Type Number (%)* AIS3+ Head Injury 555 (75.3%) AIS3+ limb / pelvis / spine injury 136 (18.5%) AIS3+ thoracic / abdominal injury 213 (28.9%) Percentage of patients AIS3+ Head Injury AIS3+ limb / pelvis / spine injury AIS3+ thoracic / abdominal injury *Patients with multiple injuries will appear in multiple groups The severity of an injury can be described using the Abbreviated Injury Scale (AIS) score. The score can range from 1 (minor) to 6 (fatal). AIS 3+ describes injuries that are severe. Severe head injury is present in a large proportion of severely injured children, emphasising the importance of neurointensive and neurosurgical care within the Trauma Networks. 8 THE TRAUMA AUDIT AND RESEARCH NETWORK

11 Arrival time Average number of severely injured children treated each year by hour and day of week. Severely injured children attend hospital mainly during daytime hours, although a small percentage attends after midnight. Many injured children attend at the weekend and in the evenings. This pattern of attendance has an implication for the staffing of paediatric trauma services which need to be geared to receive severely injured children during the evening and at weekends. The relatively low number of severe injuries occurring at night raises a question about the cost effectiveness of on-site paediatric trauma expertise during the night. SEVERE INJURY IN CHILDREN

12 Arrival month Number (%) January 54 (7.3%) February 40 (5.4%) March 39 (5.3%) April 36 (4.9%) May 80 (10.9%) June 67 (9.1%) July 72 (9.8%) August 92 (12.5%) September 93 (12.6%) October 72 (9.8%) November 46 (6.2%) December 46 (6.2%) Percentage of patients January February March April May June July August September October November December 10 THE TRAUMA AUDIT AND RESEARCH NETWORK

13 Mode of arrival (direct admissions) n = 537 Number (%) Arrived by ambulance 302 (56.2%) Arrived by helicopter 91 (16.9%) Arrived by other means (eg. car) 144 (26.8%) Percentage of patients Arrived by ambulance Arrived by helicopter Arrived by other means (eg. car) A large proportion of severely injured children are not brought to hospital by ambulance. This has a significant implication for the future configuration of paediatric trauma services, as the trauma system must anticipate that as many as a third of patients will continue to arrive at the nearest hospital (which may or may not be part of the trauma system). For children where there is no information recorded about their initial hospital stay we are unable to comment on the mode of arrival. SEVERE INJURY IN CHILDREN

14 Type of first admitting hospital Number (%) Adult & Children s MTC* 189 (25.6%) Adult MTC* 69 (9.4%) Children s MTC* 71 (9.6%) Trauma Unit 408 (55.4%) Percentage of patients Adult & Children s MTC* Adult MTC* Children s MTC* Trauma Unit *MTC - Major Trauma Centre Few children are initially treated in a specialist paediatric or adult major trauma centre with most being initially treated in a hospital accredited as a Trauma Unit. This means that the trauma network should ensure a system for the initial resuscitation of injured children in all hospitals followed by an efficient inter-hospital transfer system. 12 THE TRAUMA AUDIT AND RESEARCH NETWORK

15 Transfer between hospitals Number (%) Multiple hospitals, not MTC* 31 (4.2%) Multiple hospitals, adult MTC* 8 (1.1%) Multiple hospitals, children s MTC* 373 (50.6%) Single hospital, not MTC* 87 (11.8%) Single hospital, adult MTC* 27 (3.7%) Single hospital, children s MTC* 211 (28.6%) Percentage of patients Multiple hospitals, Multiple hospitals, Multiple hospitals, Single hospital, Single hospital, Single hospital, not MTC* adult MTC* children s MTC* not MTC* adult MTC* children s MTC* *MTC - Major Trauma Centre Most children are eventually cared for in an appropriate hospital with few remaining outside of the Major Trauma Centres. However this emphasises once more the importance of the transfer system. SEVERE INJURY IN CHILDREN

16 ICU / HDU admissions n = 737 Number (%) All patients 351 (47.6%) Isolated AIS 3+ Head Injuries 179 (42%) Isolated AIS 3+ Abdominal Injuries 22 (48.9%) Isolated AIS 3+ Limb / Pelvic Injuries 4 (13.8%) Isolated AIS 3+ Thoracic Injuries 9 (37.5%) Polytrauma* 121 (67.2%) The percentage values represent the proportion of patients in each group that visited ICU / HDU. *Multiple AIS3+ injuries in different body regions Intubation (direct admissions only) n = 537 Number (%) Intubated 208 (38.7%) Intubated in ED 164 (30.5%) Intubated pre-hospital 44 (8.2%) Median hours to intubation from incident (IQR) 1.1 ( ) Hospital Stay n = 737 Number (%) Median LOS (IQR) 6 (3-12) Median LOS, transfers in (IQR) 6 (4-15) Admitted to ICU / HDU 351 (47.6%) Median LOS in ICU (IQR) 3 (1-6) Median LOS, patients that went to ICU (IQR) 10 (5-23) Length of stay is measured in days. There may be some underestimation as the complete length of stay for patients treated at more than one hospital may be unknown if one of those hospitals has not submitted data on the patient to TARN. 14 THE TRAUMA AUDIT AND RESEARCH NETWORK

17 Mortality (cases with recorded outcome) Total number Number of Mortality of cases deaths % All admissions % Admissions with GCS < % Injury Mechanism Road Traffic Collision % Fall < 2m % Fall > 2m % NAI under 2 years % Penetrating % Blows % Other (eg. sport/drowning) % Injury Type AIS3+ head injury % AIS3+ limb / pelvis / spine injury % AIS3+ thoracic / abdominal injury % *Percentages are of children with known outcome with that particular GCS / mechanism / injury pattern SEVERE INJURY IN CHILDREN

18 Injuries associated with death Number of deaths Head Face Chest AIS3+ Injuries Abdomen Spine Limbs Other Polytrauma Asphyxia Drowning Head Face Chest Abdomen Spine Limbs Other Polytrauma Asphyxia Drowning Head Injury is the most important injury in fatal paediatric trauma, although there is a significant contribution from thoracic injury, asphyxia and drowning. Polytrauma accounts for 35.7% of the deaths. Interaction of AIS 3+ injuries Body Region Head Face Chest Abdomen Spine Limbs Other Asphyxia Drowning Head Chest Abdomen Limbs Other Drowning Asphyxia Please note patients can be in more than one AIS3+ category or mechanism 16 THE TRAUMA AUDIT AND RESEARCH NETWORK

19 Grade of most senior clinician in the ED Direct Admissions ISS n Consultant Associate Specialist STR, 4+ STR, 1-3 STR, year unknown Foundation Year Other Not Recorded ISS > (74.1%) 10 (1.9%) 21 (3.9%) 10 (1.9%) 52 (9.7%) 21 (3.9%) 8 (1.5%) 3 (0.6%) 299 (55.7%) of patients were seen by a paediatric specialist 14 (2.6%) had no ED visit recorded Percentage of patients Consultant Ass Specialist STR, 4+ STR, 1-3 STR, year FY Other Not unknown recorded 74.1% of severely injured children were resuscitated by Consultants. SEVERE INJURY IN CHILDREN

20 Grade of most senior clinician involved in surgery (all operations, n = 394) Direct Admissions Consultant Ass. Specialist STR 4+ STR 1-3 STR, year unknown Foundation Year Other No grade recorded Grade of Anaesthetist Grade of Paediatric Surgeon Grade of Surgeon 239 (60.7%) 4 (1%) 34 (8.6%) 4 (1%) 57 (14.5%) 0 (0%) 6 (1.5%) 50 (12.7%) 48 (92.3%) 0 (0%) 1 (1.9%) 0 (0%) 2 (3.8%) 0 (0%) 0 (0%) 1 (1.9%) 271 (68.8%) 1 (0.3%) 13 (3.3%) 4 (1%) 84 (21.3%) 0 (0%) 2 (0.5%) 19 (4.8%) Percentage of patients Grade of Surgeon Grade of Paediatric Surgeon Grade of Anaesthetist Consultant Ass Specialist STR, 4+ STR, 1-3 STR, year unknown FY Other No grade recorded 68.8% of all operations were carried out by Consultants, 92.3% of those operations carried out by paediatric specialists were performed by Consultants and 60.7% of severely injured children were anaesthetised for their operation by a Consultant anaesthetist. 18 THE TRAUMA AUDIT AND RESEARCH NETWORK

21 Time to first surgery from arrival Direct Admissions Category n with operations recorded Median hours to operation Interquartile Range (hours) All surgery, ISS > Neurosurgery Abdominal surgery Cardiothoracic surgery Orthopaedic surgery Time to surgery (hours) All surgery, ISS > 15 Neurosurgery Abdominal surgery Cardiothoracic surgery Orthopaedic surgery *Patients can be in multiple groups Operations 24 hours after admission are excluded. The majority of surgical intervention takes place in a timely fashion although improvement may follow as trauma systems develop. SEVERE INJURY IN CHILDREN

22 Glossary AIS AIS 3+ Direct admissions GCS HES ISS MTC Polytrauma TARN TARNlet TU Abbreviated Injury Scale score. A value between 1 (minor) and 6 (fatal) is assigned to each injury. Injuries with an AIS severity score of 3 or more. Describes care in the first treating hospital. Glasgow Coma Scale. A measure of consciousness ranging from 3, indicating complete unconsciousness, to 15, indicating a state of normal alertness. GCS is composed of eye, verbal and motor scores. Hospital Episode Statistics. Data collected in hospitals on all admissions. This data is used to produce an expected number of eligible patients that should be submitted to TARN. Injury Severity Score. A score ranging from 1, (minor) to 75 (severe injuries that are likely to result in death). An ISS between 9 and 15 is considered moderate. An ISS of 16 or more is considered severe. ISS is calculated using the Abbreviated Injury Scale (AIS). Major Trauma Centre AIS 3+ injuries in more than one body region. The Trauma Audit & Research Network. The TARNlet committee, consisting of clinicians, managers and academics that focus on injured children was established to address specific questions relating to paediatric trauma care. Trauma Unit Grades of Doctor Consultant Associate Specialist STR 4+ Consultant Associate Specialist Specialist registrar and speciality trainee years 4, 5 and above STR 1-3 Specialist registrar and speciality trainee years 1, 2 and 3 STR, year unknown Specialist registrar and speciality trainee year unknown, clinical fellow, senior registrar, staff grade Foundation Year SHO, HO, foundation year 1, 2 and unknown, core trainee year 1 and 2 Other Core trainee year 3 and above, advanced SHO, vocational training scheme, emergency nurse practitioner 20 THE TRAUMA AUDIT AND RESEARCH NETWORK

23 SEVERE INJURY IN CHILDREN 2012

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