One in four children miss treatment at a pediatric trauma center

One in four children miss treatment at a pediatric trauma center

If a child is injured in Canada, it can still be determined whether they will receive specialized trauma treatment. New national data shows who was left out and why.

Study: Access to pediatric trauma centers in Canada: a population-based retrospective cohort study. Photo credit: Sergey Mikheev/Shutterstock.com

Children who suffer severe trauma are best treated in pediatric trauma centers. A recent studypublished in the magazineCMAJexamined the accessibility of such centers in Canada, focusing onthe proportion of needy children they looked after.

Specialized trauma care prevents death and disability

Trauma remains the leading cause of death among children in Canada. In 2018 alone, there were 202 deaths due to trauma in children aged 14 and under, and 3,574 children remained disabled. Overall, there were 14,237 hospitalizations and 818,166 emergency department visits in this population. In economic terms, that amounts to almost three billion dollars.

These effects could be mitigated by good trauma care, an important aspect of which is timely access to specialized centers. Each Canadian province has had its own trauma system since the 1980s. These include acute care hospital networks for each geographic zone that include multiple levels of care, with pediatric trauma centers being Level I and Level II hospitals.

Children with severe trauma are 41% less likely to die when treated at pediatric trauma centers than adults. They also require significantly fewer emergency surgeries and imaging procedures. Previous studies have examined the potential and realized access to such centers in North America.

The aim of the current study was to determine the proportion of children with severe trauma attending a pediatric trauma center in Canada and to identify differences in age, severity of trauma, part injured, and mechanism of injury.

Tracking access to pediatric trauma care

The study used a population-based cohort design that included children up to 16 years of age hospitalized for major trauma in nine provinces (excluding Quebec). The Injury Severity Score was used to identify major trauma based on anatomical and severity classifications. In all cases the score was above 12.

The researchers used Poisson regression to estimate the rate of access to such a center across provinces, stratifying it by age and injury severity.

Access varies depending on age, severity of injury and province

The study involved 3,007 children hospitalized in acute care centers with severe trauma and whose average age was about nine years. While about 64% were male, 18% were seriously injured. Head and chest injuries accounted for approximately 61% and approximately 33% of major injuries, with approximately 43% of traumas resulting from motor vehicle collisions.

Only the proportion of head and abdominal injuries and the mechanisms of injury varied between provinces.

Almost 77.6% (2,335 children) reached a children's trauma center. This is consistent with US figures from 2019 and 2020 showing that 73% to 74% of children with trauma have potential access to such centers within an hour, compared to 59% in 2006. However, the corresponding figure in Canada was only 65% ​​in 2016.

The current improved access may reflect both subsequent guidelines recommending treatment of pediatric trauma in such centers and the evolution of these systems over time.

Of these 2,335 children, 879, or 29%, were transported directly to the facility. In contrast, 48.4% (1,456 children) were initially admitted to another acute care center, including adult trauma centers or hospitals without a trauma designation, and then transferred to their respective trauma centers.

Over 80% of traumatized children aged up to twelve years were admitted to trauma centers. In contrast, 70% of children between 13 and 15 years old received access. Children with more severe injuries attended these centers more frequently, with the admission rate for those with severe injuries approaching 90%.

In the nine provinces studied, a quarter of traumatized children did not receive access to a trauma center.

Provincial comparisons showed lower access in British Columbia, the Atlantic Provinces and Saskatchewan, with opportunities approximately 20-30% lower compared to Ontario. In contrast, Alberta and Manitoba had a 6-14% higher chance of access.

These differences in access were reflected in subgroups based on age group, mechanism of injury, and severity. They also reflect US findings. Recent research suggests that such centers are of greater benefit to younger children than to adolescents, for whom access to pediatric centers is not consistently associated with improved mortality outcomes.

Admission prices correlated with potential one-hour access prices and reflect the availability of such centers. For example, compared to Ontario with 0.37 centers per 10,000 km and Manitoba with 0.38 centers per 10,000 residents under 15, British Columbia has only 0.11 and 0.14 centers respectively.

Likewise, the Atlantic provinces face logistical difficulties, with fewer than half of children within an hour's drive of such a center.

However, other factors also play a role, such as prehospital care and decision protocols as well as transfers between hospitals. Again, nonpediatric hospitals may contribute to delays in definitive pediatric trauma care, particularly when pediatric readiness and pathways are limited.

Improving access to pediatric trauma centers in Canada therefore requires a multi-pronged strategy, starting with standardized management protocols at trauma sites and non-pediatric hospitals. This would facilitate and improve trauma care even more than the initially investment-intensive infrastructure. A similar US guideline was published by the American College of Surgeons in 2021.

Other potentially useful steps include enabling all hospitals to rapidly assess pediatric trauma and establishing teleconsultation hotlines to take advantage of capabilities available in pediatric trauma centers. This has the double advantage of avoiding unnecessary transfers when a child can be cared for closer to home, including in a non-pediatric center.

National databases should be established to capture all trauma data from across the country, with links to emergency department and hospital discharge data. This would help ensure high quality, equitable and properly monitored care and identify areas for future investment.

Improving access requires policy action

One in four traumatized children in Canada are treated outside of a pediatric trauma center, and this varies by province. Both short- and long-term policy interventions are essential to improving pediatric trauma care.

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