where pediatric trauma fits into a trauma system
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04/21/23 1
Where Pediatric Trauma Fits into a Trauma System
R. Todd Maxson, MD, FACSTrauma Medical Director
Arkansas Children’s HospitalTrauma Consultant
Arkansas Dept. of Health
Something more to it
ACS verification improves outcomes
Level matters
Pediatric centers improve outcomes
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American Medical Association
Arkansas ranked 50th in the United States for timely trauma center accessibility for its citizens.
Pre-hospital times are long leading to preventable mortality
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AMA 293:2633-2633, 2005
National Report Card of the State of Emergency Medicine
Arkansas’ emergency care system is the worst in the nation.
Receiving a “ D-”
Only state without a designated / verified trauma center.
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American College of Emergency PhysiciansDecember 2008
American College of Surgeons Committee on Trauma
Overall injury fatality is 50% higher than the national average
CDC Data puts mortality for children involved in motor vehicle crashes at almost three times the national average.
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Michael Rotondo, MDChair COTNov. 2008
Motor Vehicle Crash Mortality Rates Arkansas vs. U.S., 2007-2009, All Ages
Source: CDC WISQARS 6
AR deaths, age 1-14, 1999-2007
1.28% mortality rate at Arkansas Children’s Hospital
Why would Mortality at Arkansas Children’s Hospital be so much better than the National Average ?
A. ACH just kick’s butt !
B. Helicopter transport services based at Children’s Hospitals lead to improved outcomes
C. The pre-hospital services are efficient and decrease preventable mortality
D. Most patient’s died prior to reaching the facility
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AR deaths, age 1-14, 1999-2007
1.28% mortality rate
791 injury deaths in the state; only 97 (12%) at Arkansas Children’s Hospital
% ISS > 16 below the national average
AR deaths, age 1-14, 1999-2007
1.28% mortality rate
791 injury deaths in the state; only 97 (12%) at Arkansas Children’s Hospital
Vast majority of Arkansas pediatric trauma deaths occur outside ACH
Contribution of Mortality
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Are we really doing the best we can to care injured children?
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What happened in Arkansas
2008 – ACS, ACEP and CDC all publicized the highest mortality rates in the Country.
The Med was going broke
Momentum for a trauma bill
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2009 Legislature Established a funded mandate for the
creation of a trauma system
Infra-structure within the ADH Call center for rapid transportation Designation of Trauma Centers Establishment State-wide education Establish triage and care guidelines State-wide trauma registry Develop quality indicators
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What’s Different about Pediatric Trauma Patients?
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Well…Nothing and Plenty!
17│
Vehicles and equipment Environment
Behavioral Avoidance Design Avoidance Design
Factors
Phase Human
Pre-Event
Behavioral Response Systems Response SystemsEvent
Post-Event Treatment Tools System
Haddon Matrix
Pre-Hospital Skills Paramedics in busy urban areas intubate
children 1.5 times per year and children < 5 yrs once every three years. CJEM Jan 2006
Multiple ETI attempts are associated with significant morbidity. J. Ped. Surg. Sept 2004
Pre-hospital care of children is suboptimal because of lack of ETI, PIV and fluid resuscitation skills Ped. Crit. Care Med. Aug 2010
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Scary Mary
Pre-hospital
Triage Criteria
Education – Mandated Foundation
Equipment – Mandated ACEP / AAP Braslow
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First Receiving Hospitals
Few critically injured children seen Few practitioners with significant
pediatric resuscitation skills
Causes of preventable death Airway management IV access and fluid resuscitation Ability to transfer to definitive care
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Community Hospital Education – Mandated Equipment - Mandated Clinical Practice Guidelines
Imaging, Fluid resuscitation Communications Center Trauma Image Repository Performance Improvement
Regional State-wide
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) ) )
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Hub SiteRemote Site
T-1
Transfer
Specialized transport services
All others****
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Tertiary Hospital
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ACS may not be the best way to provide care in a pediatric hospital Collaborative Outcome based Continuously ready Benchmarked
Psycho-social
Defining Quality Care
Collaborative Research PECARN ATOMAC
Benchmark TQIP NTDB – State-wide comparisons ACS verification
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Rehabilitation
Must have a place to go
Care should be specific
Must have funding for patients to get care
Demonstrate value
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Drinking and Driving
Caregiver behavior that contributes to pediatric injury
Behaviors are socially normative
Social psychology and marketing
Pursuit all available avenues04/21/23 29
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No Helmet
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Gunshot wound
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No Booster Seat
Disaster preparedness Rare
No “pop off”
Drill deep into the facility Identify weaknesses and solutions
Medical Society, Legal, Credentialing, liability, financial
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Influencing Policy There should NOT be a Pediatric
Committee
Pediatric issues should be considered in Every discussion
Sit at the table with the policy makers
Inform the electorate
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Back at Arkansas Children’s
Volume has gone up Transfers have gone down Scene runs have gone up Mortality at ACH
2007 - 1.28% 2012 – 1.6%
Mortality in the State is down
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There is something more to it
04/21/23 36
Pediatric centers improve outcomes
What are the roles and responsibilities of a Pediatric Trauma Center?
A. Educate pre-hospital and receiving hospital personnel
B. Define guidelines for care and provide benchmarked outcome data
C. Advocate for regulatory and legislative changes that positively impact injured children
D. All of the above
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Role of the Pediatric Trauma Center in a Region
Educate
Protocols
24/7 support – Telemedicine Where are the mistakes made?
Regional Peer Review
04/21/23 38
Role of the Pediatric Trauma Center in a Region
Define and provide care
Rehabilitate – family
Injury Control
Advocacy
04/21/23 39
Thank you
04/21/23 40
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