Pediatric Trauma This is a general report on the state of ...€¦ · Pediatric (ages 0-14)...
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Zeyno Nixon, PhD MPH Pediatric Trauma
Transcript of Pediatric Trauma This is a general report on the state of ...€¦ · Pediatric (ages 0-14)...
Zeyno Nixon, PhD MPH
Pediatric Trauma
Presenter
Presentation Notes
This is a general report on the state of pediatric trauma care.
Pediatric (ages 0-14) mortality and volumes
Presenter
Presentation Notes
Let’s start our discussion of the pediatric trauma registry data with case fatality and pediatric trauma volumes.
As Washington’s Trauma System Matured, Pediatric (Age<15) Inpatient Trauma Mortality Improved
Quickly (Department of Health Criteria, excluding transfer-outs)
0
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8
9Pe
rcen
t Die
d
The percentage of hospital deaths, 1997-2013
Ages 0-14 All Trauma
0
0.5
1
1.5
2
2.5
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 99 102
Perc
ent D
ied
Age
Percent Died by Age, 1995-1999
In recent years, we have observed a surge in older adult deaths. Earlier, the youth had most inpatient
trauma deaths.
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0.5
1
1.5
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2.5
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0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 99 102
105
Perc
ent D
ied
Age
Percent Died by Age, 2008-2012
0%
2%
4%
6%
8%
10%
12%
14%
16%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Deat
hs p
er 1
00 p
atie
nts
The Percentage of Major TBI (Max Head AIS>=3) Deaths Among Pediatric (Ages<15) Trauma Patients
While the Overall Mortality Came Down, Major TBIs are Still the Deadliest of All Pediatric Trauma with
7 percent Case Fatality in 2013 (Department of Health criteria, excluding transfers in)
While Washington’s Adult Trauma Volume Increased Significantly Over the Years, Since 2001 the Statewide Pediatric Volume Stayed Stable, Around 2,400 to 2,800
Patients (Department of Health criteria, excluding transfers-out)
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5,000
10,000
15,000
20,000
25,000
30,000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Trau
ma
Patie
nt V
olum
e
Washington's Trauma Volume
Ages 0-14 All Trauma
Starting with 2003, The Percentage of Pediatric Trauma in the Trauma Registry Went Down
(Department of Health criteria, excluding transfers-out)
0
500
1,000
1,500
2,000
2,500
3,000
0
2
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18
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Pedi
atric
Tra
uma
Volu
me
Perc
ent o
f WTR
Pediatric (ages 0-14) Trauma in WTR, 1997-2013
Number Percentage
Since 2001, The Statewide Pediatric Volume Stayed Stable, Around 2,400 to 2,800 Patients, and the Level 2 Pediatric Centers Increased
Their Number of Pediatric Patients (Department of Health criteria, excluding transfers-out)
0
500
1000
1500
2000
2500
3000
1995
1996
1997
1998
1999
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2008
2009
2010
2011
2012
2013
Pedi
atric
Tra
uma
Volu
me
Washington’s Pediatric Trauma Volumes by Pediatric Designation Level
No Pediatric Designation Peds Level 1
Peds Level 2 Peds Level 3
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500
1000
1500
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2500
3000
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1996
1997
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2002
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2009
2010
2011
2012
2013Pe
diat
ric T
raum
a Pa
tient
Vol
ume
Pediatric Trauma Volumes for Definitive Care by Region
Central West East SC
SW North NC NW
Presenter
Presentation Notes
Increase in level 2 volumes and increase in the West region
97%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
ent H
ospi
taliz
ed
The percentage of pediatric patients with serious injuries (ISS 16+) receiving definitive hospital care by level I-II pediatric designated services
Most major (ISS 16+) pediatric (age <15) trauma patients receive definitive care from level I – II
pediatric designated services (Department of Health Criteria, admitted patients only)
Some of This Decline in Pediatric Patient Volumes as well as the Mortality Could be Attributed to Washington’s Injury
Prevention Activities
Injury Prevention – Related State Laws
• Personal Flotation Devices/Life Jackets (1999): All people on a personal watercraft (PWC) and any person under 12 years of age on a vessel under 19 feet in length must wear a U.S. Coast Guard-approved life jacket that fits the individual.
• Child Passenger Safety (2005): A child must be restrained in a child restraint system (rear-facing, forward-facing, or booster seat) until the child is 8 years old, unless the child is four feet nine inches tall or taller. Children under 13 years of age shall be transported in the back seat where it is practical to do so.
• Zach Lystedt Law (2009): A youth athlete suspected of sustaining a concussion or head injury in a practice or game shall be removed from play or competition at that time. The youth removed may not return to play until he or she is evaluated by a licensed health care provider who is trained in the evaluation and management of concussion, and receives written clearance to return to play.
Currently, there is no state law requiring helmet use. However, some cities and counties do require helmet use with bicycles Location Name Who is Affected Effective Date
Aberdeen All ages 2001 Bainbridge Island All ages 2001 Bremerton All ages 2000 DuPont All ages 2008 Eatonville All ages 1996 Fircrest All ages 1995 Gig Harbor All ages 1996 Kent All ages 1999 King County All ages 1993, 2003 updated to include Seattle Lynnwood All Ages 2004 Lakewood All ages 1996 Milton All ages 1997 Orting Under 17 1997 Pierce County All ages 1994 Port Angeles All ages 1994 Port Orchard All ages 2004 Poulsbo Under 18 1995 Puyallup All ages 1994 Renton All ages 1999 Spokane All ages 2004 Steilacoom All ages 1995 Tacoma All ages 1994 University Place All ages 1996 Vancouver All ages 2008 All Military Installations All ages N/A
Data Source: Washington State Department of Transportation, http://www.wsdot.wa.gov/bike/helmets.htm
010203040506070
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
ent o
f MV
Occ
upan
t Inj
urie
s Protective device use in Pediatric (ages<15) motor vehicle
occupant injuries
Booster Seat (Age<9) Seat Belt (Age 9-14)
The WTR is more likely to capture those injuries with no injury prevention device use, because they tend to be more life-threatening than those injuries with seat belts or helmets. (Department of Health criteria, excluding transfers in)
05
101520253035404550
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
ent o
f bic
ycle
inju
ries
Helmet use in pediatric (ages<15) bicycle injuries
Demographic and injury characteristics
Gender Dynamics (Department of Health criteria, excluding transfers out)
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200
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600
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1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Pedi
atric
Tra
uma
Volu
me
Pediatric Trauma (Age<15) by Gender
Females Males
Watch out for those youngsters! After puberty, penetrating and intentional injuries go up!
(Department of Health criteria, excluding transfers in)
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5
10
15
20
25
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Perc
ent H
avin
g Pe
netr
atin
g In
jurie
s
Age (Years)
The percentage of penetrating injuries by age, 2010-2013
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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Perc
ent H
avin
g In
tent
iona
l Inj
urie
s
Age (Years)
The percentage of intentional injuries by age, 2010-2013
Most Commonly Observed Injury Mechanisms in Pediatric Trauma, 2011-2013
(Department of Health criteria, excluding transfers out)
Bicycle 7% Burns
8%
Falls 40%
Motor Vehicle 10%
Pedestrian vs. Vehicle
4%
Sports or Play Injury 12%
Other Injuries 19%
In Recent Years, Falls Show an Upward Trend While Motor Vehicle-Related Injuries are on the Decline
(Department of Health criteria, excluding transfers in)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Mec
hani
sm-s
peci
fic P
erce
nt o
f Ped
iatr
ic P
atie
nts
Trends for Top Pediatric (Age<15) Injury Mechanisms
Bicycle Burn Fall
Motor Vehicle Pedestrian vs. Vehicle Sports or Play Injury
Other
Pediatric (ages 0-14) falls from windows and balconies
We See an Increase in Pediatric (Ages 0-14) Falls From Windows and Balconies
(Department of Health criteria, excluding transfers in)
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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
ent o
f Ped
iatr
ic A
ll Tr
aum
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The Percentage of Building-Related Pediatric (Ages <15) Falls
This Increase in Building-Related Falls Mostly Affects Children Ages 1-6
(Department of Health criteria, excluding transfers out)
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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Age-
spec
ific P
erce
nt
The Percentage of Building-Related Pediatric Falls by Age Groups
Age <1 Ages 1-6 Ages 7-14
No Gender Differences Among Children Ages 1-6 With Window-Balcony Falls
(Department of Health criteria, excluding transfers out)
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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Gen
der-
spec
ific p
erce
nt o
f kid
s age
s 1-6
The Percentage of Building-Related Pediatric Falls by Gender
Females Males
Regional Distribution of Building-Related Falls Among Children Ages 1-6
(Department of Health criteria, excluding transfers out)
Central 37%
North 14%
North Central 1%
Northwest 0%
South Central 4%
Southwest 10%
East 7%
West 27%
Pediatric Window-Balcony Falls by Region, 2011-2013
N=333
Washington Trauma Registry Data
ZIP code level analysis
The Outcomes of Building-Related Trauma Among Children Ages 1-6, 2011-2013
(Department of Health criteria, excluding transfers out)
• Out of 333 statewide window/balcony falls: – 92 (28 percent) received ICU care – 18 (5 percent) had serious (AIS 3+) head injury – 2(1 percent) died – 321 (96 percent) were discharged home – 10 (3 percent) were discharged to a rehab facility or
received rehab care at home.
Other issues related to the management of pediatric trauma care
Median emergency department length of stay of transfer out patients
(Department of Health criteria)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Med
ian
ED LO
S (in
hou
rs)
Age 0-14 Age 15-24 Age 25-54 Age 55-74 Age 75+
0
5
10
15
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40
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
ent o
f Spl
een
Inju
ries
The percentage of splenectomies by age
Children (Ages 0-14) Adults (Ages 15+)
The percentage of spleen injuries managed with splenectomies declined over time
(Department of Health criteria, hospital admissions)
The use of CT scans to diagnose pediatric TBIs is going down in pediatric designated
centers
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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
ent o
f ped
iatr
ic E
D ar
rival
s fr
om th
e sc
ene
Pediatric (Ages 0-14) Utilization of Head CTs for Minor Head Injuries (AIS <=3) by Pediatric Designation Level
Adult Designation Only Peds Level I Peds Level II Peds Level III
WTR Records with No Emergency Department Systolic Blood Pressure Recorded by Age and Year
(Department of Health Criteria, excluding transfers-out)
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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Age-
spec
ific
perc
ent
Age 0-14 Age 15-24 Age 25-54 Age 55-74 Age 75+
Full Trauma Team Activations (FTTA) for hypotensive pediatric (age 5-14) and older adult (age 55+) trauma patients are lower
than other adult age groups (DOH Criteria, Age-Appropriate Systolic Blood Pressure Thresholds, and Excluding Transfers in)
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10
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90
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Perc
ent o
f WTR
pat
ient
s with
low
blo
od p
ress
ure
The Percentage of Full Trauma Team Activations (FTTA) for Hypotensive Trauma Patients
Age 0-14 Age 15-24 Age 25-54 Age 55-74 Age 75+
In summary
• After the implementation of Washington’s Trauma System, outcomes of pediatric (age <15) trauma improved significantly.
• This suggests effectiveness of coordinated trauma care efforts in this age group.
• Two major coordinated efforts took place. – Injury prevention resulted in a relative decline in pediatric
volumes in recent years. – Better trauma care resulted in a decline in pediatric
inpatient mortality.
• Despite all these improvements, TBIs are still the main cause of pediatric deaths, and rising pediatric window-balcony falls in ages 1-6 is a concern.
