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Pediatric Trauma in the Spotlight

Harkins, Deborah MBA, BSN, RN, CCRN

doi: 10.1097/JTN.0b013e3181b9e009
President's Message
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Corresponding Author: Deborah Harkins MBA, BSN, RN, CCRN, 936 N Main St, Ann Arbor, MI 48104 (dharkins@mdcontent.com).

Figure. Deb

Figure. Deb

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PEDIATRIC TRAUMA

It is emotional. Whether reading about a teen alcohol-related motor vehicle crash in the local paper, consoling a devastated and overwhelmed parent in the trauma bay, or documenting child abuse—related injuries.

It challenges us clinically. Whether calculating infant drug doses in the heat of the moment, ensuring pediatric equipment availability, developing evidence-based protocols despite low-volume patient populations, or creating effective injury prevention programs that truly affect outcomes.

It makes us question. Whether access to care is adequate, whether teams are sufficiently trained to recognize the unique aspects of an injured child, or why there is variation in clinical practice patterns.

It motivates us. To be an advocate for those who cannot speak for themselves, to create a research infrastructure, to educate why children are not just small adults, to establish national benchmarks,...and so much more.

Injury is the leading cause of death in children. This statistic is well known, and yet it continues to be a pervasive public health problem that eludes us. The good news is that we have made some progress, with fatality rates from unintentional injury in children aged 14 years and under falling 45% since 1987.1 Whether in a pediatric verified level 1 or a combined adult/pediatric center or a rural hospital that transfers children, pediatric trauma affects all of us. To emphasize this point, key findings from the Centers for Disease Prevention and Control childhood injury report released on December 10, 2008, illustrate2:

  • On average 12,175 children 0 to 19 years of age died each year in the United States from an unintentional injury.
  • Injuries due to transportation were the leading cause of death for children.
  • An estimated 9.2 million children annually had an initial emergency department (ED) visit for an unintentional injury.
  • Injuries due to falls were the leading cause of nonfatal injury.

Pediatric trauma carries an enormous cost to society, in both money and the psychological toll experienced by patients, parents, and families alike. An article published in Pediatrics estimated that there were 50,658 traumatic brain injury hospitalizations in patients 17 years of age or younger in 2000. The author's conclusion demonstrated that pediatric traumatic brain injury alone is a substantial contributor to the health resource burden in the United States, accounting for more than $1 billion in total hospital charges annually.3 It is important to realize that this cost does not take into account the downstream expenses associated with long-term recovery or parents' inability to work as their child recuperates. Another report concentrating on children's utilization of injury-related ED care noted that nationally, in 2003, 5.4% of children had an injury-related ED visit, and approximately $2.3 billion was spent on outpatient injury-related ED visits.4 There is no doubt that the cost of care for pediatric injuries weighs heavily on our healthcare system as a whole. Moreover, it is difficult to quantify the costs associated with the psychological effects of pediatric trauma. Recent research advances move us toward validated acute and posttraumatic stress disorder (PTSD) screening tools to allow for earlier intervention for adult and child.5

Access to care for the pediatric population is also of key concern and recently has been highlighted in the media and medical literature. Currently, there is no national catalog of pediatric trauma centers. The American College of Surgeons (ACS) lists 55 verified pediatric centers (inventory includes 22 level I pediatric trauma centers, 13 level II pediatric centers, 12 level I adult/pediatric centers, and 8 level II adult/pediatric6) and while this list is a valuable source, it is by no means exhaustive.

In an attempt to inventory trauma center resources for children, Nance and coauthors designed a study to collate information from national, state, and local trauma system authorities. A total of 170 pediatric trauma centers in 41 states were identified through various methods including state designation, the ACS verified centers, the American Trauma Society Trauma Information Exchange Program (TIEP), and the National Association of Children's Hospitals and Related Institutions (NACHRI).

The authors concluded that an estimated 71.5% of pediatric patients were within 60 minutes of a pediatric trauma center by air or ground transport and 43% if only ground transportation was considered. An estimated 17.4 million children did not have access to a pediatric trauma center within 60 minutes. In addition, access ranged from 22.9% of the population in the most rural areas of the United States to 93.5% in the most urban areas.7 This study outlines quite a disparity when it comes to trauma care access across the country. This is of concern given the many articles substantiating improved clinical outcomes and decreased mortality for pediatric and adult patients treated at trauma centers.8–10 In fact, one study showed a decrease in the probability of mortality by 3.15% for patients aged 0 to 19 years treated at designated trauma centers versus nontrauma centers.11

Indeed, we have made headway impacting pediatric outcomes, but we have much work yet to do. The Society of Trauma Nurses (STN) recognizes the confounding issues facing the pediatric trauma patient population and is committed to addressing them head on. I am proud to say that one of our strongest and most successful Special Interest Groups (SIG) is our Pediatric SIG. More than 400 members strong, their focus and work product span the pediatric trauma care continuum. Here is a glimpse into some of their endeavors:

  1. Posttraumatic stress disorder and acute stress disorder (ASD) work group
  2. A survey was sent to the STN membership and results showed that most centers do not have a formal screening process for PTSD/ASD. The goal of this group is to raise awareness about PTSD/ASD and screening, develop resources including a self-learning packet, conduct research, and educate nurses via webinar.
  3. Screening, brief intervention and referral to treatment (SBIRT) work group
  4. A literature review was completed and survey distributed to the STN and NACHRI memberships. Response revealed no standardized process for SBIRT. Next steps include development of a consensus guideline for best practice. The group also presented at the annual conference this past April in Phoenix.
  5. Education work group
  6. This subcommittee's focus is to develop electronic resources to provide trauma education for nonpediatric trauma centers as well as advanced information for pediatric trauma centers.
  7. Pediatric committee: Strategic plan and goals
  8. The pediatric committee oversees the workings of the Pediatric SIG. The committee has 12 members as well as 2 cochairs. They are well organized with scheduled conference calls and active subcommittees. The goals of their strategic plan are to increase communication among members, increase the presence of the Pediatric SIG, develop processes to investigate and distribute pediatric best practices, and facilitate development of a research infrastructure and outreach with professional colleagues.
  9. Pediatric preconference
  10. This year at the STN's 12th Annual Conference, we hosted the first pediatric preconference session titled “The Growth and Development of Pediatric Trauma Care.” The inaugural event was a success, with 53 attendees enjoying education sessions and networking opportunities. Topics ranged from developing a new trauma center, to massive transfusion in the pediatric patient, to use of human simulator for staff training, to developing a pediatric injury study group. The Pediatric SIG is busy planning another preconference session for next year's conference in Orlando, so mark your calendars!

That is a quick snapshot of how the STN supports and nurtures the future of pediatric trauma care. We know there is much work to do, and at times it can feel overwhelming. Given the finite resources at pediatric trauma centers and a lower volume of patients, it is of utmost importance that we drive change and discover new information. This is one of our biggest challenges—and it makes us question. It motivates us. The STN is excited to provide avenues for this important work. We encourage you to get involved! Feel free to access STN's Web site www.traumanurses.org for SIG contact information. In the words of Margaret Mead, “Never doubt that a small group of thoughtful, committed people can change the world. Indeed it's the only thing that ever has.”

We hope you enjoy the first Journal of Trauma Nursing dedicated to pediatrics. Thanks to the many authors and advocates working diligently to bring pediatric trauma issues into the spotlight.

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REFERENCES

1. Safe Kids USA. Report to the Nation: Trends in Unintentional Childhood Injury Mortality and Parental Views on Child Safety. Washington, DC: Safe Kids USA; 2008.
2. Centers for Disease Control and Prevention. CDC childhood injury report.. Published December 10, 2008. Accessed July 6, 2009.
3. Schneier A, Shields B, Hostetler S, Xiang H, Smith G. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics. 2006;118:483–492.
4. Owens P, Zodet M, Berdahl T, Dogherty D, McCormick M, Simpson L. Annual report on health care for children and youth in the United States: focus on injury-related emergency department utilization and expenditures. Ambul Pediatr. 2008;8:219–240, e12.
5. Kassam-Adams N, Winston F. Predicting child PTSD: the relationship between acute stress disorder and PTSD in injured children. J Am Acad Child Adolesc Psychiatry. 2004;43(4):403–410.
6. American College of Surgeons. Verified trauma centers.. Accessed July 6, 2009.
7. Nance M, Carr B, Branas C. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med. 2009;163(6):512–518.
8. Macias C, Rosengart MR, Puyana JC, et al. The effects of trauma center care, admission volume, and surgical volume on paralysis after traumatic spinal cord injury. Ann Surg. 2009;249(1):10–17.
9. Potoka D, Schall L, Gardner M, Stafford P, Peitzman A, Ford H. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma. 2000;49(2):237–245.
10. Mackenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma center-care on mortality. N Engl J Med. 2006;354(4):366–378.
11. Pracht EE, Tepas JJ III, Langland-Orban B, Simpson L, Pieper P, Flint LM. Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatr Surg. 2008;43(1):212–221.
© 2009 Lippincott Williams & Wilkins, Inc.