Quality care in pediatric trauma.

Infrastructure, processes of care and outcome measurements are the cornerstone of quality care for pediatric trauma. This review aims to evaluate current evidence on system organization and concentration of pediatric expertise in the delivery of pediatric trauma care. It discusses key quality indicators for all phases of care, from pre-hospital to post-discharge recovery. In particular, it highlights the importance of measuring quality of life and psychosocial recovery for the injured child.

INTRODUCTION

Injury is the number one cause of death in children ages 1-14 in the US, with head injury (38%) as the leading cause of all pediatric injuries.[12] While the creation of integrated and regionalized trauma systems has increased access and improved survival for all trauma victims, research on specifically improving pediatric trauma outcomes has emerged as an important focus in recent years. Infrastructure, processes of care, and outcome measurements are the cornerstone of quality care.

Survival is frequently cited as the primary outcome of interest after trauma, yet this may no longer be a sufficient indicator of quality care since mortality is relatively low in injured children (about 4% in the recent literature).?[3] Current research indicates that care processes and posthospital indicators, including health-related quality of Life (HRQOL), long-term effects on family and care-takers, and rates of post-traumatic stress disorder (PTSD) and psychosocial recovery are perhaps better measures of the overall quality of care for the injured child. This review aims to familiarize health providers with key concepts that define quality in pediatric trauma care.

TRAUMA SYSTEM ORGANIZATION

Regionalization and pediatric expertise

The impetus for regionalization grew from concern that not all acute facilities were equally prepared to care for the injured child. In fact, half of all U.S. emergency departments see fewer than 10 pediatric patients per day.[4] This contrasts with regional centers, which are staffed by surgeons and intensivists with specialized pediatric training. Surgeons experienced in pediatric trauma have championed the development of non-operative management of solid organ injuries for over 20 years.[5-7] Successful nonoperative management avoids the surgical costs and complications associated with unnecessary laparotomies. Nonoperative management of solid organ injuries is the current accepted standard of care in hemodynamically stable children. Yet, nonpediatric hospitals have been slow to adopt this practice. Bowman and colleagues report that US children with splenic injuries treated in general hospitals have five times the odds ratio of splenectomy compared to those treated at children's hospitals.[8] A recent study by Hamlat found that there are still large variations in splenectomy rates across the country, unexplained by severity of injury.[9] The rate of successful splenic salvage is arguably a quality indicator in pediatric trauma.

The organization of critical care services is another determinant of quality care. Developing and maintaining a pediatric intensive care unit (PICU) is a necessary first step.[10-12] The PICU assembles the expertise of pediatric-trained providers, nurses, and the proper equipment to care for critically ill children. While there is general consensus that PICUs are desirable, some debate exists over the best physician staffing model for pediatric trauma. In the open-ICU model, pediatric and trauma surgeons are responsible throughout the continuum of care, including the emergency department, operating room, and ICU. This model is appealing in that both the trauma expertise and the knowledge about the individual patient are concentrated in the same team. The disadvantage is that surgeons are not always immediately available to the PICU because these individuals have operative and other responsibilities in addition to ICU care. In contrast, the closed-ICU model consists of a dedicated staff intensivist who is solely responsible for the injured child in the PICU. This physician may be a surgeon-intensivist, or more frequently a pediatric intensivist. To be effective, this model requires close communication between intensivists and surgeons because care of the injured child clearly requires both areas of expertise.[13] Current research indicates that the closed-ICU model is superior in adult critical care, but this concept awaits validation in pediatric trauma.[1415]

Whereas organized trauma systems clearly reduce deaths in adults, similar evidence to support regional pediatric trauma care remains limited.[1617] Seminal work by Pollack and others provided the initial evidence that critically ill and injured children treated in tertiary care facilities had a reduced risk of death compared to nontertiary care centers.[1011] Based on this and other early studies, task forces organized by the American Academy of Pediatrics (AAP) and Society of Critical Care Medicine (SCCM) advocated for regionalization of pediatric trauma care. During the last two decades, pediatric-specific trauma centers have been developed as resources for the comprehensive care of injured children. A nationwide retrospective analysis of the US Kids’ Inpatient Database indicated that severely injured children (Injury Severity Score>15) treated at children's hospitals had improved survival compared to those treated in adult hospitals.[18] However, this study used only administrative data, did not account for trauma system designation, and was not able to fully control for confounding by injury severity and other risk factors. Statewide analyses suggest that both trauma designation and pediatric expertise are important components to reduce trauma deaths.[19-21] To date, there has been no large-scale prospective study comparing outcomes of pediatric trauma centers to non-trauma centers as has been done with adult trauma care.

Despite this regionalization effort, most injured children in the US are not treated at specialized pediatric centers.[1822] Segui-Gomez and colleagues reported that 77% of injured children receive care at centers without pediatric designation.[23] This disparity in access also highlights the limitations of the existing observational literature comparing outcomes, as it is difficult to account for the likelihood of referral to a specialized pediatric trauma center. Even in organized trauma systems, factors such as mode of transport and prehospital patient condition heavily influence where an injured child will receive their hospital care. For instance, children with apparent minor injuries may be transported by their parents than by EMS. Parents often transport based on geography rather than level of care.[24] Recent data indicate that many children have inappropriate delays to definitive care in current trauma systems.[25]

Only through improved coordination among acute care facilities will the injured child be able to receive definitive care at the facility with the most appropriate resources. This is the goal of inclusive trauma systems. In contrast to exclusive trauma systems, in which only a handful of centers develop the expertise to care for trauma patients, inclusive trauma systems seek the participation of virtually all facilities to develop a tiered-triage system. Each participating facility within the regional network receives a designation-level (usually 1 through 4) based on their capability. In adult trauma, inclusive trauma systems provide greater inpatient survival of severely injured patients. This is thought to be due to early referral of severely injured patients within an integrated regional network system.[26] Inclusive systems also have lower splenectomy rates after spleen trauma and lower nephrectomy rates after renal trauma, likely because of transfer to tertiary centers where non-operative management of solid organ injuries is more common.[2627] Although specific data about inclusive pediatric trauma systems are currently lacking, we believe that their development can be rationalized based on the available adult data. Proper evaluation of inclusive systems in pediatric trauma care will be possible during the development phase.

QUALITY INDICATORS BY PHASE OF CARE

Prehospital care

Advances in pediatric transport medicine have also taken place over the last two to three decades, paralleling regionalization efforts. The identification of severely ill children and early stabilization permit rapid pre-hospital transport in the “golden hour” to specialized centers capable of definitive interventions. The “golden hour” concept originated from an early 1970s study by Cowley et al. who demonstrated improved outcomes with rapid delivery of patients to trauma centers.[28] This is the foundation of transport teams, which focuses primarily on scene-related triage. As mentioned above, however, much of scene-related transport for minor trauma is done by parents and the majority of EMS pediatric transport is interfacility.[24] Recent studies allude to a misapplication of the “golden hour” concept in pediatric trauma.[2930] This occurs because of the focus on transport to tertiary trauma centers from outlying hospitals as quickly as possible. This can delay early critical therapies, which can be initiated in local emergency departments. The IMPACT prospective randomized trial indicated that patients who had enhanced monitoring during transport subsequently had shorter lengths of stay and lower rates of multi organ dysfunction.[31] Future research and system implementation should focus on critical early goal-directed therapies initiated at the referring hospital and continued in transport to the pediatric trauma center.

In-hospital care

Changes in the care of the injured child can be challenging to implement system-wide when data are limited. Both the proper documentation in a registry and its timely and thorough review are required processes for quality improvement. Important quality issues can be tracked, and set up as audit filters for discussion among the leadership within a trauma network. The issue of quality control of trauma care arose in the mid 1960s in a US National Research Council report.[32] Cook County Hospital in Chicago started the first computerized trauma database in 1969, which eventually grew into the Illinois statewide registry in 1971.[33] Large-scale registries have subsequently been created around the world, which has allowed for a more objective comparison of treatment techniques with national or international standards. Registry data also allows for monitoring of performance over time and identification of institutional outliers for internal review.[34] The initial use of registries was primarily in the adult trauma literature; however, its use has also been applied to the pediatric population. In the pediatric setting large shifts in management of trauma have occurred from evaluation of trauma registry data. In 2006, the American College of Surgeons Committee on Trauma (ACS-COT) created the Trauma Quality Improvement Program (TQIP) to develop national reporting and quality improvement for trauma patients.[35-37] Glance and colleagues recently used a statewide trauma registry to evaluate ACS-COT quality indicators and patient outcomes. The ACS-COT audit filters have been found to be predictive of increased mortality (6 specific audits were identified) but less predictive of which specific processes of care affect other clinical outcomes.[38] The identification of quality metrics, which can identify specific in-hospital care processes associated with changes in clinical outcomes, is needed. Table 1 summarizes currently proposed quality metrics in pediatric trauma care. Posthospital outcome measures, however, may be more appropriate to evaluate quality of care than audit filters of care processes.

Table 1

Quality metrics

Posthospital care: Outcomes measures

Long-term rehabilitation and reintegration

After discharge from acute care hospital treatment, recovery and reintegration into society can be challenging. For instance, motor, cognitive and behavioral functions can be impaired for years after brain injury.[44] Inpatient rehabilitation is indicted for all children with severe TBI and many of those with moderate TBI as well as other injuries such as severe burns and extensive orthopedic trauma. Rivara and colleagues have recently developed quality of care indicators for the structure/organization and for the process of inpatient rehabilitation care.[4546] Analysis of data from nine centers indicates large variation both within and across hospitals in the quality of inpatient rehabilitation care delivered for children with TBI.[47]

The recent literature has focused on long-term outcomes as indicators of recovery, rehabilitation and reintegration. Table 2 summarizes important outcome measures for pediatric TBI, burns, rehabilitation, orthopedics and injury prevention. Key measures are reviewed below.

Table 2

Published outcome measures in select pediatric trauma disciplines

Health-related quality of life

Indicators of quality care in pediatric trauma has been somewhat limited by the number of outcomes measured. Clinical markers, rates of recidivism and mortality are inadequate to properly assess the burden of injury and effectiveness of treatment.[61] HRQOL has been proposed as a complementary outcome measure. As a patient (or proxy) reported outcome, HRQOL reflects the patient's measure of physical, mental and social well-being. HRQOL therefore offers an important perspective on the success of health services and treatments rendered.[5262] A number of studies have evaluated HRQOL as a means to measure improvements in care of the pediatric trauma patient. Several screening and assessment tools have been used including the Pediatric Quality of Life Inventory (PedsQL), PEDI, TACQOL, QWB, CHO, WeeFIM and the NIH PROMIS measures.[6364] (www.nihpromis.org) These measurement tools have been widely validated in the chronic disease setting.[65] These tools have both a patient and parent version. In general self-reported QOL from injured children rather than their parents is preferred as parents may be influenced their own psychopathology and experiences during the recovery phase.[64] Table 3 summarizes the domains and items queried in current HRQOL tools. None was specifically designed for trauma, and their use in pediatric trauma has been limited until recently. No current consensus exists on which screening assessment to use. Other challenges include the heterogeneity of the patient population, variations in follow-up lengths. Current research efforts aim to provide long-term follow-up data in specific diseases such as TBI.[73] More recent research has modified existing screening tools to tailor to the specific disease burden of trauma patients, primarily long-term cognitive defects and family burden. More recent research has modified existing screening tools to tailor to the specific disease burden of trauma patients, primarily long-term cognitive defects and family burden. Most studies show an initial plateau in recovery after the 6 month postdischarge rapid initial recovery (discharge 24-36 months out).[77] Long-term follow-up studies are needed, as are tools to identify which patients are at greatest risk for long-term deficits.

Table 3

Health-related quality of life screening tools

Family/care-taker burden

There is a significant long-term impact on caregivers and families from pediatric trauma. This is particularly true in the traumatic brain injury population. Family burden is higher when a child's functioning is poorer and healthcare needs are unmet. It is manifested by a high degree of family stress and disorganization, mental health problems, and unmet needs for health care. This is even more evident in families of lower socioeconomic status with less access to care and higher rates of being uninsured.[78] Severe TBI is a source of considerable family morbidity when compared to other traumatic injuries. Rates of family dysfunction and stress are perceptibly higher 3 years after injury.[50] HRQOL assessment tools can be used to identify caregivers with significant distress. Family functioning before and after the injury has a significant effect on HRQOL outcomes in children after trauma.[79] Parental behaviors after the traumatic event are perhaps more important for the child's adjustment and recovery than the actual event exposure itself. Identification of these at-risk families is crucial to provide support and ultimately mitigate these stressors.[80]

Pediatric post-traumatic stress disorder/psychosocial recovery

Newer literature has begun to recognize the significant role of pediatric post-traumatic stress disorder (PTSD) in HRQOL after pediatric trauma. The following features distinguish PTSD if symptoms persist longer than 1 month: 1) re-experiencing the traumatic event, 2) avoidance of stimuli associated with the trauma or emotional numbing, and 3) hyper-arousal.[81] Some even suggest that injuries result in higher rates of PTSD than other serious pediatric medical conditions including diabetes and cancer.[82] A recent meta-analysis identified a number of risk factors that contribute to development of PTSD after trauma. The most important risk factors included female sex, pretrauma psychopathology, perception of threat to life and post-trauma parental distress.[83] This meta-analysis primarily included children injured from motor vehicle collisions. Thus it is unknown whether these risk factors can be extrapolated to other injury mechanisms.[84] Although it may seem intuitive that more severe injuries predispose children to PTSD, a number of divergent reports have been published on this issue.[85-87] As such, a clear link between injury severity (ISS) and rates of PTSD has been difficult to establish, yet it appears that certain injury mechanisms such as gunshot wounds are associated with higher PTSD development.[88] Age at the time of injury may also play a significant factor. Holbrook showed that adolescents in major trauma have significant long-term deficits in quality of life.[89] We expect that future investigations will help clarify the associations between age, injury mechanism, and rate of psychosocial recovery.

Despite the growing body of research highlighting the significance of PTSD in pediatric trauma, most injured children do not currently receive the acute and long term psychological care that they need postinjury. Currently, very few (20%) trauma centers have PTSD-specific screening and intervention services available.[59] One screening tool developed to identify youth at-risk is the Screening Tool for Early Predictors of PTSD (STEPP). Winston and colleagues have indicated that STEPP has high specificity to identify children at high risk of developing PTSD by using risk factors reported in the literature.[90] The existing literature suggests that interventions that address cognitive behaviors and family stress burden may help promote psychological recovery.

CONCLUSIONS

Quality care improvement in pediatric trauma can be achieved via a system-based approach that addresses infrastructure, care processes, and outcomes measurements. Beyond the traditional mortality benchmark, pediatric trauma is associated with measurable long-term effects on disability and reintegration, quality of life, and family stress. To address these issues, trauma providers need to revamp the way we conceptualize care and integrate long-term follow-up into the acute care model. Long-term outcomes should also be tracked by national registries to enable us to determine which changes in care may improve postdischarge outcomes.