Page 14 - Delaware Medical Journal - October 2016

Pediatric Head Injury in the Delaware Trauma System: Toward Improved Calibration
of Severity and Resource Utilization
Joseph Piatt, MD, FAAP; Diane Hochstuhl, MSN, RN, NP-C; Stephen Murphy, MD, FAAP
Background: How the existence of trauma systems affects the care of less severely injured patients has received little attention. Objective: The current study examines the longitudinal effect on the care of children with traumatic brain injuries (TBIs) of the
incorporation of a pediatric trauma center into a regional trauma system.
Methods: The Delaware Trauma System provided registry data from 2000 to 2014. Inclusion criteria were age less than 18 years and ICD9 diagnostic coding for any head injury. Admissions were assessed as “substantial” or “non-substantial” based on study criteria. We hypothesized a step-wise increase in registrations of mild TBI and non-substantial admissions coinciding with the opening of Delaware’s pediatric trauma center in late 2006.
Results: There were 5,272 registrations. Before the opening of the pediatric trauma center, 1,737 of 2,038 (85.2 percent) head injuries were mild; afterwards mild TBI accounted for 2,894 of 3,230 registrations (89.6 percent; odds ratio 1.49, 95 percent
CI 1.26 – 1.76; p < 0.0001). Before the opening, 850 of 2,038 (41.7 percent) encounters were categorized as non-substantial; afterwards 1,528 of 3,230 admissions (47.3 percent) were non-substantial (odds ratio 1.25; 95 percent CI 1.12 - 1.40; p < 0.0001). Inter-hospital transports within the system exhibited similar trends.
Conclusions: Registrations of mild TBI and non-substantial admissions trended upward steadily during the years of this study with a suggestive step-wise increase correlating with the opening of a pediatric trauma center. Guidelines are needed to facilitate management of patients with minor injuries at the lowest appropriate level of care.
IntroductionThe imperative to provide critically injured trauma
victims sophisticated medical services in a timely fashion has been the motivation for the development of regional trauma systems, and in this respect, regional trauma systems have been a success. Numerous epidemiological studies have documented diminution of trauma mortality rates in regions that have organized trauma systems as compared with historical data or with neighboring regions.1-5 On the other hand, the effect of the existence of a regional trauma system on the experiences of patients with less severe injuries has received little attention.
The Delaware Trauma System (DTS) was organized in 2000. The Nemours/AI duPont Hospital for Children (NAIDHC)
is the only children’s hospital in the state of Delaware, but it was not integrated into the system fully until July 2006, when it was designated a provisional Level 3 center. It advanced to provisional Level 2 in January 2008, and in December 2008 evolutionary changes have created an opportunity to study
how organization of trauma services in Delaware has affected patterns of injury and intensity of care.
METHODS
The registry of the Delaware Trauma System captures all inpatient admissions due to injury at all eight Delaware acute care hospitals with emergency departments (EDs), all transfers out of EDs to higher level or specialty care, and all injury-related hospital or ED head injury (432.1, 800.XX, 801.XX, 803.XX, 804.XX, 850.XX, 851.XX, 852.XX, 853.XX, 854.XX, 959.0X) for patients under
18 years of age from 2000 through 2014. Traumatic brain injury (TBI) was characterized as “mild,” “moderate,” or “severe” based on the accepted partitioning of the Glasgow Coma Scale (GCS),
3 to 8, 9 to 12, and 13 to 15, respectively. Encounters with the Trauma System were categorized as “substantive” if any of the following criteria were met: a surgical procedure in the operating
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Del Med J | October 2016 | Vol. 88 | No. 10
Abstract