Gaps in Pediatric Trauma Care: Meeting the Demands

After a traumatic injury—a gunshot wound, severe concussion, broken bone—in a child, emergency care will be needed.

Injuries remain the leading cause of death among children in the United States, accounting for about 30 million or 21% of emergency department visits each year, but about half of these children are not treated by a pediatric-trained emergency physician or in a pediatric trauma center (N Engl J Med 2018;379:2468-2475; GAO report).

A major reason for this situation is infrastructure and access limitations. Of the 6,000 hospitals in the United States, about 170 are Level I or II pediatric trauma centers. Further, most of these centers are concentrated near cities, leaving large expanses of rural areas without pediatric-centered care. In fact, about one in four children live more than an hour by car or plane from a pediatric trauma center.

Limited opportunities to train a pediatric surgery–specialized workforce also have led to gaps in pediatric emergency care. Pediatric surgeons represent a small fraction of practicing surgeons in the country—estimated at 1,000 compared with 18,000 active general surgeons.

“Trauma is a team sport, but outside of high-level pediatric trauma centers and high-level adult trauma centers that routinely care for children, many providers simply do not have the training or resources to deliver high-quality care to children,” Mary Fallat, MD, a professor of surgery at the University of Louisville in Kentucky, told General Surgery News.

At the 2021 Eastern Association for the Surgery of Trauma Annual Scientific Assembly, Dr. Fallat gave the keynote lecture, tracing the long-standing gaps in pediatric trauma care, and outlined efforts to develop and integrate pediatric standards of care into the blueprint of the U.S. trauma system.

A History of ‘Uneven’ Access

In medical school, Dr. Fallat knew pediatric surgery was her calling. Over the next 40 years, she championed pediatric-centered emergency care—starting the first pediatric trauma service in Louisville in 1989, training the latest crops of pediatric surgeons and spearheading leadership roles at the American College of Surgeons to improve pediatric emergency care, and leading the Emergency Medical Services (EMS) for Children Program in Kentucky.

But during this time, Dr. Fallat also saw a glaring problem: As America’s trauma care system developed roots and standards of care within hundreds of hospitals nationwide, children largely remained on the fringes of the conversation.

A 2006 report from the Institute of Medicine characterized pediatric emergency care in this country as “uneven.” In the report, Dr. Fallat and pediatric subcommittee co-authors detailed a host of deficiencies: a lack of pediatric supplies in the emergency department, inconsistent practice patterns and coordinated care across institutions and providers, and geographic disparities.

One reason for these deficiencies is that children constitute a small fraction of the patients providers encounter, especially those in rural areas.

“Some hospitals only treat five to 14 children a day and hospital administration may be hesitant to spend the money or allocate resources for pediatric emergencies, if they do not encounter many,” Dr. Fallat said.

However, Dr. Fallat stressed, being pediatric ready—implementing guidelines, tools and training to provide optimal care for children—can save lives. A recent retrospective cohort study, focusing on 20,483 critically ill children up to 18 years of age presenting to 426 hospitals in four states, found that as a hospital’s pediatric readiness scores increased, in-hospital pediatric mortality decreased—11.1%, 5.4%, 4.9% and 3.4% by lowest to highest readiness quartile (Pediatrics 2019;144:e20190568).

Increasing Pediatric Readiness

The first step to improving readiness is to identify where the gaps are.

In 2013, Kate Remick, MD, FAAP, FACEP, FAEMS, an associate professor in the Departments of Pediatrics and Surgery, Dell Medical School at The University of Texas, in Austin, and her colleagues embarked on a large-scale project evaluating the pediatric readiness of thousands of emergency departments across the country. The analysis revealed that 4,146 respondents, representing 82% of U.S. emergency departments, had a median score of 69 out of 100, up from 55 in 2003 (JAMA Pediatr 2015;169[6]:527-534). Results showed that emergency departments had improved markedly, but that many still lacked essential tools and training, and less than half reported having pediatric quality improvement processes or disaster plans that include children.

“A particularly striking finding was that a large proportion of pediatric emergency department visits are happening in rural and remote areas, not urban centers where most pediatric trauma centers exist,” said Dr. Remick, the EMS director for the pediatric emergency medicine fellowship at Dell Medical School. “Now that we’re aware of the needs and resource limitations, we can put strategies in place to drive improvements.”

But launching a quality improvement effort on this scale takes planning and time. To begin enhancing quality, Drs. Fallat and Remick, and a team of experts developed a pediatric readiness tool kit aligned with national guidelines that provides a checklist of equipment, supplies, medications and protocols that physicians, nurses and departments need at their fingertips during emergencies.

To improve access, Dr. Fallat and her colleagues, through the American Pediatric Surgical Association, are also working on an initiative to expand telehealth options for pediatric patients in rural areas, where the majority of pediatric trauma deaths occur and where surgical and trauma specialty care often is not readily available (Health Aff 2019 Nov 20). Dr. Fallat also recently created a task force to develop pediatric trauma curricula that can be integrated into traditional training.

“Pediatric surgeons, trauma surgeons and pediatric emergency medicine need to lead the charge in establishing training, spreading our knowledge of pediatric trauma care and engaging providers along the continuum of care, including in geographic areas where there are no high-level trauma centers,” Dr. Fallat said.

Dr. Remick agreed: “We need a groundswell, an army of providers willing to stand up and advocate on behalf of children and be pediatric champions on the front lines, and it’s exciting to see a lot of the pieces coming together.”

That support is growing. According to Dr. Remick, 17 states have established a pediatric facility recognition system, a state initiative that recognizes and encourages emergency departments to prioritize and meet established readiness standards. A 2020 analysis showed that states with such a system in place demonstrated significantly higher pediatric readiness scores (J Pediatr 2020;218:210-216.e2).

“The privilege of my career will be knowing these philosophies are being embraced and that I will be leaving things in good hands when I retire,” Dr. Fallat said.

This article is from the July 2021 print issue.