Pediatric Trauma: To the Adult Trauma Center or Children’s Hospital?

A 2-year-old falls from a window, a 16-year-old is injured in a high-speed car accident and a 7-year-old is run over by a lawn mower. All of these injuries occur within range of a Level I adult trauma center and a Level III children’s hospital that are four miles apart. Where would these pediatric trauma patients best be served?

To answer this question, investigators in Omaha, Nebraska, which has the unique trauma system setup described above, analyzed trauma encounters at both hospitals between 2015 and 2022. The median age of pediatric patients presenting to the children’s hospital was 6 years; at the adult center, the median age was 13 years.

“Interestingly, there was an inflection point seen at patients 14-and-a-half years old, where young trauma patients were much more likely to interface with the adult center rather than the children’s hospital,” said Maria Tecos, MD, a pediatric surgery fellow at Oregon Health & Science University, in Portland. (She was formerly a surgical resident at the University of Nebraska Medical Center.)

To elucidate why this might be, Dr. Tecos and her colleagues considered the method of transportation by which these pediatric trauma patients arrived at their treatment designations. They found most of the patients presenting at the children’s hospital arrived via private vehicle, while the majority of those presenting to the adult trauma center arrived by ambulance.

“There could be many factors influencing this, such as the perceived severity of injury in the pre-hospital setting, or the assessment of field personnel that a larger or older appearing teenager may be an adult,” Dr. Tecos said.

Patients presenting to the adult trauma center were more likely to have a higher injury severity score (ISS) than those presenting to the children’s hospital. Also, the adult center saw nearly twice the number of penetrating injuries than the children’s hospital. Patients presenting to the children’s hospital were less likely to be admitted, and those who were had a shorter length of stay than those admitted to the adult center. Length of stay averaged one day in both centers.

Patients receiving intensive care at the children’s hospital were less likely to intubated, but when they were, they were on a ventilator one day longer than patients intubated at the adult trauma center. “This may be due to cultural differences with a pediatric intensive care unit interfacing with pediatric versus adult trauma surgeons,” Dr. Tecos said.

Patients admitted to the adult trauma center were more likely to require rehabilitative care following discharge, possibly due to their higher ISS on presentation. Overall mortality was lower at the children’s hospital, but when considering only severely injured patients, there was no difference between the two institutions.

“So where should those children have been sent for care? I don’t think there’s a right or wrong answer. What we do know about pediatric trauma care in general is that these patients do best when they are cared for at a trauma-accredited facility. Studies like these may be able to reveal nuances that can optimize that care,” Dr. Tecos said.

She observed that in the system they studied, the children’s hospital provided more efficient care of minor injuries and had a higher threshold for admitting patients, while the adult center seemed more appropriate for older, larger or more severely injured young patients.

Dina Filberto, MD, an associate professor of surgery at the University of Tennessee Health Science Center, in Memphis, said her system has a similar geographic setup, with a Level I pediatric center and a Level I adult center being the only two centers in the region.

“Our field triage guidelines preferentially bring more injured patients to the adult trauma center. However, we really only take care of patients who are in the adolescent age range.” She asked Dr. Tecos if they considered restricting their population to an age range of 10 to 19 for the comparison. “Otherwise, you might have a skewed perception of what’s taking place, because the patients at the pediatric center are so much younger.”

Dr. Filberto also inquired whether the Nebraska system has field triage guidelines that would preferentially bring more severely injured patients to the adult trauma center, which would explain the higher ISS at that center.

Dr. Tecos said they can’t apply the same age stratification approach to their system because they don’t have that in-field designation. “Children are brought to whatever facility is deemed appropriate by the first responding personnel, in the moment, in the field. But it’s an interesting point and may be something we can bring into fruition in the future.”