Pediatric Trauma Care in Harris County, Texas- How do we Fare? Chantal Caviness, MD MPH Geetha Devdas, MD Mary Frost, RN Jennifer L Jones, MS Rohit Shenoi, MD

Background Injuries are the most frequent cause of mortality in children over one year of age Patients with the most severe injuries are transported or referred to Level 1 trauma centers for treatment in order to optimize their care

Background (cont.) Houston, located in Harris County (HC), Texas is the fourth largest city in the U.S. However, there are only two Level 1 trauma centers that serve HC and the surrounding region There have been no comparisons of pediatric injury mortality in HC to national pediatric injury mortality stratified by severity

Purpose/Objectives To compare pediatric injury mortality in HC to national injury mortality stratified by Injury Severity Score (ISS) To report pediatric injury mortality frequency in HC by ISS and trauma center designation

Methods De-identified data of hospitalized pediatric trauma patients (age 0-19) was obtained from the Texas Trauma Registry for HC for the year 2003 and compared to the 2003 National Trauma Data Bank (NTDB) created by the American College of Surgeons for the same ages The Injury Severity Scores (ISS) were categorized as follows: 0-8, 9-14, 15-24, and >24

Methods (cont.) Trauma centers were designated as Level 1, 3, 4 and Undesignated with Level I being the highest level of care The percent mortality and 95% confidence intervals (CI) by ISS categories were calculated for HC and the NTDB

Data Table 1. Trauma and Mortality in HC and Nationwide Harris County Registry (2003) National Trauma Data Bank (2003) ISS category # Patients # Deaths % Mortality (95% CIs) 1-9 1367 7 0.51 (0.13-0.89) 33920 141 0.42 (0.35-0.49) 10-15 179 1 0.56 (0-1.65) 4899 41 0.84 (0.58-1.10) 16-24 197 3.55 (0.97-6.14) 4830 170 3.52 (3.00-4.04) >24 132 29 21.97 (14.91-29.03) 16300 4655 28.56 (27.87-29.25) Unknown 31 3.03 (0-8.88) 47

Table 2. Trauma Hospital Designations and Mortality in Harris County # Patients # Deaths % Mortality 95% Confidence Interval (CI) ISS 0-9 Level 1 Level 3 Level4 Undesignated Total 778 253 52 283 1367 5 1 7 0.64 0.00 1.92 0.35 0.51 0-1.20 0-0.00 0-5.66 0-1.04 0.13-0.89 ISS 10-15 Level 4 142 23 3 11 179 0.70 0.56 0-2.08 0-0 0-1.65 ISS 16-24 153 15 24 197 4.58 3.55 1.26-7.89 0.97-6.14 ISS >24 114 9 132 2 29 21.05 33.33 22.22 21.97 13.57-28.54 3.95-71.05 0-49.38 14.91-29.03 Unknown 4 22 33 25 3.03 0-67.44 0-8.88

Results There were 1906 patients from HC There were 59,996 from the NTDB Trauma cases in HC comprised 1367 (71.68%) patients with ISS scores of 1-9, 179 (9.37%) with ISS scores of 10-15, 197 (10.31%) patients with ISS scores of 16-23 and 132 patients (6.91%) with ISS scores >24 ISS score was unknown in 33 patients (1.73%)

Results cont. Table 1 depicts the percent mortality by ISS for HC and the NTDB for 2003 Table 2 summarizes the mortality for pediatric trauma patients admitted to local hospitals based on the ISS and level of trauma designation of the hospitals

Results (cont.) The percent mortality for patients with ISS of 1-9 was 0.51 (0.13-0.89 CI), for ISS 10-15 was 0.56 (0.00-1.65 CI), for ISS 16-24 was 3.55 (0.97-6.14) and for ISS >24 was 21.97 (14.91-29.03 CI) For ISS 0-24 the highest mortality rates in HC were seen in Level 1 trauma centers, but for ISS >24 the highest mortality is seen in Level 3 trauma centers

# of Patients per ISS Group Harris County # of Patients per ISS Group Number Of Patients ISS Scores

Harris County Mortality Compared to National Rates ISS

Conclusion The mortality rates for pediatric trauma patients of HC based on severity of injuries are comparable with national rates Overall the majority of trauma patients fall within the ISS range 0-9, both in HC and nationally Additionally the least mortality is seen in this ISS range score, where the injury is the least severe

Conclusion (cont.) Although for most of the ISS scores in HC the majority of the mortality is seen in Level 1 trauma centers, for ISS>24 the mortality is the highest in the Level 3 trauma center The question is then raised if there is adequate triaging of patients to appropriate trauma centers This is however limited to time, access to various trauma centers, emergency rooms/hospital capacity

Conclusion (cont.) Previous studies have correlated site of care with corresponding outcomes in pediatric trauma, specifically looking at the benefit of pediatric trauma care at a children’s facility versus an adult facility These studies have shown that children’s needs are optimally provided in a children’s hospital Future studies could further stratify pediatric trauma care and outcomes in children’s hospitals based on trauma hospital designation, severity of injury, length of hospital stay, types of injury, hospital cost, and long term disability

Limitations The study was limited by the number of patients in HC, as there was only data used from 2003 There were also a number of unknown ISS that could contribute to mortality in different groups had they been appropriately identified

References Densmore, John C., et al. Outcomes and Delivery of Care in Pediatric injury. Journal of Pediatric Surgery 2006; 41: 92-98. National Trauma Data Bank. American College of Surgeons. (http://web.facs.org/ntdb_cf/demo_0.cfm?) The Texas EMS/Trauma Registry, Department of State Health Services. www.dshs.state.tx.us/injury.