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Cited by 19 publications
References 17 publications
Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma
ImportanceAdult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking.ObjectiveTo assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma.Data SourcesMEDLINE, Embase, and Web of Science through March 2023.Study SelectionStudies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years).Data Extraction and SynthesisThis systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence.Main Outcome(s) and Measure(s)Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI).ResultsA total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes.Conclusions and RelevanceIn this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.
Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma
ImportanceAdult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking.ObjectiveTo assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma.Data SourcesMEDLINE, Embase, and Web of Science through March 2023.Study SelectionStudies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years).Data Extraction and SynthesisThis systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence.Main Outcome(s) and Measure(s)Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI).ResultsA total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes.Conclusions and RelevanceIn this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.
Mortality Among Severely Injured Adolescents Admitted to Pediatric vs Adult Trauma Centers
ImportanceCare in a pediatric (vs adult) trauma center improves outcomes for injured children aged 0 to 12 years, but whether pediatric care benefits injured adolescents is unclear.ObjectiveTo evaluate the association of pediatric vs adult trauma center care with mortality among severely injured adolescents.Design, Setting, and ParticipantsThis retrospective cohort study was conducted between April 1, 2012, and March 31, 2020, among adolescents aged 12 to 16 years who were admitted to level I or level II adult trauma centers or a level I pediatric trauma center in British Columbia, Canada. Analysis was conducted between January and September 2024.ExposureAdmission to a level I pediatric trauma center or level I or level II adult trauma center.Main Outcomes and MeasuresThe primary outcome was hospital mortality for the index trauma incident. Inverse probability of treatment weighting was used to estimate the association of admission to a pediatric trauma center with mortality.ResultsA total of 416 patients aged 12 to 16 years (median [IQR] age, 15 [13-16] years; 308 male [74.0%]) were admitted to a level I or level II trauma center with severe injury (201 [48.6%] at a pediatric trauma center; 83 [20.0%] at a level I adult trauma center; and 132 [31.7%] at a level II adult trauma center). Patients admitted to the pediatric trauma center (vs level I or level II adult centers) had lower median (IQR) age (14 [13-15] years vs 15 [14-16] years), higher median (IQR) Injury Severity Score (16 [9-21] vs 13 [9-18]) and fewer penetrating injuries (10 injuries [5.0%] vs 28 injuries [13.0%]). Hospital mortality was 7.0% (14 of 201 patients) among patients admitted to the pediatric center vs 4.2% (9 of 215 patients) among those admitted to an adult trauma center. There was no statistically significant difference in hospital mortality between patients admitted to pediatric vs adult trauma centers (adjusted odds ratio, 2.61; 95% CI, 0.88-7.69; P = .08).Conclusions and RelevanceIn this cohort study of severely injured adolescents, pediatric trauma center admission was not associated with improved hospital mortality. These findings suggest that severely injured adolescents aged 12 to 16 years may be safely treated at either adult or pediatric trauma centers.
Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates
BackgroundMore than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community‐based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric‐specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency.MethodsThis was a prospective, survey‐based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email.ResultsA total of 222 responses were obtained from 570 eligible participants (39.1%). Non‐ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation–based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001).Conclusions/discussionThis survey‐based cohort study found considerable variation in pediatric‐specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.
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