TARN Severe injury in children v2€¦ · Severe Injury in Children (ISS > 15) Injury Mechanism Number (%) Analysis of injury mechanism data shows a preponderance of road traffic

England & Wales

SEVERE INJURY IN CHILDREN

2012

THE TRAUMA AUDIT AND RESEARCH NETWORK

1SEVERE INJURY IN CHILDREN 2012

The TARNlet Committee

Mr Ross FisherCo-chairman of TARNletConsultant in Paediatric SurgerySheffi eld Children’s NHS Foundation Trust

Dr Ian MaconochieCo-chairman of TARNletConsultant in Paediatric Emergency MedicineImperial College Healthcare NHS Trust

Dr Derek BurkeConsultant in Paediatric Emergency MedicineSheffi eld Children’s NHS Foundation Trust

Professor Tim CoatsProfessor of Emergency MedicineUniversity of Leicester

Dr Lorcan DuaneConsultant in Emergency MedicineCentral Manchester University Hospitals NHS Foundation Trust

Julie FlahertyPaediatric Nurse ConsultantSalford Royal NHS Foundation Trust

Dr Muhuntha GnanalinghamConsultant in Paediatric Intensive CareCentral Manchester University Hospitals NHS Foundation Trust

Professor Fiona LeckyProfessor of Emergency MedicineUniversity of Sheffi eld

Mr Roberto RamirezConsultant in Paediatric NeurosurgeryCentral Manchester University Hospitals NHS Foundation Trust

Maralyn WoodfordExecutive DirectorThe Trauma Audit & Research Network

Acknowledgements

We would like to thank the staff at each trauma receiving hospital and Mr Thomas Lawrence, Data Analyst at the Trauma Audit & Research Network.

THE TRAUMA AUDIT AND RESEARCH NETWORK2

Contents

3 Introduction

4 Summary

5 Data completeness

6 Demographics

7 Injury mechanism

8 Injury type

9 Time of arrival at hospital

10 Month of arrival at hospital

11 Mode of arrival at hospital

12 Type of fi rst admitting hospital

13 Transfer between hospitals

14 ICU / HDU admissions, intubation & length of stay in hospital

15 Mortality rates

16 Injuries associated with death

17 Grade of most senior clinician in the ED

18 Grade of most senior clinician involved in surgery

19 Time to fi rst surgery from arrival

20 Glossary


Introduction

“Children are different” but, remarkably, very little work has been published which permits an analysis of paediatric trauma care. The Trauma Audit and Research Network (TARN) registry contains information on over 4700 children under the age of 16 injured in 2012. Data from previous years has been a valuable asset in demonstrating improvements in outcome*.

The TARNlet committee, consisting of clinicians, managers and academics that focus on injured children was established to address specifi c questions relating to paediatric trauma care and this is its fi rst annual report.

This report is based on data reported to TARN from England & Wales for 2012. Those that died at the incident scene and were not transported to hospital are not reported to TARN. Further information about the data methodology can be found at www.tarn.ac.uk.

Injury produces a signifi cant health burden for children, being a leading cause of both death and disability, with the numbers of different severities being shown in Figure 1.

This report concentrates on the 737 children in 2012 who sustained the most serious injuries - an injury severity score (ISS) greater than 15.

This report gives an overview of when and where injured children present in the healthcare system, along with some measures of the process of care. Future reports will look in more detail at specifi c aspects of injury management in children.

*Reducing accident rates in children and young adults: the contribution of hospital care.

All children attending ED with injury

All children in the TARN database

n = 4720

ISS > 15n = 737

Figure 1 (2012 data)

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Severe Injury in Children

Summary

During 2012 there were 737 severely injured children treated in England & Wales. Road traffi c collisions and resulting head injuries predominate as the major causes of severe injury and mortality. The peak incidence in infants is often caused by non-accidental injury.

A signifi cant proportion of severely injured children were not conveyed to hospital by ambulance so the pre-hospital triage system will not have been applied. Trauma systems need to anticipate that children will continue to arrive at trauma units or non-designated hospitals and have systems to ensure that children are not disadvantaged by initially presenting to the “wrong” hospital. Staff in all hospitals need suffi cient continuing training to enable them to provide initial care until either a specialist team arrives or an inter-hospital transfer is carried out. The data showed that most severely injured children are moved to a specialist Trauma Centre, which emphasises the need for a prompt inter-hospital transfer system.

Time to surgery is related to outcome therefore an effi cient transport and transfer system that minimises delays is important.

The pattern of arrival of severely injured children implies that staffi ng for paediatric trauma needs to be matched to a pattern that includes high rates of arrival outside the conventional working day (especially in the evening and at weekends), and low rates of arrival after midnight.

As trauma systems evolve and mature there will be changes in the way in which the healthcare system responds to severely injured children. The TARNlet annual reports will aim to present the best information that is available about our care of children and young people and strive to produce data that will improve the delivery of trauma services.


Trauma in children

Data Completeness

All Submissions Deaths

Trust n HESCompletion

%n HES

Completion%

England & Wales 2562 3485 73.5 56 31 180.6

This is displayed as a percentage and represents the number of patients submitted to TARN compared to the number of patients expected based on the 2012 Hospital Episode Statistics (HES) dataset. The HES dataset is used as a general baseline and the TARN fraction may be more than 100% as deaths in the ED are not recorded in HES.

This data refers to submissions to TARN, however the same patient may be submitted more than once if they undergo an inter-hospital transfer. Reducing the dataset to individual cases results in 2360 children who met the TARN entry criteria admitted to hospitals in the area covered by this report.

737 children had severe injuries that were assigned an injury severity score (ISS) of more than 15 and 56 died of those injuries.


Severe Injury in Children (ISS > 15)

Demographics Number (%)

Two thirds of injured children are male. There is a bimodal distribution of age with a peak in the first year of life followed by another from 6 years old.

Total 737

age < 1 year 171 (23.2%)

age 1 - 2 years 60 (8.1%)

age 3 - 5 years 96 (13%)

age 6 - 10 years 142 (19.3%)

age 11 - 13 years 146 (19.8%)

age 14 - 15 years 122 (16.6%)

Median Age (IQR) 7.7 (1.3 - 12.7)

Male (percentage) 65.8

Median ISS (IQR) 22 (16 - 26)

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25

age <1 year age 1 - 2 years age 3 - 5 years age 6 - 10 years age 11 - 13 years age 14 - 15 years

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Injury Mechanism Number (%)

Analysis of injury mechanism data shows a preponderance of road traffic collisions and falls of less than 2 metres.

10.1% of the patients are aged under 2 and were injured intentionally (recorded as Non-Accidental Injury).

Road Traffic Collision 284 (38.5%)

Fall < 2m 164 (22.3%)

Fall > 2m 110 (14.9%)

NAI under 2 years 74 (10%)

Penetrating 10 (1.4%)

Blows 46 (6.2%)

Other (eg. sport/drowning) 49 (6.6%)

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30

35

40

Road Traffic Fall > 2m Fall < 2m NAI under 2 years Penetrating Blows Other (eg. Collision sport/drowning)

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Injury Type Number (%)*

*Patients with multiple injuries will appear in multiple groups

The severity of an injury can be described using the Abbreviated Injury Scale (AIS) score. The score can range from 1 (minor) to 6 (fatal). AIS 3+ describes injuries that are severe.

Severe head injury is present in a large proportion of severely injured children, emphasising the importance of neurointensive and neurosurgical care within the Trauma Networks.

AIS3+ Head Injury 555 (75.3%)

AIS3+ limb / pelvis / spine injury 136 (18.5%)

AIS3+ thoracic / abdominal injury 213 (28.9%)

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60

70

80

AIS3+ Head Injury AIS3+ limb / pelvis / spine injury AIS3+ thoracic / abdominal injury

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Arrival time

Average number of severely injured children treated each year by hour and day of week.

Severely injured children attend hospital mainly during daytime hours, although a small percentage attends after midnight. Many injured children attend at the weekend and in the evenings. This pattern of attendance has an implication for the staffing of paediatric trauma services which need to be geared to receive severely injured children during the evening and at weekends. The relatively low number of severe injuries occurring at night raises a question about the cost effectiveness of on-site paediatric trauma expertise during the night.



Arrival month Number (%)

January 54 (7.3%)

February 40 (5.4%)

March 39 (5.3%)

April 36 (4.9%)

May 80 (10.9%)

June 67 (9.1%)

July 72 (9.8%)

August 92 (12.5%)

September 93 (12.6%)

October 72 (9.8%)

November 46 (6.2%)

December 46 (6.2%)

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6

8

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14

January February March April May June July August September October November December

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Mode of arrival (direct admissions)n = 537 Number (%)

A large proportion of severely injured children are not brought to hospital by ambulance. This has a significant implication for the future configuration of paediatric trauma services, as the trauma system must anticipate that as many as a third of patients will continue to arrive at the nearest hospital (which may or may not be part of the trauma system).

For children where there is no information recorded about their initial hospital stay we are unable to comment on the mode of arrival.

Arrived by ambulance 302 (56.2%)

Arrived by helicopter 91 (16.9%)

Arrived by other means (eg. car) 144 (26.8%)

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30

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60

Arrived by ambulance Arrived by helicopter Arrived by other means (eg. car)

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Type of first admitting hospital Number (%)

*MTC - Major Trauma Centre

Few children are initially treated in a specialist paediatric or adult major trauma centre with most being initially treated in a hospital accredited as a Trauma Unit. This means that the trauma network should ensure a system for the initial resuscitation of injured children in all hospitals followed by an efficient inter-hospital transfer system.

Adult & Children’s MTC* 189 (25.6%)

Adult MTC* 69 (9.4%)

Children’s MTC* 71 (9.6%)

Trauma Unit 408 (55.4%)

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Adult & Children’s MTC* Adult MTC* Children’s MTC* Trauma Unit

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Transfer between hospitals Number (%)

*MTC - Major Trauma Centre

Most children are eventually cared for in an appropriate hospital with few remaining outside of the Major Trauma Centres. However this emphasises once more the importance of the transfer system.

Multiple hospitals, not MTC* 31 (4.2%)

Multiple hospitals, adult MTC* 8 (1.1%)

Multiple hospitals, children’s MTC* 373 (50.6%)

Single hospital, not MTC* 87 (11.8%)

Single hospital, adult MTC* 27 (3.7%)

Single hospital, children’s MTC* 211 (28.6%)

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60

Multiple hospitals, Multiple hospitals, Multiple hospitals, Single hospital, Single hospital, Single hospital, not MTC* adult MTC* children’s MTC* not MTC* adult MTC* children’s MTC*

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ICU / HDU admissionsn = 737 Number (%)

*Multiple AIS3+ injuries in different body regions

The percentage values represent the proportion of patients in each group that visited ICU / HDU.

Intubation (direct admissions only)n = 537 Number (%)

Hospital Stayn = 737 Number (%)

Length of stay is measured in days.

There may be some underestimation as the complete length of stay for patients treated at more than one hospital may be unknown if one of those hospitals has not submitted data on the patient to TARN.

All patients 351 (47.6%)

Median LOS (IQR) 6 (3 - 12)

Intubated 208 (38.7%)

Isolated AIS 3+ Head Injuries 179 (42%)

Median LOS, transfers in (IQR) 6 (4 - 15)

Intubated in ED 164 (30.5%)

Isolated AIS 3+ Abdominal Injuries 22 (48.9%)

Admitted to ICU / HDU 351 (47.6%)

Intubated pre-hospital 44 (8.2%)

Isolated AIS 3+ Limb / Pelvic Injuries 4 (13.8%)

Median LOS in ICU (IQR) 3 (1 - 6)

Median hours to intubation from incident (IQR) 1.1 (0.6 - 1.6)

Isolated AIS 3+ Thoracic Injuries 9 (37.5%)

Median LOS, patients that went to ICU (IQR) 10 (5 - 23)

Polytrauma* 121 (67.2%)



Mortality (cases with recorded outcome) Total number Number of Mortality of cases deaths %

Injury Mechanism

Injury Type

*Percentages are of children with known outcome with that particular GCS / mechanism / injury pattern

All admissions 621 56 9%

Admissions with GCS < 15 158 43 19.5%

Road Traffic Collision 245 23 9.4%

Fall < 2m 135 6 4.4%

Fall > 2m 92 1 1.1%

NAI under 2 years 56 5 8.9%

Penetrating 9 2 22.2%

AIS3+ head injury 457 34 7.4%

Blows 37 0 0%

AIS3+ limb / pelvis / spine injury 120 4 3.3%

Other (eg. sport/drowning) 47 19 40.4%

AIS3+ thoracic / abdominal injury 184 24 13%



Injuries associated with death

Number of deaths

Head Face ChestAIS3+ Injuries

AbdomenSpine Limbs Other Polytrauma Asphyxia Drowning

56 34 0 22 5 0 4 1 20 12 6

Head Injury is the most important injury in fatal paediatric trauma, although there is a significant contribution from thoracic injury, asphyxia and drowning. Polytrauma accounts for 35.7% of the deaths.

Interaction of AIS 3+ injuries

Body Region Head Face Chest Abdomen Spine Limbs Other Asphyxia Drowning

Head 34 0 19 2 0 4 0 0 0

Chest 19 0 22 3 0 4 0 0 0

Abdomen 2 0 3 5 0 0 0 0 1

Limbs 4 0 4 0 0 4 0 0 0

Other 0 0 0 0 0 0 1 0 1

Drowning 0 0 0 1 0 0 1 0 6

Asphyxia 0 0 0 0 0 0 0 12 0

Please note patients can be in more than one AIS3+ category or mechanism

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35

Head Face Chest Abdomen Spine Limbs Other Polytrauma Asphyxia Drowning



Grade of most senior clinician in the ED

Direct Admissions

ISS n ConsultantAssociate Specialist

STR, 4+ STR, 1-3STR, year unknown

Foundation Year

OtherNot

Recorded

ISS > 15 537 398 (74.1%) 10 (1.9%) 21 (3.9%) 10 (1.9%) 52 (9.7%) 21 (3.9%) 8 (1.5%) 3 (0.6%)

299 (55.7%) of patients were seen by a paediatric specialist 14 (2.6%) had no ED visit recorded

74.1% of severely injured children were resuscitated by Consultants.

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70

80

Consultant Ass Specialist STR, 4+ STR, 1-3 STR, year FY Other Not unknown recorded

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Grade of most senior clinician involved in surgery (all operations, n = 394)

Direct Admissions

Consultant Ass.Specialist

STR 4+ STR 1 - 3 STR, yearunknown

FoundationYear

Other No graderecorded

Grade of Anaesthetist

239 (60.7%) 4 (1%) 34 (8.6%) 4 (1%) 57 (14.5%) 0 (0%) 6 (1.5%) 50 (12.7%)

Grade of PaediatricSurgeon

48 (92.3%) 0 (0%) 1 (1.9%) 0 (0%) 2 (3.8%) 0 (0%) 0 (0%) 1 (1.9%)

Grade of Surgeon

271 (68.8%) 1 (0.3%) 13 (3.3%) 4 (1%) 84 (21.3%) 0 (0%) 2 (0.5%) 19 (4.8%)

68.8% of all operations were carried out by Consultants, 92.3% of those operations carried out by paediatric specialists were performed by Consultants and 60.7% of severely injured children were anaesthetised for their operation by a Consultant anaesthetist.

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80

100

Grade of Surgeon Grade of Paediatric Surgeon Grade of Anaesthetist

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Consultant

FY

Ass Specialist

Other

STR, 4+

No grade recorded

STR, 1-3 STR, year unknown



Time to first surgery from arrival

Direct Admissions

Categoryn with operations

recordedMedian hours to

operationInterquartile

Range (hours)

All surgery, ISS > 15 222 4.5 1.9 - 13.9

Neurosurgery 104 3.0 1.6 - 6

Abdominal surgery 66 3.6 2.3 - 8

Cardiothoracic surgery 18 1.0 0.5 - 5.7

Orthopaedic surgery 288 6.1 3.4 - 18.3

*Patients can be in multiple groupsOperations 24 hours after admission are excluded.

The majority of surgical intervention takes place in a timely fashion although improvement may follow as trauma systems develop.

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All surgery, ISS > 15 Neurosurgery Abdominal surgery Cardiothoracic surgery Orthopaedic surgery

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(ho

urs)


Glossary

AIS Abbreviated Injury Scale score. A value between 1 (minor) and 6 (fatal) is assigned to each injury.

AIS 3+ Injuries with an AIS severity score of 3 or more.

Direct admissions Describes care in the fi rst treating hospital.

GCS Glasgow Coma Scale. A measure of consciousness ranging from 3, indicating complete un-consciousness, to 15, indicating a state of normal alertness. GCS is composed of eye, verbal and motor scores.

HES Hospital Episode Statistics. Data collected in hospitals on all admissions. This data is used to produce an expected number of eligible patients that should be submitted to TARN.

ISS Injury Severity Score. A score ranging from 1, (minor) to 75 (severe injuries that are likely to result in death). An ISS between 9 and 15 is considered moderate. An ISS of 16 or more is considered severe. ISS is calculated using the Abbreviated Injury Scale (AIS).

MTC Major Trauma Centre

Polytrauma AIS 3+ injuries in more than one body region.

TARN The Trauma Audit & Research Network.

TARNlet The TARNlet committee, consisting of clinicians, managers and academics that focus on injured children was established to address specifi c questions relating to paediatric trauma care.

TU Trauma Unit

Grades of Doctor

Consultant Consultant

Associate Specialist Associate Specialist

STR 4+ Specialist registrar and speciality trainee years 4, 5 and above

STR 1-3 Specialist registrar and speciality trainee years 1, 2 and 3

STR, year unknown Specialist registrar and speciality trainee year unknown, clinical fellow, senior registrar, staff grade

Foundation Year SHO, HO, foundation year 1, 2 and unknown, core trainee year 1 and 2

Other Core trainee year 3 and above, advanced SHO, vocational training scheme, emergency nurse practitioner

SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012SEVERE INJURY IN CHILDREN 2012

The University of ManchesterManchester Academic Health Science Centre (MAHSC)

3rd Floor, The Mayo Building Salford Royal NHS Foundation TrustStott LaneSalford M6 8HD

Tel: 00 44 (0)161 206 4397Fax: 00 44 (0)161 206 4345Email: [email protected]: www.tarn.ac.uk

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TARN Severe injury in children v2€¦ · Severe Injury in Children (ISS > 15) Injury Mechanism Number (%) Analysis of injury mechanism data shows a preponderance of road traffic