The W’s of Pediatric Trauma Transfers

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And Gross Things You Find Inside Kids!

Disclosures

1) I wish I had some cool financial interest I was bound to report, but I don’t.

2) I am a fan of the Buffalo Bills “professional” football team

3) Consider #2 when deciding to trust this talk.

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WHO?

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Patient 1:6 Yo Auto vs. Ped

Airway: Intact

Breathing: Equal Bilaterally BS, Saturating 98%

Circ: Pulse 120, BP 100/70, IV in place

Disability: Localizing to pain (5), Disoriented speech(4), Opens eyes to pain (2)

Exposure: Sequentially fully exposed, warm blankets placed

Secondary Survey shows a temporal bruise with possible fracture, mildly tender abdomen and a mid-shaft femur deformity

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Patient 2: 10yo fell off skateboard onto side of a bench

A: Intact

B: Intact, mildly diminished on left

C: HR 100, BP 110/80, Resp 20, Sat 100% RA

D: GCS 15, full range of motion

E: Sequentially fully exposed, warm blankets placed

Secondary Survey with Moderate LUQ/Lower thoracic tenderness

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WHAT?

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What Imaging Should These Kids Get?

Well, it depends, right?

The American College of Surgeons, GETAC and the STRAC pedscommittee would also say that the goal of initial imaging is to triage the patient to the appropriate level and location of care

NOT TO FIND ALL INJURIES!

“ATLS recommendations indicating that scans should not be performed [at a referring facility] when a child is to be transferred for treatment, or not performed at all without clinical indications”

So the first question is really, what is the facility capable of?

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Imaging Before Transfer to Pediatric Trauma Center

A four year review of every kid transferred with a trauma diagnosis who had an OSH CT scan

670 kids included

They found that the average radiation dose (dose-length product) was 54% higher at outside facilities.

8% of kids who underwent scans did not meet any documented ATLS criteria for imagingAnd none of them required any procedures at the receiving hospital

Puckett et al. J of Trauma 2016

CT and Time to Craniotomy

5 year registry study of all patients transferred in for trauma at a Level 1 adult and peds center in Iowa who went from ED to OR for craniotomy

Numbers are very small! 56 patients who got a scan at outside hospital and 8 who did not

Patients who got a scan at the referring hospital sent an average of 2 hours and 20 minutes there

If they didn’t get a head CT, they spent an average of 50 minutes there

No significant difference in time to craniotomy at receiving hospital ( 2 hours with a CT and 1hr 36mins without a CT from sending hospital)

¼ of Patients were re-imaged- 5 for change in status, 5 for couldn’t read disc, 3 no reason

Tonui et al. The Am Surgeon 2018

THINK YOU’RE HAVING A BAD DAY?

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WHERE?

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OHIO

11.02.15

6 Pediatic Trauma Centers

But Ohio looks a lot like Texas in many ways…

They did a 5 year registry study specifically to look at undertriage of pediatric patients. (All who died or were admitted for 48 hours)

What was Cool: Although they could not track individual patients through system, they used probabilistic data as a surrogate.

They also separated out stable from unstable by prehospital CPR or low systolic pressure. If an unstable kid went to the nearest hospital, that was ok. Also if they started unstable but were transferred at any point, that was also ok.

Gurria JP et al., J of Trauma 2016

What Wasn’t Maybe So Cool?

Primary Undertriage was transfer to an Adult Center or Non-Trauma Center when a pediatric center is within 30 minutes (sensitivity done for 45 minutes and 1 hour)

Secondary undertriage was failure to transfer injured child to a PTC or failure within 2 and 4 hours.

This covers a VERY wide range of patients that are categorized as “undertriaged” 15

Results

14,000 kids met criteria for inclusion

7000 patients met were 2 hour undertriage, 35% met 4 hour undertriage. 19% were never transferred

If you look at undertriage by distance, 65% of the population lives within 30 minutes of a trauma center, but 31% of patients went to a non-trauma center

The 2 most rural regions had the lowest rates! 14 and 15%!

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“The available data set also did not allow for us to evaluate

the appropriateness of trauma center use based on need for

acute resources used”

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UTAH

11.02.15

Think STRAC but Bigger!

All hospitals in state must report trauma patients by law for:Trauma DeathsAdmissions greater than 24 hoursInterhospital TransfersAny helicopter transfers for trauma

Check this out!They classified hospitals this way: 1. Undertriage: transfer of 85% or less of patients with anInjury Severity Score (ISS) of 16 or greater.2. Overtriage: transfer of 75%or greater of patients with ISS of15 or less3. Both or neither: met both criteria or neither criteria

Hewes HA et al. J of Trauma 2017

44 Hospitals and 1 Pediatric Trauma Center

Over 13 year period, 7200 kids under 15 were initially treated at another facility. 73% were transferred to the PTC.

Hospitals meeting undertriage criteria were

13 times less likely to transfer an injured child for higher care than hospitals meeting overtriage criteria, even when controlling for injury severity, injury diagnosis, child age, and geographic distance.

But in the same breath!

We also found that more than 60% of trauma patientstransferred to the PTC were discharged within 24 hours, potentiallyresulting in unnecessary health care costs for thoseovertriaged patients.

About that Bad Day…

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WHY?

2311.02.15The Children’s Hospital of San Antonio

Washington Gives Us a Reason?

Review Low Grade, Isolated Blunt Liver, Spleen and Kidney injuries in kids 16 and under in the State of Washington

They looked at:

Kids cared for at their Level 1 and 2 centers

Kids cared for at a level 3-5 and stayed

Kids transferred from 3-5 to 1-2 and those who transferred from 2-1.

Tessler RA J of Trauma 2017

RESULTS?

1200 kids

20% Taken to level 1-2

50% Presented to a 3-5 and stayed

30% Transferred

Nearly 100% Survival, no difference in splenectomy

You Might Want to Call Maintenance

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HOW?

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WE LOOK TO ARKANSAS!!!!!

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The WBIR

WEB-BASED IMAGING REPOSITORYInstituted initiated in 2011 and fully implemented in 2013Used in 77 facilities across the state They examined transfers to the level one pediatric center in the years before and after implementation

254 and 233 transfers before and after with no demographic differences

48% air transfers pre and 36% post

Nabaweesi R et al. J am coll rad 2017

Results?

Odds of a repeat CT dropped by 46% overall, and by 72% for kids admitted to floor or sent home

Results

Did not reduce scan rates in kids with severe injuries and those sent to OR or ICU(But these were usually heads who needed a repeat anyway)

11.02.15 The Children’s Hospital of San Antonio 31

AND OZ!!!!!!

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Don’t Tell Me About Transport Times!

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Pediatric Burn Telehealth

8 year retrospective audit of referrals to Western Australia’s pediatric burn telehealth service

904 patients aged 3 weeks to 16 years, the majority were toddlers

54% ages 1-4

33% aboriginal, 58% male

Clinical Nurse Consultant conducts 97% of wound reviews

McWilliams T el at. Burns 2016

How they did

37% telehealth post admit or clinic22% telehealth pre and post admission41% telehealth only, never transferred

GREAT!!!!!!

Sorry Air Medical Folks…

4,068 wound reviews, avoided 364 transfers

1863 scar reviews resulting in 1700 avoided patient flights

Where do we go from here?

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THE TAKE HOME POINTS

-KIDS DO WELL AT PEDIATRIC TRAUMA CENTERS

-MANY KIDS WILL ALSO DO WELL AT WELL-STAFFED, WELL-TRAINED LOCAL FACILITIES

-TOO MANY KIDS STILL GET TOO MANY SCANS AND ARE NOT “IMAGED GENTLY”

-TOO MANY KIDS GET REPEAT SCANS

-SHARED IMAGING PLATFORMS, TELEHEALTH RELATIONSHIPS AND COLLABORATIONS BETWEEN RURAL AND PEDIATRIC CENTERS IN OUR REGION HAVE THE POTENTIAL TO ENSURE GREAT CARE FOR OUR KIDS

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If We Can Do This:

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THANKS TO STRAC FOR INVITING ME!

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