Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma

Abstract

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 Trauma Center Access, Regional Injury Burden, and Socioeconomic Disadvantage

“…We found that some states with high fatal pediatric injury burden disproportionately lack timely PTC access and observed increased travel time to PTCs in socioeconomically disadvantaged regions. Treatment at PTCs has been associated with lower mortality (particularly for those aged ≤16 years), whereas many adult trauma centers have suboptimal readiness to manage injuries in children …”

UpToDate

“…In a meta-analysis of 34 studies that evaluated children hospitalized for traumatic injury, treatment in a pTC was associated with lower mortality than in an adult trauma center (ATC, odds ratio 0.59). 3 Compared with an ATC, care of children with blunt trauma in a pTC was also associated with a lower likelihood of computed tomography or operative management for blunt solid organ injury. For seriously injured infants, children, and adolescents, these findings support treatment in a pTC.…”