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Close to zero preventable in-hospital deaths in pediatric trauma patients – An observational study from a major Scandinavian trauma center

  • Amund Hovengen Ringen
    Correspondence
    Corresponding author at: Department of Anesthesia, Oslo University Hospital Ullevaal, PB 4950 Nydalen, Oslo 0424, Norway.
    Affiliations
    Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway

    Department of Anesthesia, Oslo University Hospital Ullevaal, PB 4950 Nydalen, Oslo 0424, Norway

    Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway

    Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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  • Kjersti Baksaas-Aasen
    Affiliations
    Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway

    Department of Anesthesia, Oslo University Hospital Ullevaal, PB 4950 Nydalen, Oslo 0424, Norway

    Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway

    Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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  • Nils Oddvar Skaga
    Affiliations
    Department of Anesthesia, Oslo University Hospital Ullevaal, PB 4950 Nydalen, Oslo 0424, Norway

    Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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  • Torben Wisborg
    Affiliations
    University of Tromsø, The Arctic University of Norway, Hammerfest, Norway

    Department of Anesthesia and Intensive Care, Finnmark Health trust, Hammerfest Hospital, Hammerfest, Norway

    Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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  • Christine Gaarder
    Affiliations
    Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway

    Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway

    Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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  • Paal Aksel Naess
    Affiliations
    Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway

    Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway

    Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Open AccessPublished:July 27, 2022DOI:https://doi.org/10.1016/j.injury.2022.07.043

      Highlights

      • This mature and multidisciplinary trauma service was associated with a very low in-hospital mortality in severely injured children.
      • Deaths were shown to be almost exclusively non-preventable.
      • The rate of futile care and extensive emergency surgical procedures significantly decreased during the study period; there were no ED thoracotomies in non-survivors after 2013.

      Abstract

      Background

      In line with international trends, initial treatment of trauma patients has changed substantially over the last two decades. Although trauma is the leading cause of death and disability in children globally, in-hospital pediatric trauma related mortality is expected to be low in a mature trauma system. To evaluate the performance of a major Scandinavian trauma center we assessed treatment strategies and outcomes in all pediatric trauma patients over a 16-year period.

      Methods

      A retrospective cohort study of all trauma patients under the age of 18 years admitted to a single institution from 1st of January 2003 to 31st of December 2018. Outcomes for two time periods were compared, 2003–2009 (Period 1; P1) and 2010–2018 (Period 2; P2). Deaths were further analyzed for preventability by the institutional trauma Mortality and Morbidity panel.

      Results

      The study cohort consisted of 3939 patients. A total of 57 patients died resulting in a crude mortality of 1.4%, nearly one quarter of the study cohort (22.6%) was severely injured (Injury Severity Score > 15) and mortality in this group decreased from 9.7% in P1 to 4.1% in P2 (p<0.001). The main cause of death was brain injury in both periods, and 55 of 57 deaths were deemed non-preventable. The rate of emergency surgical procedures performed in the emergency department (ED) decreased during the study period. None of the 11 ED thoracotomies in non-survivors were performed after 2013.

      Conclusion

      A dedicated multidisciplinary trauma service with ongoing quality improvement efforts secured a low in-hospital mortality among severely injured children and a decrease in futile care. Deaths were shown to be almost exclusively non-preventable, pointing to the necessity of prioritizing prevention strategies to further decrease pediatric trauma related mortality.

      Keywords

      Background

      Trauma is a leading cause of death and disability in children globally [
      • Mokdad A.H.
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      • Nesje E.
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      ]. In the United States (US) a child dies every hour from injury or violence [
      • Ballesteros M.F.
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      The epidemiology of unintentional and violence-related injury morbidity and mortality among children and adolescents in the United States.
      ]. Experience with trauma in pediatric patients is crucial to optimize treatment, whether in specialized pediatric trauma centers or securing pediatric experience in adult trauma centers. A significant number of severe injuries in children happen in rural areas, underlining the importance of efficient transport to trauma centers to optimize trauma care and improve outcomes as shown in a Swedish study [
      • Träff H.
      • Hagander L.
      • Salö M.
      Association of transport time with adverse outcome in paediatric trauma.
      ]. Although most children are healthy prior to the injury, their anatomical constitution provides less protection against traumatic insults compared to adults [
      • McCarthy A.
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      Paediatric trauma systems and their impact on the health outcomes of severely injured children: an integrative review.
      ]. Furthermore, pediatric patients challenge most medical teams more than adults, both emotionally and technically [
      • McGarry S.
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      • McDonald A.
      • Valentine J.
      • Lee S.L.
      • Blair E.
      • et al.
      Paediatric health-care professionals: relationships between psychological distress, resilience and coping skills.
      ]. Over the last decades, knowledge about pediatric trauma care has improved substantially, but outside the US there are few major studies describing the characteristics of the pediatric trauma population [
      • Nesje E.
      • Valøy N.N.
      • Krüger A.J.
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      Epidemiology of paediatric trauma in Norway: a single-trauma centre observational study.
      ,
      • Kristiansen T.
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      Paediatric trauma mortality in Norway: a population-based study of injury characteristics and urban-rural differences.
      ,
      • Myers S.R.
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      • French B.
      • Nance M.L.
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      A national analysis of pediatric trauma care utilization and outcomes in the United States.
      ,
      • Odetola F.O.
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      Paediatric trauma in the USA: patterns of emergency department visits and associated hospital resource use.
      ,
      • Oliver J.
      • Avraham J.
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      The epidemiology of inpatient pediatric trauma in United States hospitals 2000 to 2011.
      ,
      • Schoeneberg C.
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      • Keitel J.
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      Mortality in severely injured children: experiences of a German level 1 trauma center (2002 - 2011).
      ,
      • Nurmi M.
      • Järvelä S.
      • Mattila V.M.
      • Luoto T.M.
      • Pauniaho S.L.
      Paediatric traffic accidents - current epidemiological trends at a finnish university hospital.
      ,
      • M L.W.
      • Tenovuo O.
      • Mattila V.M.
      • Gissler M.
      • Celedonia K.L.
      • Impinen A.
      • et al.
      Pediatric TBI in Finland: an examination of hospital discharges (1998-2012).
      ,
      • Suominen J.S.
      • Pakarinen M.P.
      • Kääriäinen S.
      • Impinen A.
      • Vartiainen E.
      • Helenius I.
      In-hospital treated pediatric injuries are increasing in Finland–a population based study between 1997 and 2006.
      ].
      In line with international trends, our initial treatment of trauma patients has changed substantially over the last two decades. Increased focus on Damage Control Resuscitation (DCR) protocols and interventional radiology have improved outcomes in adults overall and in subgroups of patients with specific injuries [
      • Groven S.
      • Eken T.
      • Skaga N.O.
      • Roise O.
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      Long-lasting performance improvement after formalization of a dedicated trauma service.
      ,
      • Gaski I.A.
      • Barckman J.
      • Naess P.A.
      • Skaga N.O.
      • Madsen J.E.
      • Klow N.E.
      • et al.
      Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies.
      ,
      • Gaski I.A.
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      • Gaarder C
      Decreased mortality, laparotomy, and embolization rates for liver injuries during a 13-year period in a major Scandinavian trauma center.
      ,
      • Ringen A.H.
      • Gaski I.A.
      • Rustad H.
      • Skaga N.O.
      • Gaarder C.
      • Naess P.A.
      Improvement in geriatric trauma outcomes in an evolving trauma system.
      ,
      • Gaarder C.
      • Dormagen J.B.
      • Eken T.
      • Skaga N.O.
      • Klow N.E.
      • Pillgram-Larsen J.
      • et al.
      Nonoperative management of splenic injuries: improved results with angioembolization.
      ,
      • Gaarder C.
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      • Skaga N.O.
      • Pillgram-Larsen J.
      • Klow N.E.
      • et al.
      Liver injuries–improved results with a formal protocol including angiography.
      ]. However, whether this holds true for the pediatric trauma population as a whole needs clarification. Evaluation of the care provided is necessary to optimize treatment and outcome. In-hospital mortality in pediatric trauma patients in a mature trauma system is expected to be low compared to adults [
      • Nesje E.
      • Valøy N.N.
      • Krüger A.J.
      • Uleberg O.
      Epidemiology of paediatric trauma in Norway: a single-trauma centre observational study.
      ,
      • Myers S.R.
      • Branas C.C.
      • French B.
      • Nance M.L.
      • Carr B.G.
      A national analysis of pediatric trauma care utilization and outcomes in the United States.
      ,
      • Frydrych L.M.
      • Keeney-Bonthrone T.P.
      • Gwinn E.
      • Wakam G.K.
      • Anderson M.S.
      • Delano M.J.
      Short-term versus long-term trauma mortality: a systematic review.
      ] and in a recent study including 880 injured children referred to a Danish trauma center a crude mortality rate of 2.7% was reported [
      • Hansen O.M.
      • Mikkelsen R.
      • Eskol J.R.
      • Brink O.
      Characteristics and outcomes of paediatric patients admitted to a Danish level-1 trauma centre.
      ]. Despite low mortality rates pediatric trauma is a major burden on the health care system and causes a wide range of morbidity in children [
      • M L.W.
      • Tenovuo O.
      • Mattila V.M.
      • Gissler M.
      • Celedonia K.L.
      • Impinen A.
      • et al.
      Pediatric TBI in Finland: an examination of hospital discharges (1998-2012).
      ,
      • Suominen J.S.
      • Pakarinen M.P.
      • Kääriäinen S.
      • Impinen A.
      • Vartiainen E.
      • Helenius I.
      In-hospital treated pediatric injuries are increasing in Finland–a population based study between 1997 and 2006.
      ]. Therefore, we assessed treatment strategies and outcomes including preventability of deaths in all pediatric trauma patients admitted to a major trauma center during a 16-year period.

      Methods

      Oslo University Hospital Ullevaal (OUHU) is the only high-volume trauma center in Norway with a catchment area of 3 million people covering approximately 60% of Norway`s population. We performed a retrospective cohort study of all trauma patients under the age of 18 years admitted to OUHU during the period 1st of January 2003 to 31st of December 2018 and included in Oslo University Hospital Trauma Registry (OUH-TR)
      The OUH-TR includes all trauma patients admitted through trauma team activation and patients with penetrating injuries proximal to elbow or knee, or patients with Injury Severity Score (ISS) [
      • Baker S.P.
      • O’Neill B.
      • Haddon W.
      • Long W.B
      The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care.
      ] > 9 admitted to OUHU directly or via local hospitals within 24 h after injury. Approximately 15% of all trauma team activations are for the age group 1 – 17 years and nearly 40% of the total trauma population are severely injured with an ISS > 15 [
      • Skaga N.O.
      • Eken T.
      • Søvik S.
      Validating performance of TRISS, TARN and NORMIT survival prediction models in a Norwegian trauma population.
      ].
      The study is presented according to STROBE-guidelines, checklist completed and uploaded as part of the submission [
      • von Elm E.
      • Altman D.G.
      • Egger M.
      • Pocock S.J.
      • Gøtzsche P.C.
      • Vandenbroucke J.P.
      The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
      ]. From the OUH-TR we extracted age, gender, mechanism of injury (MOI), date of injury, Glasgow Coma Scale (GCS) score, admission systolic blood pressure (SBP), heart rate (HR), hemoglobin (Hb), base deficit (BD), lactate, platelets, fibrinogen, International Normalized Ratio (INR), ISS, anatomic injury classified according to the Abbreviated Injury Scale (AIS) 1990 revision-Update 98 [

      Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale 1990 revision-Update 98 Des Plains, IL 60018 USA: association for the Advancement of Automotive Medicine.

      ], preinjury physical status according to the American Society of Anesthesiologists physical status classification system (PPS-ASA) [
      ASA Physical status classification system.
      ], transfusions prior to admission in the intensive care unit (ICU), trauma team activation rate, hospital length of stay (LOS), LOS in ICU, probability of survival (Ps) calculated according to the Trauma and Injury Severity Score (TRISS) methodology with coefficients published from the National Trauma Data Bank in 2009 [
      • Schluter P.J.
      • Nathens A.
      • Neal M.L.
      • Goble S.
      • Cameron C.M.
      • Davey T.M.
      • et al.
      Trauma and Injury Severity Score (TRISS) coefficients 2009 revision.
      ], 30-day mortality, and main cause of death. Survival status 30 days after injury was obtained from patient records and the Norwegian Population Registry. The study population was analyzed for differences between the periods 2003 and 2009 (Period 1; P1) and 2010–2018 (Period 2; P2). The cut-off point between time periods was chosen to visualize effects of institutional changes in trauma organization including improved DCR strategies with an updated massive hemorrhage protocol and the implementation of the regional trauma system further detailed with defined triage and transfer criteria [
      • Gaski I.A.
      • A B.
      • T K.
      • Eken T.
      • PA N.
      • Gaarder C
      Decreased mortality, laparotomy, and embolization rates for liver injuries during a 13-year period in a major Scandinavian trauma center.
      ]. Blood tests were not obtained routinely from all pediatric trauma patients leading to a high number of missing values, especially in Period 1. Furthermore, the study cohort was stratified into four age groups; <1, 1 – 4, 5 – 14 and 15 – 17 years of age and subjected to sub-group analyses.
      Continuous data are presented as medians with interquartile range (IQR). Comparisons between groups were performed using Mann-Whitney U test. Categorical data are reported as proportions and tested for significance using Pearson's chi- square test with Yates continuity correction and Fisher's exact test when appropriate. For all analyses, a p-value < 0.05 (derived from a two-tailed test or calculated as double the exact one-tailed probability) was considered to indicate statistical significance.
      Mortality in the two time periods was compared and analyzed including W-statistics [
      • Champion H.R.
      • Copes W.S.
      • Sacco W.J.
      • Lawnick M.M.
      • Keast S.L.
      • Bain Jr., L.W.
      • et al.
      The major trauma outcome study: establishing national norms for trauma care.
      ] (where differences in case mix are adjusted in line with ISS, physiology on arrival according to Revised Trauma Score, age, and injury mechanism). W-statistics (expressing excess survivors per 100 patients treated at OUH compared to TRISS model predictions) were calculated according to convention and used to compare outcomes for the two periods. Non-overlapping 95% confidence intervals were deemed as significant differences between groups. Deaths were further analyzed by retrieving information from patient charts. As part of the formal Mortality and Morbidity (M&M) conferences at OUHU, initiated by the Department of Traumatology in 2010, all trauma deaths are subjected to an assessment of preventability and whether futile operative care was performed. A primary reviewer assesses all trauma deaths and decides – based on defined criteria – whether they should be subject to a multidisciplinary discussion. The M&M panel consists of consultants and trauma coordinators from the Department of Traumatology, and consultants from all involved departments, i.e. anesthesiology, ICU, prehospital / helicopter emergency services, forensic medicine and all relevant surgical specialties. Deaths are categorized as non-preventable, possibly preventable, probably preventable or preventable in accordance with international standards [
      American college of surgeons committee on trauma. resources for optimal care of the injured patient.
      ]. All mortality assessments were performed according to the standards of care at the time of injury. The conclusion is based on panel consensus. All pediatric trauma deaths in the study period prior to 2010 were now assessed and relevant cases evaluated in a separate M&M conference in 2020. Cases already assessed were not reviewed again and the original conclusion was maintained.
      All statistical analyses were performed using the IBM SPSS Version 28.0.1.1 (IBM SPSS Statistics, Armonk, NY). Approval for the study was obtained from the Institutional Data Protection Officer at Oslo University Hospital (18/06,570, 23.04.2019).

      Results

      The study cohort consisted of 3939 patients; of whom 63% were male, and median age was 9 years (IQR 4;14). A total of 57 patients died for a crude mortality of 1.4%. The vast majority (80.7%) of the non-survivors died within 48 h as shown in Fig. 1. The MOI was blunt in 96.2% of the children. The injuries were secondary to falls in 33.6% and traffic related incidents in 32.5%, mainly represented by pedestrians, occupants in cars, or bicyclists. Nearly one quarter of the study cohort (22.6%) was severely injured and crude mortality in this subgroup was 6.2%.
      Fig. 1
      Fig. 1Fatalities (n = 57) stratified by days after admission.

      Comparison between periods

      P1 included 1152 patients and P2 included 2787 patients. Mechanism of injury was blunt in
      > 95% in both periods (Table 1). Median ISS, hospital LOS, and LOS in ICU were lower in P2. Trauma team activation rate increased to 96.6% in P2, whereas crude mortality rate fell to 0.8% (Table 1). The main cause of death was brain injury in both periods, 80.0% in P1 and 90.9% in P2 (p 0.272). The number of severely injured patients (ISS > 15) was 360 in P1 and 531 in P2 with an observed reduction in mortality from 9.7% to 4.1% (p < 0.001)
      Table 1Patient characteristics stratified by time periods.
      P 1 n = 1152P 2 n = 2787p
      Age, years11 (5;15)9 (3;14)<0.001
      Male gender, n (%)744 (64.6)1749 (62.8)0.279
      SBP, mm Hg120 (110;135)118 (105;130)0.001
      HR, beats/min100 (85;115)103 (85;120)<0.001
      GCS score15 (14;15)15 (15;15)<0.001
      ISS10 (4;17)5 (1;10)<0.001
      ISS > 15, n (%)360 (31.3)531 (19.1)<0.001
      BD, mmol/L1.6 (0.5;3.4)2.1 (0.8;3.5)0.001
      Penetrating injury, n (%)55 (4.8)95 (3.4)0.042
      Transfused, n (%)56 (4.9)46 (1.7)<0.001
      ED surgery, n (%)11 (1.0)2 (0.1)<0.001
      Endovascular procedures32 (2.8)41 (1.8)0.006
      Intubated, n (%)302 (26.2)321 (11.5)<0.001
      Ps Mean (SD)0.966 (0.125)0.987 (0.067)<0.001
      TTA n (%)974 (84.5)2693 (96.6)<0.001
      Mortality, n (%)35 (3.0)22 (0.8)<0.001
      LOS in ICU, days3 (2;8)2 (2;6)<0.001
      LOS in hospital, days2 (0;3)1 (0;2)<0.001
      P1; Period 1, P2; Period 2, SBP; Systolic blood pressure, HR; heart rate, GCS; Glasgow Coma Scale, ISS; Injury Severity Score, BD; Base deficit, Transfused; patients transfused in the Emergency Department, ED surgery; Emergency Department surgery Intubated; patients intubated prehospital or in the Emergency Department, Ps; probability of survival, TTA; Trauma team activation, ICU; Intensive Care Unit, LOS; Length of stay, Values are median and interquartiles when not stated otherwise. Number of patients with missing values in P1: SBP; 185 HR; 113 ISS; 35, Patients transfused; 5, ED Surgery; 4, Ps; 35, LOS ICU; 1. P2: SBP; 385, HR; 137, GCS; 2, ISS; 140, Ps; 140.
      In the groups of patients with an ISS > 25 median ISS was 29 (26;36) in P1 and 30 (26;35) in P2. However, mortality fell from 18.5% (34/184) to 8.5% (19/223) (p=0.003).

      Comparison between age groups

      Patient characteristics stratified by age groups are presented in Table 2. Differences between adjacent age groups were modest, except when comparing the two oldest cohorts. Median ISS, hospital LOS, and LOS in ICU were higher in the oldest age group accompanied by a higher proportion of patients with penetrating injuries and patients undergoing acute interventions. Main cause of death was brain injury in all age groups.
      Table 2Patient characteristics stratified by age groups.
      A1(<1 year) n = 126A2(1 – 4 years) n = 983pA3(5 – 14 years) n = 1901pA4(15 – 17 years) n = 929p
      Male, n (%)76 (60.3)606 (61.6)0.7731204 (63.3)0.374607 (65.3)0.297
      SBP, mm Hg104 (90;120)110 (95;120)0.077119 (109;130)<0.001125 (115;140)<0.001
      HR, beats/min155 (135;170)128 (110;150)<0.00197 (85;110)<0.00190(77;101)<0.001
      GCS score15 (15;15)15 (15;15)0.75915 (15;15)<0.00115 (14;15)<0.001
      Mean (SD)14.50 (1.765)14.43 (2.018)14.09 (2.503)13.58 (3.160)
      ISS2 (1;16)2 (1;9)0.0685 (2;14)<0.00110 (4;19)<0.001
      ISS > 15, n (%)28 (22.2)116 (11.8)0.001422 (22.2)<0.001325 (35.0)<0.001
      BD, mmol/L5.7 (4.3;10.5)3.6 (2.4;5.2)0.0052 (0.8;3.3)<0.0011.6 (0.3;3)<0.001
      Penetrating injury, n (%)0 (0.0)29 (3.0)0.05862 (3.3)0.65059 (6.4)<0.001
      Transfused, n (%)6 (4.8)17 (1.7)0.07643 (2.3)0.33736 (3.9)0.014
      ED surgery, n (%)0 (0.0)2 (0.2)13 (0.2)18 (0.9)0.016
      Intubated, n (%)9 (7.1)115 (11.7)0.127281 (14.8)0.023218 (23.5)<0.001
      Ps Mean (SD)0.994 (0.028)0.990 (0.071)0.0500.985 (0.081)<0.0010.960 (0.117)<0.001
      TTA, n (%)109 (86.5)918 (93.4)0.0091770 (93.1)0.778870 (93.6)0.590
      Mortality, n (%)2 (1.6)7 (0.7)0.54425 (1.3)0.14323 (2.5)0.025
      LOS in ICU, days1 (0;2)1 (0;2)0.1951 (0;2)<0.0012 (1;3)<0.001
      Mean (SD)2.30 (4.156)1.66 (3.520)2.04 (4.039)3.50 (5.892)
      LOS in hospital, days2 (2;6)3 (2;13)0.0142 (2;6)<0.0013 (2;7)<0.001
      SBP; Systolic blood pressure, HR; heart rate, GCS; Glasgow Coma Scale, ISS; Injury severity score, BD; Base deficit, Transfused; patients transfused in the Emergency Department, ED surgery; Emergency Department surgery, Intubated; patients intubated prehospital or in the Emergency Department, Ps; probability of survival, TTA; Trauma team activation, ICU; Intensive Care Unit, LOS; Length of stay. Values are median and interquartiles when not stated otherwise. p-values; A1 vs A2, A2 vs A3, A3 vs A4. Number of patients with missing values in A1; SBP; 66 HR; 27, ISS; 16, Ps; 16, in A2; SBP; 354 HR; 110, ISS; 40, Ps; 40, in A3; SBP; 129, HR; 89, CGS; 2, ISS; 87, Patients transfused; 5, PS; 87, in A4; SBP; 21, HR; 24, ISS; 32, Ps; 32.

      Evaluation of mortality, preventability, and futile care

      Patient characteristics in survivors and non-survivors are shown in Table 3. Not surprisingly, non-survivors were more physiologically compromised on admission, more severely injured (median ISS = 35) and with reduced Ps when compared to survivors (Tables 3 and 4). W-statistics showed 0.24 excess survivor per 100 patients in P1 (95% CI, −0.53; 1.00) and 0.50 excess survivor per 100 patients in P2 (95% CI, 0.14; 0.85). As previously described, brain injury was the main cause of death throughout the study period (Table 5) and in all age groups and most deaths (46/57) occurred within the two first days after injury (Fig. 1). Based on the assessment by the panel in the M&M conferences 55 out of 57 deaths were deemed non-preventable, one potentially preventable due to inadequate volume resuscitation, and one probably preventable due to delayed targeted treatment of a patient with head injury. The M&M panel found elements of futile care in 11 patients based on information of extensive surgery in patients in whom survival were unlikely, e.g., patients that underwent Emergency Department (ED) thoracotomy with additional operative procedures after severe blunt trauma. Most of these patients (8/11) were admitted in P1. The rate of emergency surgical procedures performed in the ED also decreased during the study period.
      Table 3Patient characteristics stratified by survivors and non-survivors.
      Survivors n = 3882Non-survivors n = 57p
      Male, n (%)2463 (63.4)30 (52.6)0.093
      SBP, mm Hg120 (107;130)75 (49;120)<0.001
      HR, beats/min100 (85;120)100 (60;130)0.173
      GCS score15 (15;15)3 (3;5)<0.001
      ISS5 (1;13)35 (26;47)<0.001
      Penetrating injury, n (%)145 (3.7)5 (8.8)0.128
      Transfused n (%)73 (1.9)29 (51)<0.001
      ED surgery n (%)1 (0.0)12 (21.1)<0.001
      Intubated, n (%)569 (14.7)54 (94.7)<0.001
      Ps Mean (SD)0.988 (0.053)0.490 (0.301)<0.001
      TTA, n (%)3611 (93)56 (98.2)0.174
      LOS in ICU1 (0;2)1 (0;2)0.274
      LOS in hospital3 (2;7)2 (1;2)<0.001
      SBP; Systolic blood pressure, HR; heart rate, GCS; Glasgow Coma Scale, ISS; Injury severity score, Transfused; patients transfused in the Emergency Department, ED surgery; Emergency Department surgery, Intubated; patients intubated prehospital or in the Emergency Department, Ps; probability of survival, TTA; Trauma team activation, LOS; Length of stay, ICU; Intensive Care Unit, Values are median and interquartiles when not stated otherwise. Number of patients with missing values in survivors; SBP; 566, HR; 244, GCS; 2, Patients transfused; 5, ISS; 175 Ps; 175, LOS in ICU; 1, in Non-survivors; SBP; 4, HR; 6.
      Table 4Body temperature and conventional coagulation tests on arrival in survivors and non-survivors in Period 2.
      Survivors n = 2765Non-survivors n = 22p
      BT, °C36.5 (36.1;36.9)34.3(32.1;35.9)<0.001
      Lactate, mmol/L1.5 (1;0;2.2)7.3 (3.5;11)<0.001
      Platelets, x 109/L273 (231;320)157 (112;213)<0.001
      Hemoglobin, g/dL12.7 (11.9;13.7)11.5 (8.8;13.5)<0.001
      INR1.1 (1.1;1.2)1.3 (1.2;1.5)<0.001
      Fibrinogen, g/L2.5 (2.2;2.)1.2 (0.6;1.9)<0.001
      Values are median and interquartiles. BT; Body temperature, INR; International normalized ratio. Number of patients with missing values in survivors; Temperature; 1139, Lactate; 1692, Platelets; 1148, INR; 1252, Hb; 1023, Fibrinogen; 1263, in Non-survivors; Temperature; 6, Lactate; 4, Platelets; 5, INR; 4, Hemoglobin; 3, Fibrinogen; 3.
      Table 5Main causes of death in Period 1 (P1) and Period 2 (P2).
      P1P2
      Brain injury2820
      Bleeding62
      Unknown10
      Total3522

      Discussion

      This study describes the pediatric trauma population in a major Norwegian trauma center over a 16-year period. In a large cohort of 3939 patients, we registered an overall in-hospital mortality of 1.4%. The total number of patients more than doubled from P1 to P2 accompanied by a reduction in mortality from 3.0% to 0.8%. Although this reduction is probably related to differences in case mix, one of the known limitations of retrospective studies, the actual numbers of deaths declined from 35 in P1 to 22 in P2, and the mortality in the group of severely injured (ISS > 15) confirmed a decrease from 9.7% in P1 to 4.1% in P2. Moreover, in the group of patients with an ISS > 25, mortality fell from 18.5% to 8.5% from P1 to P2, despite a slightly increased median ISS in P2. Since in-hospital pediatric trauma related mortality is expected to be low in a mature trauma system [
      • Nesje E.
      • Valøy N.N.
      • Krüger A.J.
      • Uleberg O.
      Epidemiology of paediatric trauma in Norway: a single-trauma centre observational study.
      ,
      • Kristiansen T.
      • Rehn M.
      • Gravseth H.M.
      • Lossius H.M.
      • Kristensen P.
      Paediatric trauma mortality in Norway: a population-based study of injury characteristics and urban-rural differences.
      ], causality between improved survival and specific elements of quality development might be difficult to prove, but still worth mentioning and indicates that ongoing quality improvement work is fruitful.
      Previous studies from our institution have shown similar tendencies in the adult trauma population and specific subgroups [
      • Groven S.
      • Eken T.
      • Skaga N.O.
      • Roise O.
      • Naess P.A.
      • Gaarder C.
      Long-lasting performance improvement after formalization of a dedicated trauma service.
      ,
      • Gaski I.A.
      • Barckman J.
      • Naess P.A.
      • Skaga N.O.
      • Madsen J.E.
      • Klow N.E.
      • et al.
      Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies.
      ,
      • Gaski I.A.
      • A B.
      • T K.
      • Eken T.
      • PA N.
      • Gaarder C
      Decreased mortality, laparotomy, and embolization rates for liver injuries during a 13-year period in a major Scandinavian trauma center.
      ,
      • Ringen A.H.
      • Gaski I.A.
      • Rustad H.
      • Skaga N.O.
      • Gaarder C.
      • Naess P.A.
      Improvement in geriatric trauma outcomes in an evolving trauma system.
      ,
      • Gaarder C.
      • Dormagen J.B.
      • Eken T.
      • Skaga N.O.
      • Klow N.E.
      • Pillgram-Larsen J.
      • et al.
      Nonoperative management of splenic injuries: improved results with angioembolization.
      ,
      • Gaarder C.
      • Naess P.A.
      • Eken T.
      • Skaga N.O.
      • Pillgram-Larsen J.
      • Klow N.E.
      • et al.
      Liver injuries–improved results with a formal protocol including angiography.
      ,
      • Søvik S.
      • Skaga N.O.
      • Hanoa R.
      • Eken T.
      Sudden survival improvement in critical neurotrauma: an exploratory analysis using a stratified statistical process control technique.
      ]. Groven et al. demonstrated that increased survival coincided in time with the formalisation of a dedicated trauma service [
      • Groven S.
      • Eken T.
      • Skaga N.O.
      • Roise O.
      • Naess P.A.
      • Gaarder C.
      Long-lasting performance improvement after formalization of a dedicated trauma service.
      ]. Such an improvement in trauma outcomes is most likely multifactorial and includes increased focus on multidisciplinary approach, development of a clinical governance structure and performance improvement programs as the most important contributors.
      Curtis et al. evaluated care provided to 490 severely injured children in New South Wales, Australia and found adverse events in 7.6% of the cases. However, none of the 18 fatalities were deemed absolutely preventable [
      • Curtis K.
      • Kennedy B.
      • Holland A.J.A.
      • Tall G.
      • Smith H.
      • Soundappan S.S.V.
      • et al.
      Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical, system and human factors peer-review tool.
      ]. In our study 55 out of 57 fatalities were deemed non-preventable by the M&M panel, one potentially preventable and one probably preventable. It is important to underline that the mortality assessments were performed according to the standards of care at the time of injury, potentially contributing to the low rate of preventable deaths also during the early study period. This might appear as a weakness of the study in addition to the ones associated with its retrospective design. The study addresses two consecutive periods, and the number of patients has increased steadily over the study period which we attribute to the maturing trauma system leading to general improvement in care.
      Extensive emergency surgical procedures decreased significantly over the study period; in fact, there were no ED thoracotomies in non-survivors after 2013. This is in accordance with international contemporary standards, trying to avoid desperate procedures in dying children, which in retrospect were deemed to be futile as summarized in a review article by Moskowitz et al. in 2017 [
      • Moskowitz E.E.
      • Burlew C.C.
      • Kulungowski A.M.
      • Bensard D.D.
      Survival after emergency department thoracotomy in the pediatric trauma population: a review of published data.
      ]. They reported no survivors after ED thoracotomy in blunt trauma patients under the age of 15 in cardiac arrest and advised cautiousness in applying adult guidelines in such patients. However, they recommended that guidelines for adults can be followed in children with cardiac arrest after penetrating trauma.
      A trimodal distribution of time to death after fatal injuries used to be referenced. This pattern is under debate and whether this can be found in the pediatric trauma population has been questioned [
      • Kristiansen T.
      • Rehn M.
      • Gravseth H.M.
      • Lossius H.M.
      • Kristensen P.
      Paediatric trauma mortality in Norway: a population-based study of injury characteristics and urban-rural differences.
      ,
      • Bardes J.M.
      • Inaba K.
      • Schellenberg M.
      • Grabo D.
      • Strumwasser A.
      • Matsushima K.
      • et al.
      The contemporary timing of trauma deaths.
      ,
      • Do H.Q.
      • Steinmetz J.
      • Rasmussen L.S.
      In-hospital mortality pattern of severely injured children.
      ]. McLaughlin et al. studied time to death in children (0 – 14 years) and compared this with adults (15 – 64 years) [
      • McLaughlin C.
      • Zagory J.A.
      • Fenlon M.
      • Park C.
      • Lane C.J.
      • Meeker D.
      • et al.
      Timing of mortality in pediatric trauma patients: a National Trauma Data Bank analysis.
      ]. They found a time of death distribution in pediatric patients similar to the pattern in adults, with a small, but significantly higher proportion of early deaths and a lower proportion of late fatalities. Our data shows that most pediatric deaths after hospital admission (46/57) occurred within the first two days (Fig. 1), and data from the Norwegian Institute of Public Health confirms that most deaths occur on scene [,
      • Søreide K.
      • Krüger A.J.
      • Ellingsen C.L.
      • Tjosevik K.E.
      Pediatric trauma deaths are predominated by severe head injuries during spring and summer.
      ]. This supports a bimodal fatality curve. Multi-organ failure was a rare cause of death in our pediatric trauma population where most fatalities are caused by the primary insult. This is in accordance with the findings of Lichte et al. in a retrospective study of 1110 pediatric trauma patients compared to an adult cohort [
      • Lichte P.
      • Andruszkow H.
      • Kappe M.
      • Horst K.
      • Pishnamaz M.
      • Hildebrand F.
      • et al.
      Increased in-hospital mortality following severe head injury in young children: results from a nationwide trauma registry.
      ]. They found an increased rate of multi-organ failure and sepsis in adults compared to children, but a higher mortality after severe brain injury in children. Brain injury was the main cause of death in the vast majority of cases in our cohort (Table 5). Our findings are in accordance with the result presented in a Finnish study from 2011 in which head traumas constituted 67% of injury-related deaths in children [
      • Suominen J.S.
      • Pakarinen M.P.
      • Kääriäinen S.
      • Impinen A.
      • Vartiainen E.
      • Helenius I.
      In-hospital treated pediatric injuries are increasing in Finland–a population based study between 1997 and 2006.
      ]
      Hypothermia and coagulopathy are shown to be important predictors of mortality in pediatric trauma patients. This corresponds well to the data presented in our study where non-survivors were hypothermic and coagulopathic on admission (Table 4). Based on analysis of more than 400 000 patients from the US National Data Bank, McCarty et al. found that hypothermia is an independent risk factor for mortality in pediatric trauma [
      • McCarty T.R.
      • Abramo T.J.
      • Maxson R.T.
      • Albert G.
      • Rettiganti M.R.
      • Saylors M.E.
      • et al.
      Hypothermia as an outcome predictor tool in pediatric trauma: a propensity-matched analysis.
      ]. When evaluating close to 1000 children and adolescents from their institutional trauma registry in a retrospective study from a single trauma center, Liras et al. found that 57% of patients meeting the highest level of trauma activation presented in a state of coagulopathy with a 4-fold increased risk of death [
      • Liras I.N.
      • Caplan H.W.
      • Stensballe J.
      • Wade C.E.
      • Cox C.S.
      • Cotton B.A.
      Prevalence and impact of admission acute traumatic coagulopathy on treatment intensity, resource use, and mortality: an evaluation of 956 severely injured children and adolescents.
      ]. This association was even stronger in those with severe head injuries.
      The reduction in in-hospital mortality in Period 2 coincides with a reduction in pediatric trauma-related fatalities in our Health Region which decreased from 47 fatalities in 2003 to 16 in 2018 []. In our material the vast majority of deaths were deemed non-preventable. On that background one might speculate that the annual number of children sustaining life-threatening injuries in our region is declining. This is in accordance with the findings in an in-depth evaluation of real-world car collisions from south eastern Norway, where Skjerven-Martinsen et al. documented that fatal and severe injuries in children were predominantly caused by restraint errors and unstrapped cargo [
      • Skjerven-Martinsen M.
      • Naess P.A.
      • Hansen T.B.
      • Rognum T.O.
      • Lereim I.
      • Stray-Pedersen A.
      In-depth evaluation of real-world car collisions: fatal and severe injuries in children are predominantly caused by restraint errors and unstrapped cargo.
      ]. The same group later showed that during the period 2009 – 2013 there were no fatalities among child occupants in south eastern Norway, compared to 18 in the time period 1999 to 2002 and attributed the reduction in mortality to improvements in child occupant safety and in automobile design [
      • Skjerven-Martinsen M.
      • Naess P.A.
      • Hansen T.B.
      • Gaarder C.
      • Lereim I.
      • Stray-Pedersen A.
      A prospective study of children aged <16 years in motor vehicle collisions in Norway: severe injuries are observed predominantly in older children and are associated with restraint misuse.
      ]. As clearly pointed out in a Swedish study published 15 years ago, pediatric injury related deaths were reduced more than 50% from the first period (1966 – 1981) to the second period (1982 – 2001) on a national basis through implementation of prevention strategies such as improved car safety, the expansion of public child day-care centers including more organized leisure activities, mandatory program for swim training among school children and local child-safety programs [
      • Jansson B.
      • De Leon A.P.
      • Ahmed N.
      • Jansson V.
      Why does Sweden have the lowest childhood injury mortality in the world? The roles of architecture and public pre-school services.
      ]. In a retrospective study of 386 childhood traffic accidents admitted to a Finnish university hospital Nurmi et al. found that the majority were mild and required only minor treatment. However, the risk of traffic accidents and resulting injuries increased dramatically when the child reached the legal age of acquiring a driving license for a moped underlining the need for targeted prevention programs [
      • Nurmi M.
      • Järvelä S.
      • Mattila V.M.
      • Luoto T.M.
      • Pauniaho S.L.
      Paediatric traffic accidents - current epidemiological trends at a finnish university hospital.
      ]. Moreover, the American Center for Disease Control and Prevention has stated that child injuries are predictable and preventable and that many effective strategies to reduce child injuries and mortality are available [

      National action plan for child injury prevention; National Center for Injury Prevention and Control (U.S.), Division of Unintentional Injury Prevention.Published Date : 2012URL : https://stacks.cdc.gov/view/cdc/12060

      ]. On this background, a continuous focus on prevention strategies seems to be the most important factor for further reduction of pediatric trauma related mortality.

      In conclusion

      A dedicated multidisciplinary trauma service with ongoing quality improvement efforts secured a low in-hospital mortality among severely injured children and a decrease in futile care. Deaths were shown to be almost exclusively non-preventable, pointing to the necessity of prioritizing prevention strategies to further decrease pediatric trauma related mortality.

      Contributors

      AHR, CG and PAN designed the study and conducted the literature search. AHR, NOS, TW, KBA, CG and PAN analyzed the data. All authors interpreted the data, and participated in writing, revising, and editing the article.

      Funding

      The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      Patient consent

      Not required.

      Ethics approval

      Approval for the study was obtained from the Institutional Data Protection Officer at Oslo University Hospital.

      Declaration of Competing Interest

      None declared.

      Appendix. Supplementary materials

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