England & Wales SEVERE INJURY IN CHILDREN 2012 THE TRAUMA AUDIT AND RESEARCH NETWORK The TARNlet Committee
Mr Ross Fisher Co-chairman of TARNlet Consultant in Paediatric Surgery Sheffi eld Children’s NHS Foundation Trust
Dr Ian Maconochie Co-chairman of TARNlet Consultant in Paediatric Emergency Medicine Imperial College Healthcare NHS Trust
Dr Derek Burke Consultant in Paediatric Emergency Medicine Sheffi eld Children’s NHS Foundation Trust
Professor Tim Coats Professor of Emergency Medicine University of Leicester
Dr Lorcan Duane Consultant in Emergency Medicine Central Manchester University Hospitals NHS Foundation Trust
Julie Flaherty Paediatric Nurse Consultant Salford Royal NHS Foundation Trust
Dr Muhuntha Gnanalingham Consultant in Paediatric Intensive Care Central Manchester University Hospitals NHS Foundation Trust
Professor Fiona Lecky Professor of Emergency Medicine University of Sheffi eld
Mr Roberto Ramirez Consultant in Paediatric Neurosurgery Central Manchester University Hospitals NHS Foundation Trust
Maralyn Woodford Executive Director The 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.
SEVERE INJURY IN CHILDREN 2012 1 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
2 THE TRAUMA AUDIT AND RESEARCH NETWORK 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.
ISS > 15 n = 737
All children in the TARN database n = 4720
All children attending ED with injury
Figure 1 (2012 data)
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.
SEVERE INJURY IN CHILDREN 2012 3 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.
4 THE TRAUMA AUDIT AND RESEARCH NETWORK Trauma in children
Data Completeness
All Submissions Deaths
Completion Completion Trust n HES n HES % %
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 2012 5 Severe Injury in Children (ISS > 15)
Demographics Number (%)
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)
25
20
15
10 Percentage of patients Percentage
5
0 age <1 year age 1 - 2 years age 3 - 5 years age 6 - 10 years age 11 - 13 years age 14 - 15 years
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.
6 THE TRAUMA AUDIT AND RESEARCH NETWORK Severe Injury in Children (ISS > 15)
Injury Mechanism Number (%)
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%)
40
35
30
25
20
15 Percentage of patients Percentage 10
5
0 Road Traffic Fall > 2m Fall < 2m NAI under 2 years Penetrating Blows Other (eg. Collision sport/drowning)
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).
SEVERE INJURY IN CHILDREN 2012 7 Severe Injury in Children (ISS > 15)
Injury Type Number (%)*
AIS3+ Head Injury 555 (75.3%)
AIS3+ limb / pelvis / spine injury 136 (18.5%)
AIS3+ thoracic / abdominal injury 213 (28.9%)
80
70
60
50
40
30 Percentage of patients Percentage 20
10
0 AIS3+ Head Injury AIS3+ limb / pelvis / spine injury AIS3+ thoracic / abdominal injury
*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.
8 THE TRAUMA AUDIT AND RESEARCH NETWORK Severe Injury in Children (ISS > 15)
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.
SEVERE INJURY IN CHILDREN 2012 9 Severe Injury in Children (ISS > 15)
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%)
14
12
10
8
6 Percentage of patients Percentage 4
2
0 January February March April May June July August September October November December
10 THE TRAUMA AUDIT AND RESEARCH NETWORK Severe Injury in Children (ISS > 15)
Mode of arrival (direct admissions) n = 537 Number (%)
Arrived by ambulance 302 (56.2%)
Arrived by helicopter 91 (16.9%)
Arrived by other means (eg. car) 144 (26.8%)
60
50
40
30
20 Percentage of patients Percentage
10
0 Arrived by ambulance Arrived by helicopter Arrived by other means (eg. car)
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.
SEVERE INJURY IN CHILDREN 2012 11 Severe Injury in Children (ISS > 15)
Type of first admitting hospital Number (%)
Adult & Children’s MTC* 189 (25.6%)
Adult MTC* 69 (9.4%)
Children’s MTC* 71 (9.6%)
Trauma Unit 408 (55.4%)
60
50
40
30
20 Percentage of patients Percentage
10
0 Adult & Children’s MTC* Adult MTC* Children’s MTC* Trauma Unit
*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.
12 THE TRAUMA AUDIT AND RESEARCH NETWORK Severe Injury in Children (ISS > 15)
Transfer between hospitals Number (%)
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%)
60
50
40
30
20 Percentage of patients Percentage
10
0 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*
*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.
SEVERE INJURY IN CHILDREN 2012 13 Severe Injury in Children (ISS > 15)
ICU / HDU admissions n = 737 Number (%)
All patients 351 (47.6%)
Isolated AIS 3+ Head Injuries 179 (42%)
Isolated AIS 3+ Abdominal Injuries 22 (48.9%)
Isolated AIS 3+ Limb / Pelvic Injuries 4 (13.8%)
Isolated AIS 3+ Thoracic Injuries 9 (37.5%)
Polytrauma* 121 (67.2%)
*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 (%)
Intubated 208 (38.7%)
Intubated in ED 164 (30.5%)
Intubated pre-hospital 44 (8.2%)
Median hours to intubation from incident (IQR) 1.1 (0.6 - 1.6)
Hospital Stay n = 737 Number (%)
Median LOS (IQR) 6 (3 - 12)
Median LOS, transfers in (IQR) 6 (4 - 15)
Admitted to ICU / HDU 351 (47.6%)
Median LOS in ICU (IQR) 3 (1 - 6)
Median LOS, patients that went to ICU (IQR) 10 (5 - 23)
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.
14 THE TRAUMA AUDIT AND RESEARCH NETWORK Severe Injury in Children (ISS > 15)
Mortality (cases with recorded outcome) Total number Number of Mortality of cases deaths %
All admissions 621 56 9%
Admissions with GCS < 15 158 43 19.5%
Injury Mechanism
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%
Blows 37 0 0%
Other (eg. sport/drowning) 47 19 40.4%
Injury Type
AIS3+ head injury 457 34 7.4%
AIS3+ limb / pelvis / spine injury 120 4 3.3%
AIS3+ thoracic / abdominal injury 184 24 13%
*Percentages are of children with known outcome with that particular GCS / mechanism / injury pattern
SEVERE INJURY IN CHILDREN 2012 15 Severe Injury in Children (ISS > 15)
Injuries associated with death
AIS3+ Number Head Face Chest Injuries Spine Limbs Other Polytrauma Asphyxia Drowning of deaths Abdomen
56 34 0 22 5 0 4 1 20 12 6
35
30
25
20
15
10
5
0 Head Face Chest Abdomen Spine Limbs Other Polytrauma Asphyxia Drowning
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 Head Face Chest Abdomen Spine Limbs Other Asphyxia Drowning Region
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
16 THE TRAUMA AUDIT AND RESEARCH NETWORK Severe Injury in Children (ISS > 15)
Grade of most senior clinician in the ED
Direct Admissions
Associate STR, year Foundation Not ISS n Consultant STR, 4+ STR, 1-3 Other Specialist unknown Year 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
80
70
60
50
40
30 Percentage of patients Percentage 20
10
0 Consultant Ass Specialist STR, 4+ STR, 1-3 STR, year FY Other Not unknown recorded
74.1% of severely injured children were resuscitated by Consultants.
SEVERE INJURY IN CHILDREN 2012 17 Severe Injury in Children (ISS > 15)
Grade of most senior clinician involved in surgery (all operations, n = 394)
Direct Admissions
Consultant Ass. STR 4+ STR 1 - 3 STR, year Foundation Other No grade Specialist unknown Year recorded
Grade of 239 (60.7%) 4 (1%) 34 (8.6%) 4 (1%) 57 (14.5%) 0 (0%) 6 (1.5%) 50 (12.7%) Anaesthetist
Grade of Paediatric 48 (92.3%) 0 (0%) 1 (1.9%) 0 (0%) 2 (3.8%) 0 (0%) 0 (0%) 1 (1.9%) Surgeon
Grade of 271 (68.8%) 1 (0.3%) 13 (3.3%) 4 (1%) 84 (21.3%) 0 (0%) 2 (0.5%) 19 (4.8%) Surgeon
100
80
60
40 Percentage of patients Percentage
20
0 Grade of Surgeon Grade of Paediatric Surgeon Grade of Anaesthetist
Consultant Ass Specialist STR, 4+ STR, 1-3 STR, year unknown FY Other No grade recorded
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.
18 THE TRAUMA AUDIT AND RESEARCH NETWORK Severe Injury in Children (ISS > 15)
Time to first surgery from arrival
Direct Admissions
n with operations Median hours to Interquartile Category recorded operation 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
20
16
12
8 Time to surgery (hours)
4
0 All surgery, ISS > 15 Neurosurgery Abdominal surgery Cardiothoracic surgery Orthopaedic surgery
*Patients can be in multiple groups Operations 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.
SEVERE INJURY IN CHILDREN 2012 19 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
20 THE TRAUMA AUDIT AND RESEARCH NETWORK SEVERE INJURY IN CHILDREN 2012 The University of Manchester Manchester Academic Health Science Centre (MAHSC)
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