England & Wales
SEVERE INJURY IN CHILDREN
January 2015 – December 2016
2 Years of Severe Injury in Children
Contents Members of the Working Group ...... 4 Introduction ...... 5 Summary ...... 6 Data completeness ...... 7 Demographics ...... 8 Injury mechanism ...... 9 Road traffic collisions ...... 12 Injury type ...... 14 Time of arrival at hospital ...... 15 Month of arrival at hospital ...... 16 Mode of arrival at hospital ...... 17 Type of first admitting hospital ...... 18 Transfer between hospitals ...... 21 ICU / HDU admissions ...... 22 Definitive airway management ...... 23 Mortality rates ...... 24 Injuries associated with death ...... 25 Grade of most senior clinician in the ED ...... 26 Location and time to first surgery ...... 28 Glossary ...... 29 Appendix: Data tables and figures ...... 31
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2 Years of Severe Injury in Children
The TARNlet Committee
Mr Ross Fisher Samantha Jones Chairman of TARNlet Major Trauma Co‐ordinator/ Academic Clinical Fellow Consultant in Paediatric Surgery Royal Manchester Children’s Hospital Sheffield Children’s NHS Foundation Trust
Professor Tim Coats Professor Fiona Lecky Professor of Emergency Medicine Professor of Emergency Medicine University of Leicester University of Sheffield
Miss Naomi Davis Dr Ciara Martin Consultant in Paediatric Orthopaedic Surgery Consultant in Emergency Medicine Royal Manchester Children’s Hospital The Adelaide and Meath Hospital, Incorporating The National Children's Hospital, Tallaght, Dublin
Dr Patrick Davies Dr Samantha Negus Consultant in Paediatric Intensive Care Paediatric Radiologist Nottingham Children's Hospital Surrey and Sussex Hospitals NHS Trust
Dr Lorcan Duane Mr Roberto Ramirez Consultant in Emergency Medicine Consultant in Paediatric Neurosurgery Royal Manchester Children’s Hospital Royal Manchester Children’s Hospital
Antoinette Edwards Miss Alice Roberts Executive Director Patient & Public Representative The Trauma Audit & Research Network
Dr Chris Fitzsimmons Dr Damian Roland Consultant in Emergency Medicine Consultant and Honorary Associate Professor in Sheffield Children’s NHS Foundation Trust Paediatric Emergency Medicine University of Leicester
Nathan Griffiths Paediatric Nurse Consultant Salford Royal NHS Foundation Trust
Acknowledgements We would like to thank the staff at each trauma receiving hospital and Mike Young, Data Analyst at the Trauma Audit and Research Network.
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2 Years of Severe Injury in Children
Introduction
Injury produces a significant health burden for children, being a leading cause of both death and disability. About half of the 4 million attendances by children to EDs each year follow an injury, but most are minor. Information about the more serious injuries is collected by the Trauma Audit and Research Network (TARN), the UK’s national audit of major trauma. Details of the methods used to collect data, the injury severity scoring system and the predictive model used to allow evaluation of the process and outcomes of treatment can be found on the TARN website (www.tarn.ac.uk).
Children are included in the TARN dataset if they are injured and either (1) are admitted to hospital for more than 72 hours, or (2) admitted to an intensive care area, or (3) die in hospital. Outcome (lived or died) is recorded either on discharge from hospital or at 30 days (whichever comes first). Patients who die at the incident scene and are not transported to hospital are not reported to TARN. Individual injuries are classified according to the Abbreviated Injury Scale (AIS), which allows an overall Injury Severity Score (ISS) to be calculated (giving a score of 0 to 75). Links to the details of these scoring systems are on the TARN website (www.tarn.ac.uk). Conventionally a child with an ISS of >15 is classified as ‘major trauma’ with an ISS of 25 or more being the most severe of injuries. Further information about the data methodology can be found at www.tarn.ac.uk
The TARNlet committee is comprised of clinicians, managers, academics and patients. All are involved in the management of children who have sustained injury and are keen that the information within the National Clinical Audit of Major Trauma should be used to optimise care. This report focusses on areas where we think improvement could be made in either the prevention of injury, or the process of care for injured children. This is the third report produced by the TARNlet committee, providing data on children with severe injury from January 2015 to December 2016 in England & Wales, and comparing these data with that produced in the last report on data from 2013 and 2014. The Trauma Audit and Research Network (TARN) registry contains information on 5093 children under the age of 16 injured from January 2015 to December 2016, as compared with data on 4886 in 2013/14.
All children attending ED following injury (approximately 4 million)
All children in the TARN database n = 5093
ISS 1 to 8 ISS 9 to 15 ISS > 15 n = 667 n = 2808 n = 1618
Figure 1 (January 2015 ‐ December 2016 data)
This report concentrates on the 1618 children recorded in the TARN database from January 2015 to December 2016 who sustained the most serious injuries ‐ an injury severity score (ISS) greater than 15 (which is the conventional definition of ‘major trauma’). The true number of severe injuries is somewhat higher than this due to missing data (estimated case ascertainment of 76.7%), which is similar to the previous 2013/14 report which found 1511 children with ISS > 15 (estimated case ascertainment of 80.7%).
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2 Years of Severe Injury in Children Summary
During January 2015 to December 2016 there were 1618 severely injured (ISS > 15) children treated in England & Wales. Pedestrian injury resulting in head trauma is still the commonest cause of severe injury and mortality after the age of 1 year, suspected Non‐Accidental Injury (NAI) being the predominant cause in the first year of life. Other types of road traffic incident (vehicle occupant or cyclist) and falls (both low and high) are also common. Despite being uncommon injury mechanisms, the highest case fatality rates were for asphyxia and drowning. This is shown in the new data on the injury mechanisms (page 8) and in the breakdown of patients injured in road traffic incidents (page 9).
The number of severely injured children follows a well‐known seasonal pattern (peaking during the summer) and weekly pattern (more cases occurring at weekends) and daily pattern (a small morning and larger late afternoon / evening peak). The pattern of arrival of severely injured children has not changed and still implies that staffing for paediatric trauma needs to be focussed ‘out of hours’ to match high rates of arrival in the evening and at weekends. There are few patients arriving after midnight.
Major trauma in childhood is commonest in the first year of life, the first 3 months having the highest incidence (suspected non‐accidental injury accounting for about 10% of all major trauma in childhood). Trauma systems need to be refocussed to account for the way in which NAI presents1, as these children are not identified by the standard prehospital and hospital trauma triage tools.
About 25% of severely injured children are not taken to hospital by ambulance, meaning that many parents/carers are taking severely injured children to the nearest hospital (usually a Trauma Unit). 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. Most severely injured children are moved to a specialist Trauma Centre, although about a third remain in a TU. At present we don’t have data about the speed of the inter‐hospital transfer system or appropriateness of remaining in a TU.
Severe traumatic brain injury is still the leading numeric cause associated with death, but new categories for the mechanism of trauma introduced in this report show that proportionately asphyxia and drowning have the highest relative risks for mortality. Public health interventions aimed at reducing these, or any other, mechanisms of injury could be monitored using the TARN system. This report also demonstrates the importance of close alignment between neurosurgical and cardiothoracic services as head, chest and combined head and chest injuries are the body areas associated with most deaths.
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 assist in the improvement of the delivery of trauma services. The addition of these new data sets in this report will allow for greater comparison in future reports on progress made in paediatric trauma management and act as a guide to injury prevention.
1 A profile of suspected child abuse as a subgroup of major trauma patients Ffion C Davies, Timothy J Coats, Ross Fisher, Thomas Lawrence, Fiona E Lecky Emerg Med J 2015;32:921‐925 doi:10.1136/emermed‐2015‐205285
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2 Years of Severe Injury in Children Case ascertainment
All Submissions Submissions of patients that died
Trust n HES Ascertainment Deaths HES Ascertainment
England & Wales 5833 7603 76.7% 118 111 100+%
Case ascertainment is displayed as a percentage and represents the number of patients submitted to TARN compared to the number of patients expected based on the 2015 Hospital Episode Statistics (HES) dataset. The HES dataset is not perfect, but is used as a general baseline. We found better case ascertainment for patients who die, in other words deaths are more likely to be reported. It is likely that for more severely injured children studied in this report case ascertainment is higher than that for all TARN eligible children on HES (may be close to 100%).
In order to be comparable to the HES data this Table shows the number of submissions from hospitals to the TARN database (n=5833) rather than the number of unique patients (n=5093). If a child is transferred each hospital should submit the case to TARN – so total submissions is more comparable to Hospital Episodes than unique patients.
1618 children had severe injuries with an injury severity score (ISS) of > 15 and 114 of these (represented by 118 submissions) died of those injuries.
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2 Years of Severe Injury in Children
Demographics of severely injured children 2015/16
Age breakdown by year
25
20
15 patients
of
10 Percentage 5
0 <11 2 3 4 5 6 7 8 9 101112131415 Age (years)
There is a clear peak in the first few months of life (related to NAI), with low level through early childhood until the pre‐teen years when there is a rise.
Patients aged less than 1 year – age by month
20
18
16
14
12 patients
of 10
8
Percentage 6
4
2
0 <11234567891011 Age (months)
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2 Years of Severe Injury in Children
Injury Mechanism
50 45 40 35 patients
30 of 25 20 15
Percentage 10 5 0
2012 2013/14 2015/16
Analysis of injury mechanism data continues to show a preponderance of road traffic incidents and falls of less than 2 metres. 11.3% of the patients were aged under 2 and injured intentionally (recorded as Suspected Non‐Accidental Injury). It is difficult to interpret trends in the groups (such as penetrating trauma) where there are low numbers.
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2 Years of Severe Injury in Children
Proportion deaths by injury mechanism
50
45
40
35
30 patients
of 25
20
15 Percentage
10
5
0
2012 2013/14 2015/16
Case fatality rate by Injury Mechanism
100 90 80 (%)
70 60 Rate
50 40 Fatality
30 Case 20 10 0
2012 2013/14 2015/16
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2 Years of Severe Injury in Children
Injury Mechanism by age
100
90
80
70
60 patients
of 50
40 Percentage
30
20
10
0 <1123456789101112131415 Age (years)
NAI under 2 years Blunt assault Road Traffic Collision Fall < 2m Fall > 2m Other
The importance of NAI <1year old has been addressed in separate TARN publications. There is a high incidence of low (<2m) falls in the younger children and road traffic collisions (child pedestrian and cyclist) become important as soon as the child become independently mobile (3 years onwards) and increase gradually throughout childhood.
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2 Years of Severe Injury in Children
Patients injured in a road traffic incident
60
50
40 patients
of 30
20 Percentage
10
0 Pedestrian Cyclist Vehicle occupant Motorcyclist/Quad Not Known biker
2012 2013/14 2015/16
Children involved in road traffic incidents are mostly undertaking self‐determined activities such as walking or cycling, where factors such as poor situational awareness, inexperience and distraction lead to vulnerability. Only about 20% of severe road traffic injury in children occurs when a child is within a vehicle. This may have implications for parental choice of transport and exercise levels among children.
Proportion road traffic incident deaths by position in vehicle
80
70
60
50 patients
of 40
30 Percentage 20
10
0 Pedestrian Cyclist Vehicle occupant Motorcyclist/Quad Not Known biker
2012 2013/14 2015/16
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2 Years of Severe Injury in Children
Mortality rate of patients injured in a road traffic incident
60
50
40 patients
of 30
20 Percentage
10
0 Pedestrian Cyclist Vehicle occupant Motorcyclist/Quad Not Known biker
2012 2013/14 2015/16
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2 Years of Severe Injury in Children
Injury Type (AIS 3+) 2015/16*
100
90
80
70
60 patients
of 50
40 Percentage
30
20
10
0 3+ Head Injury 3+ Thoracic Injury 3+ Abdominal 3+ Limb / Pelvis Polytrauma** 3+ Spinal Injury Injury Injury
Severe traumatic brain injury is by far the commonest type of trauma in children, emphasising the importance of early neuroprotection and neurointensive / neurosurgical care within the Trauma Networks. The very low incidence of polytrauma (AIS 3+ injuries in more than one body area) is striking and suggests that focussed CT scanning rather than whole body CT may be appropriate in children.
*The severity of each injury is described using the Abbreviated Injury Scale (AIS) score. The score can range from 1 (minor) to 6 (fatal). An AIS 3 head injury always involves brain injury.
**AIS 3+ injuries in multiple body regions
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2 Years of Severe Injury in Children
Average number of patients arriving per hour 2015/16
0 23 14 1 22 2 12
21 10 3
8 20 4 6
19 4 5
2
18 0 6
17 7
16 8
15 9
14 10 13 11 12 Weekday Weekend
Severely injured children attend hospital mainly during daytime hours, with a small peak on the way to school and large peak after school. At the weekend injuries are more spread throughout the day, with the peak occurring two or three hours earlier. This pattern of attendance has an implication for the staffing of paediatric trauma services which need to be geared to receive peak activity ‘out of hours’ in the late afternoon, evening and at weekends. There are a very low number of severe injuries occurring at night. These patterns are similar to previous reports.
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2 Years of Severe Injury in Children
Presentation by month
14
12
10
patients 8
of
6
Percentage 4
2
0
2015‐16 2012 ‐ 2014 Average
More children present with injury during the summer months, probably linked to outdoor activity with increased length of daylight hours. This pattern seems to be consistent across the years and suggests that paediatric trauma care systems require more staff in summer. Our previous reports have also shown that there are large peaks in paediatric major trauma during school holidays, which may have an implication for the annual leave pattern of trauma care staff.
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2 Years of Severe Injury in Children
Mode of arrival to hospital Direct admissions only (n = 1,326)
70
60
50
40 patients
of
30 Percentage
20
10
0 Ambulance Helicopter Other*
Many severely injured children are not brought to hospital by ambulance or helicopter. This has a continuing significant implication for the future configuration of paediatric trauma services, as trauma systems must anticipate that nearly a third of patients will continue to arrive (unannounced) at the nearest hospital (which is likely to be a non‐specialist Trauma Unit).
* Other includes walk in patients, in patients, those brought in by car and those who are recorded as ‘unknown’. The ‘unknown’ category is seldom used for patients who arrive by ambulance / helicopter and usually represents being brought to hospital by own transport.
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2 Years of Severe Injury in Children
Type of first admitting hospital*
60
50
40 patients
of 30
Percentage 20
10
0 Children's MTC Adult & Children's MTC Adult MTC Trauma Unit
2013/14 2015/16
Just over half of severely injured children are initially treated in a Trauma Unit, with only about 40% being taken to an appropriate specialist centre from the beginning (an Adult‐only MTC has not been counted as an appropriate centre). Paediatric inter‐hospital trauma transfer remains a key function of the wider trauma network, and the efficiency and appropriateness of this system is a key area for future audit.
* In some cases details about the first admission site may not have been sent to TARN (better data is received from MTCs than TUs), but the hospital type of first admission can be deduced from the transfer site’s notes (e.g. If a patient presented to a TU and was transferred to an MTC, the MTC might identify the first hospital even if the case was not reported from the TU).
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2 Years of Severe Injury in Children
Proportion of Patients initially admitted to a Trauma Unit by Age
80
70
60
50 patients
of 40
30 Percentage
20
10
0 < 1123456789101112131415 Age (years)
Ambulance arrival Other arrival
The youngest patients (under one year) were the most likely to be admitted to a TU rather than a MTC, probably because babies are easy to carry to hospital by parents / carers, and even if an ambulance is called major trauma is difficult to recognise at this age. This emphasise the need to provide excellent paediatric services in Trauma Units in order to resuscitate and undertake initial interventions before transfer. It is a paradox of the current trauma system organisation that the least experienced teams are most likely to get the most challenging patients. Providing a system that gives experienced trauma resuscitation and decision making in these patients in every TU will need novel solutions.
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2 Years of Severe Injury in Children
Patients initially admitted to a Trauma Unit by ISS
60
50
40 patients
of 30
Percentage 20
10
0 15 to 24 25 to 49 50 to 75 ISS band
This chart suggests that the prehospital triage system works best for the most severely injured patients, with only about a fifth of ISS>50 patients being taken to a TU. These extreme multiple injuries are rare, are probably immediately obvious and are probably more likely to result in a 999 call rather than parent or bystander transport to the nearest hospital. Pre‐hospital trauma triage is an evolving science and research is underway to improve the pre‐hospital identification of severe injury, these data suggests that this research should focus on the 15 to 49 ISS groups.
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2 Years of Severe Injury in Children
Transfer from initial hospital of children ISS>15
Transfer to: No transfer Initial site Adult MTC Children's MTC TU Adult MTC (n=126) 2 (0.1%) 62 (3.8%) 21 (1.3%) 41 (2.5%) Children's MTC (n=671) 2 (0.1%) 14 (0.9%) 39 (2.4%) 616 (38.1%) TU (n=821) 6 (0.4%) 520 (32.1%) 87 (5.4%) 208 (12.9%) This Table represents the inter‐hospital transfer activity for ISS>15 patients within the major trauma systems. Not all of the transfers were acute.
Patients initially admitted to a Trauma Unit (n=821)
Transfer site 100
90
80
70
60 patients
of 50
40
Percentage 30
20
10
0 < 1123456789101112131415 Age (years)
Children's MTC Adult MTC TU No transfer
Although most severely injured children who are admitted to a non‐specialist Trauma Unit are transferred to a specialist centre, it seems surprising that about a third, across all ages, are not transferred to a MTC. These patients either have no transfer or are transferred to another Trauma Unit (which may represent repatriation for rehabilitation nearer home). This is an area that should be the subject of future investigation, in order to evaluate whether or not this is an appropriate pathway of care.
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2 Years of Severe Injury in Children
Patients admitted to ICU / HDU
100
90
80
70
60 patients
of 50
40 Percentage
30
20
10
0 2012 2013/14 2015/16
About half of severely injured children require ICU/HDU admission, a proportion that has remained constant across the three reports since 2012.
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2 Years of Severe Injury in Children
Definitive airway management 2015/16
Direct admissions to hospital* n = 1326
Number of children with definitive airway management n = 441 (33.3%)
Pre‐hospital ED n = 156 (35.4%) n = 285 (64.6%)
Of the 1618 patients with an ISS>15 there were 292 with no record from the first hospital. Of the 1326 with a complete record, one third had definitive airway management (intubation, cricothyroidotomy or tracheostomy) at a median of 1.1 hours after injury (IQ range 0.8 to 1.6). One third of intubations were carried out in the pre‐hospital phase.
Length of stay in hospital
Length of stay All children ISS > 15
Total hospital length of stay (days) 54358 22760 Total length of stay in critical care (days) 5104 4489
Average length of stay
Length of stay Median days Interquartile range (days)
LOS** 6 4 – 12 LOS, patients transferred 6 4 – 12 LOS in ICU/HDU 2 1 – 5 LOS, patients that went to ICU / HDU 9 5 – 19
**Length of stay is the calculated from the date of admission to hospital/ICU/HDU to the date of discharge from hospital/ICU/HDU.
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 of these figures are similar to 2012 and 2014 Reports.
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2 Years of Severe Injury in Children
Mortality
95% confidence interval Total number of Number of Category Mortality % cases ISS>15 deaths Lower Upper
All admissions 1514 114 7.5% 6.2 8.9 All admissions with GCS < 15 619 102 16.5% 13.6 19.4
Final outcome is unknown for 104 of the 1618 (6%) patients due to missing data. The crude mortality is similar to 2012 and 2014. A more detailed analysis of mortality trends would require a risk adjusted paediatric trauma outcome model. Proportion deaths by body area with most severe injury
50 45 40 (%)
35
deaths 30
all 25 of
20 15
Proportion 10 5 0 Head Asphyxia Drowning Multiple Chest Spine Limbs Abdomen Other*
Brain injury is numerically the most important cause of severe injury and injury death in childhood. Asphyxia and drowning have a much lower incidence but are the most lethal types of injury with very high mortalities.
* Other includes injuries such as burns, hypothermia and frostbite.
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2 Years of Severe Injury in Children
Interaction of AIS 3+ injuries & associated mortality
Head Spine Chest Abdomen Limbs Pelvis Head 64 (5.8%) Spine 12 (23.1%) 13 (16.7%) Chest 37 (22.7%) 9 (29%) 47 (14.3%) Abdomen 6 (20.7%) 3 (42.9%) 10 (13.3%) 10 (4.8%) Limbs 9 (10.3%) 3 (25%) 9 (13.8%) 2 (20%) 11 (8.3%) Pelvis 6 (30%) 2 (66.7%) 6 (19.4%) 2 (33.3%) 2 (16.7%) 6 (8.5%)
Values are the number of patients that died (mortality %) within each category i.e. 10 patients with AIS 3+ injuries to the chest and abdomen died representing a mortality rate of 13.3% for patients in this group. Please note patients may appear in multiple groups. Asphyxia (71% mortality) and drowning (58% mortality) have been excluded from the table as these are usually isolated mechanisms.
The majority of deaths occurred in children with severe isolated traumatic brain, isolated chest injury or a combination of brain and chest injury. This suggests a need for neurosurgical and cardiothoracic services to be well aligned in paediatric trauma services.
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2 Years of Severe Injury in Children
Patients seen by a consultant in ED
100
90
80
70
60 patients
of 50
40 Percentage 30
20
10
0 Children's MTC Adult MTC TU
2012 2013/14 2015/16
Severely injured children are much more likely to have consultant involvement in the ED in a specialist centre. The overall low level of senior involvement in Trauma Units is worrying in the light of the large number and suggests that the current organisation of trauma care might not be providing best care for paediatric major trauma. The apparent trend to a decrease in consultant involvement with severely injured children in Adult MTCs will be closely observed in future reports.
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2 Years of Severe Injury in Children
Percentage of patients seen by consultant in ED by time of day (2012 to 2016)
0 23 100 1 22 2 80 21 3
60 20 4
40
19 5 20
18 0 6
17 7
16 8
15 9
14 10 13 11 12 Children's MTC Adult MTC TU
Very few children present with major trauma during the night (as described on page X), however when this does occur there is less likely to be a consultant present. There are too few presentations at night to look at trends over time.
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2 Years of Severe Injury in Children
Location of first surgery (2012 to 2016)
100 90 80 70 60 patients
of 50 40 30 Percentage 20 10 0 All surgery, ISS > 15 Abdominal surgery Cardiothoracic surgery Neurosurgery Orthopaedic surgery
Children's MTC Adult MTC TU
Median hours from hospital arrival to first surgery (2012 to 2016)
20
18
16
14
12 operation
to 10 hours 8
6 Median
4
2
0 All surgery, ISS > 15 Abdominal surgery Cardiothoracic surgery Neurosurgery Orthopaedic surgery
Children's MTC Adult MTC TU
Data on time to surgery shows a greater variation for the specialties (such as orthopaedics) where fewer initial operations are emergencies. As few children require emergency surgery and there is a lot of variation further subdivision of this data would be difficult to interpret. It is difficult to draw any conclusions about the organisation of services from this data.
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2 Years of Severe Injury in Children
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.
Child A patient up to the age of 16 years
Definitive Airway Intubation, cricothyroidotomy or tracheostomy. Management
Direct admissions Describes care in the first treating hospital.
GCS Glasgow Coma Scale. A measure of consciousness ranging from 3, indicating complete unconsciousness, to 15, indicating a state of normal alertness. GCS is composed of eye, verbal and motor scores.
HDU High Dependency Unit
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.
ICU Intensive Care Unit
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).
LOS Length of Stay. Calculated from the date of admission to hospital/ICU/HDU to the date of discharge from hospital/ICU/HDU.
MTC Major Trauma Centre
NAI Non‐Accidental Injury
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 who focus on injured children, was established to address specific questions relating to paediatric trauma care.
TU Trauma Unit
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2 Years of Severe Injury in Children
Grades of Doctor
Consultant Consultant
Associate Specialist Associate Specialist
ST3 and above Specialist registrar, speciality trainee, clinical fellow, senior registrar, staff grade
FY / ST 1‐2 FY/ST 1‐2
Trust Grade
Other / Not recorded Not known / recorded, Nurse Consultant, Advanced Practitioner
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2 Years of Severe Injury in Children Appendix: Data tables and figures
Table 1: Demographics of severely injured children
Age (Years) Number of severely injured children (%) Total 1618 age < 1 343 (21.2%) 1 77 (4.8%) 2 75 (4.6%) 3 59 (3.6%) 4 67 (4.1%) 5 66 (4.1%) 6 52 (3.2%) 7 70 (4.3%) 8 70 (4.3%) 9 68 (4.2%) 10 62 (3.8%) 11 88 (5.4%) 12 109 (6.7%) 13 110 (6.8%) 14 120 (7.4%) 15 182 (11.2%)
Medians Age, ISS and gender split Median Age (IQR) 8 (1.7 ‐ 13) Median ISS (IQR) 24 (16‐ 26) Male 66.3% Female 33.7%
Table 2: Patients aged under 1 year old
Age (Months) Number of severely injured children (%) Total 343 age < 1 38 (11.1%) 1 65 (19%) 2 53 (15.5%) 3 36 (10.5%) 4 27 (7.9%) 5 34 (9.9%) 6 23 (6.7%) 7 21 (6.1%) 8 8 (2.3%) 9 14 (4.1%) 10 15 (4.4%) 11 9 (2.6%)
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2 Years of Severe Injury in Children
Table 3: Injury mechanism
Category 2012 2013/14 2015/16 Road Traffic Collision 304 (40.5%) 628 (41.6%) 642 (39.7%) Fall < 2m 154 (20.5%) 305 (20.2%) 377 (23.3%) Fall > 2m 106 (14.1%) 175 (11.6%) 163 (10.1%) NAI under 2 years 77 (10.3%) 147 (9.7%) 183 (11.3%) Blunt assault 56 (7.5%) 121 (8%) 143 (8.8%) Other (e.g. sport) 25 (3.3%) 42 (2.8%) 34 (2.1%) Asphyxia 16 (2.1%) 35 (2.3%) 35 (2.2%) Drowning 9 (1.2%) 46 (3%) 23 (1.4%) Penetrating 4 (0.5%) 12 (0.8%) 18 (1.1%)
Table 4: Proportion deaths by injury mechanism (case with known outcome only)
Category 2012 2013/14 2015/16 Road Traffic Collision 32 (47.1%) 40 (33.6%) 47 (41.2%) Fall < 2m 5 (7.4%) 1 (0.8%) 3 (2.6%) Fall > 2m 1 (1.5%) 4 (3.4%) 4 (3.5%) NAI under 2 years 7 (10.3%) 10 (8.4%) 7 (6.1%) Blunt assault 1 (1.5%) 12 (10.1%) 8 (7%) Other (eg. sport) 2 (2.9%) 5 (4.2%) 1 (0.9%) Asphyxia 12 (17.6%) 25 (21%) 27 (23.7%) Drowning 7 (10.3%) 20 (16.8%) 14 (12.3%) Penetrating 1 (1.5%) 2 (1.7%) 3 (2.6%)
Table 5: Mortality by injury mechanism (cases with known outcome only)
Category 2012 2013/14 2015/16
Road Traffic Collision 32 (12.3%) 40 (6.9%) 47 (7.7%) Fall < 2m 5 (3.9%) 1 (0.4%) 3 (0.8%) Fall > 2m 1 (1.1%) 4 (2.5%) 4 (2.7%) NAI under 2 years 7 (11.5%) 10 (7.8%) 7 (4.5%) Blunt assault 1 (2.2%) 12 (10.8%) 8 (5.9%) Other (e.g. sport) 2 (8.7%) 5 (14.7%) 1 (3.3%) Asphyxia 12 (70.6%) 25 (78.1%) 27 (71.1%) Drowning 7 (70%) 20 (45.5%) 14 (58.3%) Penetrating 1 (33.3%) 2 (20%) 3 (16.7%)
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Table 6: Patients injured in a road traffic collision
Category 2012 2013/14 2015/16 Pedestrian 154 (50.7%) 312 (49.7%) 299 (46.6%) Cyclist 72 (23.7%) 149 (23.7%) 163 (25.4%) Vehicle occupant 61 (20.1%) 122 (19.4%) 142 (22.1%) Motorcyclist/Quad biker 13 (4.3%) 38 (6.1%) 32 (5%) Not Known 4 (1.3%) 7 (1.1%) 6 (0.9%)
Table 7: Proportion road traffic deaths by position in vehicle (case with known outcome only)
Category 2012 2013/14 2015/16 Pedestrian 11 (34.4%) 24 (60%) 32 (68.1%) Cyclist 8 (25%) 7 (17.5%) 6 (12.8%) Vehicle occupant 13 (40.6%) 7 (17.5%) 9 (19.1%) Motorcyclist/Quad biker 0 (0%) 2 (5%) 0 (0%) Not Known 0 (0%) 0 (0%) 0 (0%)
Table 8: Mortality of patients injured in a road traffic collision (cases with known outcome only)
Category 2012 2013/14 2015/16 Pedestrian 11 (8.3%) 24 (8.4%) 32 (11.3%) Cyclist 8 (12.9%) 7 (5.1%) 6 (3.8%) Vehicle occupant 13 (23.6%) 7 (6.2%) 9 (6.7%) Motorcyclist/Quad biker 0 (0%) 2 (6.5%) 0 (0%) Not Known 0 (0%) 0 (0%) 0 (0%)
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Table 9: AIS 3+ injuries
Anatomical injury location Number of patients with this injury (%) 3+ Head Injury 1186 (73.3%) 3+ Thoracic Injury 360 (22.2%) 3+ Abdominal Injury 217 (13.4%) 3+ Limb / Pelvis Injury 208 (12.9%) Polytrauma 119 (7.4%) 3+ Spinal Injury 84 (5.2%)
Table 10: Average number of patients arriving per hour
Hour Weekday Weekend
0 2.6 5.5 1 2.4 3
2 2.3 2.5 3 1.3 2.5 4 1.9 1.8
5 1.2 1.5 6 1.7 1 7 1.2 2.7
8 2.8 1.5 9 5.4 2.5 10 4.6 2.8
11 3.7 4.5
12 4.3 6.3 13 3.4 6.3
14 4.9 11.3
15 4.7 8.5 16 8.4 13
17 11.5 13.3
18 11.2 9.5 19 8.7 8
20 7.1 10.3
21 7.3 7 22 5.9 6.8 23 4 4.5
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Table 11: Patients per month
Month Number of severely injured children (%)
January 95 (5.9%) February 95 (5.9%) March 130 (8%) April 122 (7.5%) May 167 (10.3%) June 167 (10.3%) July 184 (11.4%) August 155 (9.6%) September 172 (10.6%) October 136 (8.4%) November 96 (5.9%) December 99 (6.1%)
Table 12: Mode of arrival (direct admissions)
Arrival mode Number of severely injured children (%) Ambulance 780 (58.8%) Helicopter 207 (15.6%) Other* 339 (25.6%)
Table 13: Type of first admitting hospital
Category 2013/14 2015/16 Children's MTC 195 (12.6%) 229 (14.2%) Adult & Children's MTC 425 (27.6%) 442 (27.3%) Adult MTC 127 (8.2%) 126 (7.8%) Trauma Unit 795 (51.6%) 821 (50.7%)
Table 14: Patients initially admitted to a Trauma Unit by ISS
ISS band Number of severely injured children (%) 15 to 24 467 (56.3%) 25 to 49 344 (46.2%) 50 to 75 10 (22.2%)
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Table 15: Patients admitted to ICU / HDU
Year Admitted to ICU /HDU (%) 2012 352 (46.9%) 2013/14 806 (52.3%) 2015/16 847 (52.3%)
Table 16: Mortality by most severe injury
Most severe injury Deaths (%) Head 54 (47.4%) Asphyxia 27 (23.7%) Drowning 14 (12.3%) Multiple 7 (6.1%) Chest 6 (5.3%) Spine 2 (1.8%) Limbs 2 (1.8%) Abdomen 1 (0.9%) Other 1 (0.9%)
Table 17: Most senior doctor in ED (direct admissions only)
Number of cases (%) Most senior in ED All Children's MTC TU Adult MTC Consultant 971 (73.2%) 592 (88.8%) 300 (54.6%) 79 (71.8%) Associate Specialist 22 (1.7%) 3 (0.4%) 14 (2.6%) 5 (4.5%) ST 3+ 116 (8.7%) 26 (3.9%) 77 (14%) 13 (11.8%) FY / ST 1‐2 63 (4.8%) 13 (1.9%) 48 (8.7%) 2 (1.8%) Other / Not recorded 154 (11.6%) 33 (4.9%) 110 (20%) 11 (10%) Total 1326 667 549 110
Table 18: Patients seen by a consultant in ED
Category 2012 2013/14 2015/16
Children's MTC 232 (86.9%) 542 (89.3%) 592 (88.8%) Adult MTC 48 (85.7%) 93 (80.9%) 79 (71.8%) TU 132 (55.9%) 276 (57.5%) 300 (54.6%)
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Table 17: Location of first surgery
Category Total Children's MTC Adult MTC TU
All surgery, ISS > 15 569 488 (85.8%) 36 (6.3%) 45 (7.9%) Abdominal surgery 65 45 (69.2%) 5 (7.7%) 15 (23.1%) Cardiothoracic surgery 25 20 (80%) 1 (4%) 4 (16%) Neurosurgery 275 245 (89.1%) 19 (6.9%) 11 (4%) Orthopaedic surgery 175 145 (82.9%) 14 (8%) 16 (9.1%)
Table 18: Median hours from hospital arrival to first operation (IQR)
Category Total Children's MTC Adult MTC TU
All surgery, ISS > 15 569 4 (1.9 ‐ 12.7) 2.5 (1.8 ‐ 3.7) 3.5 (1.7 ‐ 7.3) Abdominal surgery 65 2.1 (1.4 ‐ 4.1) 3 (3 ‐ 3.4) 3.5 (2.3 ‐ 4.6) Cardiothoracic surgery 25 1.3 (0.9 ‐ 2.8) ‐ 0.8 (0.7 ‐ 0.9) Neurosurgery 275 3 (1.6 ‐ 5.5) 2.3 (1.8 ‐ 3) 1.7 (1.3 ‐ 4) Orthopaedic surgery 175 10.9 (3.9 ‐ 17.9) 3.5 (2.6 ‐ 13.7) 7.2 (4.1 ‐ 15.9)
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