Almost a quarter of Canadian children with major physical trauma did not access a pediatric trauma center for their care between 2016 and 2021, according to a recent study.

Of 3007 children younger than 16 years with major trauma, 77.6% were directly transported or transferred to a pediatric trauma center. The rest were admitted to a level I or II adult trauma center or an acute care non-trauma hospital, according to the population-based, retrospective cohort study.

The results “suggest the opportunity for improvement” in Canadian trauma systems to ensure “optimal injury care for all children,” senior author Lynne Moore, PhD, professor of social and preventive medicine at the Université Laval in Quebec City, told Medscape News Canada.

The study was published on December 15 in CMAJ.

Strengthening Decision Support

“Children with minor injuries can safely be treated in nonpediatric centers, but there is evidence of better outcomes when children with major injuries are treated in pediatric trauma centers,” said Moore. The current study did not examine clinical outcomes, however.

A 2023 meta-analysis showed that children treated in a pediatric trauma center were 41% less likely to die than those treated in a nonpediatric center, she added. They also had a 52% lower risk for CT use and a 64% lower risk for operative management of solid organ injuries, “which are interventions that clinical guidelines recommend be avoided in children, suggesting that adherence to guidelines is better in pediatric centers,” said Moore.

Because most severely injured children first present to nonpediatric hospitals, the most effective strategies to improve pediatric trauma care involve “strengthening decision support in prehospital environments and nonpediatric hospitals, not in costly new infrastructure,” the study authors wrote.

To better understand where access gaps occur, the researchers estimated crude and adjusted access to a pediatric trauma center among children younger than 16 years (the age cutoff used for transport or transfer to a pediatric trauma center in most Canadian trauma systems) and admitted to an acute care hospital with severe trauma (ie, Injury Severity Score [ISS] > 12) between April 1, 2016, and March 31, 2021.

Data were collected from nine provinces, but Quebec was excluded because of provincial data sharing restrictions. The territories also were excluded because patient volume was too small. Admissions for burns, frostbite, drowning, poisoning, complications of medical care, and late effects of injury were also excluded because these conditions are not typically indications for transport to a pediatric trauma center.

The investigators performed subgroup analyses and adjustment for variables such as age (0-5 years, 6-12 years, and 13-15 years), sex, body region of injuries (ie, head, spine, thorax, abdomen, upper extremities, and lower extremities), injury mechanism (ie, motor vehicle collision, fall, and other), and ISS.

National Data Needed

The average age of patients was 9.2 years. About 64% of the patients were male, and 18.2% of the patients had critical injuries (ISS ≥ 25). Most severe injuries were to the head (60.7%) and thorax (32.6%). About 47% of children were injured in motor vehicle collisions.

Crude access to pediatric trauma centres was highest in Manitoba (94.5%) and Alberta (87.9%) and lowest in the Atlantic provinces (64.7%), Saskatchewan (62.0%), and British Columbia (56.3%).

Using Ontario as the reference (crude access, 83%) because it has the largest population, the researchers found lower adjusted access to a pediatric trauma center in British Columbia (relative risk [RR], 0.68), the Atlantic provinces (RR, 0.80), and Saskatchewan (RR, 0.77) but higher adjusted access in Alberta (RR, 1.06) and Manitoba (RR, 1.14).

Subgroup analysis showed that access was higher for younger children (crude access, 80.9%, 81.7%, and 69.9% for those aged 0-5, 6-12, and 13-15 years, respectively; RR, 1.19 and 1.17) and for those with critical injuries (crude access, 88.8%; RR, 1.16) vs less severe injuries (crude access, 73.0% for ISS 13-15 and 75.7% for ISS 16-24). There was little variation in access based on injury mechanism or body region.

The authors noted that geography may play a role in access to pediatric trauma centers. Geography did not fully explain the observed interprovincial differences, however. For example, in Saskatchewan and the Atlantic provinces, only 27%-48% of children are within a 1-hour drive of a pediatric trauma center, and in Prince Edward Island and New Brunswick, children must be transferred to neighboring provinces to access a pediatric trauma center.

“Other factors — such as prehospital triage, interhospital transfer protocols, and lack of pediatric readiness in nonpediatric hospitals — likely play a role,” they wrote.

“Injury is the first cause of death and disability in Canadian children, so improving injury care for children has enormous potential to improve the lives of Canadian kids and their families,” said Moore.

Prehospital triage tools that consider children’s unique needs and toolkits to improve pediatric readiness at nonpediatric hospitals “are already available, so they could be implemented in the short term,” she added. But more research is needed to develop and validate interhospital transfer protocols.

“More generally, we really need better national data on trauma so we can identify opportunities for improvement and evaluate whether those improvements lead to better patient care,” said Moore.

She pointed to Quebec as an example of how system-level coordination can improve access. Quebec has a regionalized trauma system with 60 trauma centers, including three pediatric centers, thus ensuring good geographic coverage. The province also has implemented a standardized prehospital triage tool that considers children’s needs, and regional trauma systems have interhospital transfer agreements along with no-refusal policies.

Such system-level coordination, however, may be more difficult to assess and replicate nationally. Since funding of the Canadian National Trauma Registry was withdrawn in 2012, it has become more challenging to promote national improvements in injury care.

Investigating the Mechanisms

Commenting on the study for Medscape News Canada, Kazuhide Matsushima, MD, associate professor of clinical surgery at the Keck Medicine of USC, Los Angeles, said that the findings were not surprising, “given that there are less than 15 level I/II pediatric trauma centers in Canada, which is more or less in line with data in the United States.” Matsushima did not participate in the study.

“In addition to differences in the geographic coverage of pediatric trauma centers, future research should focus on elucidating all the potential underlying mechanisms on the interprovincial variations in access to pediatric trauma centers,” he said. “Certainly, province- or nationwide granular data will be required for those studies, and instead of conventional quantitative research, qualitative research such as focus group interviews with prehospital providers might help improve understanding of the current practice variations.”

While some studies suggest that pediatric trauma patients, particularly younger children, may have better outcomes when treated at standalone pediatric trauma centers vs adult or mixed trauma centers, geographic and systemic constraints make it crucial to identify clinical phenotypes that may benefit the most from care at pediatric trauma centers to optimize prehospital triage and guide interfacility transfer decisions.

“For example, previous studies observed significant outcome benefits related to the care at pediatric trauma centers in children with traumatic brain injury, and some data suggest that penetrating injury patients might do better at pediatric centers, although that is different from my own clinical experience,” said Matsushima.

The study was funded by the Canadian Institutes of Health Research and the Fonds de recherche du Québec — Santé. Moore and Matsushima reported having no relevant financial relationships.

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.