England & Wales SEVERE INJURY IN CHILDREN

Transcription

1 England & Wales SEVERE INJURY IN CHILDREN January 215 December 216

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3 Contents Members of the Working Group... 4 Introduction... 5 Summary... 6 Data completeness... 7 Demographics... 8 Injury mechanism... 9 Road traffic collisions Injury type Time of arrival at hospital Month of arrival at hospital Mode of arrival at hospital Type of first admitting hospital Transfer between hospitals ICU / HDU admissions Definitive airway management Mortality rates Injuries associated with death Grade of most senior clinician in the ED Location and time to first surgery Glossary Appendix: Data tables and figures THE TRAUMA AUDIT AND RESEARCH NETWORK 3

4 The TARNlet Committee Mr Ross Fisher Chairman of TARNlet Consultant in Paediatric Surgery Sheffield Children s NHS Foundation Trust Samantha Jones Major Trauma Co ordinator/ Academic Clinical Fellow Royal Manchester Children s Hospital Professor Tim Coats Professor of Emergency Medicine University of Leicester Professor Fiona Lecky Professor of Emergency Medicine University of Sheffield Miss Naomi Davis Consultant in Paediatric Orthopaedic Surgery Royal Manchester Children s Hospital Dr Ciara Martin Consultant in Emergency Medicine The Adelaide and Meath Hospital, Incorporating The National Children's Hospital, Tallaght, Dublin Dr Patrick Davies Consultant in Paediatric Intensive Care Nottingham Children's Hospital Dr Samantha Negus Paediatric Radiologist Surrey and Sussex Hospitals NHS Trust Dr Lorcan Duane Consultant in Emergency Medicine Royal Manchester Children s Hospital Mr Roberto Ramirez Consultant in Paediatric Neurosurgery Royal Manchester Children s Hospital Antoinette Edwards Executive Director The Trauma Audit & Research Network Miss Alice Roberts Patient & Public Representative Dr Chris Fitzsimmons Consultant in Emergency Medicine Sheffield Children s NHS Foundation Trust Dr Damian Roland Consultant and Honorary Associate Professor in 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. 4 THE TRAUMA AUDIT AND RESEARCH NETWORK

5 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 ( 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 3 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 to 75). Links to the details of these scoring systems are on the TARN website ( 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 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 215 to December 216 in England & Wales, and comparing these data with that produced in the last report on data from 213 and 214. The Trauma Audit and Research Network (TARN) registry contains information on 593 children under the age of 16 injured from January 215 to December 216, as compared with data on 4886 in 213/14. All children attending ED following injury (approximately 4 million) All children in the TARN database n = 593 ISS 1 to 8 n = 667 ISS 9 to 15 n = 288 ISS > 15 n = 1618 Figure 1 (January 215 December 216 data) This report concentrates on the 1618 children recorded in the TARN database from January 215 to December 216 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 213/14 report which found 1511 children with ISS > 15 (estimated case ascertainment of 8.7%). THE TRAUMA AUDIT AND RESEARCH NETWORK 5

6 Summary During January 215 to December 216 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 1% of all major trauma in childhood). Trauma systems need to be refocussed to account for the way in which NAI presents 1, 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 215;32: doi:1.1136/emermed THE TRAUMA AUDIT AND RESEARCH NETWORK

7 Case ascertainment All Submissions Submissions of patients that died Trust n HES Ascertainment Deaths HES Ascertainment England & Wales % % 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 215 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 1%). 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=593). 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 children had severe injuries with an injury severity score (ISS) of > 15 and 114 of these (represented by 118 submissions) died of those injuries. THE TRAUMA AUDIT AND RESEARCH NETWORK 7

8 Demographics of severely injured children 215/16 Age breakdown by year 25 2 Percentage of patients < 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 Percentage of patients < Age (months) 8 THE TRAUMA AUDIT AND RESEARCH NETWORK

9 Injury Mechanism Percentage of patients /14 215/16 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. THE TRAUMA AUDIT AND RESEARCH NETWORK 9

10 Proportion deaths by injury mechanism Percentage of patients /14 215/16 Case fatality rate by Injury Mechanism Case Fatality Rate (%) /14 215/16 1 THE TRAUMA AUDIT AND RESEARCH NETWORK

11 Injury Mechanism by age Percentage of patients < 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. THE TRAUMA AUDIT AND RESEARCH NETWORK 11

12 Patients injured in a road traffic incident 6 5 Percentage of patients Pedestrian Cyclist Vehicle occupant Motorcyclist/Quad biker /14 215/16 Not Known 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 2% 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 Percentage of patients Pedestrian Cyclist Vehicle occupant Motorcyclist/Quad biker /14 215/16 Not Known 12 THE TRAUMA AUDIT AND RESEARCH NETWORK

13 Mortality rate of patients injured in a road traffic incident 6 5 Percentage of patients Pedestrian Cyclist Vehicle occupant Motorcyclist/Quad biker /14 215/16 Not Known THE TRAUMA AUDIT AND RESEARCH NETWORK 13

14 Injury Type (AIS 3+) 215/16* Percentage of patients Head Injury 3+ Thoracic Injury 3+ Abdominal Injury 3+ Limb / Pelvis Injury Polytrauma** 3+ Spinal 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 14 THE TRAUMA AUDIT AND RESEARCH NETWORK

15 Average number of patients arriving per hour 215/ 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. THE TRAUMA AUDIT AND RESEARCH NETWORK 15

16 Presentation by month Percentage of patients 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. 16 THE TRAUMA AUDIT AND RESEARCH NETWORK

17 Mode of arrival to hospital Direct admissions only (n = 1,326) Percentage of patients 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. THE TRAUMA AUDIT AND RESEARCH NETWORK 17

18 Type of first admitting hospital* 6 5 Percentage of patients Children's MTC Adult & Children's MTC Adult MTC Trauma Unit 213/14 215/16 Just over half of severely injured children are initially treated in a Trauma Unit, with only about 4% 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). 18 THE TRAUMA AUDIT AND RESEARCH NETWORK

19 Proportion of Patients initially admitted to a Trauma Unit by Age Percentage of patients < 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. THE TRAUMA AUDIT AND RESEARCH NETWORK 19

20 Patients initially admitted to a Trauma Unit by ISS 6 5 Percentage of patients to to 49 5 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>5 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. 2 THE TRAUMA AUDIT AND RESEARCH NETWORK

21 Transfer from initial hospital of children ISS>15 Transfer to: Initial site Adult MTC Children's MTC TU No transfer Adult MTC (n=126) 2 (.1%) 62 (3.8%) 21 (1.3%) 41 (2.5%) Children's MTC (n=671) 2 (.1%) 14 (.9%) 39 (2.4%) 616 (38.1%) TU (n=821) 6 (.4%) 52 (32.1%) 87 (5.4%) 28 (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 Percentage of patients < 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. THE TRAUMA AUDIT AND RESEARCH NETWORK 21

22 Patients admitted to ICU / HDU Percentage of patients /14 215/16 About half of severely injured children require ICU/HDU admission, a proportion that has remained constant across the three reports since THE TRAUMA AUDIT AND RESEARCH NETWORK

23 Definitive airway management 215/16 Direct admissions to hospital* n = 1326 Number of children with definitive airway management n = 441 (33.3%) Pre hospital n = 156 (35.4%) ED 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.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) Total length of stay in critical care (days) Average length of stay Length of stay Median days Interquartile range (days) LOS** LOS, patients transferred LOS in ICU/HDU LOS, patients that went to ICU / HDU **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 212 and 214 Reports. THE TRAUMA AUDIT AND RESEARCH NETWORK 23

24 Mortality Category Total number of cases ISS>15 Number of deaths Mortality % 95% confidence interval Lower Upper All admissions % All admissions with GCS < % Final outcome is unknown for 14 of the 1618 (6%) patients due to missing data. The crude mortality is similar to 212 and 214. 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 Proportion of all deaths (%) 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. 24 THE TRAUMA AUDIT AND RESEARCH NETWORK

25 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 (2.7%) 3 (42.9%) 1 (13.3%) 1 (4.8%) Limbs 9 (1.3%) 3 (25%) 9 (13.8%) 2 (2%) 11 (8.3%) Pelvis 6 (3%) 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. 1 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. THE TRAUMA AUDIT AND RESEARCH NETWORK 25

26 Patients seen by a consultant in ED Percentage of patients Children's MTC Adult MTC TU /14 215/16 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. 26 THE TRAUMA AUDIT AND RESEARCH NETWORK

27 Percentage of patients seen by consultant in ED by time of day (212 to 216) 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. THE TRAUMA AUDIT AND RESEARCH NETWORK 27

28 Location of first surgery (212 to 216) Percentage of patients 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 (212 to 216) Median hours to operation 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. 28 THE TRAUMA AUDIT AND RESEARCH NETWORK

29 Glossary AIS AIS 3+ Child Definitive Airway Management Direct admissions GCS HDU HES ICU ISS LOS MTC NAI Polytrauma TARN TARNlet TU Abbreviated Injury Scale score. A value between 1 (minor) and 6 (fatal) is assigned to each injury. Injuries with an AIS severity score of 3 or more. A patient up to the age of 16 years Intubation, cricothyroidotomy or tracheostomy. Describes care in the first treating hospital. 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. High Dependency Unit 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. Intensive Care Unit 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). Length of Stay. Calculated from the date of admission to hospital/icu/hdu to the date of discharge from hospital/icu/hdu. Major Trauma Centre Non Accidental Injury AIS 3+ injuries in more than one body region. The Trauma Audit & Research Network. 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. Trauma Unit THE TRAUMA AUDIT AND RESEARCH NETWORK 29

30 Grades of Doctor Consultant Associate Specialist ST3 and above Consultant Associate Specialist 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 3 THE TRAUMA AUDIT AND RESEARCH NETWORK

31 Appendix: Data tables and figures Table 1: Demographics of severely injured children Age (Years) Number of severely injured children (%) Total 1618 age < (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 7 (4.3%) 8 7 (4.3%) 9 68 (4.2%) 1 62 (3.8%) (5.4%) (6.7%) (6.8%) (7.4%) (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 (1.5%) 4 27 (7.9%) 5 34 (9.9%) 6 23 (6.7%) 7 21 (6.1%) 8 8 (2.3%) 9 14 (4.1%) 1 15 (4.4%) 11 9 (2.6%) THE TRAUMA AUDIT AND RESEARCH NETWORK 31

32 Table 3: Injury mechanism Category /14 215/16 Road Traffic Collision 34 (4.5%) 628 (41.6%) 642 (39.7%) Fall < 2m 154 (2.5%) 35 (2.2%) 377 (23.3%) Fall > 2m 16 (14.1%) 175 (11.6%) 163 (1.1%) NAI under 2 years 77 (1.3%) 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 (.5%) 12 (.8%) 18 (1.1%) Table 4: Proportion deaths by injury mechanism (case with known outcome only) Category /14 215/16 Road Traffic Collision 32 (47.1%) 4 (33.6%) 47 (41.2%) Fall < 2m 5 (7.4%) 1 (.8%) 3 (2.6%) Fall > 2m 1 (1.5%) 4 (3.4%) 4 (3.5%) NAI under 2 years 7 (1.3%) 1 (8.4%) 7 (6.1%) Blunt assault 1 (1.5%) 12 (1.1%) 8 (7%) Other (eg. sport) 2 (2.9%) 5 (4.2%) 1 (.9%) Asphyxia 12 (17.6%) 25 (21%) 27 (23.7%) Drowning 7 (1.3%) 2 (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 /14 215/16 Road Traffic Collision 32 (12.3%) 4 (6.9%) 47 (7.7%) Fall < 2m 5 (3.9%) 1 (.4%) 3 (.8%) Fall > 2m 1 (1.1%) 4 (2.5%) 4 (2.7%) NAI under 2 years 7 (11.5%) 1 (7.8%) 7 (4.5%) Blunt assault 1 (2.2%) 12 (1.8%) 8 (5.9%) Other (e.g. sport) 2 (8.7%) 5 (14.7%) 1 (3.3%) Asphyxia 12 (7.6%) 25 (78.1%) 27 (71.1%) Drowning 7 (7%) 2 (45.5%) 14 (58.3%) Penetrating 1 (33.3%) 2 (2%) 3 (16.7%) 32 THE TRAUMA AUDIT AND RESEARCH NETWORK

33 Table 6: Patients injured in a road traffic collision Category /14 215/16 Pedestrian 154 (5.7%) 312 (49.7%) 299 (46.6%) Cyclist 72 (23.7%) 149 (23.7%) 163 (25.4%) Vehicle occupant 61 (2.1%) 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 (.9%) Table 7: Proportion road traffic deaths by position in vehicle (case with known outcome only) Category /14 215/16 Pedestrian 11 (34.4%) 24 (6%) 32 (68.1%) Cyclist 8 (25%) 7 (17.5%) 6 (12.8%) Vehicle occupant 13 (4.6%) 7 (17.5%) 9 (19.1%) Motorcyclist/Quad biker (%) 2 (5%) (%) Not Known (%) (%) (%) Table 8: Mortality of patients injured in a road traffic collision (cases with known outcome only) Category /14 215/16 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 (%) 2 (6.5%) (%) Not Known (%) (%) (%) THE TRAUMA AUDIT AND RESEARCH NETWORK 33

34 Table 9: AIS 3+ injuries Anatomical injury location Number of patients with this injury (%) 3+ Head Injury 1186 (73.3%) 3+ Thoracic Injury 36 (22.2%) 3+ Abdominal Injury 217 (13.4%) 3+ Limb / Pelvis Injury 28 (12.9%) Polytrauma 119 (7.4%) 3+ Spinal Injury 84 (5.2%) Table 1: Average number of patients arriving per hour Hour Weekday Weekend THE TRAUMA AUDIT AND RESEARCH NETWORK

35 Table 11: Patients per month Month Number of severely injured children (%) January 95 (5.9%) February 95 (5.9%) March 13 (8%) April 122 (7.5%) May 167 (1.3%) June 167 (1.3%) July 184 (11.4%) August 155 (9.6%) September 172 (1.6%) 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 78 (58.8%) Helicopter 27 (15.6%) Other* 339 (25.6%) Table 13: Type of first admitting hospital Category 213/14 215/16 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 (5.7%) Table 14: Patients initially admitted to a Trauma Unit by ISS ISS band Number of severely injured children (%) 15 to (56.3%) 25 to (46.2%) 5 to 75 1 (22.2%) THE TRAUMA AUDIT AND RESEARCH NETWORK 35

36 Table 15: Patients admitted to ICU / HDU Year Admitted to ICU /HDU (%) (46.9%) 213/14 86 (52.3%) 215/ (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 (.9%) Other 1 (.9%) Table 17: Most senior doctor in ED (direct admissions only) Most senior in ED Number of cases (%) All Children's MTC TU Adult MTC Consultant 971 (73.2%) 592 (88.8%) 3 (54.6%) 79 (71.8%) Associate Specialist 22 (1.7%) 3 (.4%) 14 (2.6%) 5 (4.5%) ST (8.7%) 26 (3.9%) 77 (14%) 13 (11.8%) FY / ST (4.8%) 13 (1.9%) 48 (8.7%) 2 (1.8%) Other / Not recorded 154 (11.6%) 33 (4.9%) 11 (2%) 11 (1%) Total Table 18: Patients seen by a consultant in ED Category /14 215/16 Children's MTC 232 (86.9%) 542 (89.3%) 592 (88.8%) Adult MTC 48 (85.7%) 93 (8.9%) 79 (71.8%) TU 132 (55.9%) 276 (57.5%) 3 (54.6%) 36 THE TRAUMA AUDIT AND RESEARCH NETWORK

37 Table 17: Location of first surgery Category Total Children's MTC Adult MTC TU All surgery, ISS > (85.8%) 36 (6.3%) 45 (7.9%) Abdominal surgery (69.2%) 5 (7.7%) 15 (23.1%) Cardiothoracic surgery 25 2 (8%) 1 (4%) 4 (16%) Neurosurgery (89.1%) 19 (6.9%) 11 (4%) Orthopaedic surgery (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 > ( ) 2.5 ( ) 3.5 ( ) Abdominal surgery ( ) 3 (3 3.4) 3.5 ( ) Cardiothoracic surgery (.9 2.8).8 (.7.9) Neurosurgery ( ) 2.3 (1.8 3) 1.7 (1.3 4) Orthopaedic surgery ( ) 3.5 ( ) 7.2 ( ) THE TRAUMA AUDIT AND RESEARCH NETWORK 37