England & Wales 2 YEARS OF SEVERE INJURY IN CHILDREN

Transcription

1 England & Wales 2 YEARS OF SEVERE INJURY IN CHILDREN January 2013-December 2014

2 THE TRAUMA AUDIT AND RESEARCH NETWORK

3 The TARNlet Committee Mr Ross Fisher Co-chairman of TARNlet Consultant in Paediatric Surgery Sheffield Children s NHS Foundation Trust Dr Ian Maconochie Co-chairman of TARNlet Consultant in Paediatric Emergency Medicine Imperial College Healthcare NHS Trust Professor Tim Coats Professor of Emergency Medicine University of Leicester Dr Naomi Davis Consultant in Paediatric Orthopaedic Surgery Royal Manchester Children s Hospital Dr Lorcan Duane Consultant in Emergency Medicine Royal Manchester Children s Hospital Antoinette Edwards Operations Director, Deputy to the Executive Director The Trauma Audit & Research Network Dr Chris Fitzsimmons Consultant in Emergency Medicine Sheffield Children s NHS Foundation Trust Nathan Griffiths Paediatric Nurse Consultant Salford Royal NHS Foundation Trust Professor Fiona Lecky Professor of Emergency Medicine University of Sheffield Dr Ciara Martin Consultant in Emergency Medicine The Adelaide and Meath Hospital, Incorporating The National Children s Hospital, Tallaght, Dublin Dr Samantha Negus Radiologist St George s University Hospitals NHS Foundation Trust Mr Roberto Ramirez Consultant in Paediatric Neurosurgery Royal Manchester Children s Hospital 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, Program Developer and Registry Manager at the Trauma Audit and Research Network. 2 YEARS OF SEVERE INJURY IN CHILDREN 1

4 Contents 3 Introduction 4 Summary 6 Data completeness 7 Demographics 8 Injury mechanism 9 Patients injured in road traffic incident 10 Injury type 11 Time of arrival at hospital 12 Month of arrival at hospital 13 Mode of arrival at hospital 14 Type of first admitting hospital 15 Transfer between hospitals 16 ICU / HDU admissions 17 Definitive airway management & Length of stay in hospital 18 Mortality rates 19 Injuries associated with death 20 Interaction of AIS 3+ injuries & associated mortality 21 Grade of most senior clinician in the ED 22 Grade of most senior clinician involved in surgery 23 Time to first surgery from arrival 24 Glossary 2 THE TRAUMA AUDIT AND RESEARCH NETWORK

5 Introduction This is the second report produced by the TARNlet committee, providing data on children with severe injury from January 2013 to December 2014 in England & Wales, and comparing these data with that produced in the first report on data from The Trauma Audit and Research Network (TARN) registry contains information on over 5,402 children under the age of 16 injured from January 2013 to December 2014, as compared with data on 4,720 in The TARNlet committee is comprised of clinicians, managers and academics who are involved in the management of children who have sustained injury and are keen that this resource should be used to improve the care of paediatric trauma cases; in this report data have been interpreted to suggest guidance towards prevention of injury, or that networks of care could be reviewed to see if further improvement for the delivery of services to children could be achieved. 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 ISS > 15 n = 1,511 All children in the TARN database n = 5,402 All children attending ED following injury Figure 1 (January 2013-December 2014 data). Injury produces a significant health burden for children, being a leading cause of both death and disability, with the numbers of different severities being shown above. In 2012, there were 737 children with ISS > 15 within the TARN database, similar to the numbers per year in this report. Estimates of children attending with trauma to EDs vary between 30-60% of their total workloads, depending on the location of the ED, with rural EDs seeing more trauma than inner city ones. The overall picture is that there are about 4 million attendances by children to EDs each year. This report concentrates on the 1,511 recorded children from January 2013 to December 2014 who sustained the most serious injuries - an injury severity score (ISS) greater than 15. The true figure may be higher than this but, as will be seen, the completeness of data transfer from hospitals reporting to TARN continues to improve. 2 YEARS OF SEVERE INJURY IN CHILDREN 3

6 2 Years of Severe Injury in Children Summary During January 2013 to December 2014 there were 1,511 severely injured children treated in England & Wales. Road traffic incidents and resulting head injuries still predominate as the major causes of severe injury and mortality; however, as a proportion of injury mechanisms, asphyxia and drowning have the highest percentages for death. 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). Many of the same data sets that were provided in the 2012 report have been repeated so allowing for comparisons over time to be made.these are detailed below. Other additional data sets have been included in the report, for example a new feature is the division of the injury type from 3 categories in 2012 to 6 which separates out polytrauma, spinal injury, and divides the previous category of thoracic/abdominal into 2 distinct categories (Page 10). Additional data sets include: 1. The numbers and proportion of children with definitive airway management (and where this occurred) 2. When a definitive airway was secured 3. The length of stay in hospital 4. Mortality data where cause of death was known 5. The most severe injury pattern associated with the death 6. Interaction of injuries with the risk of mortality 7. The grade of surgeon involved with operations 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 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. COMPARISONS OF 2012 WITH The data from shows many similarities with 2012, with an improved completeness of data returned by TARN involved hospitals, from 73.7% to 80.7%. The number of severely injured children is similar on a yearly basis, with a similar picture of seasonality (from April to October) and with more cases occurring at weekends and in the afternoon and evenings. The pattern of arrival of severely injured children implies that staffing 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. This may play a part in resource implications for Major Trauma Centres in terms of staffing, but nonetheless, optimally trained staff should be available to ensure the best care that can be given. It is still worrying that about 25% of severely injured children are taken by transport means other than ambulance or helicopter, meaning that many parents/carers are taking these children to Trauma Units, so adding to the delay for definite treatment to be delivered. Trauma systems need to anticipate that children will continue to arrive at Trauma Units or nondesignated hospitals and have systems to ensure that children are not disadvantaged by initially presenting to the wrong hospital. There is a public health message that needs to get to parents and carers about the trauma network; time to definite treatment may be reducible in severely injured children by the use of prehospital triage systems. Staff in all hospitals need sufficient ongoing 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. 4 THE TRAUMA AUDIT AND RESEARCH NETWORK

7 Severe traumatic brain injury is still the leading numeric cause associated with death, but new categories for the mechanism of trauma show that proportionately asphyxia and drowning have high relative risks for mortality. Again, a public health policy aimed at reducing these mechanisms could be conceived with any effects being monitored in future TARN publications. Common themes in the first and this report on trauma are that more males are severely injured, non-accidental injury still makes up about 10% of the causes for severe injury (under the age of 2 years) further work may be undertaken to drill down into this important and possibly reducible cause of morbidity 1. The other peak for severe trauma lies between 6 to 13 years (Page 7), when looking at both reports. Road traffic incidents are high on the list for causing severe injury too, accounting for about 40% consistently across the years. About half of the children are involved as pedestrians, and cyclists are recorded as being 20% of these road traffic incident figures. Time to surgery is related to outcome therefore an efficient transport and transfer system that minimises delays is important for those children who have not been brought to a centre where the appropriate management can be conducted. 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: doi: /emermed YEARS OF SEVERE INJURY IN CHILDREN 5

8 Trauma in children Data Completeness All Submissions Deaths Trust n HES Completion % Deaths HES Completion % England & Wales 5,402 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 2013 Hospital Episode Statistics (HES) dataset. The HES dataset is used as a general baseline. These data refer 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 4,802 children who met the TARN entry criteria admitted to hospitals in the area covered by this report. 1,511 children had severe injuries that were assigned an injury severity score (ISS) of more than 15 and 119 died of those injuries. 6 THE TRAUMA AUDIT AND RESEARCH NETWORK

9 Demographics of severely injured children Age (Years) Number of severely injured children (%) Total 1,511 (100%) age < (20.3%) (11.4%) (13.4%) (20.2%) (17.8%) (16.9%) Median Age (IQR) 6.5 ( ) Gender and Median ISS Male (percentage) 68.6 Female (percentage) 31.4 Median ISS (Interquartile Range) 16 (16-25) Percentage of patients age <1 year age 1-2 years age 3-5 years age 6-10 years age years age years 2013 & Two thirds of injured children are male. There is a peak in the first year of life followed by another from 6 years old. 2 YEARS OF SEVERE INJURY IN CHILDREN 7

10 Injury Mechanism Mechanism Number of cases (%) Road Traffic Incident 628 (41.6%) Fall < 2m 305 (20.2%) Fall > 2m 175 (11.6%) NAI under 2 years 147 (9.7%) Blows 90 (6%) Drowning 46 (3%) Asphyxia 35 (2.3%) NAI over 2 years 31 (2.1%) Other (e.g. sport) 42 (2.8%) Penetrating 12 (0.8%) Total 1,511 (100%) Percentage of patients Road Traffic Fall < 2m Fall > 2m NAI Blows Drowning Asphyxia NAI Other Penetrating Incident under 2 years over 2 years (e.g. sport) 2013 & Analysis of injury mechanism data shows a preponderance of road traffic incidents and falls of less than 2 metres. 9.7% of patients were injured intentionally (Non-Accidental Injury) and were under 2 years of age. 8 THE TRAUMA AUDIT AND RESEARCH NETWORK

11 Breakdown of patients injured in road traffic incident Road traffic incident Number of cases (%) Pedestrian 312 (49.7%) Cyclist 149 (23.7%) Vehicle occupant 122 (19.4%) Motorcyclist/Quad biker 38 (6.1%) Not known 7 (1.1%) Total 628 (100%) Percentage of patients Pedestrian Cyclist Vehicle Occupant Motorcyclist/ Not known Quad Biker 2013 & YEARS OF SEVERE INJURY IN CHILDREN 9

12 Injury Type (AIS 3+)* Anatomical injury location Number of patients with this injury (%) 3+ Head 1,122 (74.2%) 3+ Thoracic 306 (20.2%) 3+ Abdominal 197 (13%) 3+ Limb / Pelvis 172 (11.4%) Polytrauma** 106 (7%) 3+ Spinal 71 (4.7%) Percentage of patients Head Injury 3+ Thoracic Injury 3+ Abdominal 3+ Limb/Pelvis Polytrauma 3+ Spinal Injury Injury Injury 2013 & 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. *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. **AIS 3+ injuries in multiple body regions 10 THE TRAUMA AUDIT AND RESEARCH NETWORK

13 Arrival time at hospital Hour Weekday Weekend Hour Weekday Weekend Average number of severely injured children attending by hour and day of week during 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 /14 weekday 2013/14 weekend 2012 weekday 2012 weekend 2 YEARS OF SEVERE INJURY IN CHILDREN 11

14 When children with severe injuries present by month Month Number of severely injured children (%) January 104 (6.9%) February 80 (5.3%) March 123 (8.1%) April 137 (9.1%) May 135 (8.9%) June 170 (11.3%) July 161 (10.7%) August 167 (11.1%) September 141 (9.3%) October 104 (6.9%) November 92 (6.1%) December 97 (6.4%) Total 1,511 (100%) Percentage of patients January February March April May June July August September October November December 2013 & THE TRAUMA AUDIT AND RESEARCH NETWORK

15 Mode of arrival at hospital Direct admissions only = 1,169 Mode of transport Number of severely injured children (%) Ambulance 657 (56.2%) Helicopter 200 (17.1%) Arrived by other means (e.g. car) 312 (26.7%) Total 1,169 (100%) Percentage of patients Arrived by ambulance Arrived by helicopter Arrived by other means (eg. car) 2013 & A large proportion of 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 the trauma system must anticipate that more than a quarter of patients will continue to arrive at the nearest hospital (which may or may not be part of the trauma system). For some children there is no information recorded about their initial hospital stay, including their mode of arrival. 2 YEARS OF SEVERE INJURY IN CHILDREN 13

16 Type of first admitting hospital First admitting hospital Number of severely injured children (%) Adult & Children s MTC* 411 (27.2%) Adult MTC* 122 (8.1%) Children s MTC* 195 (12.9%) Trauma Unit 783 (51.8%) Total 1,511 (100%) Percentage of patients Adult & Children s MTC* Adult MTC* Children s MTC* Trauma Unit 2013 & *MTC - Major Trauma Centre Just under 50% of children are initially treated in a specialist paediatric or adult major trauma centre whilst over half are still 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. There is an important public health message that should be disseminated to the parents and carers of children. 14 THE TRAUMA AUDIT AND RESEARCH NETWORK

17 Transfer between hospitals Type of hospital where severely injured children were admitted Number of cases (%) Multiple hospitals, not MTC* 62 (4.1%) Multiple hospitals, adult MTC* 17 (1.1%) Multiple hospitals, children s MTC* 661 (43.8%) Single hospital, not MTC* 151 (10%) Single hospital, adult MTC* 48 (3.2%) Single hospital, children s MTC* 572 (37.8%) Total 1,511 (100%) Percentage of patients 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* 2013 & *MTC - Major Trauma Centre Most children are eventually cared for in an appropriate hospital with few remaining outside of the Major Trauma Centres. This emphasises once more the importance of the transfer system and should promote an assessment by the network of the location of specialist paediatric services. 2 YEARS OF SEVERE INJURY IN CHILDREN 15

18 ICU / HDU admissions Patient group by anatomical injury Total number of severely injured children Number (%) All patients 1, (52.6%) Polytrauma* (62.3%) Isolated AIS 3+ thoracic injuries (58.2%) Isolated AIS 3+ head injuries (45.6%) Isolated AIS 3+ limb / pelvic injuries (42.9%) Isolated AIS 3+ abdominal injuries (36.9%) *AIS 3+ injuries in multiple body regions The percentage values represent the proportion of patients in each group that visited ICU/HDU Percentage of patients All patients Polytrauma* Isolated AIS 3+ Isolated AIS 3+ Isolated AIS 3+ Isolated AIS 3+ thoracic injuries head injuries limb / pelvic injuries abdominal injuries 2013 & THE TRAUMA AUDIT AND RESEARCH NETWORK

19 Definitive airway management Direct admissions to hospital = 1,169 Number (%*) Number of children with definitive airway management 444 (38%) Pre-hospital 131 (8.7%) ED 313 (20.7%) Median hours to definitive airway management from incident (Interquartile Range) 1.2 hours ( ) *The percentage values shown here for patients with definitive airway management pre-hospital and in the ED use the total number of patients with definitive airway management as the denominator. Definitive airway management is defined as intubation, cricothyroidotomy or tracheostomy. Length of stay in hospital n = 1,511 Length of stay Median days Interquartile range (days) LOS** (IQR) LOS, patients transferred (IQR) LOS in ICU/HDU (IQR) LOS, patients that went to ICU/HDU (IQR) **Length of stay is 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. 2 YEARS OF SEVERE INJURY IN CHILDREN 17

20 Mortality Confirmed cases of death analysed in relation to injury type and mechanisms Category Total number Number of Mortality* 95% confidence of cases of deaths due % interval severely injured to severe children injury Lower Upper All admissions 1, % of which have a GCS < % Injury Type AIS 3+ head injuries 1, % AIS 3+ limb / pelvis / spine injuries % AIS 3+ thoracic / abdominal injuries % Polytrauma % Injury Mechanism Asphyxia % Blows % Drowning % Fall < 2m % Fall > 2m % NAI over 2 years % NAI under 2 years % Other (e.g. sport) % Penetrating % Road Traffic Incident % Total 1, *As a proportion of all severely injured children in that category In absolute numbers, severe traumatic brain injury is the most common injury type to cause death, but as a proportion for the mechanism of mortality, asphyxia and drowning have the highest percentages. This information is important when considering public health measures. 130 children (8.6%) were transferred out where final outcome is unknown. 18 THE TRAUMA AUDIT AND RESEARCH NETWORK

21 Most severe injury associated with death Category Total number Number of Mortality* 95% confidence of cases deaths % interval Lower Upper Head % Asphyxia % Drowning % Abdomen % Polytrauma % Chest % Other % Spine % Limbs % Total 1, *As a proportion of all severely injured children in that category Number of deaths Head Asphyxia Drowning Abdomen Polytrauma Chest Other Spine Limbs Head injury is the most important injury in fatal paediatric trauma, although there is a significant contribution from asphyxia, drowning and polytrauma. 2 YEARS OF SEVERE INJURY IN CHILDREN 19

22 Interaction of AIS 3+ injuries & associated mortality Head Spine Chest Abdomen Limbs Pelvis Head 11 (27.5%) 30 (19.9%) 10 (34.5%) 10 (12.2%) 2 (16.7%) Spine 11 (27.5%) 6 (21.4%) 4 (50%) 2 (22.2%) 1 (25%) Chest 30 (19.9%) 6 (21.4%) 12 (16.2%) 10 (17.9%) 2 (10.5%) Abdomen 10 (34.5%) 4 (50%) 12 (16.2%) 1 (6.7%) 1 (11.1%) Limbs 10 (12.2%) 2 (22.2%) 10 (17.9%) 1 (6.7%) 1 (6.3%) Pelvis 2 (16.7%) 1 (25%) 2 (10.5%) 1 (11.1%) 1 (6.3%) Values are in the format of; number of patients that died (mortality %) within each category i.e. 12 patients with AIS 3+ injuries to the chest and abdomen died representing a mortality rate of 16.2% for patients in this group. Please note patients may appear in multiple groups. 20 THE TRAUMA AUDIT AND RESEARCH NETWORK

23 Most senior clinician in the ED Direct admissions to hospital = 1,169 Most senior in ED Number of cases (%) All Children s MTC TU Adult MTC Consultant 894 (76.5%) 534 (90.1%) 269 (57.8%) 91 (82%) Associate Specialist 34 (2.9%) 29 (6.2%) 5 (4.5%) ST3 and above 103 (8.8%) 38 (6.4%) 58 (12.5%) 7 (6.3%) FY / ST (6.5%) 15 (2.5%) 58 (12.5%) 3 (2.7%) Other / Not recorded 62 (5.3%) 6 (1%) 51 (11%) 5 (4.5%) Total 1,169 (100%) 593 (100%) 465 (100%) 111 (100%) All patients directly admitted visited the ED Percentage of patients Consultant Associate Specialist ST FY/ST 1-2 Other/not recorded 2013 & % of severely injured children were resuscitated by consultants, 49% were seen by a paediatric specialist in the ED. 2 YEARS OF SEVERE INJURY IN CHILDREN 21

24 Grade of most senior clinician involved in patient s first operation during the time in hospital Direct admissions to hospital All operations n = 305 Category Consultant Associate ST3 and FY / ST 1-2 Other / Not Specialist above recorded Grade of surgeon 225 (73.7%) 2 (0.7%) 65 (21.3%) 9 (3.0%) 4 (1.3%) Grade of paediatric surgeon* 39 (72.2%) 0 (0%) 12 (22.2%) 2 (3.7%) 1 (1.9%) Grade of anaesthetist 202 (66.2%) 2 (0.7%) 56 (18.4%) 10 (3.3%) 35 (11.5%) *Paediatric surgeons are a subset of all surgeons with a paediatric speciality Percentage of patients Consultant Associate Specialist ST3 and above FY / ST 1-2 Other / Not recorded Grade of surgeon Grade of paediatric surgeon Grade of anaesthetist 73.7% of all operations were carried out by consultants, 72.2% of those operations carried out by paediatric specialists were performed by consultants and 66.2% of severely injured children were anaesthetised for their operation by a consultant anaesthetist. 22 THE TRAUMA AUDIT AND RESEARCH NETWORK

25 Time to first surgery from arrival at hospital Direct admissions to hospital Category* Number of severely Median hours Interquartile injured children with to operation range (hours) operations recorded All surgery, ISS > Abdominal surgery Cardiothoracic surgery Neurosurgery Orthopaedic surgery Median Hours To All surgery, ISS > 15 Neurosurgery Abdominal surgery Cardiothoracic surgery Orthopaedic surgery 2013 & *Patients can appear 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. 2 YEARS OF SEVERE INJURY IN CHILDREN 23

26 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 under 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. These data are 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 Grades of Doctor Consultant Associate Specialist ST3 and above FY / ST 1-2 Other / Not recorded Consultant Associate Specialist Specialist Registrar, Speciality Trainee, Clinical Fellow, Senior Registrar, Staff Grade Foundation Year / Speciality Trainee 1-2 / Trust Grade Not known / recorded, Nurse Consultant, Advanced Practitioner 24 THE TRAUMA AUDIT AND RESEARCH NETWORK

27 2 YEARS OF SEVERE E INJURY IN CHILDREN

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