Perspectives of health professionals on the best care settings for pediatric trauma casualties: a qualitative study

Traumatic injury refers to physical injuries of sudden onset and severity which require immediate medical attention. Children are injured in a wide variety of geographic locations, and the involvement of local and regional centers is paramount to optimizing care for pediatric casualties [1]. The structure and care processes for critically-injured children vary [2]. In the USA, nearly 90% of children are seen in general emergency departments (EDs) [3] and many of them are treated in level I or level II adult trauma centers [4]. The majority of clinicians of all disciplines are understandably anxious when faced with a child presenting to a general ED [5]. Frequently, these children are treated by providers who lack specialty pediatric training in facilities that have not been modified for the care of children [6]. These factors impede the quality of care; it has been shown that younger and more seriously-injured children have better outcomes when treated at trauma centers located within children’s hospitals or at trauma centers that integrate pediatric and adult trauma services [1, 7, 8]. In Israel, there are 6 level I trauma centers and 14 regional trauma centers [9]; however there are no pediatric trauma centers and most injured children are treated in general EDs [10].

We examined the attitudes of policy makers, senior medical and nursing managers in the Israeli healthcare system, concerning the provision of medical care to pediatric trauma casualties in EDs.

The key characteristics of the 17 senior healthcare stakeholders that were interviewed are presented in Table 2.

We identified 3 major categories and 8 major sub-categories. These are summarized in Fig. 1 and described below. Representative quotes are provided in Table 3.

Pediatric patients are not small adults; their unique anatomy, physiology, and pathophysiology have to be considered in order to provide specialized care, especially during emergency situations. Their needs include practitioners trained in the care of children, specialized equipment, and appropriate resources for potential hospitalization and surgical intervention [14]. Previous studies related to the attitudes of healthcare professionals towards other aspects of pediatric emergency care, including family presence during resuscitation, or to the use of information technology in the ED [15]. To the best of our knowledge, this is the first study that assessed the perceptions and attitudes of healthcare professionals concerning the settings and resources required for providing optimal care to pediatric trauma casualties.

To provide optimal treatment to pediatric trauma casualties in the most appropriate setting and by the most suitable manager, the term “pediatric patient” should first be defined and should include the pediatric patient’s upper age cutoff. The definition of pediatric age varies greatly among hospitals in Israel due to various considerations [16]. The Israeli National Committee for the Management of Pediatric Multiple Casualty Incidents formed to improve the management of children involved in multiple casualty incidents, defined the upper age cutoff at 12 years [16]. There is also great variability in the definitions of pediatric patients in medical settings around the world. Some consider the upper age limit of pediatric patients as early as 12 years [2], some at 16 [3], others at 18–19 years of age [3, 17], and there are those who consider patients as old as 24 years to be young adults/adolescents that require specialized emergency care [17].

Further to defining the pediatric patient, it should be decided who would be the most appropriate care manager for pediatric trauma patients. The shortage in pediatric trauma professionals has led to situations where pediatric casualties are often treated by adult trauma physicians [18]. Indeed some studies have suggested that using adult general surgeons to care for pediatric patients may not result in optimal care given the lower number of pediatric cases being performed by general surgery trainees [19]. Although some of our interviewees thought that pediatric surgeons should be the case managers of pediatric trauma patients, most of them stated that management should reside with the pediatric emergency medicine expert. Both views can be supported by research findings. Pediatric surgeons have been credited with providing more accurate diagnoses and better long-term outcomes for pediatric trauma casualties [20, 21]. However, a larger body of research supports a leadership role for the pediatric emergency medicine specialist in the management of pediatric trauma care, using the pediatric surgeon as an ad-hoc consultant [22‐25]. This may be further supported by the shortage of pediatric surgeons in hospitals, as mentioned by the interviewees; they are often occupied in the operating rooms and are not available for treating trauma cases.

One element that evoked consensus among all study participants is the shortage in qualified staff that can provide around-the-clock optimal emergency care to pediatric trauma casualties. This is in line with previous findings that described the human resource as the single most important factor for a successful pediatric emergency care system [26, 27]. Implementation of an effective trauma team and trauma service was associated with a significant reduction in delayed diagnosis of injury team [28], decreased time required for ED treatment of severe trauma and improved survival [29]. In a recent publication, the American Committee on Pediatric Emergency Medicine stated that the scarcity of pediatric trauma care specialists, especially those with critical care training, constitutes a significant risk to children that have been afflicted by traumatic injuries and severely impedes the delivery of quality care [1]. This shortage and its severe implications have been previously described [3, 30].

There was a disagreement among the participants regarding the optimal setting for providing the best and most successful care for children with traumatic injuries. Several participants considered this to be general EDs, particularly for pediatric casualties with major trauma, because their staff comprises emergency medicine specialists, while others considered pediatric EDs to be the best suited for admitting these patients upon arrival. Presented with the option of a designated pediatric ED, many of the participants perceived that specialized centers should be the destination for all major pediatric trauma cases, citing that such a center would have a very high level of expertise and be equipped with the most cutting-edge medical technology [26, 31]. It has been suggested that pediatric patients and the elderly who are at risk for higher mortality from their injuries are subpopulations that would most likely benefit from more aggressive care in designated trauma centers [32, 33]. Studies examining the optimal trauma center type for children have mostly shown an outcome advantage for children treated at a pediatric trauma center or mixed trauma center as compared to those treated at adult trauma centers [34‐41]. Several studies have shown that children who were treated in pediatric trauma centers had higher success rates when treated conservatively [4, 42], shorter stays and consequently lower costs to the medical center [37, 43]. The Committee on Pediatric Emergency medicine recommended that the pediatric patient should be stabilized at the closest medical center and then transferred to a designated trauma center [1]. Controversial results on the effect of trauma center type on pediatric mortality were reported in several studies. Amini et al. [44] reported improved survival in children treated at pediatric trauma centers than those treated at all other levels of adult trauma centers. Potoka et al. [37] found improved survival for children treated at pediatric trauma centers and adult trauma centers with added qualifications in pediatrics than those treated at level I or level II adult trauma centers. Sherman et al. [45] reported improved survival for children treated at level I adult trauma centers and adult trauma centers with added qualifications in pediatrics when compared with those treated at pediatric trauma centers or level II adult trauma centers. Conversely, Osler et al. [46] did not find significant differences in pediatric trauma mortality between adult trauma centers and pediatric trauma centers.

Detractors of the designated pediatric trauma center approach claimed that it would prevent staff in other hospitals from experiencing pediatric trauma care and acquiring the skills needed for handling such cases. A solution for this is to have rotations of experts among EDs and designated pediatric EDs. This would enable medical teams to increase their exposure to pediatric trauma cases and to enhance and maintain their skills. Another layer of this discussion involved the physical location of the pediatric ED, i.e., whether severely injured children should be evacuated to a small number of centrally-located hospitals or whether such care should be dispersed over many geographical regions. Currently available research findings provide little in the way of concrete guidance on this matter, because of the difficulty of studying the centralization paradigm due to adjustments for case mix differences between specialty and non–specialty hospitals, a limited number of assessed outcomes, and failure to account for the quality of individual hospitals in the analysis.

Our participants were not unanimous regarding the type of training that is optimal for teams that treat pediatric trauma casualties. The prevailing notion among them was that the current level of training is sub-optimal and that training should be enhanced. In Israel there are no guidelines on the type of trauma training required by medical staff, and specifically nurses, who deal with trauma cases. Advanced trauma life support certification has become mandatory for all surgery residents [9]. As for nurses, the head nurse usually decides upon the type of training, which is commonly pediatric intensive care or pediatric emergency medicine. Similarly, the Committee on Pediatric Emergency Medicine of the American Academy of Pediatrics has found significant variability in pediatric training and experience among physicians and nurses working in EDs [1]. Researchers have determined that specialized training in pediatric emergency care is crucial for emergency medicine teams and that the initial training should be supplemented by periodic refresher courses. In fact, it was strongly recommended that specialized training be supported by renewable certifications [47].

Leaders in the field of pediatric trauma in Israel have long been aware that the current state of resource availability, management structure and personnel training in the field of emergency medicine are sub-optimal. This awareness has led to the formation of a subcommittee of the National Council on Emergency Medicine and Trauma in the Israeli Ministry of Health with the aim of issuing national-level recommendations for the improvement of management of pediatric trauma casualties in designated adult trauma centers, level II hospitals, and emergency medical systems in Israel. The committee was led by a pediatric emergency physician and, in addition, included: a trauma surgeon, a pediatric surgeon, a pediatric intensivist and hospital administrator, a pediatrician, the medical director of the ED and an additional pediatric emergency physician. The committee took into consideration the wide variability in pediatric trauma management among hospitals, and wrote, based on a comprehensive analysis of the Israeli national trauma registry, specific recommendations on the upper age cutoff, treatment site, team composition, infrastructure and equipment, educational and training programs as well as ways to preserve skills and knowledge acquired (Waisman Y, Kessel B, Herbertal M, et al.: Report of the task force on improving pediatric trauma systems of the National Council on Emergency Medicine and Trauma. Waisman Y, personal communication of unpublished data). These recommendations will be developed into a model of pediatric trauma causalities’ intake and care to be approved as guidelines by the Ministry of Health’s directive with the hope of improving outcomes and reducing disability of injured children.

One of the limitations of the study is that the views represented are specific to its 17 participants; however we believe that their positions as leaders in their fields make them appropriate representatives of their sectors. In addition, interpretation by reflection of responses was conducted by the authors through their professional and own opinions. Nonetheless, the researchers attempted to minimize the potential effect of the investigator’s personal biography by maintaining an investigator’s diary in which thoughts, feelings and subjective experiences that were raised during the study were listed, and by review of the interviews and analyses by an independent colleague in order to assist the preservation of the original context as given in the interviews. Further research will examine the views and perspectives of emergency medicine teams (physicians and nurses) working in EDs across Israel.

Our findings indicate that specialized pediatric EDs, located at a defined number of hospitals would constitute the best location for intake of children with major traumatic injuries. Pediatric emergency medicine specialists should manage trauma cases using pediatric surgeons as ad-hoc consultants. The term ‘pediatric patient’ should be defined to allow trauma patients to be referred to the most appropriate ED. Teams working at these EDs should undergo specialized pediatric emergency medicine training. Finally, to regulate the key aspects of trauma care, clear statutory guidelines should be formulated at the national and local levels.