Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers

Abstract

Importance: Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear.

Objective: To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children.

Design, setting, and participants: This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022.

Exposures: Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]).

Main outcomes and measures: In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality.

Results: This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives).

Conclusions and relevance: These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.

Figure 1.. Children Receiving Care in US Emergency Departments (EDs) With High Pediatric Readiness Based on Actual and Potential Receiving Trauma Centers (N = 212 689)

The x-axis is organized from left to right, starting with the actual receiving trauma center, then based on trauma center proximity to the injury location (closest to farthest). Each point on the x-axis presents the median transport time (bars, y-axis) and the cumulative percentage of children who could have been transported to high-readiness trauma center EDs (line plot, z-axis). For example, if the 5 closest trauma centers were considered in addition to the actual receiving trauma center, 76.9% of children could have been cared for in high-readiness EDs (compared with 49.8% of children). This scenario would have increased the median transport time from 20 minutes (actual receiving trauma centers) to 32.5 minutes.

Figure 2.. Adjusted Probability of Death by Quartile of Emergency Department (ED) Pediatric Readiness and Transport Time (N = 212 689)

To generate the predicted probability of mortality within each level of ED pediatric readiness, the risk estimation model included quartiles of ED pediatric readiness, transport time intervals, proximity to trauma centers within 30 minutes, patient demographics, initial physiology, emergent airway intervention, blood transfusion, Injury Severity Score, mechanism of injury, mode of arrival, surgical intervention, transfer status, and an interaction for ED pediatric readiness × transport time. The number of pediatric deaths among children with transport times greater than 45 minutes was small, which created instability in the estimates and wide 95% CIs.