Quality of care criteria globally, and in the specific case of trauma care systems, rely on the standardization of definitions and procedures.3, 14, 20
The current investigation highlights the marked variability in age cutoffs used to define pediatric and adolescent patients and the reported heterogeneity in services available. Thus, a key tenet of quality criteria, standardization, does not appear to be occurring for pediatric patients at Level I trauma centers in the US. This variability can be seen to constitute a major impetus for enhanced coordination of research and policy dialogues targeting quality of care enhancements for child and adolescent patients at the nation’s trauma centers. 4, 6, 13
The observation of little agreement on the upper age used to define a “pediatric” patient at trauma centers is of particular concern. It is well documented that injured pediatric patients have special needs.3
Beyond pediatric injury, adolescents have distinct developmental issues that are physiologically and psychologically different from younger children and adults.22
Prior investigation suggests that the distinct needs of adolescents may require specialized trauma center psychosocial resource development.16, 23
In addition, by separating out the adolescent end of the pediatric age range and treating these patients in an exclusively adult setting, the goal of achieving adequate volumes of pediatric trauma at an institution is further threatened.
The current investigation provides new data on the number of Level I trauma centers caring for children and adolescents as well as patient volumes. Although there are a large number of institutions caring for children and adolescents, the individual institutional volume of cases is relatively low. In this study 116 Level I trauma centers reported treating pediatric patients, with a median of 250 cases at each site. Nance et al24
identified 170 pediatric trauma centers, based on data from the American College of Surgeons, the American Trauma Society, and the National Association of Children’s Hospitals and Related Institutions. However, this includes both verified and self-designated centers. Segui-Gomez9
found that 87% of hospitals treating injured children in the US were non-trauma centers for either adults or children. For adult trauma, there is good evidence that volume of patients treated annually matters.25
The lower number of serious pediatric trauma compared with that involving adults, combined with the large number of institutions caring for injured children suggests that substantially more regionalization of pediatric trauma care for seriously injured children is needed.
Because of the growing body of literature suggesting PTSD and alcohol use problems are prevalent conditions among injured youth, the investigation assessed screening and intervention practices for these disorders at Level I trauma centers.15–17
Although the majority of sites screened injured youth for alcohol use problems, marked variability was observed in the actual percentage of children and adolescents screened. Only 20% of sites endorsed having specialized PTSD screening and intervention services available for injured youth. A heterogeneous group of providers conducted the screenings including social workers, psychologists, nurses, and psychiatrists. Future randomized clinical trial investigations could assess the outcomes of model trauma center programs targeting PTSD and alcohol screening and intervention in injured youth.
Certain limitations of the study must be considered. The information was obtained from trauma program coordinators and not from directors of trauma or pediatrics at these institutions. We were not able to follow-up the survey with questions for pediatricians, pediatric surgeons, and pediatric ICU providers. However, these were senior level coordinators who on average had worked for the institution for more than a decade and would have been familiar on a daily basis with the care delivered at the trauma centers. An additional limitation of the investigation is that the survey did not assess reasons why some trauma centers did not report routinely screening adolescents for alcohol, despite the existence of the American College of Surgeons’ alcohol screening requirement. The survey also did not include more in-depth questions regarding services for PTSD screen positive patients, and in house versus transfer services for pediatric rehabilitation. Finally, the psychometric characteristics of the questionnaire employed in the investigation have not been meticulously evaluated.
Beyond these considerations, this investigation documents marked variability in the characteristics of pediatric psychosocial services delivered at US Level I trauma centers Future research could systematically evaluate how this variability in child and adolescent trauma center service delivery impacts pediatric functional and symptomatic outcomes after injury. These efforts could productively occur in concert with the expansion of trauma center organizational capacity for sustainable pediatric service improvement initiatives.20, 21