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The primary hypothesis proposed by the authors states that the proportion of children who were treated operatively would vary inversely with the level of pediatric resources of the hospitals. A secondary hypothesis pro- posed was that within hospitals of the same level of resources, operative management would decrease over time. The study population includes children who had a diagnosis of blunt splenic trauma and were hospitalized in the state of Pennsylvania during the 10-year study period. Statewide discharge data were obtained on each child, including age, gender, diagnosis codes, procedure codes, discharge status, length of stay, and a hospital identifier. Hospitals were stratified into S groups based on pediatric and trauma resources: pediatric trauma centers, level 1 trauma centers with additional qualifications in pediatrics, level 1 trauma centers, level 2 trauma centers, and nontrauma centers. The proportion of patients who were treated operatively was stratified by hospital type and adjusted for age and splenic injury severity. A total of 3,245 children were included in the study, 23% of whom were managed operatively. Across hospital types, operative management increased as the resources for pediatric trauma care decreased. Those treated operatively were older and had a higher grade of splenic injury severity, a longer length of stay, and a higher mortality. Even after adjustment for age and injury severity, significant variation in practice patterns was seen both over time and across hospital types. As hypothesized, the results of this study do indicate that nonoperative management was significantly higher and increased over time in those hospitals with larger volumes of pediatric patients. The authors do acknowledge limitations of this study that should be considered in interpreting its results. The decision on whether to operate on a child with blunt trauma to the spleen is complex and influenced by a number of factors. Many of these factors may not be available when conducting a retrospective study using an existing database. In this study, for example, data that may have influenced the decision on whether to operate, ie, hemoglobin levels, were not available from the data source and may have influenced outcomes. [ABSTRACT FROM AUTHOR]

The purpose of this article was to report the number and configuration of trauma centers in the United States as of April 2002. The total number of trauma centers and the number of trauma centers per million were the main outcome measures. The American Trauma Society's Trauma Information Exchange Program developed the inventory tool for this project. The design for data collection was discussions and interviews with trauma center directors or managers in all 50 states and the District of Columbia. Trauma centers were categorized into 3 groups: (1) state and regional designated centers, (2) centers designated by both state and regional authority and by the American College of Surgeons Commission on Trauma, (3) and American College of Surgeons Commission on Trauma—verified centers. The inventory included all trauma center levels from level I to level IV/V. The type of ownership participation in a healthcare system and/or hospital network, the number of setup and staffed beds, the percentage of resident physician trauma programs, and membership in the council of Teaching Hospitals of the Association of American Medical Colleges were surveyed. Hospitals that only treat children were excluded. The data for rurality of the country were obtained from the 2001 US Health Resources Administration's Area Resource File. Hospital characteristics and the hospitals' available services were obtained from the American Hospital Association Annual Survey of Hospitals. Along with many other data, the characteristics of the trauma registry collection and the registry software used were surveyed. Statistically significant differences were tested using X² statistics. An interesting, and probably expected, discovery in this study was that level I and II trauma centers were larger, more likely to be teaching hospitals, and more likely to offer specialized services when compared with nontrauma centers. Trauma centers are more likely to be public hospitals and less likely to be private for-profit hospitals. Metropolitan areas have more than 90% of level I and II trauma centers, and in the south, level III and VI/V trauma centers are more common. Another important comparison was whether trauma registry data were submitted. It was found that not all trauma centers contribute to a state or regional trauma registry. The level I and II trauma centers in states without formal trauma systems were less likely to contribute to trauma registry. The most widely used software for trauma registry was Collector®. Since 1991, the number of trauma centers has more than doubled, which includes a 21% increase in level I and II trauma centers. Maps of trauma centers in the United States, plotted by zip codes, and a table of geographic and organizational characteristics of trauma centers and nontrauma centers show the details of the study. I noted some interesting details on the maps and on the table. Of course, my curiosity was first drawn to look at the states recently devastated by hurricanes. I was relieved to see that a level I or II trauma center was located near the costal areas of Louisiana and Mississippi. However, I do not know how these trauma centers function. It was surprising to see the lack of level II or VI/V trauma centers in the before-mentioned states. Another interesting detail was to see all the level III and IV/V trauma centers in Texas, Oklahoma, and Iowa—there were lots. Whereas in Alaska, there is a level I/II trauma center but no level III or IV/V trauma centers. I also noted that many other states did not have level III or IV/V trauma centers. The table showed regions, rurality, ownership, bed size, participation, teaching, services, and registry registration (29 references). [ABSTRACT FROM AUTHOR]

The authors of this article studied the amount of resident work hours saved per month at a hospital that employed TNSs. The level I trauma center trained a group of registered nurses to respond to trauma calls in the emergency department, assist the surgeons and residents on the floor, and perform specific procedures. Each TNS had a 3-month credentialing and orientation period. The chief resident or attending physician was responsible for teaching the advanced skills to the TNS. Two TNSs worked each 12-hour shift, providing 24-hour coverage. The TNSs were required to abstain from performing procedures during the first 2 weeks of each academic year to ensure that the incoming house staff had an opportunity to meet their educational requirements. Both the residents and the TNS maintained procedure logs. The TNS maintained logs for 12 months, whereas the residents maintained logs for only 4 months. In total, 423 procedures were completed during the study period. The residents performed 98 procedures, and the TNS performed 325 procedures. The study found that an average of 42 hours per month was spent by the TNS performing advanced procedures. There was no statistical difference in the number of complications or the time it took to perform the procedures as compared with the residents. [ABSTRACT FROM AUTHOR]

Objective: To identify sociodemographic factors associated with completing a follow-up survey about health status on the web versus by telephone, and to examine differences in reported health-related quality of life by method of response., Data Sources/study Settings: Survey about child health status of 896 parents of children aged 0-17 years treated in a hospital emergency department or admitted for a traumatic brain injury or arm injury, and 227 injured adolescents aged 14-17 years., Study Design: The main outcomes were characteristics of those who completed a follow-up survey on the web versus by telephone and health-related quality of life by method of response., Principal Findings: Email addresses were provided by 76.9 percent of parents and 56.5 percent of adolescents at baseline. The survey was completed on the web by 64.9 percent of parents and 40.2 percent of adolescents through email. Parents with email access who were Blacks, Hispanics, had lower incomes, and those who were not working were less likely to choose the web mode for completing the survey. Unlike adolescents, the amount of time for parents to complete the survey online was significantly shorter than completion by telephone. Differences by survey mode were small but statistically significant in some of the six functional outcome measures examined., Conclusions: Survey mode was associated with several sociodemographic characteristics. Sole use of web surveys could provide biased data., (© Health Research and Educational Trust.)

Background: Mild traumatic brain injury (MTBI) is common in the pediatric population. The symptom complex that might be expected in children after MTBI is not well documented. We sought to clarify the frequency and severity of concussive symptoms reported by children who required hospitalization for MTBI., Methods: Pediatric blunt trauma patients (age, 11-17 years) admitted for treatment of MTBI (GCS 14-15) were prospectively enrolled over a 2-year period. Consented patients were administered a 22-question Likert-based concussion symptom scale (normal, total score 0-8). The symptom scale was repeated at the time of routine follow-up trauma clinic visit. The frequency and severity of concussive symptoms were analyzed at both time-points., Results: For the 2-year period, 116 children participated in the study including 63 who returned for clinic follow-up. The overall population had mean age of 14.1 years (median 14) and was 69.8% male. The mean symptom score (sum of Likert scores [scale 0-6] for 22 questions) was 27.9 (median, 23.5) at hospitalization and 9.2 (median, 4.0) at follow-up. An abnormal symptom score (>8) was reported in 83.6% of hospitalized patients and 38.1% at follow-up. Girls had a significantly higher mean symptom score at initial testing than boys (33.9 vs 25.3, respectively; P < .05). This difference disappeared by the time of follow-up (girls 9.2 vs boys 9.1, P = .98) The most common initial symptom was headache (71.5% of patients) and most severe (highest mean score) was fatigue (mean, 2.0; median, 2.0). At follow-up, the most common symptom was excess sleep (38.1%) and most severe symptom falling asleep (mean, 1.0; median, 0). There were no significant differences in initial scores based on reported loss of consciousness, prior concussion history, or GCS 14 vs 15., Conclusions: Symptoms after MTBI are quite common at the time of hospitalization. Symptom scores improve to near normal for most by outpatient follow-up. The most common symptom was headache, but the most severe was fatigue, in this hospitalized pediatric population. Thoughtful assessment and follow-up of this patient population are warranted.

Purpose: To document the health-related quality of life (HRQOL) of children with an extremity fracture at 3 and 12 months postinjury and to determine whether it varies significantly by fracture region and site., Methods: Children hospitalized for an extremity fracture at 4 pediatric trauma centers were studied. A baseline, 3-month, and 12-month telephone interview were completed by a primary caregiver to measure the child's HRQOL using the Pediatric Quality of Life Inventory (PedsQL). HRQOL was modeled as a function of injury, patient, and family characteristics using a longitudinal regression model., Result: Of the 100 children enrolled, 52 sustained a lower extremity fracture (LEF) and 48 an upper extremity fracture (UEF). Postinjury HRQOL scores were significantly poorer than preinjury scores for all subjects (P = 0.05). In addition, a significant proportion of subjects reported impaired physical and psychosocial HRQOL at 3 (44% and 46%, respectively) and 12 months (23% and 33%, respectively) postinjury. At 3 months postinjury, children with an LEF had significantly poorer HRQOL outcomes compared to children with a UEF. By 12 months postinjury, the physical function of children with a tibia and/or fibula fracture remained significantly lower than children with a UEF (P < or = 0.05)., Conclusions: Children hospitalized for an extremity fracture suffered dramatic declines in physical and psychosocial well-being during the first 3 months postinjury. By 1 year postinjury, most children recovered; however, children with a tibia and/or fibula fracture still reported significantly poorer physical functioning.

Evaluation of the pediatric trauma patient frequently requires radiologic studies. Although low-dose radiation from diagnostic radiology is considered safe, lifetime risks per unit dose of radiation are increased in children compared to adults. The total effective dose of radiation to a typical pediatric trauma patient is unknown. We sought to estimate the total effective dose of radiation related to the radiologic assessment of injured children admitted to a pediatric Level I trauma center. We reviewed the radiology records of all children admitted directly to a trauma center in 2002 and tabulated all plain films, computed tomograms, angiographic/fluoroscopic studies, and nuclear medicine studies. Using age-adjusted effective doses (which incorporate biologic effects of radiation), we computed each patient's total effective dose of radiation. Of 506 admitted patients, 394 (78%) underwent at least one radiologic study. The mean total effective dose per patient was 14.9 mSv (median: 7.2 mSv; interquartile range: 2.2-27.4 mSv). On average, computed tomography accounted for 97.5% of total effective dose. Age and injury severity score did not predict total effective dose. We conclude that in pediatric trauma patients, the estimated total effective dose of radiation varied widely. Computed tomography contributed virtually the entire total effective dose. Regarding radiographic evaluation of pediatric trauma patients, the risks and benefits of current practices should continue to be evaluated critically, because lifetime risks associated with radiation exposure are inversely proportional to age at exposure.