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

Nina E Glass; Apoorva Salvi; Ran Wei; Amber Lin; Susan Malveau; Jennifer N B Cook; N Clay Mann; Randall S Burd; Peter C Jenkins; Matthew Hansen; Nicholas M Mohr; Caroline Stephens; Mary E Fallat; E Brooke Lerner; Brendan G Carr; Stephen P Wall; Craig D Newgard

doi:10.1001/jamasurg.2023.3344

. 2023 Aug 9;158(10):1078–1087. doi: 10.1001/jamasurg.2023.3344

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

Nina E Glass ^1,^✉, Apoorva Salvi ², Ran Wei ³, Amber Lin ², Susan Malveau ², Jennifer N B Cook ², N Clay Mann ⁴, Randall S Burd ⁵, Peter C Jenkins ⁶, Matthew Hansen ², Nicholas M Mohr ⁷, Caroline Stephens ⁸, Mary E Fallat ⁹, E Brooke Lerner ¹⁰, Brendan G Carr ¹¹, Stephen P Wall ¹², Craig D Newgard ²

¹Department of Surgery, Rutgers New Jersey Medical School, Newark

²Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland

³School of Public Policy, University of California, Riverside

⁴Department of Pediatrics, University of Utah School of Medicine, Salt Lake City

⁵Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, DC

⁶Department of Surgery, Indiana University School of Medicine, Indianapolis

⁷Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City

⁸Department of Surgery, University of California, San Francisco

⁹Department of Surgery, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, Kentucky

¹⁰Department of Emergency Medicine, University at Buffalo, Buffalo, New York

¹¹Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York

¹²Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York

Accepted for Publication: May 25, 2023.

Published Online: August 9, 2023. doi:10.1001/jamasurg.2023.3344

^✉

Corresponding Author: Nina E. Glass, MD, Department of Surgery, Rutgers New Jersey Medical School, University Hospital, 150 Bergen St, M 233, Newark, NJ 07103 (ng470@njms.rutgers.edu).

Author Contributions: Dr Newgard and Ms Lin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Glass, Cook, Fallat, Lerner, Carr, Newgard.

Acquisition, analysis, or interpretation of data: Glass, Salvi, Wei, Lin, Malveau, Cook, Mann, Burd, Jenkins, Hansen, Mohr, Stephens, Fallat, Wall, Newgard.

Drafting of the manuscript: Glass, Salvi, Wei, Lin, Cook.

Critical review of the manuscript for important intellectual content: Glass, Lin, Malveau, Mann, Burd, Jenkins, Hansen, Mohr, Stephens, Fallat, Lerner, Carr, Wall, Newgard.

Statistical analysis: Glass, Salvi, Wei, Lin, Wall.

Obtained funding: Newgard.

Administrative, technical, or material support: Malveau, Cook, Mann, Hansen, Mohr, Newgard.

Supervision: Burd, Newgard.

Conflict of Interest Disclosures: Dr Wei reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Ms Lin reported receiving grants from the NIH during the conduct of the study. Ms Malveau reported receiving grants from the US Department of Health and Human Services Health Resources and Services Administration (HRSA) Emergency Medical Services for Children during the conduct of the study. Dr Mann reported receiving grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the HRSA during the conduct of the study. Dr Newgard reported receiving grants from the NICHD and the HRSA during the conduct of the study. No other disclosures were reported.

Funding/Support: This project was supported by grant R24HD085927 from the NICHD (Ms Malveau and Ms Cook) and Emergency Medical Services for Children Targeted Issues grant H34MC33243-01-01 from the HRSA (Ms Malveau and Ms Cook).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors.

Data Sharing Statement: See Supplement 2.

^✉

Corresponding author.

PMCID: PMC10413216 PMID: 37556154

Key Points

Question

How does the proximity of injury location to trauma centers, including emergency department (ED) pediatric readiness, affect outcomes after pediatric trauma?

Findings

In this cohort study of 212 689 injured children seen at 765 US trauma centers, matching children to trauma centers with high-readiness EDs within 30 minutes was associated with potential prevention of 468 pediatric deaths after injury. However, increasing the level of ED pediatric readiness at all trauma centers was estimated to prevent more than 3 times as many deaths.

Meaning

These findings suggest that increasing the level of pediatric readiness at all US trauma centers may substantially improve patient outcomes.

This cohort study investigates the association of transport time, US trauma center proximity, and emergency department (ED) readiness with pediatric survival.

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.

Introduction

Despite the importance of specialized care for injured children, access to high-quality pediatric trauma care remains limited. Only 43% of US children live within an hour of a pediatric trauma center; in 15 states, fewer than 25% of children live within 30 miles of such a hospital.^1,2 In vast portions of the US, the only hospitals available to care for injured children are adult trauma centers or nontrauma hospitals, where the quality of pediatric care varies greatly.^3,4,5,6 To standardize and improve the emergency and trauma care of children, the National Pediatric Readiness Project (NPRP)⁷ was created as a national quality improvement initiative to ensure that all emergency departments (EDs) have the pediatric-specific resources necessary to care for children (including equipment, personnel, care coordination, policies and procedures, safety processes, and quality improvement processes).^8,9,10 Detailed ED checklists and tool kits have also been developed to increase the level of readiness.⁷ Despite the association of high-readiness EDs with improved survival,^3,6,11,12 there is large variability in ED pediatric readiness among US trauma centers.^3,4 To improve care, the American College of Surgeons Committee on Trauma incorporated assessment and improvement of ED pediatric readiness into its 2022 criteria for trauma center verification.¹³

Although limited access to high-quality pediatric trauma care is well documented,^1,2 the association between trauma center proximity and pediatric mortality remains unclear. The concept of the “golden hour” emphasizes that early access to definitive trauma care lowers mortality. However, evidence of the association between time and survival in trauma has been mixed^{14,15,16,17,18,19,20,21,22} and research specific to children is sparse. A recent study suggests that most injured children who die do so within a few hours of arrival to a trauma center,¹¹ which underscores the importance of early effective trauma care for children.

To examine the association of ED pediatric readiness with proximity to trauma care on pediatric trauma mortality, we performed a geospatial analysis of injured children transported by ground to 765 trauma centers across the US and outcomes of different strategies to optimize the number of pediatric lives saved following trauma.

Methods

Study Design

This retrospective cohort study was reviewed and approved by the institutional review boards of Oregon Health & Science University and the University of Utah School of Medicine. A waiver of consent was granted because this was a retrospective review of medical records, and we limited the amount of personal health information accessed to a minimum (ie, zip codes and hospital addresses). We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies.

Study Setting

We included 765 trauma centers (level I-V, adult and pediatric) in 50 US states and the District of Columbia that provided care for injured children; submitted data to the National Trauma Data Bank (NTDB) from January 1, 2012, through December 31, 2017; and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013).⁸ This 6-year time period for the NTDB was selected to align with the 2013 National Pediatric Readiness Assessment. Trauma centers participating in the NTDB collect data using the National Trauma Data Standard,^23,24 with standardized inclusion criteria and data on demographics, injury characteristics, initial ED presentation, physiology, comorbidities, injury severity, resuscitation, procedures, and in-hospital mortality.

Patient Population

We included injured children aged 0 to 17 years who were transported by ground (ie, via emergency medical services [EMS] or private automobile) to a participating trauma center and required either hospital admission or interhospital transfer or died following injury. The analysis focused on the trauma center providing initial care. We included children designated as dead on arrival, as done in a previous study of ED pediatric readiness.¹¹ For children who were transferred to another hospital, we linked available records from the second hospital using probabilistic linkage.²⁵ We excluded children who were missing the initial ED record (eg, children treated initially in non–trauma center EDs), missing hospital disposition (ie, in-hospital mortality), missing the zip code for the injury incident location, transported by air medical services (or with an unknown mode of transport), or had outlier values for transport time (>99th percentile) (eFigure in Supplement 1).

Emergency Department Pediatric Readiness

We categorized ED pediatric readiness for the initial trauma center using the 2013 NPRP assessment.⁸ The weighted pediatric readiness score (wPRS; range, 0-100) is a global score based on questions with moderate to high clinical relevance,²⁶ with 100 representing the highest level of ED pediatric readiness. The wPRS has been used to measure ED pediatric readiness for US hospitals⁸ and trauma centers.⁴ We matched the 2013 NPRP assessment to NTDB trauma centers using hospital name and address, and we then calculated quartiles of wPRS at the hospital level. We considered the highest quartile (quartile 4) to represent high-readiness EDs, as done in previous studies.^3,11

Transport Time and Proximity

We geocoded the injury incident location for every child in the sample using the incident zip code centroid (population-weighted center of a zip code) and geocoded the location of NTDB trauma centers using hospital address. When a reliable hospital address was not available (n = 18 hospitals), we used the hospital zip code centroid for hospital location. To calculate the actual transport time from the scene of injury to the receiving hospital (only available for children transported by EMS), we used the difference in time from leaving the scene to ED arrival, as available in the NTDB. When these times were not available (ie, for children not transported by EMS or missing EMS times), we estimated transport time using geospatial methods based on average automobile speed from historical traffic data by time of day and day of week using ArcGIS StreetMap Premium, version 2022 Q1 (Esri),²⁷ and ArcPro Network Analyst, version 3.1 (Esri), to identify the optimal driving routes.²⁸ We also estimated transport times to all potential trauma centers from the NTDB within a 30-minute driving radius. We considered a time of 30 minutes for 3 reasons: (1) a maximum of 30 minutes has been used to assess ambulance proximity to high-readiness EDs,²⁹ (2) 30 minutes is the maximum time that most parents are willing to travel for urgent medical concerns,³⁰ and (3) a maximum 30-minute transport time is commonly used by EMS agencies when determining hospital selection to maintain 911 response coverage for other calls. We validated estimated transport times against actual transport times in the NTDB data, which demonstrated a median difference of 1 minute and 42 seconds (actual time minus estimated time; IQR, −2 minutes and 54 seconds to 6 minutes and 48 seconds).

Variables

We included variables for patient demographics (age, sex, and race), comorbid conditions, initial ED physiology (age-adjusted hypotension and Glasgow Coma Scale score), emergent airway intervention, mechanism of injury, mode of transport, injury severity (Abbreviated Injury Scale³¹ score and Injury Severity Score [ISS]^31,32), surgical procedures, blood transfusion, and interhospital transfer. Race was included as a variable to recognize differences in care and outcomes after trauma by race. In the NTDB, race is a self-reported variable from patients or their representatives and is reported herein as Asian, Black, White, or other (American Indian, Native Hawaiian or Other Pacific Islander, or other). Because ethnicity was missing for 67.6% of patients, we could not impute it into our models and it was therefore omitted. We used abstracted NTDB data fields and International Classification of Diseases (Ninth and Tenth Revisions) procedure codes, categorized using the Agency for Healthcare Research and Quality Clinical Classification System³³ to create variables for surgical interventions, airway management, and blood transfusion. To evaluate high-risk children with injuries that were potentially more sensitive to proximity and level of ED pediatric readiness, we created subgroups for seriously injured children (ISS scores ≥16 and ≥25), those with penetrating injury, and those requiring early resuscitative care (emergent airway intervention, blood transfusion, or nonorthopedic operative care within 24 hours of ED arrival).^3,34 We also evaluated hospital characteristics, including trauma center level (I-V), trauma center type (adult vs pediatric), annual pediatric trauma volume, and annual ED pediatric volume. We created a variable for urban hospitals vs rural hospitals based on population, with metropolitan areas greater than 50 000 vs fewer than 50 000.

Outcomes

The primary outcome was in-hospital mortality. This outcome included deaths in the ED.

Statistical Analysis

We used descriptive statistics to characterize children by proximity to trauma centers, quartile of ED pediatric readiness, and actual vs potential receiving hospitals. To evaluate the roles of transport time, proximity to a trauma center, and ED pediatric readiness, we used a patient-level, mixed-effects logistic regression model based on a standardized risk-adjustment model for trauma,³⁵ as previously applied to children.³ The model included a random intercept to account for clustering by the initial ED. The following variables were included in the model: ED pediatric readiness, transport time (in 15-minute increments), number of trauma centers within 30 minutes (a measure of access, urbanicity, and trauma system design), patient demographics, initial physiology, emergent airway intervention, blood transfusion, ISS, mechanism of injury, mode of arrival, surgical intervention, and transfer status. We tested for effect modification of ED pediatric readiness by transport time using an interaction term, with P < .05 denoting the presence of an interaction. We further evaluated the association among ED pediatric readiness, transport time, and mortality by calculating the marginal estimated probability of death at each level of ED pediatric readiness across 15-minute intervals of transport time. The 15-minute intervals of transport time provided clinical relevance, ease with interpretation and use, and consistent time intervals (even though the number of children in each interval differed), and facilitated modeling the time variable as a categorical term to evaluate nonlinear associations with mortality. We repeated these analyses for the subgroups of serious injury, penetrating injury, and need for critical early resources. Given the large sample sizes in our cohorts, we had the power to detect absolute differences in mortality of less than 1% between groups.

We calculated the number of additional lives potentially saved to assess outcomes of 2 approaches to ED pediatric readiness: (1) selectively matching all children to a trauma center with a high-readiness ED within 30 minutes or (2) increasing ED pediatric readiness among all trauma centers to the highest quartile. We calculated this metric using marginal estimated probabilities of mortality from the multivariable model under each of the 2 scenarios: (1) if children cared for in trauma centers with lower-readiness EDs (quartiles 1-3) that were within 30 minutes of a high-readiness ED had been transported to the trauma center with a high-readiness ED, and (2) if all children cared for in lower-readiness EDs (quartiles 1-3) were cared for in high-readiness EDs (ie, increasing the level of ED pediatric readiness among all trauma centers). We calculated 95% CIs for additional lives saved using the bootstrap method.

Missingness for individual variables ranged from 0% to 11.3%, with no missingness for mortality. We used multiple imputation^36,37 to handle missing values to reduce bias and preserve the study sample, the validity of which has been shown for trauma data.^38,39 We generated 10 multiply imputed data sets using chained equations and then combined the results using Rubin rules to account for variance within and between data sets. Statistical analyses were conducted using SAS, version 9.4 (SAS Institute Inc), and Stata, version 17 (StataCorp LLC). Data analysis was performed between January 1 and March 31, 2022.

Results

The primary cohort included 212 689 injured children from 765 trauma centers (eFigure in Supplement 1), 4156 (2.0%) of whom died during their hospital stay. The median patient age was 10 (IQR, 4-15) years; 76 151 (35.8%) children were female and 136 538 (64.2%) were male. With regard to race, 4576 (2.2%) children were Asian, 47 376 (22.3%) were Black, 127 885 (60.1%) were White, and 32 852 (15.4%) were of other or multiple races. A total of 28 238 children (13.2%) had an ISS of 16 or greater. The median transport time to the receiving trauma center was 18 (IQR, 12-28) minutes. Patients with the shortest transport times had the highest injury severity, penetrating injury, physiological compromise, resuscitative interventions, surgery, and mortality (Table 1). More than half of patients were brought in by ambulance. Among the 765 trauma centers, the median wPRS was 79.1 (IQR, 62.9-92.7), 583 (76.2%) were adult trauma centers, the median ED pediatric volume was 7414 (IQR, 3787-14 214) patients per year, and the median pediatric trauma volume was 50 (IQR, 25-95) patients per year (eTable in Supplement 1).

Table 1. Patient Characteristics by Transport Time to the Initial Receiving Trauma Center.

Characteristic	Transport time, min^a
Characteristic	0-15 (n = 83 914 [39.4])	16-30 (n = 85 101 [40.0])	31-45 (n = 29 165 [13.7])	46-60 (n = 9603 [4.5])	>60 (n = 4906 [2.3])
wPRS, median (IQR)^b	90.7 (78.0-97.9)	94.4 (83.8-99.5)	95.0 (84.4-100.0)	95.1 (85.3-100.0)	96.2 (89.0-100.0)
Age, y
Median (IQR)	10 (4-15)	10 (4-15)	10 (5-15)	10 (4-14)	7 (3-12)
Group^c
0-4	23 974 (28.6)	22 819 (26.8)	7109 (24.4)	2420 (25.2)	1708 (34.8)
5-12	26 069 (31.1)	29 120 (34.2)	10 677 (36.6)	3648 (38.0)	1992 (40.6)
13-15	15 099 (18.0)	15 810 (18.6)	5754 (19.7)	1880 (19.6)	728 (14.8)
16-17	18 772 (22.4)	17 352 (20.4)	5625 (19.3)	1655 (17.2)	478 (9.7)
Sex
Female	28 958 (34.5)	30 821 (36.2)	10 915 (37.4)	3624 (37.7)	1833 (37.4)
Male	54 956 (65.5)	54 280 (63.8)	18 250 (62.6)	5979 (62.3)	3073 (62.6)
Race
Asian	1907 (2.3)	1993 (2.3)	511 (1.8)	116 (1.2)	50 (1.0)
Black	25 440 (30.3)	16 874 (19.8)	3717 (12.7)	951 (9.9)	394 (8.0)
White	42 175 (50.3)	52 831 (62.1)	21 338 (73.2)	7521 (78.3)	4020 (81.9)
Other or multiple^d	14 392 (17.2)	13 403 (15.7)	3599 (12.3)	1015 (10.6)	442 (9.0)
Rural or urban
Rural (<10 000 people)	493 (0.6)	266 (0.3)	59 (0.2)	<30 (<1.0)^e	<30 (<1.0)^e
Metropolitan area (>50 000 people)	73 977 (88.2)	75 027 (88.2)	25 479 (87.4)	8471 (88.2)	4226 (86.1)
Micropolitan area (10 000-<50 000 people)	3479 (4.1)	2339 (2.7)	1117 (3.8)	406 (4.2)	179 (3.6)
Unknown	5965 (7.1)	7469 (8.8)	2510 (8.6)	713 (7.4)	496 (10.1)
≥1 Comorbidities	8559 (10.2)	7663 (9.0)	237 (8.1)	797 (8.3)	366 (7.5)
Mechanism of injury
Gunshot wound	6264 (7.5)	2599 (3.1)	430 (1.5)	132 (1.4)	52 (1.1)
Stabbing or other penetrating wound	3424 (4.1)	2794 (3.3)	764 (2.6)	268 (2.8)	157 (3.2)
Burn	3154 (3.8)	2738 (3.2)	852 (2.9)	320 (3.3)	256 (5.2)
Assault	8413 (10.0)	8827 (10.4)	3124 (10.7)	1026 (10.7)	536 (10.9)
Fall	30 994 (36.9)	33 132 (38.9)	11 448 (39.3)	3682 (38.3)	2495 (50.9)
Motor vehicle	12 008 (14.3)	16 158 (19.0)	6456 (22.1)	2114 (22.0)	406 (8.3)
Bicycle	4619 (5.5)	4525 (5.3)	1363 (4.7)	431 (4.5)	187 (3.8)
Pedestrian	7390 (8.8)	5836 (6.9)	1316 (4.5)	333 (3.5)	68 (1.4)
Motorcycle	950 (1.1)	1015 (1.2)	313 (1.1)	97 (1.0)	29 (0.6)
Other^f	6697 (8.0)	7478 (8.8)	3098 (10.6)	1200 (12.5)	720 (14.7)
Arrival by ambulance	47 683 (56.8)	56 036 (65.8)	19 773 (67.8)	5987 (62.3)	1051 (21.4)
Initial hospital trauma level
I	42 818 (51.0)	50 975 (59.9)	18 390 (63.1)	6198 (64.5)	3417 (69.6)
II	29 490 (35.1)	26 764 (31.4)	8351 (28.6)	2721 (28.3)	1267 (25.8)
III, IV, or V	11 606 (13.8)	7362 (8.7)	2424 (8.3)	684 (7.1)	222 (4.5)
Initial trauma center type
Pediatric	21 708 (25.9)	31 882 (37.5)	12 335 (42.3)	42,77 (44.5)	2436 (49.7)
Adult	40 568 (48.3)	31 315 (36.8)	10 158 (34.8)	3126 (32.6)	1206 (24.6)
Mixed	21 638 (25.8)	21 904 (25.7)	6672 (22.9)	2200 (22.9)	1264 (25.8)
ED initial physiology
Age-adjusted hypotension	2279 (2.7)	1357 (1.6)	312 (1.1)	87 (0.9)	56 (1.1)
GCS group
13-15	76 997 (91.8)	80 432 (94.5)	28 153 (96.5)	9347 (97.3)	4806 (98.0)
9-12	2250 (2.7)	1883 (2.2)	456 (1.6)	118 (1.2)	34 (0.7)
≤8	4668 (5.6)	2786 (3.3)	556 (1.9)	138 (1.4)	65 (1.3)
Injury severity
ISS
Median (IQR)	4 (4-9)	4 (4-9)	4 (4-9)	4 (4-9)	4 (4-8)
0-8	54 626 (65.1)	56 252 (66.1)	19 455 (66.7)	6378 (66.4)	3712 (75.7)
9-15	16 809 (20.0)	17 787 (20.9)	6461 (22.2)	2211 (23.0)	833 (17.0)
16-24	7141 (8.5)	7048 (8.3)	2269 (7.8)	703 (7.3)	255 (5.2)
≥25	5338 (6.4)	4014 (4.7)	981 (3.4)	311 (3.2)	106 (2.2)
Head AIS ≥3	12 986 (15.5)	11 924 (14.0)	3511 (12.0)	1050 (10.9)	420 (8.6)
Hospitalization
Emergent airway intervention	9146 (10.9)	6310 (7.4)	1553 (5.3)	485 (5.1)	202 (4.1)
Blood transfusion	3585 (4.3)	2287 (2.7)	492 (1.7)	172 (1.8)	45 (0.9)
Nonorthopedic surgery	8296 (9.9)	5925 (7.0)	1586 (5.4)	507 (5.3)	208 (4.2)
Orthopedic surgery	23 984 (28.6)	27 760 (32.6)	10 393 (35.6)	3764 (39.2)	2248 (45.8)
Transfer to another hospital	8895 (10.6)	5289 (6.2)	1372 (4.7)	340 (3.5)	100 (2.0)
Mortality	2577 (3.1)	1267 (1.5)	232 (0.8)	58 (0.6)	<30 (<1.0)^e

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Abbreviations: AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; wPRS, weighted pediatric readiness score.

^{^a}

Unless indicated otherwise, values are presented as No. (%) of patients.

^{^b}

Medians (IQRs) are calculated at the patient level rather than at the hospital level.

^{^c}

Age categories were based on the following: infant to preschool (0-4 years), elementary school to preteen (5-12 years), early adolescence (13-15 years), and late adolescence to driving age (16-17 years).

^{^d}

Includes American Indian, Native Hawaiian or Other Pacific Islander, or other race or multiple races selected.

^{^e}

For subsets with fewer than 30 patients, absolute numbers are not presented and percentages are rounded to whole numbers based on requirements of our data use agreements.

^{^f}

Includes machinery, other transport, bites and stings, other natural or environmental mechanisms, boating incidents, or other (not otherwise classifiable).

There were 105 871 children (49.8%) initially transported to a trauma center with high ED pediatric readiness (Table 2). An additional 36 330 children (33.7%) were transported to lower-readiness EDs (wPRS quartiles 1-3) but were within 30 minutes of a high-readiness ED (wPRS quartile 4). Transport times were longer for children transported to high-readiness EDs (median, 20.0 [IQR, 13.0-29.0] minutes) vs low-readiness EDs (median, 15.6 [IQR, 9.8-25] minutes). There were 89 732 children (42.2%) with no trauma center with a high-readiness ED within 30 minutes, 27 796 (13.1%) with no trauma center within 30 minutes, 46 325 (21.8%) with no level I or II trauma center (pediatric or adult) within 30 minutes, and 91 574 (43.1%) with no level I or II pediatric trauma center within 30 minutes.

Table 2. Actual and Potential Transports to High Pediatric Readiness EDs at US Trauma Centers.

Quartile (wPRS)	No. of actual transports (%) (N = 212 689)	Transport time, min, median (IQR)^a	No. of children transported (%)
Quartile (wPRS)	No. of actual transports (%) (N = 212 689)	Transport time, min, median (IQR)^a	To lower-readiness EDs within 30 min of a high-readiness ED (n = 106 818)^b	Total (actual) or within 30 min (potential) of a high-readiness ED
4 (93-100)	105 871 (49.8)	20 (13-29)	36 330 (33.7)	142 201 (66.9)
3 (79-92)	58 587 (27.6)	17 (11-26.3)	NA	NA
2 (63-78)	26 955 (12.7)	16.4 (10.5-26)	NA	NA
1 (29-62)	21 276 (10.0)	15.6 (9.8-25)	NA	NA

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Abbreviations: ED, emergency department; NA, not applicable; NTDB, National Trauma Data Bank; wPRS, weighted pediatric readiness score.

^{^a}

Based on transport time to the actual initial receiving trauma center. We calculated these times directly from the NTDB data. When actual transport time was unavailable in the NTDB, we estimated transport time using geospatial methods.

^{^b}

For children initially transported to EDs with lower pediatric readiness (quartiles 1-3), we identified trauma centers with high ED pediatric readiness within a 30-minute transport time using geospatial methods.

We estimated the actual vs potential proportion of children receiving care in trauma centers with high-readiness EDs. As the radius of potential trauma centers from the injury location was expanded, the percentage of children potentially transported to high-readiness EDs and transport times increased (Figure 1). The maximum percentage of children who could have been taken to a high-readiness ED trauma center (regardless of transport time) was 77.8%, but the proportion plateaued after the 5 closest trauma centers.

Figure 1. — 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.

After adjusting for confounders, transport time, and proximity to trauma centers, children cared for in trauma centers with high ED pediatric readiness had lower adjusted mortality (wPRS quartile 4 vs quartile 1: adjusted odds ratio [OR], 0.65 [95% CI, 0.47-0.89]) (Table 3). Mortality increased with decreasing access to trauma care (0 vs ≥10 trauma centers within 30 minutes: adjusted OR for mortality, 10.42 [95% CI, 7.13-15.22]). Increased transport time was associated with lower mortality and there was effect modification of ED pediatric readiness by transport time (interaction P = .021). When the adjusted probability of death was modeled for different quartiles of ED readiness across 15-minute intervals of transport time (including the interaction for ED readiness × transport time), the survival benefit of high-readiness EDs persisted for transport times up to 45 minutes (Figure 2). The small number of deaths among children with transport times longer than 45 minutes (Table 1) limited the ability to evaluate the role of ED pediatric readiness for longer time intervals. Model diagnostics showed appropriate model fit, lack of multicollinearity, and a c statistic of 0.98. The findings were consistent across all subgroups and sensitivity analyses.

Table 3. Multivariable Model of Emergency Department Pediatric Readiness, Transport Time, and Trauma Center Proximity on Mortality.

Parameter	AOR (95% CI) (N = 212 689)
wPRS quartile
1 (Least ready)	1 [Reference]
2	1.2 (0.85-1.69)
3	0.94 (0.68-1.3)
4 (Most ready)	0.65 (0.47-0.89)
Transport time, categorical, min
0-15	1 [Reference]
16-30	0.71 (0.63-0.79)
31-45	0.23 (0.18-0.29)
46-60	0.16 (0.11-0.24)
>60	0.15 (0.09-0.27)
No. of trauma centers within 30 min
0	10.42 (7.13-15.22)
1	2.03 (1.39-2.96)
2-9	1.27 (0.89-1.81)
≥10	1 [Reference]
Sex
Male	1 [Reference]
Female	1.02 (0.91-1.13)
Age, y
0-4	1.64 (1.4-1.92)
5-12	1.31 (1.13-1.52)
13-15	1.06 (0.91-1.23)
16-17	1 [Reference]
Race
Asian	0.87 (0.76-0.99)
Black	1.08 (0.75-1.54)
White	1 [Reference]
Other^a	1.01 (0.86-1.18)
Any comorbidities
No	1 [Reference]
Yes	0.58 (0.49-0.69)
Mechanism of injury
Gunshot wound	9.37 (7.52-11.68)
Stabbing or other penetrating injury	2.94 (2.08-4.17)
Burn, fire, or flame	4.59 (3.12-6.74)
Assault or rape	1.24 (0.96-1.61)
Fall	1 [Reference]
Motor vehicle	1.35 (1.11-1.65)
Bicycle	1.21 (0.88-1.67)
Pedestrian	2.17 (1.76-2.67)
Motorcycle	1.49 (0.97-2.3)
Other^b	3.02 (2.47-3.69)
Ambulance transport
No	1 [Reference]
Yes	1.42 (1.18-1.73)
Transfer
No	1 [Reference]
Yes	0.13 (0.1-0.16)
GCS group
≥13	1 [Reference]
9-12	4.04 (2.81-5.8)
≤8	87.8 (71.27-108.15)
ISS score
0-8	1 [Reference]
9-15	2 (1.66-2.42)
16-24	1.86 (1.53-2.28)
≥25	6.76 (5.6-8.16)
Orthopedic surgery
No	1 [Reference]
Yes	0.32 (0.27-0.37)
Any ventilation or airway intervention
No	1 [Reference]
Yes	2.37 (1.95-2.87)
Major surgery
No	1 [Reference]
Yes	1.48 (1.31-1.66)

Open in a new tab

Abbreviations: AOR, adjusted odds ratio; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; wPRS, weighted pediatric readiness score.

^{^a}

Includes American Indian, Native Hawaiian or Other Pacific Islander, or other or multiple races selected.

^{^b}

Includes drowning, suffocation, machinery, other transport, bites and stings, other natural or environmental mechanisms, overexertion, poisoning, or other (not otherwise classifiable).

Figure 2. — 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.

To further evaluate the role of ED pediatric readiness in US trauma centers, we estimated the number of additional lives potentially saved under 2 scenarios. If all children transported to trauma centers with lower-readiness EDs (wPRS quartiles 1-3) were transported to a high-readiness ED available within 30 minutes, 468 lives (95% CI, 460-476 lives) may have been saved. Under a second scenario, if all trauma centers had high ED pediatric readiness, 1655 lives (95% CI, 1647-1664 lives) may have been saved.

Discussion

To our knowledge, this study is the first to examine the survival benefit of high-readiness EDs at US trauma centers after accounting for transport time and hospital proximity. Our results suggest that the benefit of high-readiness EDs persisted after accounting for these factors. Approximately half of injured children in US trauma centers received their initial care in trauma center EDs with high pediatric readiness, but additional children were within 30 minutes of such an ED. Increasing the ED readiness of all trauma centers is a critical aspect of a national strategy to minimize preventable mortality in children. We also quantified the mortality associated with limited pediatric access to trauma centers, as suggested previously.^2,40

We studied 2 system-level options for improving the quality of ED care for injured children: matching patients to nearby trauma centers with high-readiness EDs vs increasing the level of ED readiness among all trauma centers. Although both options would save lives, our findings suggest that increasing the level of ED pediatric readiness among all trauma centers would have more than tripled the number of additional lives saved. In addition, the scores for ED pediatric readiness are not publicly available and therefore cannot currently be used for transport decisions. Such a strategy is consistent with current national trauma center health policy.¹³ We also observed that the benefit of care in trauma centers with high-readiness EDs persisted for transport times up to 45 minutes, suggesting a time-based benchmark for transport.

This study further quantified the mortality risk of pediatric trauma deserts. Originally described in 2013, trauma deserts (for a mixed population of children and adults) identified areas within an urban center that were remote from trauma centers.⁴¹ Mixed populations of adults and children from these deserts were found to have increased socioeconomic disparity and poorer outcomes after trauma.^41,42,43 Similar findings have been described for children from urban centers with high mortality from gun violence.⁴² Whereas previous studies focused on geographic access to pediatric trauma centers,^1,2 our results suggest that mortality increases for children with decreasing access to any trauma center. Recognizing the challenges of creating new pediatric trauma centers, our findings highlight the potential benefit of increasing ED pediatric readiness among existing trauma centers to reduce pediatric mortality after injury. Although it seems like a sizeable endeavor, improving ED pediatric readiness aligns with most aspects of improving care for trauma patients. That is, improving the availability of resuscitation equipment, experienced personnel, care coordination, policies and procedures, safety processes, and quality improvement processes are inherent processes of care for all trauma centers and thus should be supported within existing efforts. Having high ED pediatric readiness has also been shown to improve survival among nontrauma patients, so these investments will benefit all children requiring emergency services.⁶ There have been extensive efforts to facilitate implementation, including ED tool kits and checklists.⁷ These efforts will also aid in meeting the 2022 trauma center verification criteria with regard to ED pediatric readiness.¹³

This study was not designed to evaluate the golden hour in children. While transport time is only one segment of time to definitive care, the inverse association between transport time and mortality is counterintuitive and contradicts studies suggesting a mortality benefit with shorter transport times among injured adults.^44,45 Several potential explanations may account for this discrepancy. First, children with the shortest transport times had the highest acuity, which likely influenced the speed of transport and selection of trauma centers. In addition, this study only included trauma centers participating in the NTDB, which may have affected the association between time and survival. A study testing the association between time and survival would be designed differently, with greater balance in patient severity and acuity across all time intervals. Because the association between longer transport times and lower mortality persisted in all subgroup analyses of severely injured children, we suspect that additional factors affected the association between time and mortality.

Limitations

Our study has several limitations. First, the sample only included children cared for in trauma centers participating in the NTDB, representing predominantly level I or II trauma centers with adequate resources. Level III to V trauma centers are underrepresented in the NTDB. This finding was evident in the relatively high median wPRS compared with those of general EDs.⁸ Inclusion of a greater number of trauma centers and nontrauma hospitals would provide additional insight into access to trauma care for injured children. Second, we did not study the interval from the time of injury to trauma center arrival (ie, the golden hour); rather, we focused on transport time and proximity to trauma centers. Increased survival was associated with longer transport times, a counterintuitive finding potentially accounted for by survival bias, selection bias, and the nonrandom distribution of high-risk injuries among children with close proximity to trauma centers.

We used data from the 2013 NPRP assessment of ED pediatric readiness. The NPRP assessment was repeated in 2021, but these data were not yet available for research. It is possible that the level of ED pediatric readiness among US trauma centers has changed over time. Additional research on ED pediatric readiness among US trauma centers using more contemporaneous data will be needed to evaluate potential changes over time.

Conclusions

The findings of this cohort study suggest that ED pediatric readiness plays a critical role in pediatric trauma care and may partially address unmet needs in regions without access to pediatric trauma centers. In addition, we observed that increasing all trauma center EDs to high readiness would save more than 3 times as many pediatric lives compared with selectively transporting children to trauma centers that already have high ED readiness. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes.

Supplement 1.

eFigure. Schematic for Cohort Creation of Children Treated in US Trauma Centers

eTable. Trauma Center Characteristics (n = 765 Hospitals)

Click here for additional data file.^{(148.9KB, pdf)}

Supplement 2.

Data Sharing Statement

Click here for additional data file.^{(14.4KB, pdf)}

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eFigure. Schematic for Cohort Creation of Children Treated in US Trauma Centers

eTable. Trauma Center Characteristics (n = 765 Hospitals)

Click here for additional data file.^{(148.9KB, pdf)}

Supplement 2.

Data Sharing Statement

Click here for additional data file.^{(14.4KB, pdf)}

[soi230051r1] 1.Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med. 2009;163(6):512-518. doi: 10.1001/archpediatrics.2009.65 [DOI] [PubMed] [Google Scholar]

[soi230051r2] 2.US Government Accountability Office . Pediatric Trauma Centers: Availability, Outcomes, and Federal Support Related to Pediatric Trauma Care. US Government Accountability Office; 2017. [Google Scholar]

[soi230051r3] 3.Newgard CD, Lin A, Olson LM, et al. ; Pediatric Readiness Study Group . Evaluation of emergency department pediatric readiness and outcomes among US trauma centers. JAMA Pediatr. 2021;175(9):947-956. doi: 10.1001/jamapediatrics.2021.1319 [DOI] [PMC free article] [PubMed] [Google Scholar]

[soi230051r4] 4.Remick K, Gaines B, Ely M, Richards R, Fendya D, Edgerton EA. Pediatric emergency department readiness among US trauma hospitals. J Trauma Acute Care Surg. 2019;86(5):803-809. doi: 10.1097/TA.0000000000002172 [DOI] [PubMed] [Google Scholar]

[soi230051r5] 5.Sathya C, Alali AS, Wales PW, et al. Mortality among injured children treated at different trauma center types. JAMA Surg. 2015;150(9):874-881. doi: 10.1001/jamasurg.2015.1121 [DOI] [PubMed] [Google Scholar]

[soi230051r6] 6.Newgard CD, Lin A, Malveau S, et al. ; Pediatric Readiness Study Group . Emergency department pediatric readiness and short-term and long-term mortality among children receiving emergency care. JAMA Netw Open. 2023;6(1):e2250941. doi: 10.1001/jamanetworkopen.2022.50941 [DOI] [PMC free article] [PubMed] [Google Scholar]

[soi230051r7] 7.Emergency Medical Services for Children National Resource Center . National Pediatric Readiness Project. Accessed April 30, 2023. https://emscimprovement.center/domains/pediatric-readiness-project

[soi230051r8] 8.Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr. 2015;169(6):527-534. doi: 10.1001/jamapediatrics.2015.138 [DOI] [PubMed] [Google Scholar]

[soi230051r9] 9.Remick K, Gausche-Hill M, Joseph MM, Brown K, Snow SK, Wright JL; American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Surgery; American College of Emergency Physicians Pediatric Emergency Medicine Committee; Emergency Nurses Association Pediatric Committee . Pediatric readiness in the emergency department. Pediatrics. 2018;142(5):e20182459. doi: 10.1542/peds.2018-2459 [DOI] [PubMed] [Google Scholar]

[soi230051r10] 10.Health Resources and Services Administration . National Pediatric Readiness Project: EMS Data Center. Accessed April 30, 2023. https://www.pedsready.org/

[soi230051r11] 11.Newgard CD, Lin A, Goldhaber-Fiebert JD, et al. ; Pediatric Readiness Study Group . Association of emergency department pediatric readiness with mortality to 1 year among injured children treated at trauma centers. JAMA Surg. 2022;157(4):e217419. doi: 10.1001/jamasurg.2021.7419 [DOI] [PMC free article] [PubMed] [Google Scholar]

[soi230051r12] 12.Ames SG, Davis BS, Marin JR, et al. Emergency department pediatric readiness and mortality in critically ill children. Pediatrics. 2019;144(3):e20190568. doi: 10.1542/peds.2019-0568 [DOI] [PMC free article] [PubMed] [Google Scholar]

[soi230051r13] 13.American College of Surgeons Committee on Trauma . Resources for Optimal Care of the Injured Patient. American College of Surgeons; 2022. [Google Scholar]

[soi230051r14] 14.Sampalis JS, Denis R, Lavoie A, et al. Trauma care regionalization: a process-outcome evaluation. J Trauma. 1999;46(4):565-579. doi: 10.1097/00005373-199904000-00004 [DOI] [PubMed] [Google Scholar]

[soi230051r15] 15.Sampalis JS, Lavoie A, Williams JI, Mulder DS, Kalina M. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma. 1993;34(2):252-261. doi: 10.1097/00005373-199302000-00014 [DOI] [PubMed] [Google Scholar]

[soi230051r16] 16.Lerner EB, Moscati RM. The golden hour: scientific fact or medical “urban legend”? Acad Emerg Med. 2001;8(7):758-760. doi: 10.1111/j.1553-2712.2001.tb00201.x [DOI] [PubMed] [Google Scholar]

[soi230051r17] 17.Stiell IG, Nesbitt LP, Pickett W, et al. ; OPALS Study Group . The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008;178(9):1141-1152. doi: 10.1503/cmaj.071154 [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

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

Nina E Glass, MD

Apoorva Salvi, MS

Ran Wei, PhD, MS

Amber Lin, MS

Susan Malveau, MS

Jennifer N B Cook, GCPH

N Clay Mann, PhD, MS

Randall S Burd, MD, PhD

Peter C Jenkins, MD, MSc

Matthew Hansen, MD, MCR

Nicholas M Mohr, MD, MS

Caroline Stephens, MD

Mary E Fallat, MD

E Brooke Lerner, PhD

Brendan G Carr, MD, MS

Stephen P Wall, MD, MSc, MAEd

Craig D Newgard, MD, MPH

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Study Design

Study Setting

Patient Population

Emergency Department Pediatric Readiness

Transport Time and Proximity

Variables

Outcomes

Statistical Analysis

Results

Table 1. Patient Characteristics by Transport Time to the Initial Receiving Trauma Center.

Table 2. Actual and Potential Transports to High Pediatric Readiness EDs at US Trauma Centers.

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).

Table 3. Multivariable Model of Emergency Department Pediatric Readiness, Transport Time, and Trauma Center Proximity on Mortality.

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

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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