Abstract
Purpose
Pediatric trauma centers (PTCs) have been associated with lower mortality rates and increased use of non-operative management. While not formally designated, six trauma centers in the Netherlands meet PTC criteria and are referred to as designated pediatric trauma centers (dPTCs). This study aimed to evaluate the impact of treatment at dPTCs versus adult trauma centers (ATCs) on outcomes in severely injured pediatric patients in the Netherlands.
Methods
Data were obtained from the Dutch National Trauma Registry for patients aged ≤ 16 years with an Injury Severity Score (ISS) ≥ 16, admitted between January 1, 2015, and December 31, 2022. Multivariable logistic regression was performed to assess the impact of treatment at a dPTC on in-hospital mortality and Glasgow Outcome Scale (GOS) scores.
Results
In total, 2,378 patients were included: 63% were treated in dPTCs, 17% in ATC-I, and 20% in ATC-II/III. Mortality rates were 13.1% in dPTCs, 12.6% in ATC-I, and 2.1% in ATC-II/III (p < 0.001). For children under 12 years of age, treatment at a dPTC was independently associated with a lower risk of in-hospital mortality compared to ATC-I (odds ratio [OR] 1.99, p = 0.017). dPTC treatment was also associated with more favorable GOS outcomes compared to ATC-I (OR 0.68, p = 0.022) and ATC-II/III (OR 0.34, p < 0.001).
Conclusion
Treatment at dPTCs is associated with a reduced risk of mortality for patients under 12 years of age and improved functional neurological outcomes. These findings support the further centralization of pediatric trauma care in the Netherlands.
Supplementary Information
The online version contains supplementary material available at 10.1007/s00068-025-02916-5.
Keywords: Pediatric trauma, Trauma centers, Mortality, Glasgow outcome scale, Treatment outcome
Background
In the Netherlands, an annual average of 320 multitrauma patients (ISS ≥ 16) aged 16 years or younger were admidded to emergency departments, the majority of whom were between 12 and 16 years old. The in-hospital mortality rate within this pediatric trauma population was 8.2%, most often due to road traffic accidents [1].
It is crucial to emphasize that managing pediatric trauma cases presents unique challenges due to the substantial differences in anatomy and pathophysiology in children compared to adults. These inequalities significantly influence the interpretations of physical findings and further examinations [2–4]. It is therefore essential that healthcare providers adapt their clinical approach accordingly. Therefore, alongside the regular adult trauma centers (ATCs), pediatric trauma centers (PTCs) have been established, primarly outside of Europe, to provide the highest quality of care for the pediatric population. Studies from the United States (US) have shown that pediatric trauma patients with an Injury Severity Score ≥ 16, treated at PTCs, were more frequently managed non-operatively, particularly in cases involving head, liver, and spleen injuries. Additionally, a decrease in overall mortality rates was observed [4].
PTCs have become a standard component of trauma care in countries such as the US, United Kingdom, Switzerland, and Australia [2, 4–6]. In contrast, the Netherlands has no officially recognized PTCs. However, six Dutch trauma centers meet the verification criteria set by the American College of Surgeons (ACS), including 24/7 availability of pediatric surgical specialists, a dedicated Pediatric Intensive Care Unit (PICU), access to pediatric subspecialties, child life services, and pediatric-specific trauma protocols [7, 8]. In this study, these Dutch centers are referred to as designated pediatric trauma centers (dPTCs). Table 1 summarizes the key ACS criteria for Pediatric Trauma Centers.
Table 1.
Key criteria for pediatric trauma center designation according to the American college of surgeons (ACS) [7–9]
| Domain | Key ACS requirements |
|---|---|
| 24/7 pediatric specialist access | Pediatric surgical and anesthesiology expertise must be continuously available. |
| PICU availability | On-site Pediatric Intensive Care Unit staffed 24/7 by pediatric intensivists. |
| Subspecialty services | Access to pediatric neurosurgery, orthopedics, urology, and other specialties. |
| Emergency readiness | Pediatric resuscitation protocols and size-appropriate equipment must be in place. |
| Imaging and diagnostics | Pediatric-specific imaging protocols and timely radiologist interpretation required. |
| Child life and family support | Certified child life specialists and family-centered support services must be available. |
| Rehabilitation services | Access to pediatric physical, occupational, and speech therapy for post-trauma recovery |
| Protocols and quality programs | Institutions must maintain pediatric trauma protocols and participate in quality programs. |
To date, no research has explored the impact of dPTCs compared to ATCs in the Netherlands. Therefore, the primary aim of this study was to assess the effect of treatment at a dPTC versus an ATC on in-hospital mortality among pediatric trauma patients. Secondary outcomes included the Glasgow Outcome Scale (GOS) at discharge and the total length of hospital stay.
Method
Data collection
A retrospective cohort study was performed to identify severely injured pediatric trauma patients who were admitted to trauma centers in the Netherlands during the period from January 1 st, 2015, to December 31 st, 2022. The data was acquired from the Dutch National Trauma Registry (DNTR), a prospective database that comprehensively records all patients who sustained injuries and were admitted to a hospital through the Emergency Department (ED) [10]. The study focused on severely injured pediatric patients, therefore only patients with an injury severity score (ISS) ≥ 16 and aged 16 and younger were included.
Patient characteristics extracted from the DNTR were age, gender, and comorbidities as defined by American Society of Anesthesiologists (ASA) score [9]. Injury characteristics included trauma mechanism (blunt or penetrating injuries), ISS and Abbreviated Injury Scale (AIS) [11, 12]. Prehospital data included utilization of the Helicopter Emergency Medical Service (HEMS) [13]. Hospital characteristics encompassed both the patient’s primary admitting hospital and, if applicable, the final hospital after transfer. This was categorized as either a dPTC or one of the ATC levels, including ATC-I and ATC-II/III. dPTCs were defined according to the criteria established by the American College of Surgeons (ACS), as outlined in Table 1 [4, 7, 14]. If patients were initially admitted to an ATC and transferred to a dPTC within 48 h, they were considered to have been treated at a dPTC in the analyses. For those patients who were transferred to a dPTC, patient demographics and primary and secondary outcomes were compared between those transferred from ATC-I to dPTC and those transferred from ATC-II/III to dPTC.
The primary outcome measure of the study was in-hospital mortality. The secondary outcome measures included the Glasgow Outcome Scale (GOS), administered at discharge, and the total length of hospital stay (LOS) in days, encompassing both the general ward and the intensive care unit (ICU) [15].
Statistical analysis
Descriptive statistics were used to characterize the three study groups, severely injured pediatric trauma patients treated at a dPTC versus those treated at an ATC-I versus those treated at an ATC-II/-III.
Primary and secondary outcome measures were analyzed and reported for all study groups.
Continuous variables were described using either means and standard deviations or medians with interquartile range (IQR, 25th–75th percentile) when the data followed a non-normal distribution. Categorical variables were described using frequencies and percentages. Univariate analysis included independent t-tests and one-way ANOVA for parametric data and Mann–Whitney U and Kruskal–Wallis tests for nonparametric data. Fisher’s exact tests and Chi-square tests were used for categorical data. These univariate analyses were conducted in two phases: first, a comparison was made between dPTC and ATC-I, denoted as ‘P value between dPTC and ATC-I.’ Additionally, analyses were performed comparing dPTC, ATC-I, and ATC-II/III as three groups, referred to as ‘P value overall’.
Finally, explanatory variables with a p-value < 0.10 in the initial univariate analysis were included in a multivariable binary logistic regression model and a multivariable ordinal regression model to assess the impact of treatment at a dPTC on in-hospital mortality and on the GOS, respectively. The multivariable analyses were reiterated for the age cohort under 12 and under 8 years of age. Odds ratios (ORs), 95% confidence intervals (CIs), and p-values were reported. A p-value of < 0.05 was considered significant. All statistical analyses were carried out using SPSS software (version 29.0; IBM SPSS Statistics, Armonk, NY).
Results
A total of 2,378 patients met the inclusion criteria, of whom 1,491 (63%) were treated in a dPTC, 413 (17%) in an ATC-I, and 474 (20%) in an ATC-II/III. The distribution of the pediatric patients among the hospitals over the years is shown in Fig. 1.
Fig. 1.
Distribution of severely injured pediatric trauma patients per year per type of hospital (in percentages)
The analysis of baseline characteristics revealed that patients in a dPTC had a significantly lower age (median 10, IQR 5–14, p < 0.001). The proportion of male patients was similar for all centers, with 62–65% being male. There was a significant difference in ISS score between dPTC (ISS 22, IQR 17–26) and ATC-I (ISS 21, IQR 17–26) vs. ATC-II/III (ISS 17, IQR 16–25) (overall p < 0.001), but there was no significant difference between dPTC vs. ATC-I (p = 1.000). Significantly more children presented with head injuries in dPTCs (61.6%), followed by 55.0% in ATC-I and 48.1% in ATC-II/III (overall p < 0.001). For abdominal injuries, significantly fewer children were treated in dPTCs (20.7%), followed by 21.5% in ATC-I and 33.5% in ATC-II/III (overall p < 0.001). Patients treated in dPTCs had a significantly higher incidence of HEMS involvement (38.1% in dPTC, 22.6% in ATC-I, and 3.8% in ATC-II/III, overall p < 0.001) (Table 2).
Table 2.
Comparison of baseline characteristics of severely injured pediatric trauma patients treated at a dPTC versus those treated at an ATC-I or ATC-II/III
| Characteristics | dPTC N = 1491 |
ATC-I N = 413 |
P value between dPTC and ATC-I | ATC-II/III N = 474 | P value overall | |
|---|---|---|---|---|---|---|
| Median (IQR) | ||||||
| Age | 10 (5–14) | 12 (5–15) | 0.000 | 11 (5–15) | < 0.001 | |
| ISS score | 22 (17–26) | 21 (17–26) | 1.000 | 17 (16–25) | < 0.001 | |
| Numbers (%) | ||||||
| Gender | Female | 542 (36.4) | 145 (35.1) | 0.642 | 181 (38.2) | 0.625 |
| ASA classification | I | 1168 (88.1) | 380 (92.2) | 0.019 | 374 (91.0) | 0.030 |
| II | 136 (10.3) | 31 (7.5) | 0.100 | 31 (7.5) | 0.105 | |
| III/IV/V | 22 (1.7) | 1 (0.2) | 0.028 | 6 (1.5) | 0.091 | |
| Mechanism of injury | Blunt | 1441 (97.0) | 397 (97.1) | 0.967 | 445 (98.5) | 0.250 |
| AIS score ≥ 3 | Head | 919 (61.6) | 227 (55.0) | 0.014 | 228 (48.1) | < 0.001 |
| Face | 21 (1.4) | 11 (2.7) | 0.079 | 5 (1.1) | 0.117 | |
| Neck | 13 (0.9) | 4 (1.0) | 0.773 | 1 (0.2) | 0.303 | |
| Thorax | 329 (22.1) | 97 (23.5) | 0.540 | 53 (11.2) | < 0.001 | |
| Abdomen | 309 (20.7) | 89 (21.5) | 0.715 | 159 (33.5) | < 0.001 | |
| Spine | 76 (5.1) | 19 (4.6) | 0.682 | 14 (3.0) | 0.151 | |
| Upper extremity | 19 (1.3) | 2 (0.5) | 0.284 | 2 (0.4) | 0.139 | |
| Lower extremity | 156 (10.5) | 54 (13.1) | 0.134 | 29 (6.1) | 0.002 | |
| Extern | 151 (10.1) | 54 (13.1) | 0.087 | 37 (7.8) | 0.035 | |
| Prehospital HEMS involvement | Yes | 561 (38.1) | 93 (22.6) | < 0.001 | 17 (3.8) | < 0.001 |
Univariate analyses revealed that patients treated in an ATC-II/III exhibited significantly lower mortality rates (2.1%) compared to 13.1% in dPTC and 12.6% in ATC-I (p < 0.001).
For the children treated in the dPTC, the smallest percentage entered a vegetative state (0.7% in dPTC, 5.1% in ATC-I, and 1.1% in ATC-II/III, overall p < 0.001), and the majority were discharged with a moderate disability (40.0% in dPTC, 33.4% in ATC-I, and 32.7% in ATC-II/III, overall p = 0.002). Patients treated in dPTCs had significantly longer lengths of stay on the general ward and in the intensive care unit, with medians of 7 days (IQR 4–13) and 2 days (IQR 1–5), respectively (p < 0.001) (Table 3).
Table 3.
Primary and secondary outcomes measures of severely injured pediatric trauma patients treated at a dPTC versus those treated at an ATC-I or ATC-II/III
| dPTC N = 1491 |
ATC-I N = 413 |
P-value between dPTC and ATC-I | ATC-II/III N = 474 |
P-value overall | ||
|---|---|---|---|---|---|---|
| Numbers (%) | ||||||
| Hospital mortality | 196 (13.1) | 52 (12.6) | 0.780 | 10 (2.1) | < 0.001 | |
| GOS | Vegetative state | 11 (0.7) | 21 (5.1) | < 0.001 | 5 (1.1) | < 0.001 |
| Severe disability | 219 (14.7) | 57 (13.8) | 0.348 | 122 (25.7) | < 0.001 | |
| Moderate disability | 596 (40.0) | 138 (33.4) | < 0.001 | 155 (32.7) | 0.002 | |
| Good recovery | 293 (19.7) | 120 (29.1) | < 0.001 | 68 (14.3) | < 0.001 | |
| Missing | 191 (12.8) | 25 (6.1) | 115 (24.3) | |||
| Median (IQR) | ||||||
| Hospital length of stay in days | 7 (4–13) | 4 (1–8) | 0.000 | 1 (1–2) | < 0.001 | |
| ICU length of stay in days | 2 (1–5) | 1 (0–2) | 0.000 | 0 (0–0) | < 0.001 | |
For children under 12 years of age, patient characteristics and primary and secondary outcome measurements were also analyzed (Supplementary information (SI) Table 1 and SI Table 2).
Multivariable binary logistic regression analysis for children under 16 years of age did not reveal treatment in a dPTC to be an independent predictor of a lower mortality risk (Table 4).
Table 4.
Multivariable binary logistic regression analyses for hospital mortality, of severely injured pediatric trauma patients treated at a dPTC versus those treated at an ATC-I or ATC-II/III
| Variables | Odds ratio (95% CI) | P-value | |
|---|---|---|---|
| Age | 0.937 (0.909 to 0.967) | < 0.001 | |
| ASA | ASA I | 0.284 (0.098 to 0.823) | 0.020 |
| ASA II | 0.349 (0.107 to 1.141) | 0.081 | |
| ASA III/IV/V | Reference | ||
| ISS | 1.108 (1.091 to 1.125) | < 0.001 | |
| Prehospital HEMS involvement | 4.586 (3.183 to 6.608) | < 0.001 | |
| Type of hospital: | dPTC | Reference | |
| ATC-I | 1.284 (0.837 to 1.971) | 0.253 | |
| ATC-II/III | 0.521 (0.236 to 1.151) | 0.107 | |
However, analysis for children under 12 years of age did show this association, compared to treatment in an ATC-I (OR 1.99, 95% confidence interval (CI) 1.13–3.50, p = 0.017) (Table 5).
Table 5.
Multivariable logistic regression analyses for hospital mortality, of severely injured pediatric trauma patients < 12 years old, treated at a dPTC versus those treated at an ATC-I or ATC-II/III
| Variables | Odds ratio (95% CI) | P-value | |
|---|---|---|---|
| Age | 0.853 (0.769 to 0.914) | < 0.001 | |
| ASA | ASA 1 | 0.191 (0.048 to 0.760) | 0.019 |
| ASA II | 0.338 (0.072 to 1.599) | 0.171 | |
| ASA III/IV/V | Reference | ||
| ISS | 1.122 (1.096 to 1.150) | < 0.001 | |
| Prehospital HEMS involvement | 5.351 (3.187 to 8.985) | < 0.001 | |
| Type of hospital | dPTC | Reference | |
| ATC-I | 1.989 (1.130 to 3.502) | 0.017 | |
| ATC-II/III | 0.361 (0.095 to 1.367) | 0.134 | |
Multivariable ordinal regression analysis for children under 16 years of age revealed dPTC to be an independent predictor of more favorable GOS compared to treatment in ATC-II/III (OR 0.37, 95% CI 0.30–0.47, p < 0.001) (Table 6). In the multivariable analysis for children under 12 years of age only, dPTC was also found to be an independent predictor for more favorable GOS compared to both ATC-I (OR 0.68, 95% CI 0.49–0.95, p = 0.022) and ATC-II/III (OR 0.34, 95% CI 0.25–0.47, p < 0.001) (Table 7).
Table 6.
Multivariable ordinal logistic regression analyses for GOS, of severely injured pediatric trauma patients treated at a dPTC versus those treated at an ATC-I or ATC-II/III
| Variables | Odds ratio (95% CI) | P-value | |
|---|---|---|---|
| Age | 1.012 (0.996 to 1.029) | 0.139 | |
| ASA | ASA I | 1.214 (0.536 to 2.750) | 0.641 |
| ASA II | 1.152 (0.751 to 1.769) | 0.516 | |
| ASA III/IV/V | Reference | ||
| ISS | 0.910 (0.900 to 0.921) | < 0.001 | |
| Prehospital HEMS involvement | 0.322 (0.262 to 0.394) | < 0.001 | |
| Type of hospital: | dPTC | Reference | |
| ATC-I | 0.924 (0.736 to 1.160) | 0.496 | |
| ATC-II/III | 0.373 (0.295 to 0.473) | < 0.001 | |
Table 7.
Multivariable ordinal logistic regression analyses for variables GOS, of severely injured pediatric trauma patients < 12 years old treated at a dPTC versus those treated at an ATC-I or ATC-II/III
| Variables | Odds ratio (95% CI) | P-value | |
|---|---|---|---|
| Age | 1.024 (0.992 to 1.057) | 0.149 | |
| ASA | ASA I | 1.118 (0.432 to 2.895) | 0.819 |
| ASA II | 1.143 (0.685 to 1.907) | 0.609 | |
| ASA III/IV/V | Reference | ||
| ISS | 0.910 (0.895 to 0.924) | < 0.001 | |
| Prehospital HEMS involvement | 0.290 (0.220 to 0.382) | < 0.001 | |
| Type of hospital: | dPTC | Reference | |
| ATC-I | 0.681 (0.489 to 0.946) | 0.022 | |
| ATC-II/III | 0.339 (0.247 to 0.465) | < 0.001 | |
For both the binary regression and the ordinal regression, sub-analyses were also performed for children under 8 years of age. These analyses showed similar results to the analyses for children under 12 years of age.
The LOS data for both the general ward and ICU were skewed and could not be corrected, making a multivariable analysis unfeasible.
Some patients in the dPTC group initially received treatment at a different type of center before they were transferred to the dPTC within 48 h. Specifically, 59 patients were transferred from ATC-I, and 379 from ATC-II/III. Among the patients transferred from ATC-I, the mean ISS score was 24 (IQR 17–30), which was significantly higher than the mean ISS score of 17 (IQR 16–25) (p < 0.001) observed in patients transferred from ATC-II/III. The mortality rate in the ATC-I transfer group was also higher, with a rate of 11.9%, compared to 1.3% in the ATC-II/III transfer group (p < 0.001) (SI Table 3 and SI Table 4).
Discussion
This retrospective cohort study is the first in the Netherlands to provide a comprehensive insight into how dPTCs enhance pediatric trauma care. Surprisingly, only 63% of severely injured children were treated in dPTCs, with even one in five children receiving treatment in ATC-II/III, particularly those with abdominal injuries. However, treatment in dPTCs was independently associated with more favorable GOS scores, and was also independently associated with a lower mortality risk in children under 12 years of age.
Trauma centers are designated at various levels (i.e., Level 1–3) to ensure appropriate patient allocation based on injury severity and resource availability [3, 14]. In the Netherlands, dPTCs functionally operate as Level 1 centers with pediatric specialization, whereas ATC centers often have more limited resources and less experience in managing severe pediatric trauma [14].
The improved outcomes observed in dPTCs—particularly the lower mortality in children under 12 years of age and better functional recovery—are likely attributable to the structural and organizational advantages defined by the ACS. dPTCs offer continuous access to pediatric surgical and critical care specialists, operate with pediatric-specific protocols, and have dedicated resources such as PICUs, child life services, and pediatric subspecialties including neurosurgery, anesthesiology, and radiology. These elements enable rapid and tailored interventions for severely injured children. In contrast, ATCs often lack these pediatric-specific infrastructure, which may require inter-hospital transfers of critically injured children, leading to potential delays in definitive care.
In addition, literature shows that high-volume centers with pediatric trauma expertise generally achieve lower mortality rates and improved outcomes due to increased provider familiarity and institutional experience [16].
The mortality rate of children treated in a dPTC was 13.1%. This mortality rate is comparable to mortality rates for severely injured pediatric patients in other countries, such as 11.9% in the US, 14% in Spain, 13.4% in Germany, or even lower compared to 26,2% in Switzerland and 30% in Finland [4, 17–19]. This study did not reveal treatment in a dPTC to be an independent predictor for a lower mortality risk when compared to treatment in ATC-II/III, possibly due to the higher incidence of neurotrauma in dPTCs, which is associated with high mortality [20, 21].
Regarding functional outcomes and LOS, a study in the US also investigated both outcomes among severely injured pediatric patients treated at dPTCs. Similar to our findings, the study also revealed that pediatric patients treated in a dPTC have favorable functional outcomes. But in contrast to our study, it reported a shorter LOS for children treated in a dPTC. The longer LOS in our study may be due to the high incidence of neurotrauma in dPTCs, which can lead to impaired consciousness and behavior and may delay discharge due to challenges in arranging follow-up care or rehabilitation placement [21, 22].
This is the first study in the Netherlands to compare outcomes between pediatric trauma patients treated in dPTCs versus those treated in ATCs in a nationwide study. However, our study was limited by several factors. Firstly, we encountered a high number of missing values in the GOS. Secondly, this study was unable to determine whether differences in outcomes among transferred patients were due to the transfer itself or the treatment received at the dPTC, leaving the influence of transferred patients on outcomes unclear. The GOS in dPTCs may have been negatively influenced by the lower GOS in children transferred from ATC-I, while children transferred from ATC-II/III might have positively influenced the dPTC results due to lower mortality and better GOS. Additionally, our study lacked in-hospital data on factors contributing to care provision in dPTCs, such as the frequency of surgical interventions or imaging [4]. These limitations underscore the need for further research to comprehensively understand and implement the factors contributing to improved outcomes in dPTCs.
Overall, our findings demonstrate that dPTCs in the Netherlands may provide better outcomes for severely injured pediatric patients, particularly for children under 12 years of age, with lower odds of mortality and higher odds of improved neurological outcomes compared to ATCs. These results support further centralization of pediatric trauma care in the Netherlands to improve the quality of care for this patient group. Transitioning a dPTC into a formal PTC, however, requires the integration of comprehensive pediatric services, such as child protection experts, behavioral health specialists, social work support, educational resources, and rehabilitation facilities. Future efforts should focus on optimizing these services to ensure multidisciplinary care for severely injured children and to address the needs of their families.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Erna Krusemann, policy advisor of the Dutch Network for Emergency Care (LNAZ), in collaboration with the Medical Scientific Advisory Board, approved and advised on the study protocol and provided access to the Dutch National Trauma Registry (DNTR). Karin Habets and Anneke Bloemhoff from the Network of Acute Care Eastern Netherlands (AZO) extracted data from the DNTR and created the dataset. We would like to acknowledge the following individuals, all of whom are members of the Pediatric Trauma Consortium Nijmegen: Ivo de Blaauw, Allard Hosman, Allon van Uitert, Elisa Hamer, Elke arts, Fay Sanders, Hisse Arnts, Jan Bollen, Joris Lemson, Lily Verhagen, Maarten Stessel, Malou Holtzer, Marie-Louise Loos, Mila Leeuwerik, Nienke Maas, Ozcan Sir and Tjarda Tromp.
Author contributions
Literature search: SJ. Study conception and design: SJ, SN. Data analysis and interpretation: SJ, SN. Manuscript drafting: SJ. Critical revision of the manuscript: MB, DB, AN, LT, SZ, ME, EH, SN. All authors read and approved the final manuscript.
Funding
No funding was received for conducting this study.
Data availability
The data used in this study are derived from the Dutch National Trauma Registry (DNTR) and are not publicly available. However, they may be made available by the corresponding author upon reasonable request and with explicit permission from the DNTR
Declarations
Ethics approval and consent to participate
The use of medical data for this study complied with institutional guidelines for non-WMO (Medical Research Involving Human Subjects Act)-mandatory research, as outlined in the local Standard Operating Procedure (SOP) for the use of existing medical data in research.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Fylli C, Schipper IB, Krijnen P. Pediatric trauma in the netherlands: incidence, mechanism of injury and in-hospital mortality. World J Surg. 2023;47(5):1116–28. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Svantner J, Dolci M, Heim C, Schoettker P. Pediatric trauma: six years of experience in a Swiss trauma center. Pediatr Emerg Care. 2021;37(12):e1133–8. [DOI] [PubMed] [Google Scholar]
- 3.Wyen H, Jakob H, Wutzler S, Lefering R, Laurer HL, Marzi I, et al. Prehospital and early clinical care of infants, children, and teenagers compared to an adult cohort: analysis of 2,961 children in comparison to 21,435 adult patients from the trauma registry of DGU in a 15-year period. Eur J Trauma Emerg Surg. 2010;36(4):300–7. [DOI] [PubMed] [Google Scholar]
- 4.Potoka DA, Schall LC, Gardner MJ, Stafford PW, Peitzman AB, Ford HR. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma. 2000;49(2):237–45. [DOI] [PubMed] [Google Scholar]
- 5.Curtis K, Kennedy B, Holland AJA, Tall G, Smith H, Soundappan SSV, et al. Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical, system and human factors peer-review tool. Injury. 2019;50(5):1089–96. [DOI] [PubMed] [Google Scholar]
- 6.Low SBL, Tan Y, Patel H, Johnson K. Four-year experience of paediatric penetrating injuries: findings from a paediatric major trauma centre in the UK. Clin Radiol. 2022;77(4):244–54. [DOI] [PubMed] [Google Scholar]
- 7. Wang KS, Cummings J, Stark A, Houck C, Oldham K, Grant C et al. Optimizing resources in children’s surgical care: an update on the American College of Surgeons’ Verification Program. Pediatrics. 2020;145(5):e20200708. [DOI] [PubMed]
- 8.American College of Surgeons. Optimal resources for children’s surgical care v.1. Chicago: American College of Surgeons; 2021.
- 9.Doyle DJ, Hendrix JM, Garmon EH. American society of anesthesiologists classification. StatPearls. Treasure Island: StatPearls Publishing; 2023. [PubMed]
- 10.Landelijke Netwerk Acute Zorg (LNAZ). Traumazorg in beeld: landelijke traumaregistratie 2013–2017. Rapportage Nederland. Utrecht: LNAZ; 2018.
- 11.Gennarelli TA, Wodzin E. AIS 2005: a contemporary injury scale. Injury. 2006;37(12):1083–91. [DOI] [PubMed] [Google Scholar]
- 12.Schneck HJ, Tempel G, von Hundelshausen B, Brosch R. [Injury severity score (ISS) in the classification of polytrauma patients]. Zentralbl Chir. 1986;111(17):1025–33. [PubMed] [Google Scholar]
- 13.Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;304(7872):81–4. [DOI] [PubMed] [Google Scholar]
- 14.ten Duis HJ, van der Werken C. Trauma care systems in the Netherlands. Injury. 2003;34(9):722–7. [DOI] [PubMed] [Google Scholar]
- 15.Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1(7905):480–4. [DOI] [PubMed] [Google Scholar]
- 16.Hamill J, Beasley SW. Training in paediatric trauma: the problem of safer societies. ANZ J Surg. 2006;76(7):596–9. [DOI] [PubMed] [Google Scholar]
- 17.Schoeneberg C, Schilling M, Keitel J, Burggraf M, Hussmann B, Lendemans S. Mortality in severely injured children: experiences of a German level 1 trauma center (2002–2011). BMC Pediatr. 2014;14:194. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Navascués del Río JA, Romero Ruiz RM, Soleto Martín J, Cerdá Berrocal J, Barrientos Fernández G, Sánchez Martín R, et al. First Spanish trauma registry: analysis of 1500 cases. Eur J Pediatr Surg. 2000;10(5):310–8. [DOI] [PubMed] [Google Scholar]
- 19.Suominen P, Kivioja A, Ohman J, Korpela R, Rintala R, Olkkola KT. Severe and fatal childhood trauma. Injury. 1998;29(6):425–30. [DOI] [PubMed] [Google Scholar]
- 20.Kannan N, Ramaiah R, Vavilala MS. Pediatric neurotrauma. Int J Crit Illn Inj Sci. 2014;4(2):131–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, et al. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol. 2022;21(11):1004–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma. 2001;51(5):824–32. discussion 32– 4. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data used in this study are derived from the Dutch National Trauma Registry (DNTR) and are not publicly available. However, they may be made available by the corresponding author upon reasonable request and with explicit permission from the DNTR