ABSTRACT
Background
Trauma is one of the leading causes of death in children. Trauma patients have been demonstrated to require significant resources, including operating room time. We aimed to describe the characteristics and patterns of access to surgery and outcomes of pediatric major trauma patients at The Hospital for Sick Children.
Methods
We retrospectively collected data from the Hospital for Sick Children trauma registry and the hospital's patient electronic record, from June 01, 2018, to October 31 2020. We analyzed a subset of patients requiring surgery in the operating room. The objective was to describe the distribution of major trauma cases requiring operating room access and their hospital length of stay, blood product use, and mortality rates. We summarized the results into three groups based on operating room access timing: patients with immediate access, within 24 h, and after 24 h.
Results
In total, 141 of 721 pediatric major trauma patients (19.6%) underwent surgery and were included. Among these, 67 patients received immediate access to the operating room (47.5%), 37 patients received access within 24 h (26.2%) and 37 patients received access after 24 h (26.2%). The median age was 8 (0–17) years, and 65.2% of patients were male. The median ISS score was 11.5 (1–57). The most frequently involved surgical specialties were orthopedics and neurosurgery. The median hospital length of stay was 6 days (range 1–102). The mortality rate was 1.4%. A multivariable regression analysis showed a correlation between the number of surgical procedures and length of stay (p < 0.01, 95% confidence interval 9.11–11.64).
Conclusion
Major trauma patients have a significant time impact on the anesthesia department. Further studies are needed to better define the pediatric trauma population and its intra‐hospital flow and resource use.
Keywords: pediatric airway management, pediatric anesthesia, pediatric resuscitation, pediatric trauma
What Is Already Known About This Topic
Pediatric major trauma patients treated in pediatric‐specific trauma centers have improved survival, but they place a significant and unpredictable demand on hospital resources, including operating room time. The magnitude and timing of this demand on anesthesia and operating room services have not been well characterized.
What New Information This Study Adds
In this single‐center cohort, one‐in‐five pediatric major trauma patients underwent surgery, and almost half of these received immediate operating room access, with orthopedics and neurosurgery accounting for most operating room use. These time metrics can help pediatric trauma centers plan emergency operating room capacity, on‐call staffing, and specialty‐specific scheduling.
1. Introduction
Trauma is one of the leading causes of mortality and morbidity. In Canada, access to the hospital for unintentional injury is among the first ten causes of hospitalization [1]. In the pediatric population, the global burden of death from injury in patients < 14 years was estimated to be around 30% in 2019 [2]. Since the development of pediatric‐specific trauma centers in the early ‘70s, several studies have shown a reduction in mortality for pediatric trauma patients treated in pediatric‐specific centers, compared to adult or mixed centers [3]. However, these patients have been demonstrated to require significant resources, including operating room (OR) time [4, 5, 6].
The Hospital for Sick Children in Toronto, Canada, is one of the first pediatric‐ specific trauma centers instituted in North America [7], whose trauma program cares for children from 0 to 15 years of age. The purpose of this study was to describe the patterns and distribution of major trauma patients requiring operating room access at the Hospital for Sick Children from 2018 to 2020.
2. Methods
2.1. Ethics Approval and Study Design
This retrospective study received approval, with a waiver of written consent, from the Hospital for Sick Children (SickKids) Research Ethics Board (#1000075368). All patients who presented with major pediatric trauma to the SickKids Emergency Department between June 01, 2018, to October 31 2020, were included in the study.
Pediatric patients were defined as those < = 16 years old (one 17‐year‐old was included in our study as being thought to be 16 initially, brought to the Hospital for sick Children and included in the trauma registry data). Major trauma was defined as meeting level 1 or level 2 Trauma criteria for the Hospital for Sick Children/Pre‐hospital ambulance service criteria or patients not meeting criteria for trauma level 1–2 activation, but who were subsequently found to have an ISS score greater than or equal to 12 as per the Trauma association of Canada (TAC) definition. Because inclusion could be met through either trauma team activation criteria or the ISS criterion, patients activated as level 1 or level 2 trauma who were subsequently found to have an ISS below 12 remained eligible; this accounts for the range of ISS values observed in the cohort. The flow of patients through the study is shown in Figure 1. Patients who underwent surgery in the operating room constituted the sample size for the study. Access to the operating room was evaluated with two variables: assigned priority to operating room access (immediate access, access within 24 h and access after 24 h) and total operating room time. In addition, each case booked for the operating room is assigned a surgical urgency priority (priority 1, 2, or 3, with priority 1 being the most urgent) at the time of booking; the assigned priority is reported in Table 1 and was compared with the timing of operating room access received. Details on the timing, Injury Severity Score, patient condition during transportation and arrival to the hospital, and events during the emergency department activation, were obtained from the Hospital for Sick Children trauma registry. The trauma registry was established as a hospital program and collects data prospectively on all trauma patients arriving at the Hospital for Sick Children. Data on patients' demographics, anesthetic and surgical requirements, and clinical outcomes were abstracted from the hospital's patient electronic record, Epic (Verona, WI).
FIGURE 1.
Flow diagram of patient inclusion and timing of operating room access.
TABLE 1.
Demographics.
| Demographics | ||||
|---|---|---|---|---|
| All patients = 141 | Patients with immediate access to OR = 67 | Patients with access to OR < 24 h = 37 | Patients with access to OR > 24 h = 37 | |
| Age (years) | 8 (0–17) | 7 (0–16) | 11 (1–17) | 7 (0–16) |
| Weight (Kg) | 30 (3–162) | 27 (3–70) | 35 (10–90) | 30 (6–162) |
| Sex | ||||
| F | 49 (34.7%) | 25 (37.3%) | 9 (24.3%) | 15 (40.5%) |
| M | 92 (65.2%) | 42 (62.7%) | 28 (75.7%) | 22 (59.4%) |
| ASA | ||||
| I | 34 (24.1%) | 13 (19.4%) | 12 (32.4%) | 9 (24.3%) |
| II | 19 (13.5%) | 7 (10.4%) | 6 (16.2%) | 6 (16.2%) |
| III | 51 (36.2%) | 25 (37.3%) | 12 (32.4%) | 14 (37.8%) |
| IV | 21 (14.9%) | 12 (17.9%) | 4 (10.8%) | 5 (13.5%) |
| V | 15 (10.6%) | 10 (14.9%) | 3 (8.1%) | 2 (5.4%) |
| N/A | 1 (0.7%) | 0 (0%) | 0 (0%) | 1 (2.7%) |
| ISS | 11.5 (1–57) missing = 1 | 10 (1–43) missing = 1 | 11 (1–50) | 16 (1–57) |
| Priority | ||||
| 1 | 45 (31.9%) | 35 (52.2%) | 6 (16.2%) | 4 (10.8%) |
| 2 | 43 (30.5%) | 26 (38.8%) | 11 (29.7%) | 6 (16.2%) |
| 3 | 52 (36.9%) | 6 (9%) | 20 (54%) | 26 (70.3%) |
| N/A | 1 (0.7%) | 0 (0%) | 0 (0%) | 0 (0%) |
| Trauma Team Activation level | ||||
| 1 | 52 (36.9%) | 25 (37.3%) | 14 (37.8%) | 13 (35.1%) |
| 2 | 73 (51.8%) | 35 (52.2%) | 19 (51.3%) | 19 (51.4%) |
| N/A | 16 (11.3%) | 7 (10.4%) | 4 (10.8%) | 5 (13.5%) |
| Type of Injury | ||||
| Penetrating | 15 (10.6%) | 13 (19.4%) | 2 (5.4%) | 0 (0%) |
| Blunt | 126 (89.4%) | 54 (80.6%) | 35 (94.6%) | 37 (100%) |
| GCS at the scene | ||||
| 13–15 | 62 (44%) | 30 (44.8%) | 17 (45.9%) | 15 (40.5%) |
| 9–12 | 4 (2.8%) | 3 (4.5%) | 0 (0%) | 1 (2.7%) |
| 3–8 | 12 (8.5%) | 4 (6%) | 4 (10.8%) | 4 (10.8%) |
| N/A | 63 (44.7%) | 30 (44.8%) | 16 (43.2%) | 13 (35.1%) |
| GCS in Emergency Department | ||||
| 13–15 | 95 (67.4%) | 47 (70.1%) | 25 (67.6%) | 23 (62.2%) |
| 9–12 | 8 (5.7%) | 3 (4.5%) | 4 (10.8%) | 1 (2.7%) |
| 3–8 | 8 (5.7%) | 2 (3%) | 3 (8.1%) | 3 (8.1%) |
| N/A | 30 (21.3%) | 7 (10.4%) | 5 (13.5%) | 10 (27%) |
| Arrival Time | ||||
| Day time (7 am—7 pm) | 64 (45.4%) | 32 (47.8%) | 15 (40.5%) | 17 (45.9%) |
| Afterhours (7 pm—7 am) | 65 (46.1%) | 29 (43.3%) | 22 (59.5%) | 14 (37.8%) |
| Not documented | 12 (8.5%) | 6 (9%) | 0 (0%) | 6 (16.2%) |
| Temperature in Emergency Department | 36.8 (34.3–39.4) missing = 30 | 36.9 (34.3–39.4) missing = 19 | 36.8 (36–38.1) missing = 4 | 36.6 (35.9–37.7) missing = 7 |
Note: Data are expressed in median (range) or count (%). N/A data not available.
Abbreviations: ASA, American Society of Anesthesiologists; GCS, Glasgow Coma Scale; ISS: Injury Severity Score.
The purpose of the study was to describe the distributions of major pediatric trauma patients at The Hospital for Sick Children requiring operating room access. We sought to describe the characteristics and distribution of cases requiring access to the operating room (immediate access, access within 24 h, access after 24 h); assess the hospital length of stay and factors associated with hospital length of stay, the requirement for blood in the first 24 h, and mortality. Data collected included the nature of injury (blunt vs. penetrating), Injury Severity Score, anesthesia management, ASA physical status, and airway procedures and anesthesia techniques. Results were summarized as a total and for each operating room timing access subgroup (immediate access, access within 24 h, access after 24 h).
2.2. Statistical Analysis
Categorical variables are expressed as counts (n) and frequencies (%) and categorical outcome data were compared with Pearson's Chi‐Squared test. For continuous variables, data were checked for normality with the Shapiro‐Wilk test, presented as median (m) and range (−), and continuous outcome data were evaluated using the nonparametric Kruskal‐Wallis test or the Wilcoxon rank sum test, as appropriate. Denominators are presented to indicate missing data. Categorical variables were compared between groups using Fisher's exact test. Ordinal logistic regression was implemented to calculate odds ratios with 95% confidence intervals and p values for ordinal variables. Statistical analyses were performed using R software (R Foundation for Statistical Computing [8]).
3. Results
3.1. Characteristics of Study Population
In total, 721 pediatric major trauma patients were admitted to the Hospital for Sick Children between June 01, 2018, to October 31 2020, and 141 (19.6%) received surgical management in the operating room for their injuries. Figure 1 summarizes patient inclusion: of the 141 patients, 125 (88.7%) had a documented level 1 or 2 trauma team activation (52 level 1, 73 level 2), and 16 (11.3%) had no documented level 1–2 activation and met inclusion on the basis of an ISS of 12 or greater. The median age of the patients requiring operating room access was 8 (range 0–17) years, and 65.2% of patients were male; the median ISS score was 11.5 (range 1–57) and 65.7% had a GCS score at hospital arrival of 13–15. The injuries were blunt injuries in 89.4% of patients and penetrating injuries in 10.6% of patients. Table 1 shows the complete demographics for the overall study sample and for subgroups based on operating room timing access.
3.2. Access to the Operating Room and Hospital Length of Stay, Blood Transfusion, and Mortality
Among the 141 patients requiring operating room access, 67 patients had immediate access to the operating room (47.5%), 37 patients had access within 24 h (26.2%) and 37 patients had access after 24 h (26.2%). The median time from the emergency department to access the operating room was 139 min or 2.3 h (range 22–956 min) for the immediate access group, 679 min or 11.3 h (range 111–1385 min) for the group with access within 24 h and 2680 min or 44.7 h (range 498–12 701 min) for the patients with access after 24 h. The median operating room duration was calculated for the first surgical procedure the patients underwent. For 14 patients, these data were not available. The median operating room duration was 133 min or 2.2 h (range 15–658). The first operating room duration was shorter for the group with access to the operating room after 24 h, with a median time of 97.5 min (range 27–421), p < 0.01 (Figure 2). Table 2 summarizes the primary outcome for the overall sample size and for the subgroups based on operating room time access.
FIGURE 2.
Median of 1st surgery room duration of the three study groups.
TABLE 2.
Primary outcomes.
| All Patients = 141 | Patients with immediate access to OR = 67 | Patients with access to OR < 24 h = 37 | Patients with access to OR > 24 h = 37 | p | |
|---|---|---|---|---|---|
| Destination from Emergency Department | |||||
| Floor | 54 (38.3%) | 0 (0%) | 26 (70.3%) | 28 (75.7%) | |
| PICU | 20 (14.2%) | 0 (0%) | 11 (29.7%) | 9 (24.3%) | |
| Operating Room | 67 (47.5%) | 67 (100%) | 0 (0%) | 0 (0%) | |
| Time from emergency department to Operating Room (min) | 431 (22–12 701) missing = 12 | 139 (22–956) missing = 6 | 679 (111–1385) | 2680 (498–12 701) missing = 6 | |
| 1st Room duration (min) | 133 (15–658) missing = 14 | 134.5 (37–658) missing = 7 | 194 (15–492) | 97.5 (27–421) missing = 7 | < 0.01 |
| 1st Procedure duration (min) | 88 (3–599) missing = 4 | 94 (12–599) missing = 2 | 111 (3–425) | 66 (13–322) missing = 2 | 0.011 |
When the assigned surgical urgency priority was compared with the timing of operating room access received, 35 of 45 priority 1 patients (77.8%) and 26 of 43 priority 2 patients (60.5%) received immediate access to the operating room. Among the 52 priority 3 patients, 6 (11.5%) received immediate access, 20 (38.5%) received access within 24 h, and 26 (50%) received access after 24 h (Table 1).
The median hospital length of stay was 6 days (range 1–102) and was no different among the operating time access subgroups. A multivariable regression analysis was performed to identify any factor related to prolonged length of stay. Table 3 shows the multivariable regression analysis results. The number of procedures done in the operating room was significantly associated with a prolonged hospital length of stay (p < 0.01, 95% confidence interval 9.11–11.64). Overall, 42 patients (29.8%) received a blood transfusion in the first 24 h (Table 4). Mortality for all 721 admitted trauma patients over the study period was 2.5% (18 patients). The mortality rate in our subset population (n = 141) was 1.4% with no difference among groups. Table 4 summarizes the secondary outcomes for the overall sample size and for the subgroups based on operating room time access.
TABLE 3.
Multivariable regression analysis.
| Variable | Estimate | Lower confidence level | Upper confidence level | p |
|---|---|---|---|---|
| Number of Operating Room surgeries | 10.37455 | 9.109097 | 11.64001 | < 0.0001* |
| Procedure Duration | −0.03023 | −0.09357 | 0.033111 | 0.3413 |
| Room Duration | 0.039647 | −0.01392 | 0.093214 | 0.1429 |
| Sex | −0.94889 | −2.72278 | 0.824998 | 0.2868 |
| Age | 0.473778 | −0.22376 | 1.171318 | 0.1779 |
| Weight (Kg) | −0.15474 | −0.36229 | 0.052817 | 0.1401 |
| GCS on arrival < 8 | −0.23552 | −13.6307 | 13.15965 | 0.9719 |
| GCS at scene < 8 | 6.348104 | −1.55216 | 14.24837 | 0.1125 |
| Time in OR (min) | −0.00227 | −0.03107 | 0.026531 | 0.8744 |
| ASA | −0.41098 | −6.06685 | 5.244901 | 0.8842 |
| Time from Emergency Room to Operating Room (min) | 0.000902 | −0.00044 | 0.002241 | 0.1813 |
| Injury Severity Score (ISS) | 0.218025 | −0.01824 | 0.454288 | 0.0696 |
| Emergency or Elective case | 0.927024 | −0.80882 | 2.662869 | 0.2876 |
| Massive Hemorrhage Protocol | 1.461223 | −5.27061 | 8.193055 | 0.6638 |
| Arrival Time (Daytime or Afterhours) | 0.435484 | −1.14941 | 2.020383 | 0.5824 |
| Blood transfused during admission | −1.03299 | −4.74723 | 2.681243 | 0.5779 |
| Penetrating injury or blunt injury | −1.30621 | −3.5422 | 0.929791 | 0.2453 |
Statistically significant.
TABLE 4.
Secondary outcomes.
| All patients = 141 | Patients with immediate access to OR = 67 | Patients with access to OR < 24 h = 37 | Patients with access to OR > 24 h = 37 | p | |
|---|---|---|---|---|---|
| Hospital Length of stay (days) | 6 (1–102) | 5 (1–65) | 6 (1–102) | 7 (2–66) | 0.35 |
| Blood required in the first 24 h | 0.69 | ||||
| Yes | 42 (29.8%) | 21 (31.3%) | 12 (32.4%) | 9 (24.3%) | |
| No | 99 (70.2%) | 46 (68.7%) | 25 (67.6%) | 28 (75.7%) | |
| Blood required at admission | 0.69 | ||||
| Yes | 42 (29.8%) | 21 (31.3%) | 12 (32.4%) | 9 (24.3%) | |
| No | 99 (70.2%) | 46 (68.7%) | 25 (67.6%) | 28 (75.7%) | |
| Massive Hemorrhage Protocol | 0.7 | ||||
| Yes | 10 (7.1%) | 6 (9%) | 2 (5.4%) | 2 (5.4%) | |
| No | 131 (92.9%) | 61 (91%) | 35 (94.6%) | 35 (94.6%) | |
| Mortality | 2 (1.4%) | 1 (1.5%) | 0 (0%) | 1 (2.7%) | 0.61 |
Note: Data are expressed in median (range) or count (%). N/A data not available.
Abbreviations: LOS, Length of Stay; PICU, Pediatric Intensive Care Unit.
3.3. Anesthesia Techniques
Table 5 shows the anesthetic and surgical requirements for the overall sample size and for subgroups based on operating room time access. Around 23% of the patients underwent more than one surgery. In the group with immediate access to the operating room, 50.7% of the patients received Rapid Sequence Intubation (RSI), while intravenous induction was the most prevalent in the other groups. Opiates were widely used (77.3%) for induction; ketamine was used in a minority of cases (12%). Intubation was performed more frequently (77.6%) in patients with immediate access to the operating room. A surgical airway was performed in only one case for complex maxillofacial injuries following failed video laryngoscopy. The most frequently involved surgical specialties were orthopedics, followed by plastic and neurosurgery.
TABLE 5.
Anesthetic and surgical requirements (process measures).
| Anesthetics and surgical requirements for 1st surgery | |||||
|---|---|---|---|---|---|
| All patients = 141 | Patients with immediate access to OR = 67 | Patients with access to OR < 24 h = 37 | Patients with access to OR > 24 h = 37 | ||
| Time in emergency Department (min) | 167 (0–18 914) missing = 12 | 90 (0–896) missing = 6 | 206 (30–1512) missing = 3 | 440 (18–18 914) missing = 3 | |
| Time in trauma room (min) | 39 (0–105) | 38 (0–105) | 42 (0–59) | 37 (0–94) | |
| Operating room procedures (n) | 1 (1–20) | 1 (1–9) | 1 (1–9) | 1 (1–20) | 0.89 |
| Surgical procedure | |||||
| Emergent | 88 (62.4%) | 55 (82.1%) | 24 (64.9%) | 9 (24.3%) | |
| Elective | 23 (16.3%) | 11 (16.4%) | 12 (32.4%) | 0 (0%) | |
| N/A | 30 (21.3%) | 1 (1.5%) | 1 (2.7%) | 28 (75.7%) | |
| Patients who required more than 1 surgery in the operating room | 32 (22.7%) | 16 (23.9%) | 8 (21.6%) | 8 (21.6%) | 0.95 |
| Fasted | |||||
| Yes | 54 (38.3%) | 18 (26.9%) | 16 (43.2%) | 20 (54%) | |
| No | 72 (51.06%) | 47 (70.1%) | 19 (51.3%) | 6 (16.2%) | |
| N/A | 15 (10.6%) | 2 (3%) | 2 (5.4%) | 11 (29.7%) | |
| Induction method | |||||
| Rapid sequence Intubation | 54 (38.3%) | 34 (50.7%) | 16 (43.2%) | 4 (10.8%) | |
| Inhalational | 2 (1.4%) | 0 (0%) | 1 (2.7%) | 1 (2.7%) | |
| IV | 61 (43.3%) | 28 (41.2%) | 19 (51.4%) | 14 (37.8%) | |
| N/A | 24 (17%) | 5 (7.5%) | 1 (2.7%) | 18 (48.6%) | |
| Opiate used | |||||
| Yes | 109 (77.3%) | 56 (83.6%) | 31 (83.8%) | 22 (59.4%) | |
| No | 12 (8.5%) | 4 (6%) | 3 (8.1%) | 5 (13.5%) | |
| Unknown | 20 (14.2%) | 7 (10.4%) | 3 (8.1%) | 10 (27%) | |
| Ketamine for induction | |||||
| Yes | 17 (12%) | 10 (14.9%) | 6 (16.2%) | 1 (2.7%) | |
| No | 104 (73.8%) | 50 (74.6%) | 28 (75.7%) | 26 (70.3%) | |
| Unknown | 20 (14.2%) | 7 (10.4%) | 3 (8.1%) | 10 (27%) | |
| NMBA used | |||||
| Yes | 91 (64.5%) | 54 (80.6%) | 25 (67.6%) | 12 (32.4%) | |
| No | 31 (22%) | 6 (9%) | 9 (24.3%) | 16 (43.2%) | |
| Unknown | 19 (13.5%) | 7 (10.4%) | 3 (8.1%) | 9 (24.3%) | |
| NMBA only for intubation | |||||
| Yes | 1 (0.7%) | 1 (1.5%) | 0 (0%) | 0 (0%) | |
| No | 140 (99.3%) | 66 (98.5%) | 37 (100%) | 37 (100%) | |
| Intubation | 89 (63.1%) | 52 (77.6%) | 23/37 (62.2%) | 14/37 (37.8%) | |
| Cormack‐Lehane Gr I | 67/89 (75.3%) | 39/52 (75%) | 16/23 (69.6%) | 12/14 (85.7%) | |
| Cormack‐Lehane Gr II | 15/89 (16.8%) | 4/52 (7.7%%) | 1/23 (4.3%) | 0 (0%) | |
| Cormack‐Lehane Gr III | 1/89 (1.1%) | 1/52 (1.9%) | 0 (0%) | 0 (0%) | |
| Cormack‐Lehane Gr IV | 0 (0%) | 0 (0%) | 0 (0%) | 0 (0%) | |
| Videolaryngoscopy | 15/89 (16.8%) | 7/52 (13.5%) | 6/23 (26%) | 2/14 (14.3%%) | |
| Surgical airway | 1/141 (0.7%) | 1/67 (1.5%) | 0 (0%) | 0 (0%) | |
| No airway, LMA or not documented | 52/141 (36.9%) | 15/67 (22.4%) | 14/37 (37.8%) | 23/37 (62.2%) | |
| MILS | |||||
| Yes | 23 (16.3%) | 9 (13.4%) | 9 (24.3%) | 5 (13.5%) | |
| No | 101 (71.6%) | 51 (76.1%) | 25 (67.6%) | 25 (67.6%) | |
| Not documented | 17 (12.1%) | 7 (10.4%) | 3 (8.1%) | 7 (18.9%) | |
| Surgical specialty involved | |||||
| Orthopedics | 44 (31.2%) | 13 (19.4%) | 16 (43.2%) | 15 (40.5%) | |
| General surgery | 15 (10.6%) | 11 (16.4%) | 2 (5.4%) | 2 (5.4%) | |
| ENT | 2 (1.4%) | 1 (1.5%) | 0 (0%) | 1 (2.7%) | |
| Neurosurgery | 36 (25.5%) | 21 (31.3%) | 8 (21.6%) | 7 (18.9%) | |
| Plastic | 38 (27%) | 18 (27%) | 9 (24.3%) | 11 (29.7%) | |
| Ophthalmology | 2 (1.4%) | 1 (1.5%) | 1 (2.7%) | 0 (0%) | |
| Dentistry | 1 (0.7%) | 1 (1.5%) | 0 (0%) | 0 (0%) | |
| Not documented | 3 (2.1%) | 1 (1.5%) | 1 (2.7%) | 1 (2.7%) | |
| PICU admission | 42 (29.8%) | 22 (32.8%) | 13 (35.1%) | 7 (18.9%) | |
| PICU LOS | 3 (1–66) | 2 (1–17) | 3 (1–8) | 3 (2–66) | |
Note: Data are expressed in median (range) or count (%). N/A data not available.
Abbreviations: LMA, Laryngeal Mask; MILS, Manual In‐Line Stabilization; NMBA, Neuromuscular Blocking Agents.
4. Discussion
The results of our study show that among pediatric trauma patients requiring access to the operating room (19.6%), 47.5% received immediate access. Fifty‐two percent of the patients received delayed access (26.2% within 24 h, and 26.2% after 24 h) to the operating room. The median time spent in the operating room was 133 min (range 15–658). The median hospital length of stay was 6 days (range 1–102) and this was related to having multiple surgical procedures based on multivariable regression analysis results. A blood transfusion in the first 24 h was received by 29.8% of patients, and the overall mortality in the surgical cohort was 1.4%.
The high proportion of patients triaged to immediate operating room access can affect routine operating room case flow if urgent non‐trauma cases are also admitted. A study by Brusalis et al. [9] reported how the introduction of a dedicated orthopedic trauma operating room in a pediatric trauma center was able to decrease wait time for the surgical procedure, hospital length of stay, and overall costs. This is a measure high‐volume pediatric trauma centers should consider.
Our findings have several practical applications. A center preparing for designation as a pediatric major trauma center could combine the proportions we report with its local trauma volumes to estimate the additional emergency operating room time trauma will generate, and to decide whether a dedicated trauma operating room or a second‐tier after‐hours on‐call team is warranted. The comparison of assigned surgical priority with the timing of access received (Table 1) offers a simple audit metric, as departures from assigned priority can flag periods of insufficient emergency operating room capacity. Finally, the predominance of neurosurgery in the immediate access group, consistent with standards of care for time‐critical injuries, and of orthopedics in the delayed groups can inform specialty‐specific staffing and scheduling.
Hospital length of stay did not differ across the three groups, and the only factor significantly associated with a prolonged stay was undergoing multiple surgeries. Standardized protocols of care in specialized pediatric trauma centers, applied uniformly regardless of the timing of operating room access, may explain this consistency; in addition, injuries amenable to surgical delay may simply not require prolonged postoperative hospitalization.
Our study reported a mortality of 2.5% for the entire cohort of admitted trauma patients and 1.4% among patients who underwent surgery, with no difference based on the timing of access to the operating room. This rate is slightly higher than the 1.5% American College of Surgeons Pediatric Trauma Quality Improvement Program Fall 2023 benchmark [10], but lower than others reported in this population: a study using the Japan Trauma Data Bank reported a mortality rate of 3.9% [11] and a study from Queensland, Australia, an overall mortality of 11.1% [12]. Our overall mortality may be underestimated since patients who died during transportation were not included, and our study may have been underpowered to detect minor differences. These studies also applied different definitions and inclusion criteria for major trauma, so their rates are not directly comparable to ours.
Limitations include the retrospective design, the relatively short study period, the heterogeneity of injuries, and a sample size that may be too small to detect minor differences. As a single‐center study, our findings reflect local trauma epidemiology, referral patterns, and operating room organization and may not be generalizable, although the methodology and time metrics can be replicated elsewhere. Our definition of major trauma combined institutional level 1 or 2 activation criteria with the Trauma Association of Canada ISS threshold of 12 or greater; some included patients therefore had an ISS below 12, and other jurisdictions, including the United Kingdom, use a threshold above 15, limiting comparability with ISS‐based studies. The data collection period was fixed by our research ethics board approval and could not be extended, and it partly coincided with the COVID‐19 pandemic. Finally, we report the care patients received rather than the care they required. In the last decades, there has been an increase in research on preventing and treating pediatric trauma patients; however, there is still scarcity of RCTs exploring best practices [13].
5. Conclusion
This retrospective study provides a description of the time impact on the anesthesia department of trauma patients with a need for operating room access admitted to a pediatric trauma center. Further studies are needed to better define the pediatric trauma population and its intra‐hospital flow and resource use.
Funding
The authors have nothing to report.
Conflicts of Interests
The authors declare no conflicts of interest.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
References
- 1. Yao X., Skinner R., McFaull S., and Thompson W., “Injury Hospitalizations in Canada 2018/19,” Health Promotion and Chronic Disease Prevention in Canada 40, no. 9 (2020): 281–287. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Network GBoDC , “Global Burden of Disease Study 2019 (GBD 2019),” (2019).
- 3. Moore L., Freire G., Turgeon A. F., et al., “Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta‐Analysis,” JAMA Network Open 6, no. 9 (2023): e2334266. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Anantha R. V., Zamiara P., and Merritt N. H., “Surgical Intervention in Pediatric Trauma at a Level 1 Trauma Hospital: A Retrospective Cohort Study and Report of Cost Data,” Canadian Journal of Surgery 61, no. 2 (2018): 94–98. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Acierno S. P., Jurkovich G. J., and Nathens A. B., “Is Pediatric Trauma Still a Surgical Disease? Patterns of Emergent Operative Intervention in the Injured Child,” Journal of Trauma 56, no. 5 (2004): 960–964. [DOI] [PubMed] [Google Scholar]
- 6. Bird R., Braunold D., and Matava C. T., “Chest Trauma in Children‐What an Anesthesiologist Should Know,” Paediatric Anaesthesia 32, no. 2 (2022): 340–345. [DOI] [PubMed] [Google Scholar]
- 7. Morrison W., Wright J. L., and Paidas C. N., “Pediatric Trauma Systems,” Critical Care Medicine 30, no. 11 Suppl (2002): S448–S456. [DOI] [PubMed] [Google Scholar]
- 8. Team RC , “R: A Language and Environment for Statistical Computing,” (2023).
- 9. Brusalis C. M., Shah A. S., Luan X., Lutts M. K., and Sankar W. N., “A Dedicated Orthopaedic Trauma Operating Room Improves Efficiency at a Pediatric Center,” Journal of Bone and Joint Surgery. American Volume 99, no. 1 (2017): 42–47. [DOI] [PubMed] [Google Scholar]
- 10. Moore L., Yanchar N. L., Tardif P., et al., “Evidence‐Informed Quality Indicators for Pediatric Trauma Care,” JAMA Pediatrics 179, no. 6 (2025): 666–674, 10.1001/jamapediatrics.2025.0036. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Aoki M., Abe T., Saitoh D., and Oshima K., “Epidemiology, Patterns of Treatment, and Mortality of Pediatric Trauma Patients in Japan,” Scientific Reports 9, no. 1 (2019): 917. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Coulthard M. G., Varghese V., Harvey L. P., Gillen T. C., Kimble R. M., and Ware R. S., “A Review of Children With Severe Trauma Admitted to Pediatric Intensive Care in Queensland, Australia,” PLoS One 14, no. 2 (2019): e0211530. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Stelfox H. T. and Goverman J., “The Number, Content, and Quality of Randomized Controlled Trials in the Prevention and Care of Injuries,” Journal of Trauma 65, no. 6 (2008): 1488–1493. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.