Effectiveness of an improved medical care system for children in a critical care medical center: is it possible to provide an equivalent level of trauma care for children as we do for adults?

Abstract

Aim

In trauma care, most events that result in preventable trauma death tend to occur in the initial phase of treatment, and providing prompt and accurate care affects the outcomes of patients with severe trauma. Developing a system for administering prompt and accurate care and encouraging team coordination is essential for children as well as adults. However, differences in physical size and vital signs specific to children are potential obstacles to carrying out physical assessments, decision‐making, procedures, and treatments in pediatric patients. An improved medical care system for children was designed at the Osaka Prefectural Senshu Critical Care Medical Center. We evaluated the effectiveness of the new system.

Methods

We enrolled all patients with severe trauma admitted to our center. The therapeutic process and outcomes of trauma care before and after the establishment of the improved system was retrospectively compared.

Results

The results showed a significant decline in the time required to establish an i.v. line and perform tracheal intubation before computed tomography. There were also no statistically significant differences in the timing of craniotomy or trepanation, or the time required to carry out hemostatic procedures, between children and adults. Furthermore, no patients with a probability of survival over 0.5 died following the establishment of the new system.

Conclusion

Our newly improved medical care system facilitates treatment for children using standards equivalent to those used in adults in critical care centers, regardless of the physical size and vital signs of the patient.

Introduction

In trauma care, most events that result in preventable trauma death tend to occur in the initial phase of treatment1, 2 and providing prompt and accurate care affects the outcomes of patients with severe trauma. Improving a system for providing prompt and accurate care and encouraging team coordination is essential when physicians apply techniques such as hemostatic procedures and cerebral decompression for children as well as adults.

In Japan, because most children's hospitals treat children only in the perioperative period, there is no system for treating children with severe trauma in the initial phase. Furthermore, most pediatricians do not receive training in trauma care. As a result, critical care medical centers play pivotal roles in trauma care for children.

However, differences in physical size and vital signs specific to children are potential obstacles to physical assessments, decision‐making, procedures, and treatment in pediatric patients. An improved medical care system for children was designed at Osaka Prefectural Senshu Critical Care Medical Center (Osaka, Japan), and its effectiveness was evaluated.

Methods

In 2005, we established a new system for the treatment of children at our critical care medical center as follows: (i) a classification system using a color‐coded length‐based tape3 (Broselow™ Pediatric Emergency Tape, Lincolnshire, IL, USA), which is used solely to categorize pediatric patients by color according to height; (ii) pediatric medical care sheet (Fig. 1B); (iii) pediatric equipment storage boxes (Fig. 1C), prepared corresponding to the color shown on the tape. The pediatric emergency care sheet lists the pediatric equipment (including its size) and medications envisaged for initial examinations and treatment, which are categorized according to use and size. The information is printed in Japanese in large font. The sheet also shows the medications listed by generic product name, the quantities to be given are provided consistently in mL units, and the standardized dilution methods are detailed. The storage boxes were designed and prepared to correspond to the contents listed on the sheets, with standardized information, so that medical equipment can be promptly accessed. The pediatric instructions (Table 1) are a set of orders for the treatment of pediatric trauma patients that are prepared and configured by weight and age. Various medications include dilution methods for drug preparations requiring low volume continuous infusion. A continuous infusion rate of 0.1 mL/kg/h ensures the correct dose in all drugs. Ventilator settings and standard monitoring values at which a doctor should be called were defined for each age, and recorded as guidelines for initial settings. We named the four items, that is, the color‐coded length‐based tape (Broselow Pediatric Emergency Tape), the pediatric medical care sheet, the pediatric equipment storage boxes, and the pediatric instructions, the “Senshu Version Pediatric Resuscitation Set”.

Figure 1.

Senshu Version Pediatric Medical Care Set, designed to improve medical care for pediatric trauma patients. Each set comprises nine color‐coded length‐based tapes (A) corresponding to nine Pediatric Medical Care Sheets, made up of four pages each (B). Three pediatric equipment storage boxes for newborns/infants, children, and schoolchildren were also created, and the corresponding color of the care sheet is indicated on each set (C).

Table 1.

Instructions for the treatment of pediatric trauma patients, part of an improved medical care system for children admitted to the Osaka Prefectural Senshu Critical Care Medical Center, Osaka, Japan

Ventilator settings		Initial setting
Ventilation mode		Synchronized intermittent mandatory ventilation
Mechanical breaths		Pressure controlled ventilation
Spontaneous breaths		Pressure support ventilation
Trigger formula		Pressure sense
Frequency of breath (/min)		10
Peak inspiratory pressure (cmH2O)		13
Positive end expiratory pressure (cmH2O)		5
Inspiratory time (seconds)		0.4
Pressure sense (cmH20)		2
Fraction of inspiratory oxygen (%)		50
Medication		20 mL bottle in normal saline	Preparation of infusion solution
Midazolam	10 mg/2 mL	Replace 4 mL with 4 mL (20 mg) midazolam	0.1 mL/kg/h = 0.1 mg/kg/h
Fentanyl citrate	100 μg/2 mL	Replace 8 mL with 8 mL (400 μg) fentanyl citrate	0.1 mL/kg/h = 2 μg/kg/h
Vecronium bromide	4 mg	Make a dilution of 10 A (40 mg) vecronium bromide	0.1 mL/kg/h = 0.2 mg/kg/h
Dopamine	600 mg/200 mL	Stock solution (3 mg/mL) dopamine	0.1 mL/kg/h = 5μg/kg/min
Dobutamine	100 mg/5 mL	Replace 3 mL with 3 mL (60 mg) dobutamine	0.1 mL/kg/h = 5 μg/kg/min
Epinephrine	1 mg/1 mL	Replace 1.2 mL with 1.2 mL (1.2 mg) epinephrine	0.1 mL/kg/h = 0.1 μg/kg/min
Norepinephrine	1 mg/1 mL	Replace 1.2 mL with 1.2 mL (1.2 mg) norepinephrine	0.1 mL/kg/h = 0.1 μg/kg/min
Criteria of doctor call
SpO2		<96%
Respiratory rate		>70/min or <20/min
Heart rate		>190/min or <65/min
Systolic blood pressure		>135 mmHg or <75 mmHg
Urinary volume		>body weight × 10 mL/h or <body weight × 2 mL/h

We enrolled children under 10 years of age with severe trauma, who brought to our hospital between January 2000 and December 2008, into our study. A score of 3 or more on the Abbreviated Injury Scale was defined as severe trauma. The patients were divided into two groups depending on the period of treatment, that is, before or after the establishment of the improved system in 2005. Thirty‐three cases admitted to our hospital during the 5‐year period between January 2000 and December 2004 were categorized as belonging to the pre‐pediatric (B‐) group, and 27 cases, admitted during the 3‐year period between January 2006 and December 2008, were categorized as belonging to the post‐pediatric (A‐) group. Furthermore, an adult control (C‐) group was identified, comprising 337 cases of adults aged 20 years or more with an Abbreviated Injury Scale score of 3 or above for a comparison (with children and adults), admitted to our hospital during the same period as the A‐group. We excluded any cases admitted in 2005, because they included some patients that did not yet use the improved system.

We evaluated the severity of trauma, the therapeutic process, and the outcome of primary trauma care, retrospectively by reviewing the medical records. The severity of trauma was measured using the Injury Severity Score (ISS), Revised Trauma Score (RTS), and Probability of Survival (Ps), calculated from the Trauma and Injury Severity Score. The therapeutic process was evaluated in terms of time in establishing an i.v. line, in accomplishing tracheal intubation, in entering the computed tomography (CT) room, and in initiating craniotomy/trepanation or hemostatic procedures. The outcome was evaluated as survival or death.

The first study compared the parameters prior or subsequent to the establishment of the improved system (B‐group versus A‐group). The second study also compared the parameters between children and adults, subsequent to the establishment of the improved system (A‐group versus C‐group).

Values are expressed as the median value for each group, and statistical processing was carried out using the Mann–Whitney U‐test, with a P‐value less than 0.05 considered to indicate a statistically significant difference.

Results

The first study compared the variables obtained before and after the establishment of the improved system (B‐group versus A‐group). Table 2 shows the patient characteristics and severity of trauma (ISS or RTS). There were no significant differences in age, sex, or injury severity. There were significant decreases in the time from admission to the establishment of an i.v. line (7 min versus 2 min), tracheal intubation (15 min versus 10 min), and entry to the CT room (31 min versus 23 min) between the groups (Fig. 2). There were no significant differences in the time from admission to the start of craniotomy or trepanation (58 min versus 59 min) or the hemostatic procedures (60 min versus 48 min) between the groups. The median duration to the start of surgery was within 60 min in B‐group (Fig. 3). Among the patients with a Ps over 0.5, one of 30 patients in B‐group died, whereas all of the 24 patients in A‐group survived. Among the patients with a Ps 0.5 and under, one of three patients in each group survived (Table 3).

Table 2.

Patient characteristics and trauma severity in pediatric trauma patients treated before (B‐group) and after (A‐group) introduction of an improved medical care system, compared with adults treated at the same critical care medical center (C‐group)

	B‐group ( n = 33)	A‐group (n = 27)	C‐group (n = 337)
Sex, male : female	24:9	13:14	251:86
Age, years	4 (0–9)a	4 (0–9)a	46 (20–96)a
ISS	18 (9–51)a	20 (9–43)a	21 (9–75)a
RTS	6.90 (1.47–7.84)a	6.90 (1.61–7.84)a	7.55 (1.16–7.84)a

^aMedian (minimum–maximum). ISS, Injury Severity Score; RTS, Revised Trauma Score.

Figure 2.

Significant decreases in the therapeutic process time were achieved after the establishment of an improved medical care system for children in a critical care medical center (B‐group [before the new system] versus A‐group [after]). There were no significant differences between child and adult treatment groups subsequent to the establishment of the improved system (A‐group versus C‐group). CT, computed tomography.

Figure 3.

There were no significant differences in the therapeutic process times to initiating craniotomy/trepanation or hemostatic procedures for child and adult treatment groups subsequent to the establishment of an improved medical care system for pediatric trauma patients (A‐group versus C‐group). B‐group, pediatric patients treated in the same critical care medical center before the improved system was introduced.

Table 3.

Survivals and deaths according to Probability of Survival (Ps) scores in pediatric trauma patients treated before (B‐group) and after (A‐group) introduction of an improved medical care system, compared with adults treated at the same critical care medical center (C‐group)

	B‐group (n = 33)	A‐group (n = 27)	C‐group (n = 337)
Ps > 0.5	30	24	314
No. of survivals	29	24	287
No. of deaths	1	0	27
Ps ≤ 0.5	3	3	23
No. of survivals	1	1	14
No. of deaths	2	2	9

The second study compared the variables between children and adults in the same time period subsequent to the establishment of the improved system (A‐group versus C‐group). There were no significant differences in trauma severity (ISS or RTS), as shown in Table 2. There were no significant differences in the time from admission to the establishment of an i.v. line (2 min versus 2 min), to carry out tracheal intubation (10 min versus 9 min), or to enter the CT room (23 min versus 29 min) between the groups (Fig. 2). There were also no statistically significant differences in the time from admission to the start of craniotomy or trepanation (59 min versus 52 min) or hemostatic procedures (48 min versus 50 min) between the groups (Fig. 3). Among the patients with a Ps over 0.5, 27 of 314 of the adult patients (8.6%) in C‐group died, whereas all patients in A‐group survived. Among the patients with a Ps 0.5 and under, one of three patients in A‐group and 14 of 23 patients (61%) in C‐group survived (Table 3).

Discussion

In order to improve the outcomes for children with severe trauma, it is necessary to provide the standards for decision‐making and procedures for treating children that are equivalent to those used for adults in critical care centers. Such standards including vital signs, the selection of equipment of appropriate size, optimal drug dosages, and initial respiratory settings related to physical size. These guidelines were established at Osaka Prefectural Senshu Critical Care Medical Center in 2005.

According to these standards, the optimal drug doses and selection of medical equipment are based on the patient's body weight and/or height. Fineberg et al. reported that the selection of treatment based on weight in children improves the speed and accuracy of drug administration.4 However, it is difficult to accurately ascertain the weight of the patient during the period of primary care in many cases involving children with severe trauma. For this reason, color‐coded length‐based tape was used in the improved system in order to classify children by height, allowing for the selection of medical equipment and drug dosages based on the selected color. However, the use of tape has several disadvantages, such as text written in English, small text, the use of generic not product names, and presentation of the drug dose in mg units. These disadvantages may lead to erroneous decisions and delays during the period of primary care. Therefore, we created pediatric medical care sheets (Fig. 1B) and pediatric equipment storage boxes (Fig. 1C) that correspond to the color‐coded length‐based tape classifications.

The physiological characteristics of children depend on their age and physical size, which may result in delays or errors in the dilution method used to administer drugs for low‐volume continuous infusion, especially that involving cardiovascular agents, or the initial settings for ventilator and monitor alarms. It is therefore effective to prepare a set of orders based on physical size. The establishment of this improved system for treating children is good news for doctors and health‐care professionals, who are not used to treating children in critical care centers. This study showed a significant decline in the time required to establish an i.v. line and carry out tracheal intubation before CT. The median duration to the start of craniotomy or trepanation and the time required to carry out hemostatic procedures were both within 60 min. Furthermore, no patients with a Ps over 0.5, indicating preventable trauma death, died after the establishment of the improved system. This system facilitates treatment for children using standards equivalent to these used in adults, regardless of the physical size and vital signs of the patient.

This research was limited with respect to the impact on the outcomes. Further studies are required to elucidate whether increased experience in treating children with severe trauma, as well as the development of the new system, results in improvements in the outcomes.

Conclusion

Our newly improved medical care system facilitates treatment for children using standards equivalent to those used in adults in critical care centers, regardless of the physical size and vital signs of the patient.

Conflict of Interest

None.