The evaluation of pediatric trauma care using audit filters

Objective: To evaluate the experience of a pediatric trauma system with specific reference to prehospital, trauma center resuscitation, and critical care phases of treatment. Design: Descriptive review of concurrent audit. Setting: A tertiary care referral adult and pediatric trauma center. Patients: All pediatric trauma victims in the trauma registry (includes patients less than or equal to 14 years old, who died or were hospitalized for greater than or equal to 24 hours) Interventions: None. Measurements and Main Results: Age, pediatric trauma, injury severity, and Glasgow Coma Scale scores as well as outcome (death or discharge disability score) were analyzed. Primary filters (those with the potential to contribute to morbidity and mortality), secondary filters (minor deviations from care), missed injuries and all deaths were reviewed, Of 250 patients in the registry, 20 died. One hundred thirteen had filters, with 49 having primary filters (34 with one, 14 with two, and one with four filters). Fifty percent of primary filters occurred in the prehospital phase of care with inadequate airway management and venous access accounting for 60%. Overall, primary filters occurred more commonly in patients with severe injuries (lower Pediatric Trauma and Glasgow Coma Scale and higher Injury Severity scores). Primary filters were also statistically more common in patients who died or who were disabled, In three patients (25%) who died, our review suggested that filters may have contributed to demise. Missed injuries were mostly extremity fractures and did not contribute to mortality or longterm morbidity. Conclusion: Deviations from care occur, even in a dedicated pediatric trauma system. Mortality of and by itself is not an adequate indicator of the quality of function of a trauma system. Since most primary filters occurred outside of the trauma center, improvement in trauma outcome may be expected with better training of personnel involved in the prehospital care of injured children. A comprehensive review of death and disability should include audit filters of prehospital care, triage, definitive care, and rehabilitation.