The American Journal of Surgery (2011) 201, 445 449

Society of Black Academic Surgeons

Treatment outcomes of injured children at adult level 1

trauma centers: are there benefits from added specialized
care?
Tolulope A. Oyetunji, M.D., M.P.H.a,*, Adil H. Haider, M.D., M.P.H., F.A.C.S.b,
Stephanie R. Downing, M.D.a, Oluwaseyi B. Bolorunduro, M.D., M.P.H.a,
David T. Efron, M.D., F.A.C.S.b, Elliott R. Haut, M.D., F.A.C.S.b,
David C. Chang, M.P.H., M.B.A., Ph.D.d, Edward E. Cornwell III, M.D., F.A.C.S.a,
Fizan Abdullah, M.D., Ph.D., F.A.C.S.c, Suryanarayana M. Siram, M.D., F.A.C.S.a
a

Department of Surgery, Howard University College of Medicine, Washington, DC, USA; bDepartment of Surgery and
Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; dDepartment of
Surgery, University of California, San Diego School of Medicine, San Diego, CA, USA
c

KEYWORDS:
Pediatric;
Trauma;
Trauma center

Abstract
BACKGROUND: Accidental traumatic injury is the leading cause of morbidity and mortality in
children. The authors hypothesized that no mortality difference should exist between children seen at
ATC (adult trauma centers) versus ATC with added qualifications in pediatrics (ATC-AQ).
METHODS: The National Trauma Data Bank, version 7.1, was analyzed for patients aged 18 years
seen at level 1 trauma centers. Bivariate analysis compared patients by ATC versus ATC-AQ using
demographic and injury characteristics. Multivariate analysis adjusting for injury and demographic
factors was then performed.
RESULTS: A total sample of 53,702 children was analyzed, with an overall mortality of 3.9%. The
adjusted odds of mortality was 20% lower for children seen at ATC-AQ (odds ratio, .80; 95% confidence
interval, .68 .94). Children aged 3 to 12 years, those with injury severity scores 25, and those with
Glasgow Coma Scale scores 8 all had significant reductions in the odds of death at ATC-AQ.
CONCLUSIONS: Improved overall survival is associated with pediatric trauma patients treated at ATC-AQ.
2011 Elsevier Inc. All rights reserved.

Trauma remains the leading cause of death amongst

children and adolescents aged 1 to 15 years, accounting
for approximately 15,000 deaths each year and 50% of all

Presented on April 30, 2010, at the 20th annual meeting of the Society
of Black Academic Surgeons, Durham, NC.
* Corresponding author. Tel.: 202-865-7190; fax: 202-865-7179.
E-mail address: toyetunji@howard.edu
Manuscript received July 17, 2010; revised manuscript October 20,
2010

0002-9610/$ - see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2010.10.006

pediatric deaths in the United States.1 More than 20

million children sustain injuries that require treatment,
resulting in 100,000 cases of permanent disability each
year.2 The leading mechanisms of death in this age group
are motor vehicle collisions, drowning, burns (including
those from house fires), homicides from nonaccidental
traumas (ie, child abuse), firearms, and falls. In recent
years however, there has been a markedly increased number of fatalities due to violence, including those secondary to firearms, especially in teenagers.3

446
The trauma system in the United States has significantly
helped mitigate the impact of trauma across all age groups
since its inception and development over the past 40 years,4
with the standardization of trauma care through trauma
center verification. The American College of Surgeons
(ACS), in addition to several individual states, designates
some centers as level 1 or level 2 trauma centers, on the
basis of the availability of manpower and resources, following a stringent review process. A level 1 trauma center is a
regional resource hospital able to care for every form of
injury, with around-the-clock coverage by a trained trauma
surgeon and other trauma-related specialists available when
needed. This represents the highest level of care available to
an injured patient in the US trauma system. Each center
must pass rigorous standards set by the ACS or state boards.
For pediatric trauma patients, there exist some verified level
1 pediatric trauma centers (PTC). Unfortunately, these are
very few in number and not easily accessible to all injured
pediatric patients. Currently, there are more verified level 1
adult trauma centers (ATC) in existence than level 1 PTC.
Some adult centers, in addition to being designated level 1
ATC, have added qualifications in pediatrics (ATC-AQ).
This qualifies them to offer adequate and arguably better
care to pediatric populations compared with ATC only.
Improved survival has been demonstrated with children
treated at PTC and compared with ATC-AQ and ATC
only.5 However, not all children in the country have access
to pediatric trauma care, as demonstrated by Nance et al.6
As a matter of fact, a higher proportion of pediatric traumas
are typically seen at ATC-AQ or ATC because of unavailability of PTC in the region.7 Thus, the role and impact of
ATC in the treatment of pediatric trauma patients is fairly
substantial. Potoka et al5 first alluded to an improved outcome at ATC-AQ compared with ATC on the basis of their
thorough and in-depth analysis of data from a statewide
trauma system. Though limited by the nature of the analysis
(stratified analysis vs multivariate regression) and the statebased nature of the data set, this difference has typically
been an issue of controversy. Proponents of similar outcomes argue that there are no differences in care at level 1
ATC-AQ compared with level 1 ATC only, because these
centers still represent the highest level of trauma care for
severely injured adult patient.8 A recent review of 60
published articles on pediatric trauma outcomes concluded
that enough data did not exist to conclusively determine
which type of trauma center was better in the delivery of
pediatric care.9 Unfortunately, most of the data included in
this analysis were either descriptive in nature, single institutional, or unadjusted analysis at best.
Although the pediatric trauma system remains embedded
in its adult counterpart it is imperative to verify if there truly
exists a difference in mortality among children treated ATC
compared with ATC-AQ and, if so, which subset may
benefit significantly from ATC-AQ. We therefore hypothesized in this study that ATC-AQ are more beneficial overall
and for some select subsets of pediatric trauma patients.

The American Journal of Surgery, Vol 201, No 4, April 2011

Methods
The National Trauma Data Bank (NTDB) was used for
this analysis. The NTDB is maintained by the ACS and
contains data from 700 trauma centers across the United
States and Puerto Rico. In its most recent multiyear version
(version 7), the NTDB contains 1.8 million patient records over a 5-year period (20022006).10 The NTDB documents patient records, including demographics, injury
characteristics, length of stay, discharge disposition, and
trauma center characteristics such as verification level and
number of intensive care unit beds, among other variables.
It also captures data from prehospital care to emergency
department care. It contains data across the age spectrum
from 0 to 89 years.
For this analysis, the NTDB was queried for patients
aged 18 years to delineate the pediatric population. The
age cutoff at 18 years is in keeping with many other studies
of pediatric trauma. Because the purpose of the analysis was
to compare care at level 1 ATC versus level 1 ATC-AQ, we
excluded all patient records from nonlevel 1 trauma centers. A level 1 ATC-AQ was defined in this analysis as any
trauma center with ACS-designated and/or state-designated
level 1 trauma status with added pediatric level 1 trauma
status. The added qualification in pediatric trauma may be
ACS designated or state designated. A level 1 ATC was
defined as an ACS-designated and/or state-designated level
1 trauma center without any pediatric qualification. Burn
patients were excluded from the analysis because of the
difference in their course of care. All patients transferred in
and out of facilities were also excluded. This was to circumvent the issue of severely injured patients being transferred to level 1 trauma centers who may have had poor
prognoses on admission. This also enabled us to look at
patients primarily received and cared for entirely at each
facility. Also excluded from the analysis were mildly injured patients, defined as those with injury severity scores
(ISS) 9. This was to ensure comparison of patients who
truly require level 1 trauma care and not to unduly influence
the outcomes of centers that attend to more severely injured
patients.
The outcome of interest in this study was in-hospital
mortality. This excluded patients who were dead on arrival
or dead before any treatment could be offered in the receiving facility. Because of limitations of the data set, other
outcomes of interest (eg, short-term and long-term disabilities) could not be evaluated in this analysis, because patients were not followed beyond discharge. The primary
comparison was ATC-AQ versus ATC, as defined above.
Other covariates included in the model were ISS (further
categorized as moderate [ISS 9 14], severe [ISS 1524], or
very severe [ISS 25]), mechanism of injury (including
pedestrian struck, motor vehicle collision, gunshot wound,
bicyclist, cyclist, and stab wound), insurance status (classified as commercially insured, government insured, uninsured, or other insurance), ethnicity (defined as white, African American, Hispanic, Asian, and others), presence of

T.A. Oyetunji et al.

Pediatric outcomes at trauma centers

shock (with shock defined as systolic blood pressure 74,

78, 82, 86, and 90 mm Hg for patients aged 0 2,
3 4, 5 6, 7 8, and 8 years, respectively), Glasgow Coma
Scale (GCS) motor component, head injury (defined as head
Abbreviated Injury Scale score 3), and age (3, 312,
and 12 years). The choice of age in these categories was
based on physiology. Toddlers (aged years) are more
likely to have similar causes and patterns of injury and were
therefore grouped together. The choice of 12 years as a
cutoff for the teen and adolescent group was based on a
previously published work clearly demonstrating a different
response in this age group after traumatic injury.11 In addition, we wanted to separate the group with different physiology on the basis of the onset of puberty. Severe traumatic
head injury (TBI) was defined as head maximum Abbreviated Injury Scale score 3.
Univariate analysis was performed to describe the demographic and injury characteristic of the study population.
This was followed by an unadjusted analysis to compare
and statistically verify associations between in-hospital
mortality and the different covariates on the basis of the
primary comparison of ATC-AQ versus ATC. For the bivariate analysis, Students t tests were used to compare all
continuous variables, and 2 tests were used to compare
categorical variables. All data analysis was carried out using
Stata version 10 (StataCorp LP, College Station, TX). The
adjusted (multiple logistic regression) analyses included all
the covariates listed above to establish the independent
effect of treatment at a given trauma center (ATC-AQ or
ATC) on in-hospital mortality. Furthermore, subset analyses
by GCS score (stratified as 8, 8 to 15, and 15), injury
severity categories, and the defined age categories as stated
above were performed to check if there was a difference in
outcomes on the basis of which trauma center delivered care
to the patient.

Results
A total of 53,702 children met the inclusion criteria and
were included in the final analysis, with 55.5% seen at level
1 ATC and 44.5% at ATC-AQ. The median age was 11
years (interquartile range, 4 15 years), with a median ISS
of 10 (interquartile range, 9 17). Female patients accounted
for 34.1%. The majority of the children were white (53.4%),
with African American, Hispanics, and other ethnicities
accounting for 14.6%, 11.1%, and 12.9%, respectively.
Overall mortality was 3.9%. Uninsured children constituted
9.3% of the study population, and commercially insured and
government-insured children made up 54.4%. Other types
of insurance accounted for the remaining. By injury severity, 13.2% of the children had very severe injuries (ISS
25), 19.8% with severe injuries (ISS 15 and 25). Children with severe TBIs constituted 17.8%. By age categories,
children aged 3, 3 to 12, and 12 years accounted for
17.0%, 40.0%, and 43.0%, respectively.

447
In unadjusted analysis comparing ATC with ATC-AQ,
mortality was significantly lower in ATC-AQ versus ATC
(3.2% vs 4.5%, P .001). By ethnicity, whites also accounted for the majority of children seen at both centers.
The median ISS were comparable (10 and 9 at ATC and
ATC-AQ, respectively), though significantly different statistically (P .001). However, ATC had a comparably
higher proportion of severely injured children than
ATC-AQ (17.6% vs 12.9%, respectively, P .001). Other
demographic and injury characteristic comparisons are as
shown in Table 1. The distribution by age categories also
followed a similar pattern, with whites accounting for the
majority of the population and a male predominance across
all ages (Table 2). Additional injury and demographic factors by age categories are listed in Table 2.
On multivariate analysis, the adjusted odds ratio (OR) of
mortality for all patients seen at ATC-AQ compared with
ATC was significantly lower by 20% (OR, .80; 95% confidence interval [CI], .68 .94; P .05; Table 3). In the
subset analysis by age group, children aged 3 to 12 years
seen at ATC-AQ had a significant 43% reduction in the
odds of death versus their counterparts seen at ATC irrespective of injury severity (OR, .57; 95% CI, .41.78; P
.05). However, this difference was not seen in the other age
groups. Children with very severe injuries demonstrated a
21% reduction in the odds of death (OR, .71; 95% CI,

Table 1 Demographic and injury characteristics of the

study population by type of trauma center
Variable
Mortality
Race
White
African American
Hispanic
Asian/Pacific Islander
Native American/Alaskan
Other
Age category (y)
3
312
12
Gender
Male
Female
ISS
ISS category
914
1525
25
Insurance status
Commercial
Government
Uninsured
Other
Severe TBI

ATC

ATC-AQ

4.5

3.2

59.5
17.8
15.0
1.6
1.2
4.9

53.6
12.6
8.0
1.3
.2
24.5

14.2
36.6
49.2

20.5
44.2
35.3

66.6
33.4
10 (917)

64.9
35.1
9 (916)

59.2
23.2
17.6

63.7
23.4
12.9

39.6
23.6
12.2
24.7
19.3

47.6
21.8
10.0
20.6
15.9

P
.05
.05

.05
.05
.05

.05

.05

Data are expressed as percentages or as median (interquartile

range).

448

The American Journal of Surgery, Vol 201, No 4, April 2011

Table 2 Demographic and injury characteristics of the

study population by age category

Mortality
Race
White
African American
Hispanic
Asian
Race 4
Race 5
Gender
Male
Female
ISS category
914
1525
25
Insurance status
Commercial
Government
Uninsured
Others
Severe TBI

Age
3 y

Age
312 y

Age
12 y

4.3

2.5

5.0

48.2
16.4
14.5
1.8
.8
18.3

54.6
13.3
11.4
1.5
.7
18.5

62.3
17.2
11.1
1.3
.7
7.5

59.0
41.0

63.4
36.6

70.9
29.1

58.0
28.3
13.7

68.7
20.6
10.7

55.3
24.0
20.7

35.7
37.2
9.2
17.9
24.2

44.6
22.7
9.9
22.8
16.0

44.2
17.3
13.4
25.1
17.0

P
.05
.05

.05

.05

.05

Data are expressed as percentages.

.59 .85; P .05). Children with severe TBIs (GCS score

8) also had a survival advantage, with a mortality OR of .81
(95% CI, .68 .97; P .05; Table 3).

Comments
The present study demonstrates that pediatric trauma
patients have reduced mortality when treated at level 1
ATC-AQ compared with ATC only, in contrast to some
articles on pediatric trauma care in the literature.8
To the best of our knowledge, this study is the largest
comparison of level 1 ATC-AQ versus ATC on a national
level to date. Our study population included children aged 0
to 17 years. This is similar to the age inclusion criteria used
in a study by Knudson et al.8 Other investigators, however,
have used different age cutoffs, as typified by Rhodes et
al,12 who chose 15 years as the cutoff.
Potoka et al5 demonstrated a difference in mortality between ATC and ATC-AQ in the Pennsylvania Trauma Outcome Study. In this statewide study, they compared PTC
with all other levels of ATC, including level 1 ATC-AQ.
The study concluded that children managed at PTC or
ATC-AQ had significantly better outcomes compared with
those treated at ATC only. However, this study failed to
control for commonly known predictors of outcomes after
trauma. Although our study results have numerous parallels
compared with that study, in addition to some yet unidentified findings, we went a step further in this analysis to
control for as many known independent predictors of

trauma of which we were aware. We adjusted for demographic factors (age, gender, insurance status, and ethnicity), injury severity characteristics (ISS, presence of shock,
and GCS motor component), and mechanism of injury. This
study still showed a 20% reduction in risk for mortality in
children treated at ATC-AQ compared with ATC, similar to
what was observed by Potoka et al. In addition, we demonstrated improved survival for children with severe TBIs, as
typified by GCS scores 8. Although Potoka et al showed
a difference in outcomes for severely injured children with
ISS 15 treated at PTC, we demonstrated a similar difference in children with very severe injuries (ISS 25) treated
at ATC-AQ. Because the cohort was a subset of children
with ISS 15, it is possible that this significantly influenced the results of their study. Similar to Potoka et al, we
demonstrated a significant difference in outcomes of children with severe TBIs treated at ATC-AQ. TBI is well
known to be a leading cause of pediatric trauma death.1315
On the basis of the findings of this study, it is evident that
children with TBIs will benefit from care at ATC-AQ, and
this subset of patients should be considered a triage priority
in geographic locations where this option exists.
In addition to the survival benefit outlined above, a
significant finding in this study is the age-dependent benefit
of ATC compared with ATC-AQ, showing improved survival in children aged 3 to 12 years. A similar age subset of
patients (0 10 years) has already been shown to have better
outcomes at pediatric hospitals compared with adult-centered hospitals.7 This indeed has a major impact on triage
criteria for critically injured children. The reason for this
survival benefit may be multifactorial. However, we postulate that this may be related to personnel availability and the
setup of ATC-AQ. These facilities must meet additional
stringent criteria to qualify as trauma centers for children.
Although some investigators have concluded that no difference exists in outcomes irrespective of pediatric or adult
designation, a closer review of the literature shows weaknesses in the methods used (simple descriptive articles,
unadjusted analyses, small sample sizes), and such data are

Table 3 ORs and 95% CIs after multivariate analysis on

the overall population and by different subset categories
Variable

Reference

Overall
Age category
3 y
312 y
12 y
ISS category
914
1525
25
GCS score
15
814
8

ATC
ATC

OR (95% CI)
.80 (.68.94)

P
.05

.81 (.541.22)
.57 (.41.78)
.91 (.731.14)

.31
.05
.40

1.15 (.592.22)
1.41 (.912.19)
.71 (.59.85)

.68
.121
.05

1.32 (.732.39)
.75 (.381.47)
.81 (.68.97)

.30
.40
.05

ATC

ATC

T.A. Oyetunji et al.

Pediatric outcomes at trauma centers

typically from single institutions.8,16 For the other age subsets, the reason for the lack of difference in infants and
teenagers is unknown. Although speculations can be made
regarding contributions from the improper use of safety
equipment (infant seats and seatbelts), this issue warrants
further investigation.
Free-standing PTC have been demonstrated to have the
best outcomes for injured children.1719 As mentioned previously, such centers are uncommon in every locality, making access to them an issue. In addition, construction of new
PTC is an expensive venture, even with the best intentions.
According to Nance et al,6 approximately 17 million pediatric patients lack access to pediatric trauma care. Their
definition of what constitutes a PTC was more liberal, including additional centers beyond PTC. This further underscores the role of ATC in the delivery of adequate pediatric
trauma care. At present, the majority of pediatric trauma
patients are typically seen at ATC or ATC-AQ.7 Most states
have at least one designated level 1 ATC with or without
added pediatric qualifications. There is a need for policies
that favor the triage of certain injured children to ATC-AQ
rather than ATC. That said, the role of ATC alone should
not be undermined by such triage criteria. We are of the
opinion that a role currently exists for both centers in an
evolving pediatric trauma system. Akin to the trauma level
stratification that presently exist for trauma centers, PTC,
ATC-AQ, and ATC can be seen as essential components of
the pediatric trauma system with a two-way interhospital
transfer potential, as determined by established triage criteria. This will further strengthen the quality of care and
improve access in the pediatric population. In a recent
review of pediatric trauma care, Nance et al20 surmised,
The lessons learned in trauma should be extended to include pediatric trauma care and generalized to inform the
ongoing development of the emergency care system as a
whole. No doubt the development of the pediatric trauma
system is inherently intertwined with the advancement of
the adult trauma system. However, it is important to appreciate the limitations of some ATC and acknowledge what
makes for manageable pediatric trauma, with an overall goal
of improving outcomes in all injured children.21
This study is not without its limitations. The lack of data
from PTC is a drawback, as this might have been another
opportunity to demonstrate the role of PTC in pediatric
trauma care. The NTDB is also a voluntary database and
may be limited by who chooses to contribute data. We also
acknowledge that the study may not necessarily reflect the
standard of care at individual institutions. However, this is
the largest national analysis to date comparing ATC with
ATC-AQ. We are of the opinion that the power of this study
will help mitigate some of these limitations.
In conclusion, we have demonstrated that children
treated at ATC-AQ had reduced mortality compared with
those treated at ATC. Subsets of patients (those aged 312

449
years, very severely injured [ISS 15] patients, and those
with severe TBIs [GCS score 8]) also benefited significantly when receiving care at ATC-AQ. Incorporating these
findings into triage criteria may help improve the outcomes
of pediatric trauma patients and may have policy implications for future pediatric trauma system development and
growth.

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