AAST 2014 PLENARY PAPER
The pediatric trauma center and the inclusive trauma system: Impact on splenectomy rates Emily E.K. Murphy, MD, Stephen G. Murphy, MD, Mark D. Cipolle, MD, PhD, and Glen H. Tinkoff, MD, Newark, Delaware
Before 2006, the Delaware Trauma System (DTS) did not include a designated pediatric trauma center (PTC). In 2006, the Delaware Trauma System designated and the American College of Surgeons Committee on Trauma verification/consultation program verified Nemours AI DuPont Hospital for Children, a freestanding children’s hospital, as a PTC. We evaluated the impact of the addition of the PTC to the state trauma system on pediatric traumatic splenectomy rates. METHODS: The study cohort comprised DTS trauma registry recorded children younger than 16 years with spleen injury (ICD-9 codes 865.0Y865.9) from January 1998 through December 2012. This cohort was categorized into pre-PTC (1998Y2005) and postPTC (2006Y2012) groups. Penetrating injuries were excluded. Comparisons between groups included age, gender, length of stay, organ-specific injury grade, Injury Severity Score, incidence of polytrauma, splenectomy rate, and admitting hospital. Management, operative versus nonoperative, of low grade (Organ Injury Scale [OIS] score, 1Y3) and high grade (OIS score, 4Y5) were also compared. Pearson’s W2 analysis was performed for categorical variables. Continuous variables were reported as mean (standard deviation) and compared by Student’s t test for independent normally distributed samples. Mann-Whitney U-test was used for non-normally distributed variables. A value of p G 0.05 was considered significant. RESULTS: Of the 231 pediatric spleen injuries, 118 occurred pre-PTC and 113 occurred post-PTC. There were no significant differences in age, gender, length of stay, Injury Severity Score, OIS grade, or incidence of polytrauma. Splenectomy rates decreased from 11% (13 of 118) pre-PTC to 2.7% (3 of 113) post-PTC (p = 0.012). CONCLUSION: The addition of an American College of SurgeonsYverified PTC within an inclusive trauma system that was previously without one was associated with a significant reduction in the rate of blunt traumaYrelated splenectomy. Integration of a verified PTC is an influential factor in achieving spleen preservation rates equivalent to published American Pediatric Surgery Association benchmarks within a trauma system. (J Trauma Acute Care Surg. 2015;78: 930Y934. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III. KEY WORDS: Inclusive trauma system; pediatric trauma center; splenectomy. BACKGROUND:
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n the United States, development of inclusive regional trauma systems has improved survival for critically injured patients. After the adoption of the Delaware Trauma System (DTS), trauma mortality rates dropped significantly.1 However, at the time of DTS implementation, the system did not include a designated pediatric trauma center (PTC). The DTS used a model of a PTC ‘‘without walls’’ in which the adult level 1 trauma center was used for the initial evaluation, resuscitation, and management of the majority of severely injured children. If pediatric subspecialty care or prolonged hospitalization was required, the child was then transferred to the freestanding children’s hospital. In 2006, that children’s hospital sought and successfully achieved trauma center designation verified by the Submitted: September 18, 2014, Revised: January 11, 2015, Accepted: January 19, 2015. From the Christiana Care Health System (E.E.K.M., M.D.C., G.H.T.), John H. Ammon Medical Education Center, Newark, Delaware; and Nemours AI DuPont Hospital for Children (S.G.M.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. This study was presented at the 73rd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, September 9Y13, 2014, in Philadelphia, Pennsylvania. Address for reprints: Emily E.K. Murphy, MD, Christiana Care Health System, John H. Ammon Medical Education Center, 4755 Ogletown-Stanton Rd., Suite 2E70B, Newark, DE 19718; email: [email protected]. DOI: 10.1097/TA.0000000000000610
American College of Surgeons Committee on Trauma (ACSCOT) verification/consultation program. The pediatric trauma literature has long supported nonoperative management of pediatric blunt spleen injury, first with small case series and then with published guidelines from the American Pediatric Surgery Association (APSA). Although adult trauma providers subsequently have embraced nonoperative management of blunt spleen injury in both children and adults, discrepancies still exist in the management of splenic injury between adult and pediatric trauma centers.2 The verification of an ACSCOT PTC in a previously established inclusive trauma system provided a unique opportunity to assess its impact on pediatric splenectomy rate for blunt trauma.
PATIENTS AND METHODS After institutional review board approval, the Delaware Trauma Registry was queried for all children younger than 16 years with a spleen injury (International Classification of Diseases, 9th Revision [ICD-9] diagnoses codes 865.0Y865.9) from January 1998 through December 2012. This cohort was selected based on the DTS age criteria of preferential triage to the PTC established after inclusion of the freestanding children’s hospital in the trauma system. J Trauma Acute Care Surg Volume 78, Number 5
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TABLE 1. Characteristics Pre- and Post-PTC Pre-PTC (n = 118) Age, y Male, % (n) Length of stay, d Mortality, % (n) Incidence of high-grade spleen injury, % (n) Injury Severity Score Incidence of splenectomy, % (n) Incidence of polytrauma, % (n) Admitted to pediatric hospital, % (n) Discharged from pediatric hospital, % (n)
Post-PTC (n = 113)
11 (6.75Y14) 11 (8Y13.5) 72.9 (86) 74.3 (84) 3.5 (2Y5) 3 (2Y5) 2.5 (3) 1.8 (2) 13.6 (16) 17.7 (20) 10 (5Y21) 11 (13) 28.8 (34) 25.4 (30) 30.5 (36)
16 (9Y22) 2.7 (3) 35.4 (40) 46 (52) 59.3 (67)
p 0.43 0.80 0.41 0.69 0.39 0.065 0.012 0.28 0.001 G0.001
The Delaware Trauma Registry includes both ICD-9 codes and written descriptions of injuries. ICD-9 codes 865.01, 865.02, and 865.03 correlate with spleen injury grades 1 to 3 and collectively comprise the low-grade injury group. ICD-9 code 865.04 correlated with grades 4 and 5 spleen injuries and comprised the high-grade injury group. If a discrepancy occurred between the text description and the ICD-9 code, the descriptive text determined the case assignment (e.g., a highgrade spleen injury might carry an ICD-9 code of 865.02 but have associated text documenting a grade 4 spleen injury). When descriptive text for an ICD-9 code 865.0 (unspecified spleen injury) or 865.09 (other injury to the spleen) was unavailable, the subject was placed in the low-grade injury group. For subjects experiencing interfacility transfer, classification was based on highest injury grade. Penetrating splenic injuries were excluded. Identified pediatric trauma patients with splenic injuries were then categorized into two groups, pre-PTC (1998Y2005) and post-PTC (2006Y2012). These groups were compared for age, gender, length of stay, organ-specific injury grade, Injury Severity Score (ISS), incidence of polytrauma, splenectomy rate, and admitting hospital. Management, operative versus nonoperative, of low grade (Organ Injury Scale [OIS] score, 1Y3) and high grade (OIS score, 4Y5) were also compared. SPSS version 19 (IBM, Armonk, NY) was used for all statistical analyses. Pearson’s W2 analysis was performed for categorical variables. Continuous variables were reported as mean T SD and compared by Student’s t test for independent normally distributed samples. Mann-Whitney U-test was used for non-normally distributed variables. A value of p G 0.05 was considered significant.
The median ISS was 16 (interquartile range, 9Y22) in the postPTC group compared with a median ISS of 10 pre-PTC (interquartile range, 5Y21) (p = 0.065). However, OIS grade of splenic injury and incidence of polytrauma were similar between the study cohorts. One hundred eighteen children (51%) had isolated splenic injuries. As expected, the injury severity was significantly higher in the polytrauma patients than in those with isolated spleen injuries (ISS, 23.5 vs. 11.3; p G 0.001). Polytrauma occurred in 28.8% (n = 34) of the pre-PTC group and 35.4% post-PTC (n = 40) (p = 0.28). There were five deaths during the study period. Three occurred pre-PTC, and two occurred post-PTC. All were patients with high ISS scores and significant polytrauma. None were directly attributable to the spleen alone. Throughout the entire study period, only 16 splenectomies were performed. Thirteen occurred pre-PTC, and only three splenectomies occurred post-PTC (11% [13 of 118] vs. 2.7% [3 of 113]; p = 0.012). Pre-PTC, seven splenectomies were performed for high-grade injuries and six for low-grade injuries. Post-PTC, two splenectomies were performed for high-grade injuries and one for a low-grade injury (Fig. 1). All splenectomies performed on low-grade injuries were performed at an adult trauma center; specific details are not available for splenectomy indication. As anticipated with the inclusion of an ACSCOT-verified designated PTC, pediatric patients with blunt splenic injuries were more likely to both present or be transferred to the freestanding children’s hospital. Pre-PTC, only 36 (30.5%) of 118 of these patients were managed at the freestanding children’s hospital, whereas post-PTC, 67 (59%) of 113 were managed at the PTC.
DISCUSSION Viewed with skepticism when first proposed, nonoperative management of blunt splenic injury in children has evolved into the standard of care.3 Although the APSA guidelines were the
RESULTS Two hundred thirty-one children appeared in the registry with ICD-9 codes indicating blunt spleen injury. One hundred eighteen occurred pre-PTC, and 113 occurred post-PTC. The mean age for all patients was 11 years (T3.63 years), and nearly three quarters were male. The length of hospitalization was not significantly different between the cohorts (Table 1). There were five deaths, three occurring pre-PTC and two post-PTC.
Figure 1. Management of pediatric blunt spleen injury pre- and post-PTC.
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first to support nonoperative management of blunt spleen injury, the Eastern Association for the Surgery of Trauma practice management guidelines also support a trial of nonoperative management in hemodynamically stable pediatric patients with blunt splenic injury.4 The APSA benchmark for the management of pediatric blunt spleen injury is a 5% to 11% splenectomy rate. The initial rationale for splenic salvage was based on preservation of splenic function and avoidance of postsplenectomy sepsis, which affects approximately 0.58% of children.5 The splenic preservation approach is associated with shorter hospital stays, lower transfusion rates, and decreased mortality.6 While not statistically significant, this trend is reflected in our study population with mortality and length of stay lower after incorporation of a PTC. We attribute this to an increase in injury severity in the post-PTC group. Abbreviated protocols for bed rest for the child with a blunt spleen injury have also been suggested.7 Our data and these studies have helped us to reevaluate our clinical practice guidelines and endorse even shorter hospitalizations, but all institutions have used the guidelines endorsed by APSA of grade plus 1 day of hospitalization for children with high-grade injury observed in an intensive care setting initially. Even so, spleen preservation is less likely at nonpediatric hospitals or pediatric hospitals within adult hospitals.8Y10 Although 80% of blunt spleen injuries are grade III or less, even high-grade injuries do not mandate operative intervention. Permissive anemia to a hemoglobin level of 7 g/dL seems to be better tolerated in the pediatric population. An initial nonoperative approach yields an expected 95% spleen salvage rate.11 Successful spleen preservation can be accomplished even at rural adult trauma centers.12 Although spleen preservation is not recommended in hemodynamically unstable patients, the long-term risk of complications of management without surgical intervention is less than 1% in appropriate populations.13 In adults, failure of nonoperative management is largely attributable to inappropriate patient selection (i.e., hemodynamically unstable patients or those with incorrectly interpreted imaging studies).14 Pediatric mortality and splenectomy rates are lower at PTCs than adult trauma centers.8Y10 This also is demonstrated in our data. Only 15% of children with injured spleens are cared for at a freestanding children’s hospital, whereas 35% are cared for at nontrauma centers.8 Although nonoperative management of pediatric blunt spleen injury is known to be safe and successful, discrepancies occur between the management of pediatric blunt spleen injuries by adult and pediatric trauma surgeons, with significantly increased pediatric splenectomy rates at adult trauma centers.15 Adult surgeons are more likely to transfuse and to operate on pediatric blunt spleen injuries, regarding transfusion as failure of a nonoperative approach.16 This has been demonstrated in our own data. At some adult hospitals caring for injured children, APSA benchmarks have been attained.12 In a survey of surgeons caring for pediatric trauma patients, pediatric trauma surgeons were more likely to follow APSA blunt spleen management guidelines, were more likely to continue nonoperative management in the presence of contrast blush on computed tomography scan, and were less 932
likely to be influenced by organ-specific injury grade in pursuing nonoperative management.17Although adult trauma surgeons have become more familiar with nonoperative strategies of blunt spleen injury management, pediatric trauma institutions often endorse clinical practice guidelines for blunt spleen management and are more likely to adhere to the goal of spleen salvage.8 Continued education of adult trauma surgeons in nonoperative management of pediatric blunt spleen injury is still needed.12,17,18 This might be aided by the addition of clinical pathways, which have been shown to be beneficial in the management of pediatric spleen injury.19 The significant decrease in splenectomy for pediatric blunt spleen trauma noted in this inclusive trauma system is likely multifactorial. Whereas the PTC probably significantly contributed to the philosophy of nonoperative management, the initial Eastern Association for the Surgery of Trauma guidelines also were published during this period. The PTC provided not only care for children but also education on pediatric trauma topics for providers. Grassroots education efforts disseminated the paradigm of nonoperative management at grand rounds, local trauma symposiums, and the quarterly DTS meetingsVall of which focus on quality improvement and improving the care of the injured child in the entire state. The addition of the PTC also has facilitated communication between trauma centers on a case-by-case basis, with management strategies for individual patients discussed and sometimes obviating the need for transfer. The transfer guidelines in our state include preferential transfer of children 12 years and younger to the PTC. But caring for all injured children at a PTC is neither feasible nor realistic. The educational role of the PTC is especially valuable in the care of the child with mild injuries or who is too sick to safely transfer. Limitations of this study include its relatively small sample size, its retrospective nature, and the selection bias intrinsic to a registry-based study. However, this design does allow us the opportunity to study what effect the implementation of an ACSCOT-verified PTC may have on important pediatric trauma outcomes in an inclusive trauma system. While we realize that resources are limited to permit the majority of children to be managed primarily at PTCs, the philosophy and guidelines developed by PTCs and pediatric trauma surgeons for the nonoperative management of pediatric blunt spleen injury should be adopted, to the degree possible, by adult trauma centers caring for children. AUTHORSHIP E.E.K.M. is responsible for study concept and data acquisition. E.E.K.M., S.G.M., M.D.C., and G.H.T. are responsible for study design and analysis and interpretation of the data. E.E.K.M. and S.G.M. drafted the manuscript, and M.D.C. and G.H.T. performed critical revision. E.E.K.M. and G.H.T. were responsible for statistical analysis. DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Tinkoff GH, Reed JF 3rd, Megargel R, Alexander EL 3rd, Murphy S, Jones MS. Delaware’s inclusive trauma system: impact on mortality. J Trauma. 2010;69(2):245Y252.
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2. Matsushima K, Kulaylat AN, Won EJ, Stokes AL, Schaefer EW, Frankel HL. Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database. J Surg Res. 2013;183(2): 808Y813. 3. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet. 1968;126(4):781Y790. 4. Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD, Jawa RS, Maung AA, Rohs TJ Jr., Sangosanya A, et al. Eastern Association for the Surgery of Trauma. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73: S294YS300. 5. Singer DB. Postsplenectomy sepsis. Perspect Pediatr Pathol. 1973;1: 285Y311. 6. Feigin E, Aharonson-Daniel L, Savitsky B, Steinberg R, Kravarusic D, Stein M, Peleg K, Freud E. Conservative approach to the treatment of injured liver and spleen in children: association with reduced mortality. Pediatr Surg Int. 2009;25:583Y586. 7. St Peter SD, Sharp SW, Snyder CL, Sharp RJ, Andrews WS, Murphy JP, Islam S, Holcomb GW 3rd, Ostlie DJ. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2011;46:173Y177. 8. Mooney DP, Rothstein DH, Forbes PW. Variation in the management of pediatric splenic injuries in the United States. J Trauma. 2006;61:330Y333. 9. Stylianos S. Outcomes from pediatric solid organ injury: role of standardized care guidelines. Curr Opin Pediatr. 2005;17:402Y406. 10. Potoka DA, Schall LC, Gardner MJ, Stafford PW, Peitzman AB, Ford HR. Impact of pediatric trauma centers on morality in a statewide system. J Trauma. 2000;49(2):237Y245. 11. Stylianos S, Egorova N, Guice KS, Arons RR, Oldham KT. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg. 2006;202(2):247Y251. 12. Bird JJ, Patel NY, Mathiason MA, Schroeppel TJ, D’huyvetter CJ, Cogbill TH. Management of pediatric blunt splenic injury at a rural trauma center. J Trauma Acute Care Surg. 2012;73:919Y922. 13. Kristoffersen KW, Mooney DP. Long-term outcome of nonoperative pediatric splenic injury management. J Pediatr Surg. 2007;42:1038Y1041. 14. Peitzman AB, Harbrecht BG, Rivera L, Heil B, The Eastern Association for the Surgery of Trauma Multiinstitutional Trials Workgroup. Failure of observation of blunt splenic injury in adults: variability in practice and adverse consequences. J Am Coll Surg. 2005;201:179Y187. 15. Davis DH, Localio AR, Stafford PW, Helfaer MA, Durbin DR. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics. 2005;115:89Y94. 16. Sims CA, Wiebe DJ, Nance ML. Blunt solid organ injury: do adult and pediatric surgeons treat children differently? J Trauma. 2008;65(3):698Y703. 17. Li D, Yanchar N. Management of pediatric blunt splenic injuries in CanadaVpractices and opinions. J Pediatr Surg. 2009;44:997Y1004. 18. Bowman SM, Bulger E, Sharar SR, Maham SA, Smith SD. Variability in pediatric splenic injury care: results of a national survey of general surgeons. Arch Surg. 2010;145(11):1048Y1053. 19. Bowman SM, Zimmerman FJ, Christakis DA, Sharar SR, Martin DP. Hospital characteristics associated with the management of pediatric splenic injuries. JAMA. 2005;294:2611Y2617.
DISCUSSION Dr. Mary Fallat (Louisville, Kentucky): I would like to compliment Dr. Murphy on a nicely presented study that provides additional confirmation that children with traumatic splenic rupture more often keep their spleens if they are taken care of by pediatric surgeons. The credit for this is attributed to verification of the Alfred duPont Hospital for Children as the pediatric trauma center in 2006 with subsequent more immediate triage of injured children to this facility. Nevertheless,
I’d like to recognize there has also been an evolution toward observation of adults with splenic trauma over time with at least some credit given to the pediatric trauma world. In the manuscript, the authors credit the American Pediatric Surgical Association under the guidance of Steve Stylianos with published guidelines for management of these children. For those of you who are not acquainted with these guidelines, they further refine management into how many days per injury grade one might expect to manage children in the ICU, how many days in bed before letting them up, before feeding them, before discharging them, and activity restrictions. These guidelines were modified some years later to even less conservative management with only the children with high-grade injuries needing ICU care and further trimming the length of stay. I have a few questions. The first is that although the authors should be given credit for saving spleens in Delaware, I am wondering why the length of stay hasn’t decreased over time, particularly at the pediatric trauma center? Do the authors use an evidence-based guideline to direct the care of children with solid organ injury? A corollary is that the cost of care should have decreased over time as less children need a period of observation in critical care. Second question: following 2006, 59% of children with a splenic injury were managed at the pediatric trauma center. This means that 41% stayed at the adult center. Are there transfer guidelines and protocols in place? And what are the criteria to transfer the child to the pediatric trauma center? Third, there were five deaths with a few before and a few after 2006. Were the deaths related to the splenic rupture in any of these patients? And, finally, several of the splenectomies were done in children who had low-grade injuries. Do you have any details of these cases? Were they done in conjunction with other procedures in patients with multiple injuries or as isolated splenectomies? The authors have an opportunity to educate in their manuscript by providing the reader with a care plan that will clarify a safe way to care for children with solid organ injury based on grade of injury and I would encourage them to do this. Thank you again for a nicely presented paper and for the privilege of making comments. Dr. James Tyburski (Detroit, Michigan): Very nice paper. This has significant implications on verification of trauma centers and from the American College of Surgeons. Do you think the fact that the center became verified upped all the scrutiny, i.e., peer review, processes that made the changes? Secondly, who is doing the splenectomies? Were they mostly at the children’s hospital? Were they at the adult hospital? Was it the same set of surgeons? Were these adult surgeons doing splenectomies on eight-year olds? Thank you very much. Dr. David Notrica (Phoenix, Arizona): I congratulate you on a very nice study. At the AAST a few years ago we showed that the presence of a Level I pediatric trauma center within a state was associated with a 35% decrease in mortality. One of the questions that was raised was whether or not mortality was a good marker for the care that was being delivered. I think this paper really helps to answer that question.
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My question for the authors, though, is since not all of the kids were being taken care of at the children’s hospital, what is it about having a Level I pediatric trauma center in the state that lowers the splenectomy rate? Is this a matter of peer pressure? Is this a matter of PI [performance improvement]? Is this a matter of cross-fertilization? I will tell you that when you look at these high-grade injuries and you see the decrease from a 44% splenectomy rate for the Grade IV and Grade V injuries down a to an 11% rate, what you are really seeing is that children can be managed very differently than adults. For many of the patients that I would manage non-operatively [in children], the same injury in an adult patient would not stop bleeding. Dr. Emily E. Murphy (Newark, Delaware): The coauthors and I would like to thank you for the privilege of the podium this afternoon. Change in length of stay has not significantly decreased, but we have looked at our clinical practice guidelines both at our pediatric institution and at our adult centers. And we are currently readdressing those, specifically to look at length of stay. If you further stratify the data based on the evolution of the pediatric trauma center in Delaware in 2006, AI DuPont Hospital for Children was designated as a Level III center. And in the last 12 months we have gone from a Level II to a Level I center, that that continues to change and so is a good point that I appreciate from Dr. Fallat. There are preferential triage guidelines which recommend that all children under the age of 12 be transferred to the pediatric trauma center in Delaware, usually directly to the pediatric trauma center. Geographically, sometimes this
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is not possible. But built in to our triage guidelines is a nice area of wiggle room because sometimes a 14-year old looks like me and sometimes a 14-year old looks like they are 8 years old. And so the adult center Level I center and the Level III centers are aware that there will be overlap the way our trauma system is set up. So far as the deaths represented in our study, all were related to poly-trauma for various reasons. And none were directly attributable to the spleen. The low-grade splenectomies were done at the adult centers in all cases. At the pediatric trauma center, specifically, in the last 14 years there have been two splenectomies. One was a child whose spleen had auto-infarcted and was having significant pain after she fell off a horse. The other was an adolescent who was in extremis. And it’s really the education from the pediatric trauma center providers to the Level I and Level III participants that has changed this mindset. You know, it is an about-face both for a learner like me and for an adult trauma surgeon to see a kid who is a little bit tachycardic and a little bit hypotensive and instead of taking them directly to the operating room, which is fun and exciting, giving them some blood and just waiting. And so that’s really attributable to the pediatric trauma surgeons. The verification of the pediatric trauma center made us more cognizant about how we take care of children in Delaware. It made us more cognizant about how we endorse guidelines. And it made us more cognizant of the literature in the pediatric trauma realm. Thank you again for your time. I very much appreciate it.
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The pediatric trauma center and the inclusive trauma system: Impact on splenectomy rates Emily E.K. Murphy, MD, Stephen G. Murphy, MD, Mark D. Cipolle, MD, PhD, and Glen H. Tinkoff, MD, Newark, Delaware
Before 2006, the Delaware Trauma System (DTS) did not include a designated pediatric trauma center (PTC). In 2006, the Delaware Trauma System designated and the American College of Surgeons Committee on Trauma verification/consultation program verified Nemours AI DuPont Hospital for Children, a freestanding children’s hospital, as a PTC. We evaluated the impact of the addition of the PTC to the state trauma system on pediatric traumatic splenectomy rates. METHODS: The study cohort comprised DTS trauma registry recorded children younger than 16 years with spleen injury (ICD-9 codes 865.0Y865.9) from January 1998 through December 2012. This cohort was categorized into pre-PTC (1998Y2005) and postPTC (2006Y2012) groups. Penetrating injuries were excluded. Comparisons between groups included age, gender, length of stay, organ-specific injury grade, Injury Severity Score, incidence of polytrauma, splenectomy rate, and admitting hospital. Management, operative versus nonoperative, of low grade (Organ Injury Scale [OIS] score, 1Y3) and high grade (OIS score, 4Y5) were also compared. Pearson’s W2 analysis was performed for categorical variables. Continuous variables were reported as mean (standard deviation) and compared by Student’s t test for independent normally distributed samples. Mann-Whitney U-test was used for non-normally distributed variables. A value of p G 0.05 was considered significant. RESULTS: Of the 231 pediatric spleen injuries, 118 occurred pre-PTC and 113 occurred post-PTC. There were no significant differences in age, gender, length of stay, Injury Severity Score, OIS grade, or incidence of polytrauma. Splenectomy rates decreased from 11% (13 of 118) pre-PTC to 2.7% (3 of 113) post-PTC (p = 0.012). CONCLUSION: The addition of an American College of SurgeonsYverified PTC within an inclusive trauma system that was previously without one was associated with a significant reduction in the rate of blunt traumaYrelated splenectomy. Integration of a verified PTC is an influential factor in achieving spleen preservation rates equivalent to published American Pediatric Surgery Association benchmarks within a trauma system. (J Trauma Acute Care Surg. 2015;78: 930Y934. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III. KEY WORDS: Inclusive trauma system; pediatric trauma center; splenectomy. BACKGROUND:
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n the United States, development of inclusive regional trauma systems has improved survival for critically injured patients. After the adoption of the Delaware Trauma System (DTS), trauma mortality rates dropped significantly.1 However, at the time of DTS implementation, the system did not include a designated pediatric trauma center (PTC). The DTS used a model of a PTC ‘‘without walls’’ in which the adult level 1 trauma center was used for the initial evaluation, resuscitation, and management of the majority of severely injured children. If pediatric subspecialty care or prolonged hospitalization was required, the child was then transferred to the freestanding children’s hospital. In 2006, that children’s hospital sought and successfully achieved trauma center designation verified by the Submitted: September 18, 2014, Revised: January 11, 2015, Accepted: January 19, 2015. From the Christiana Care Health System (E.E.K.M., M.D.C., G.H.T.), John H. Ammon Medical Education Center, Newark, Delaware; and Nemours AI DuPont Hospital for Children (S.G.M.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. This study was presented at the 73rd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, September 9Y13, 2014, in Philadelphia, Pennsylvania. Address for reprints: Emily E.K. Murphy, MD, Christiana Care Health System, John H. Ammon Medical Education Center, 4755 Ogletown-Stanton Rd., Suite 2E70B, Newark, DE 19718; email: [email protected]. DOI: 10.1097/TA.0000000000000610
American College of Surgeons Committee on Trauma (ACSCOT) verification/consultation program. The pediatric trauma literature has long supported nonoperative management of pediatric blunt spleen injury, first with small case series and then with published guidelines from the American Pediatric Surgery Association (APSA). Although adult trauma providers subsequently have embraced nonoperative management of blunt spleen injury in both children and adults, discrepancies still exist in the management of splenic injury between adult and pediatric trauma centers.2 The verification of an ACSCOT PTC in a previously established inclusive trauma system provided a unique opportunity to assess its impact on pediatric splenectomy rate for blunt trauma.
PATIENTS AND METHODS After institutional review board approval, the Delaware Trauma Registry was queried for all children younger than 16 years with a spleen injury (International Classification of Diseases, 9th Revision [ICD-9] diagnoses codes 865.0Y865.9) from January 1998 through December 2012. This cohort was selected based on the DTS age criteria of preferential triage to the PTC established after inclusion of the freestanding children’s hospital in the trauma system. J Trauma Acute Care Surg Volume 78, Number 5
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TABLE 1. Characteristics Pre- and Post-PTC Pre-PTC (n = 118) Age, y Male, % (n) Length of stay, d Mortality, % (n) Incidence of high-grade spleen injury, % (n) Injury Severity Score Incidence of splenectomy, % (n) Incidence of polytrauma, % (n) Admitted to pediatric hospital, % (n) Discharged from pediatric hospital, % (n)
Post-PTC (n = 113)
11 (6.75Y14) 11 (8Y13.5) 72.9 (86) 74.3 (84) 3.5 (2Y5) 3 (2Y5) 2.5 (3) 1.8 (2) 13.6 (16) 17.7 (20) 10 (5Y21) 11 (13) 28.8 (34) 25.4 (30) 30.5 (36)
16 (9Y22) 2.7 (3) 35.4 (40) 46 (52) 59.3 (67)
p 0.43 0.80 0.41 0.69 0.39 0.065 0.012 0.28 0.001 G0.001
The Delaware Trauma Registry includes both ICD-9 codes and written descriptions of injuries. ICD-9 codes 865.01, 865.02, and 865.03 correlate with spleen injury grades 1 to 3 and collectively comprise the low-grade injury group. ICD-9 code 865.04 correlated with grades 4 and 5 spleen injuries and comprised the high-grade injury group. If a discrepancy occurred between the text description and the ICD-9 code, the descriptive text determined the case assignment (e.g., a highgrade spleen injury might carry an ICD-9 code of 865.02 but have associated text documenting a grade 4 spleen injury). When descriptive text for an ICD-9 code 865.0 (unspecified spleen injury) or 865.09 (other injury to the spleen) was unavailable, the subject was placed in the low-grade injury group. For subjects experiencing interfacility transfer, classification was based on highest injury grade. Penetrating splenic injuries were excluded. Identified pediatric trauma patients with splenic injuries were then categorized into two groups, pre-PTC (1998Y2005) and post-PTC (2006Y2012). These groups were compared for age, gender, length of stay, organ-specific injury grade, Injury Severity Score (ISS), incidence of polytrauma, splenectomy rate, and admitting hospital. Management, operative versus nonoperative, of low grade (Organ Injury Scale [OIS] score, 1Y3) and high grade (OIS score, 4Y5) were also compared. SPSS version 19 (IBM, Armonk, NY) was used for all statistical analyses. Pearson’s W2 analysis was performed for categorical variables. Continuous variables were reported as mean T SD and compared by Student’s t test for independent normally distributed samples. Mann-Whitney U-test was used for non-normally distributed variables. A value of p G 0.05 was considered significant.
The median ISS was 16 (interquartile range, 9Y22) in the postPTC group compared with a median ISS of 10 pre-PTC (interquartile range, 5Y21) (p = 0.065). However, OIS grade of splenic injury and incidence of polytrauma were similar between the study cohorts. One hundred eighteen children (51%) had isolated splenic injuries. As expected, the injury severity was significantly higher in the polytrauma patients than in those with isolated spleen injuries (ISS, 23.5 vs. 11.3; p G 0.001). Polytrauma occurred in 28.8% (n = 34) of the pre-PTC group and 35.4% post-PTC (n = 40) (p = 0.28). There were five deaths during the study period. Three occurred pre-PTC, and two occurred post-PTC. All were patients with high ISS scores and significant polytrauma. None were directly attributable to the spleen alone. Throughout the entire study period, only 16 splenectomies were performed. Thirteen occurred pre-PTC, and only three splenectomies occurred post-PTC (11% [13 of 118] vs. 2.7% [3 of 113]; p = 0.012). Pre-PTC, seven splenectomies were performed for high-grade injuries and six for low-grade injuries. Post-PTC, two splenectomies were performed for high-grade injuries and one for a low-grade injury (Fig. 1). All splenectomies performed on low-grade injuries were performed at an adult trauma center; specific details are not available for splenectomy indication. As anticipated with the inclusion of an ACSCOT-verified designated PTC, pediatric patients with blunt splenic injuries were more likely to both present or be transferred to the freestanding children’s hospital. Pre-PTC, only 36 (30.5%) of 118 of these patients were managed at the freestanding children’s hospital, whereas post-PTC, 67 (59%) of 113 were managed at the PTC.
DISCUSSION Viewed with skepticism when first proposed, nonoperative management of blunt splenic injury in children has evolved into the standard of care.3 Although the APSA guidelines were the
RESULTS Two hundred thirty-one children appeared in the registry with ICD-9 codes indicating blunt spleen injury. One hundred eighteen occurred pre-PTC, and 113 occurred post-PTC. The mean age for all patients was 11 years (T3.63 years), and nearly three quarters were male. The length of hospitalization was not significantly different between the cohorts (Table 1). There were five deaths, three occurring pre-PTC and two post-PTC.
Figure 1. Management of pediatric blunt spleen injury pre- and post-PTC.
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first to support nonoperative management of blunt spleen injury, the Eastern Association for the Surgery of Trauma practice management guidelines also support a trial of nonoperative management in hemodynamically stable pediatric patients with blunt splenic injury.4 The APSA benchmark for the management of pediatric blunt spleen injury is a 5% to 11% splenectomy rate. The initial rationale for splenic salvage was based on preservation of splenic function and avoidance of postsplenectomy sepsis, which affects approximately 0.58% of children.5 The splenic preservation approach is associated with shorter hospital stays, lower transfusion rates, and decreased mortality.6 While not statistically significant, this trend is reflected in our study population with mortality and length of stay lower after incorporation of a PTC. We attribute this to an increase in injury severity in the post-PTC group. Abbreviated protocols for bed rest for the child with a blunt spleen injury have also been suggested.7 Our data and these studies have helped us to reevaluate our clinical practice guidelines and endorse even shorter hospitalizations, but all institutions have used the guidelines endorsed by APSA of grade plus 1 day of hospitalization for children with high-grade injury observed in an intensive care setting initially. Even so, spleen preservation is less likely at nonpediatric hospitals or pediatric hospitals within adult hospitals.8Y10 Although 80% of blunt spleen injuries are grade III or less, even high-grade injuries do not mandate operative intervention. Permissive anemia to a hemoglobin level of 7 g/dL seems to be better tolerated in the pediatric population. An initial nonoperative approach yields an expected 95% spleen salvage rate.11 Successful spleen preservation can be accomplished even at rural adult trauma centers.12 Although spleen preservation is not recommended in hemodynamically unstable patients, the long-term risk of complications of management without surgical intervention is less than 1% in appropriate populations.13 In adults, failure of nonoperative management is largely attributable to inappropriate patient selection (i.e., hemodynamically unstable patients or those with incorrectly interpreted imaging studies).14 Pediatric mortality and splenectomy rates are lower at PTCs than adult trauma centers.8Y10 This also is demonstrated in our data. Only 15% of children with injured spleens are cared for at a freestanding children’s hospital, whereas 35% are cared for at nontrauma centers.8 Although nonoperative management of pediatric blunt spleen injury is known to be safe and successful, discrepancies occur between the management of pediatric blunt spleen injuries by adult and pediatric trauma surgeons, with significantly increased pediatric splenectomy rates at adult trauma centers.15 Adult surgeons are more likely to transfuse and to operate on pediatric blunt spleen injuries, regarding transfusion as failure of a nonoperative approach.16 This has been demonstrated in our own data. At some adult hospitals caring for injured children, APSA benchmarks have been attained.12 In a survey of surgeons caring for pediatric trauma patients, pediatric trauma surgeons were more likely to follow APSA blunt spleen management guidelines, were more likely to continue nonoperative management in the presence of contrast blush on computed tomography scan, and were less 932
likely to be influenced by organ-specific injury grade in pursuing nonoperative management.17Although adult trauma surgeons have become more familiar with nonoperative strategies of blunt spleen injury management, pediatric trauma institutions often endorse clinical practice guidelines for blunt spleen management and are more likely to adhere to the goal of spleen salvage.8 Continued education of adult trauma surgeons in nonoperative management of pediatric blunt spleen injury is still needed.12,17,18 This might be aided by the addition of clinical pathways, which have been shown to be beneficial in the management of pediatric spleen injury.19 The significant decrease in splenectomy for pediatric blunt spleen trauma noted in this inclusive trauma system is likely multifactorial. Whereas the PTC probably significantly contributed to the philosophy of nonoperative management, the initial Eastern Association for the Surgery of Trauma guidelines also were published during this period. The PTC provided not only care for children but also education on pediatric trauma topics for providers. Grassroots education efforts disseminated the paradigm of nonoperative management at grand rounds, local trauma symposiums, and the quarterly DTS meetingsVall of which focus on quality improvement and improving the care of the injured child in the entire state. The addition of the PTC also has facilitated communication between trauma centers on a case-by-case basis, with management strategies for individual patients discussed and sometimes obviating the need for transfer. The transfer guidelines in our state include preferential transfer of children 12 years and younger to the PTC. But caring for all injured children at a PTC is neither feasible nor realistic. The educational role of the PTC is especially valuable in the care of the child with mild injuries or who is too sick to safely transfer. Limitations of this study include its relatively small sample size, its retrospective nature, and the selection bias intrinsic to a registry-based study. However, this design does allow us the opportunity to study what effect the implementation of an ACSCOT-verified PTC may have on important pediatric trauma outcomes in an inclusive trauma system. While we realize that resources are limited to permit the majority of children to be managed primarily at PTCs, the philosophy and guidelines developed by PTCs and pediatric trauma surgeons for the nonoperative management of pediatric blunt spleen injury should be adopted, to the degree possible, by adult trauma centers caring for children. AUTHORSHIP E.E.K.M. is responsible for study concept and data acquisition. E.E.K.M., S.G.M., M.D.C., and G.H.T. are responsible for study design and analysis and interpretation of the data. E.E.K.M. and S.G.M. drafted the manuscript, and M.D.C. and G.H.T. performed critical revision. E.E.K.M. and G.H.T. were responsible for statistical analysis. DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Tinkoff GH, Reed JF 3rd, Megargel R, Alexander EL 3rd, Murphy S, Jones MS. Delaware’s inclusive trauma system: impact on mortality. J Trauma. 2010;69(2):245Y252.
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2. Matsushima K, Kulaylat AN, Won EJ, Stokes AL, Schaefer EW, Frankel HL. Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database. J Surg Res. 2013;183(2): 808Y813. 3. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet. 1968;126(4):781Y790. 4. Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD, Jawa RS, Maung AA, Rohs TJ Jr., Sangosanya A, et al. Eastern Association for the Surgery of Trauma. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73: S294YS300. 5. Singer DB. Postsplenectomy sepsis. Perspect Pediatr Pathol. 1973;1: 285Y311. 6. Feigin E, Aharonson-Daniel L, Savitsky B, Steinberg R, Kravarusic D, Stein M, Peleg K, Freud E. Conservative approach to the treatment of injured liver and spleen in children: association with reduced mortality. Pediatr Surg Int. 2009;25:583Y586. 7. St Peter SD, Sharp SW, Snyder CL, Sharp RJ, Andrews WS, Murphy JP, Islam S, Holcomb GW 3rd, Ostlie DJ. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2011;46:173Y177. 8. Mooney DP, Rothstein DH, Forbes PW. Variation in the management of pediatric splenic injuries in the United States. J Trauma. 2006;61:330Y333. 9. Stylianos S. Outcomes from pediatric solid organ injury: role of standardized care guidelines. Curr Opin Pediatr. 2005;17:402Y406. 10. Potoka DA, Schall LC, Gardner MJ, Stafford PW, Peitzman AB, Ford HR. Impact of pediatric trauma centers on morality in a statewide system. J Trauma. 2000;49(2):237Y245. 11. Stylianos S, Egorova N, Guice KS, Arons RR, Oldham KT. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg. 2006;202(2):247Y251. 12. Bird JJ, Patel NY, Mathiason MA, Schroeppel TJ, D’huyvetter CJ, Cogbill TH. Management of pediatric blunt splenic injury at a rural trauma center. J Trauma Acute Care Surg. 2012;73:919Y922. 13. Kristoffersen KW, Mooney DP. Long-term outcome of nonoperative pediatric splenic injury management. J Pediatr Surg. 2007;42:1038Y1041. 14. Peitzman AB, Harbrecht BG, Rivera L, Heil B, The Eastern Association for the Surgery of Trauma Multiinstitutional Trials Workgroup. Failure of observation of blunt splenic injury in adults: variability in practice and adverse consequences. J Am Coll Surg. 2005;201:179Y187. 15. Davis DH, Localio AR, Stafford PW, Helfaer MA, Durbin DR. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics. 2005;115:89Y94. 16. Sims CA, Wiebe DJ, Nance ML. Blunt solid organ injury: do adult and pediatric surgeons treat children differently? J Trauma. 2008;65(3):698Y703. 17. Li D, Yanchar N. Management of pediatric blunt splenic injuries in CanadaVpractices and opinions. J Pediatr Surg. 2009;44:997Y1004. 18. Bowman SM, Bulger E, Sharar SR, Maham SA, Smith SD. Variability in pediatric splenic injury care: results of a national survey of general surgeons. Arch Surg. 2010;145(11):1048Y1053. 19. Bowman SM, Zimmerman FJ, Christakis DA, Sharar SR, Martin DP. Hospital characteristics associated with the management of pediatric splenic injuries. JAMA. 2005;294:2611Y2617.
DISCUSSION Dr. Mary Fallat (Louisville, Kentucky): I would like to compliment Dr. Murphy on a nicely presented study that provides additional confirmation that children with traumatic splenic rupture more often keep their spleens if they are taken care of by pediatric surgeons. The credit for this is attributed to verification of the Alfred duPont Hospital for Children as the pediatric trauma center in 2006 with subsequent more immediate triage of injured children to this facility. Nevertheless,
I’d like to recognize there has also been an evolution toward observation of adults with splenic trauma over time with at least some credit given to the pediatric trauma world. In the manuscript, the authors credit the American Pediatric Surgical Association under the guidance of Steve Stylianos with published guidelines for management of these children. For those of you who are not acquainted with these guidelines, they further refine management into how many days per injury grade one might expect to manage children in the ICU, how many days in bed before letting them up, before feeding them, before discharging them, and activity restrictions. These guidelines were modified some years later to even less conservative management with only the children with high-grade injuries needing ICU care and further trimming the length of stay. I have a few questions. The first is that although the authors should be given credit for saving spleens in Delaware, I am wondering why the length of stay hasn’t decreased over time, particularly at the pediatric trauma center? Do the authors use an evidence-based guideline to direct the care of children with solid organ injury? A corollary is that the cost of care should have decreased over time as less children need a period of observation in critical care. Second question: following 2006, 59% of children with a splenic injury were managed at the pediatric trauma center. This means that 41% stayed at the adult center. Are there transfer guidelines and protocols in place? And what are the criteria to transfer the child to the pediatric trauma center? Third, there were five deaths with a few before and a few after 2006. Were the deaths related to the splenic rupture in any of these patients? And, finally, several of the splenectomies were done in children who had low-grade injuries. Do you have any details of these cases? Were they done in conjunction with other procedures in patients with multiple injuries or as isolated splenectomies? The authors have an opportunity to educate in their manuscript by providing the reader with a care plan that will clarify a safe way to care for children with solid organ injury based on grade of injury and I would encourage them to do this. Thank you again for a nicely presented paper and for the privilege of making comments. Dr. James Tyburski (Detroit, Michigan): Very nice paper. This has significant implications on verification of trauma centers and from the American College of Surgeons. Do you think the fact that the center became verified upped all the scrutiny, i.e., peer review, processes that made the changes? Secondly, who is doing the splenectomies? Were they mostly at the children’s hospital? Were they at the adult hospital? Was it the same set of surgeons? Were these adult surgeons doing splenectomies on eight-year olds? Thank you very much. Dr. David Notrica (Phoenix, Arizona): I congratulate you on a very nice study. At the AAST a few years ago we showed that the presence of a Level I pediatric trauma center within a state was associated with a 35% decrease in mortality. One of the questions that was raised was whether or not mortality was a good marker for the care that was being delivered. I think this paper really helps to answer that question.
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My question for the authors, though, is since not all of the kids were being taken care of at the children’s hospital, what is it about having a Level I pediatric trauma center in the state that lowers the splenectomy rate? Is this a matter of peer pressure? Is this a matter of PI [performance improvement]? Is this a matter of cross-fertilization? I will tell you that when you look at these high-grade injuries and you see the decrease from a 44% splenectomy rate for the Grade IV and Grade V injuries down a to an 11% rate, what you are really seeing is that children can be managed very differently than adults. For many of the patients that I would manage non-operatively [in children], the same injury in an adult patient would not stop bleeding. Dr. Emily E. Murphy (Newark, Delaware): The coauthors and I would like to thank you for the privilege of the podium this afternoon. Change in length of stay has not significantly decreased, but we have looked at our clinical practice guidelines both at our pediatric institution and at our adult centers. And we are currently readdressing those, specifically to look at length of stay. If you further stratify the data based on the evolution of the pediatric trauma center in Delaware in 2006, AI DuPont Hospital for Children was designated as a Level III center. And in the last 12 months we have gone from a Level II to a Level I center, that that continues to change and so is a good point that I appreciate from Dr. Fallat. There are preferential triage guidelines which recommend that all children under the age of 12 be transferred to the pediatric trauma center in Delaware, usually directly to the pediatric trauma center. Geographically, sometimes this
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is not possible. But built in to our triage guidelines is a nice area of wiggle room because sometimes a 14-year old looks like me and sometimes a 14-year old looks like they are 8 years old. And so the adult center Level I center and the Level III centers are aware that there will be overlap the way our trauma system is set up. So far as the deaths represented in our study, all were related to poly-trauma for various reasons. And none were directly attributable to the spleen. The low-grade splenectomies were done at the adult centers in all cases. At the pediatric trauma center, specifically, in the last 14 years there have been two splenectomies. One was a child whose spleen had auto-infarcted and was having significant pain after she fell off a horse. The other was an adolescent who was in extremis. And it’s really the education from the pediatric trauma center providers to the Level I and Level III participants that has changed this mindset. You know, it is an about-face both for a learner like me and for an adult trauma surgeon to see a kid who is a little bit tachycardic and a little bit hypotensive and instead of taking them directly to the operating room, which is fun and exciting, giving them some blood and just waiting. And so that’s really attributable to the pediatric trauma surgeons. The verification of the pediatric trauma center made us more cognizant about how we take care of children in Delaware. It made us more cognizant about how we endorse guidelines. And it made us more cognizant of the literature in the pediatric trauma realm. Thank you again for your time. I very much appreciate it.
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