Severely injured children who are brought to an emergency medical department by their parents or carers are often not seen as quickly as those who arrive at hospital via ambulance, a study in a UK hospital has found.
The study, presented this week at the European Emergency Medicine Congress, was carried out in an inner-city level 1 major trauma centre, the Bristol Royal Hospital for Children.
It shows that children brought in by carers were seen by emergency doctors within an average time of 58.5 minutes, ranging from three to 168 minutes.
The study’s researchers identified three key trauma features that should prompt doctors to review these patients immediately and potentially prioritise their treatment: boggy swelling to the head, abdominal bruising, and thigh swelling or deformity.
Dr Robert Hirst, who led the study, believes the findings could be applicable to other centres that have similar pre-hospital and urgent and emergency care systems, especially as little is known generally about this group of patients.
Dr Hirst, who is an emergency medicine registrar at the hospital, told the congress: “We see many injured children brought to the paediatric emergency department each year.
“Most are transported by ambulance which results in pre-hospital emergency services pre-alerting the emergency department to their arrival. This leads to early trauma team activation, resulting in specialist services and resources being ready and prepared to see these patients as soon as they arrive. This has been shown to be associated with better outcomes for children with significant injuries.
“However, we know there is a group of children who are brought by their carers who do not receive this rapid activation of resources. This can lead to delays in the appropriate level of care being provided. We wanted to find out more about these patients, their ages, the types of injuries they present with, and what happens to them. At present, little is known about this particular group of patients.”
A level 1 major trauma centre is an emergency medical centre that treats injuries that are so severe they are life-altering with a risk of death or disability, and which need immediate medical attention. Injuries can include fractures and head injuries.
Dr Hirst and colleagues looked at children aged younger than 16 years who were brought to the emergency department between 5 August 2020 and 6 May 2022 by carers, without activation of pre-hospital emergency services.
During this time, 153 children with major traumas arrived; 24 of them had injuries significant enough to be added to the national Trauma Audit and Research Network (TARN) database and were included in the study.
None of them received trauma team activation. All the patients still received appropriate care for their injuries, and none suffered any detrimental effects from being brought to the children’s emergency department by their parents or carers, rather than by ambulance.
The average age of the children was just over six years, and 18 (75 per cent) were boys. Nearly all of them (23, 95.8 per cent) had injuries to one part of their bodies, and most (22, 92 per cent) had obvious external evidence of injury.
The majority (13, 54 per cent) had head injuries, eight (33 per cent) had injuries to their arms or legs, and three (12.5 per cent) had intra-abdominal injuries.
The median Injury Severity Score (a scale that measures and categorises injuries to different areas of the body) was nine, and six patients (25 per cent) scored over 15, meaning these were injuries significant enough to be classified as major trauma.
Ten (42 per cent) of children required surgery, with seven requiring surgery for a broken thigh bone, and three needing neurosurgery to evacuate blood from swellings around the brain or to correct skull fractures. No children died.
The injuries resulted from falls (12, 50 per cent), sporting injuries (6, 25 per cent), bicycle injuries (2, 8 per cent), being dropped (1, 4 per cent), or were unexplained (3, 12.5 per cent).
Dr Hirst said: “As always with all paediatric injuries, it is important to be aware of the possibility of non-accidental injury. Concerns for non-accidental injury were confirmed in three of our patients, all under the age of one. Consideration of non-accidental injury, robust safeguarding processes, and regular multidisciplinary governance review is vital to safeguard children attending the emergency department.”
“The most important issue highlighted in our study is a group of severely injured children facing delays to be seen by expert emergency doctors. If emergency departments adopted triage alerts for the three major signs identified by this study – boggy swelling of the head, abdominal bruising, and thigh swelling or deformity – this could prompt an urgent senior clinician review. This could improve management of this particular group of children by triggering trauma teams and appropriate allocation of resources for this high-risk population.”
Dr Hirst and his colleagues are improving processes in their department so that injured children with external evidence of injury are reviewed promptly by a senior clinical decision-maker.
“We will reassess the impact of these changes on our key performance indicators and outcomes for these children,” he concluded.
