PEDIATRIC TRAUMA 

CENTERS

Availability, 

Outcomes, and 

Federal Support 

Related to Pediatric 

Trauma Care

Report to Congressional Requesters

March 2017

GAO-17-334

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-334, a report to 

congressional requesters

March 2017

PEDIATRIC TRAUMA CENTERS

Availability, Outcomes, and Federal Support Related 

to Pediatric Trauma Care

What GAO Found

GAO estimates that 57 percent of the 73.7 million children in the United States 

during the period 2011-2015 lived within 30 miles of a pediatric trauma center

that can treat all injuries regardless of severity. Among states, the proportion of 

children who lived within 30 miles of these pediatric trauma centers varied 

widely. In areas without pediatric trauma centers, injured children may have to 

rely on adult trauma centers or less specialized hospital emergency departments 

for initial trauma care. Some studies GAO reviewed, including nationwide 

studies, found that children treated at pediatric trauma centers have a lower 

mortality risk compared to children treated at adult trauma centers and other 

facilities, while other state-level studies GAO reviewed found no difference in 

mortality. Further, some studies GAO reviewed and stakeholders GAO 

interviewed suggest that more information is needed on outcomes other than 

mortality for children treated at pediatric trauma centers because mortality can 

be a limited outcome measure, as overall mortality is low among severely injured 

children. 

Estimated Percentage of Children Who Lived within 30 Miles of a High-Level Pediatric Trauma 

Center, by State, 2011-2015

Note: High-level pediatric trauma centers have the resources to treat all injured children, regardless 

of injury severity.

Two agencies within the Department of Health and Human Services (HHS)—the 

Health Resources and Services Administration (HRSA) and the National 

Institutes of Health (NIH)—have grant programs and other activities that support 

hospital-based pediatric trauma care. For example, HRSA’s Emergency Medical 

Services for Children Program provides grants to integrate pediatric emergency 

care—which encompasses care for both traumatic injury and illness—into states’

larger emergency medical services systems. GAO also found that federal 

activities related to hospital-based pediatric trauma care and other emergency 

care are coordinated through an interagency group and arrangements among 

agencies. For example, HRSA and NIH staff participate in the Council on 

Emergency Medical Care, an interagency group established to coordinate 

emergency care activities across the federal government by promoting

information sharing and policy development.

View GAO-17-334. For more information, 

contact Marcia Crosse at (202) 512-7114 or 

crossem@gao.gov.

Why GAO Did This Study

Pediatric trauma—a severe and 

potentially disabling or life threatening 

injury to a child resulting from an event 

such as a motor vehicle crash or a 

fall—is the leading cause of disability 

for children in the United States. More 

children die of injury each year than

from all other causes combined. GAO 

was asked to examine issues related 

to pediatric trauma care. 

This report examines (1) what is known 

about the availability of trauma centers 

for children and the outcomes for 

children treated at different types of 

facilities, and (2) how, if at all, federal 

agencies are involved in supporting

pediatric trauma care and how these 

activities are coordinated. GAO 

analyzed data on the number of 

pediatric and adult trauma centers in 

the United States relative to the 

pediatric population under 18 years of 

age. GAO used 2015 data on trauma 

centers from the American Trauma 

Society’s Trauma Information 

Exchange Program and 5-year 

population estimates for 2011-2015

from the U.S. Census Bureau’s 

American Community Survey, which 

were the latest available data at the 

time of GAO’s analysis. GAO also 

reviewed the existing peer-reviewed, 

academic literature on outcomes for 

pediatric trauma patients, interviewed

stakeholder group representatives and 

federal agency officials involved in 

activities related to hospital-based 

pediatric trauma care, and reviewed 

available agency documentation.

HHS provided technical comments on 

a draft of this report, which GAO 

incorporated as appropriate.
Page i GAO-17-334 Pediatric Trauma Centers

Letter 1

Background 5

Over Half of the Nation’s Children Live within 30 Miles of a HighLevel Pediatric Trauma Center, and Studies Differ on How Well 

Such Centers Work to Lower Mortality 10

Two Agencies Support Hospital-Based Pediatric Trauma Care 

Activities and Coordinate Some Efforts through an Interagency 

Group 19

Agency Comments 24

Appendix I Training and Resources Available to Physicians and Nurses for 

Pediatric Trauma Care 26

Appendix II Location of High-Level Pediatric Trauma Centers, United States, 

2015 31

Appendix III Estimated Percentage of Children Who Lived within 30 Miles of a 

High- or Mid-Level Trauma Center, Detailed Tables by State, 

2011-2015 32

Appendix IV GAO Contact and Staff Acknowledgments 34

Tables

Table 1: General Criteria for Trauma Centers 7

Table 2: Key Federal Activities Related to Hospital-Based 

Pediatric Trauma Care 20

Table 3: Examples of Hospital-Based Pediatric Trauma CareRelated Coordination Efforts through Interagency Group 

and Arrangements between Agencies 24

Table 4: Description of Courses and Examples of Other Training 

Opportunities Available to Physicians and Nurses on the 

Delivery of Trauma Care 27

Table 5: Examples of Resources Available to Physicians and 

Nurses on Pediatric Trauma 29

Contents
Page ii GAO-17-334 Pediatric Trauma Centers

Table 6: Estimated Child Population and Percentage of Children 

Who Lived within 30 Miles of a High- or Mid-Level Trauma 

Center, Detailed Tables by State, 2011-2015 32

Figures

Figure 1: Continuum of Trauma Care Activities 9

Figure 2: Estimated Percentage of Children Who Lived within 30 

Miles of a High-Level Pediatric Trauma Center, by State, 

2011-2015 12

Figure 3: Estimated Percentage of Children Who Lived within 30 

Miles of a High- or Mid-Level Trauma Center, by State, 

2011-2015 14

Figure 4: Location of High-Level Pediatric Trauma Centers, United 

States, 2015 31

Abbreviations

ACS-COT American College of Surgeons Committee on Trauma

ASPR Office of the Assistant Secretary for Preparedness and

 Response

CDC Centers for Disease Control and Prevention

EMSC Emergency Medical Services for Children

HHS Department of Health and Human Services

HRSA Health Resources and Services Administration

NIH National Institutes of Health

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-17-334 Pediatric Trauma Centers

441 G St. N.W.

Washington, DC 20548

March 27, 2017

The Honorable Greg Walden

Chairman

Committee on Energy and Commerce

House of Representatives

The Honorable Michael C. Burgess

Chairman

Subcommittee on Health

Committee on Energy and Commerce

House of Representatives

The Honorable Richard Hudson

House of Representatives

The Honorable Fred Upton

House of Representatives

Pediatric trauma—a severe and potentially disabling or life threatening 

physical injury to a child resulting from an event such as a motor vehicle 

crash or a fall—is the leading cause of disability for children in the United 

States. More children die of injury each year than from all other causes 

combined. According to the Centers for Disease Control and Prevention 

(CDC), more than 8,000 children under 18 years of age suffered fatal 

injuries in 2015. Further, according to the latest available CDC estimates, 

unintentional injuries to children under 18 that resulted in hospitalization 

combined for an estimated $22.9 billion in medical and other costs in 

2010.

Most traumatic injuries—including those to children—are treated in a 

hospital emergency department. However, for severe physical injuries, 

emergency departments may not have the equipment or personnel 

resources necessary to effectively provide treatment, so severely injured 

patients may be transported directly to a trauma center or transferred to a 

trauma center by an emergency department. Trauma centers are facilities 

with the specialized resources needed to care for patients with severe 

physical injuries. Not all trauma centers have pediatric-specific 

capabilities. Pediatric trauma centers have the specialized resources—

Letter
Page 2 GAO-17-334 Pediatric Trauma Centers

providers, equipment, and expertise—needed to care for children with 

severe physical injuries.

1

Concerns have been raised that many children may not have ready 

access to pediatric trauma centers. For example, a 2009 study estimated 

that at least 17.4 million children across the United States could not reach 

a pediatric trauma center within an hour by air or ground transportation.2

Similarly, a 2005 study estimated that 46.7 million people (both adults and 

children) did not have access to a trauma center within an hour’s travel 

time.3 Timely access to appropriate hospital-based pediatric trauma care 

can be significant in limiting death or disability for injured children. 

Further, in 2006 the Institute of Medicine reported that emergency care 

services—including trauma care—for children have traditionally been 

fragmented, with emergency medical services, trauma centers, and public 

health agencies focused on their separate missions.4 Responsibility for 

trauma and emergency care is primarily at the state and local level with 

some involvement at the federal level.

You asked us to review issues related to pediatric trauma. This report 

describes

 1Pediatric trauma care refers to the care received in any setting by a child who has 

suffered a traumatic injury, while a trauma center is a hospital-based setting specifically 

designated to provide trauma care. In addition to trauma centers, trauma care can be 

provided in other settings such as a non-trauma center emergency department. In this 

report, we use the term “hospital-based pediatric trauma care” to refer to emergency 

medical care provided to children at a pediatric trauma center, adult trauma center, or 

non-trauma center emergency department.

2See M. L. Nance, B. G. Carr, and C. C. Branas, “Access to Pediatric Trauma Care in the 

United States.” Archives of Pediatric & Adolescent Medicine, vol. 163, no. 6 (2009). This 

study specifically examined “verified pediatric trauma centers” which were defined in the 

study as any pediatric-capable trauma centers that the American College of Surgeons 

Committee on Trauma (ACS-COT) or the American Trauma Society had identified or that 

a state or local authority had designated as a pediatric trauma center. 

3See C. C. Branas et al., “Access to Trauma Centers in the United States.” JAMA, vol. 

293, no. 21 (2005). 

4Institute of Medicine of the National Academies, Committee of the Future of Emergency 

Care in the United States Health System, Emergency Care for Children: Growing Pains

(Washington, D.C.: 2006). This was one report in a series of three on the emergency care 

system in the United States that the Institute of Medicine published.
Page 3 GAO-17-334 Pediatric Trauma Centers

(1) what is known about the availability of trauma centers for 

children and the outcomes for children treated at different types of 

facilities, and

(2) how, if at all, federal agencies are involved in supporting 

pediatric trauma care and how these activities are coordinated.

In appendix I we also provide information on the training and resources 

available to physicians and nurses for delivering pediatric trauma care.

To describe what is known about the availability of trauma centers for 

children, we analyzed 2015 data from the American Trauma Society 

Trauma Information Exchange Program on the number and location of 

trauma centers in the United States.5 We also analyzed data from the 

U.S. Census Bureau’s American Community Survey 5-year population 

estimates for 2011 through 2015 of children under 18.6 These data were 

the most current data available at the time of our analysis. We analyzed 

these data to estimate the number and percentage of children who live 

within 30 miles of a pediatric or adult trauma center, focusing our analysis 

on level I, II, and III pediatric or adult trauma centers.7 In this report, we 

 5The American Trauma Society Trauma Information Exchange Program collects data on 

adult and pediatric trauma centers annually through a survey of states. The program 

verifies the data it collects by comparing it to data from prior years and other publicly 

available data and by verifying the data with trauma centers and state trauma program 

managers.

6The American Community Survey 5-year estimates are updated annually and are based 

on data collected continuously from a sample of households during the entire 60 month 

period. We used the 5-year estimates rather than 1-year estimates because they are 

based on larger sample sizes and thus are more reliable. 

7We determined whether children in each zip code lived within 30 miles of a trauma center 

by calculating the distance between the central point of each zip code and the nearest 

trauma center. As such, part of the population in each distance calculation will be located 

beyond this central point. We used a 30 mile radius that was not limited by state 

boundaries and chose this distance because other studies have used 30 miles as a 

benchmark for assessing trauma center availability. For example, one study that 

measured distance in miles to trauma centers rather than time alone used this distance, 

as well as another study that measured distance to the nearest trauma center based on 

zip codes, which is the same unit of analysis we used. See R.Y. Hsia and Y. Shen, 

“Possible Geographical Barriers to Trauma Center Access for Vulnerable Patients in the 

United States: An Analysis of Urban and Rural Communities,” Archives of Surgery, vol. 

146, no. 1 (2011) and R.Y. Hsia and Y. Shen, “Rising Closures of Hospital Trauma 

Centers Disproportionately Burden Vulnerable Populations,” Health Affairs, vol. 30, no. 10 

(2011). Pediatric and adult trauma centers across the United States are categorized into 

levels that refer to the kinds of resources available in the trauma center and the number of 

patients admitted each year. 
Page 4 GAO-17-334 Pediatric Trauma Centers

refer to level I and level II centers as “high-level” trauma centers because 

they have the resources to provide definitive care for all injured patients.8

We refer to level III trauma centers as “mid-level” trauma centers because 

these facilities have the resources to provide some definitive care, have 

transfer agreements in place with high-level centers, and serve areas 

without high-level trauma centers. To assess the reliability of the data 

from the American Trauma Society Trauma Information Exchange 

Program on the number and location of trauma centers in the United 

States, we interviewed a knowledgeable official about the process for 

collecting the data and verified the location and level of trauma centers in 

selected states by comparing the data to publicly available lists of trauma 

centers from the American College of Surgeons, state emergency 

medical services websites, and other official state and hospital websites. 

To assess the reliability of the U.S. Census Bureau’s American 

Community Survey 5-year population estimates of children under 18, we 

reviewed relevant documentation and performed data checks to check for 

outliers, errors, and consistency. Based on our review of the data and 

relevant documentation, we determined that all the data we used were 

sufficiently reliable for estimating the availability of trauma centers for 

children.

To determine what is known about outcomes for children treated at 

different facility types, we performed a structured search of research 

databases, such as MEDLINE, Embase, and Scopus to identify any peerreviewed, scholarly literature published from January 1, 2007, through 

September 30, 2016, on outcomes for hospital-based care provided to 

children who have suffered physical trauma. In our searches, we used a 

combination of search terms such as “trauma center,” “pediatric,” and 

“outcome.” We identified 18 peer-reviewed studies that were relevant for 

our purposes. We considered a study relevant if it presented findings that 

compared outcomes for injured children between different types of 

facilities, such as outcomes for injured children treated at a pediatric 

trauma center compared to an adult trauma center or an emergency 

department that was not a trauma center. We also interviewed 

stakeholder groups involved in pediatric trauma care and incorporated 

 8Definitive care is care provided to completely manage a patient’s condition. This includes 

a full range of medical care, such as having the surgical capabilities to treat a lifethreatening injury and rehabilitative medical care. 
Page 5 GAO-17-334 Pediatric Trauma Centers

into our report relevant information on pediatric trauma outcomes that 

representatives identified.9

To describe how, if at all, federal agencies are involved in supporting 

pediatric trauma care, we interviewed federal agency officials about their 

ongoing activities related to hospital-based pediatric trauma care, 

including funding and any coordination with other agencies or 

departments. To corroborate statements from agency officials and to 

obtain additional information, we also reviewed available documentation 

from agencies about their activities, such as strategic plans, funding 

announcements, and other relevant documentation. We limited our review 

to agencies involved in supporting hospital-based pediatric trauma care.10

We conducted this performance audit from May 2016 to March 2017 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Children who have suffered a severe and potentially life threatening 

physical injury as a result of an event such as a motor vehicle crash or a 

fall need specialized care because of their unique anatomical, 

physiological, and psychological characteristics. Trauma centers—a key 

part of a region’s trauma system—have specialized resources to care for 

traumatically injured patients, with pediatric trauma centers having 

dedicated resources specific to the treatment of traumatically injured 

children. Responsibility for developing and operating emergency care 

systems, including trauma systems, primarily rests at the state and local 

level, with some involvement at the federal level.

 9The nine stakeholder groups we interviewed included those representing the 

perspectives of trauma care physicians and nurses, pediatric specialists, and research 

and advocacy organizations involved in hospital-based pediatric trauma care. 

10Agencies or departments primarily involved in continuum of trauma care activities other 

than hospital-based trauma care were outside the scope of our review. This includes 

agencies like the U.S. Department of Transportation’s National Highway Traffic Safety 

Administration and its efforts related to pre-hospital care—the initial assessment, 

treatment, and transport of a patient to the nearest facility capable of treating a patient’s 

injuries—and the efforts of the CDC related to injury prevention. 

Background
Page 6 GAO-17-334 Pediatric Trauma Centers

Children typically require specialized resources—both equipment and 

personnel—wherever they receive care due to unique anatomical, 

physiological, and psychological needs. For example, the use of specially 

sized equipment or the adjustment of medication dosages based on a 

child’s weight are required when treating children with traumatic injuries. 

In its 2006 report on emergency care for children, the Institute of Medicine 

recommended that all emergency departments appoint certain personnel 

who would address the resources that children need. Specifically, it 

recommended that all emergency departments have two part-time 

pediatric emergency coordinators—one a physician—who would have a 

number of responsibilities, including ensuring that fellow emergency 

department and other providers have adequate skills and knowledge to 

treat children, overseeing pediatric care quality improvement initiatives, 

and ensuring the availability of pediatric medications, equipment, and 

supplies. Additionally, the National Pediatric Readiness Project found that 

emergency departments with a pediatric emergency coordinator were 

more than twice as likely to have important policies in place related to 

treating children.11

Trauma centers have specialized resources to care for traumatically 

injured patients. Most emergency departments across the United States 

do not qualify as trauma centers because they do not have the optimal 

resources to treat severely-injured patients.

Trauma center levels. Trauma centers across the United States are 

designated as one of five levels, which refer to the kinds of resources 

available in the trauma center and the number of patients admitted yearly. 

Making this designation is the responsibility of state or sometimes local 

entities, such as a state’s office of emergency medical services. While the 

criteria used to designate a trauma center’s level can vary from state to 

state, most states have adopted guidelines that are either the same as or 

similar to the guidelines developed by the American College of Surgeons 

 

11M. Gausche-Hill et al., “A National Assessment of Pediatric Readiness of Emergency 

Departments,” JAMA Pediatrics, vol.169, no. 6 (2015). The National Pediatric Readiness 

Project is a partnership between the American Academy of Pediatrics, the American 

College of Emergency Physicians, the Emergency Nurses Association, and the federal 

Emergency Medical Services for Children (EMSC) program within the Health Resources 

and Services Administration (HRSA). 

Resources to Address 

Injured Children’s Unique 

Needs

Trauma Centers
Page 7 GAO-17-334 Pediatric Trauma Centers

Committee on Trauma (ACS-COT).12 Table 1 summarizes the general 

criteria for trauma centers based on the ACS-COT guidelines.

Table 1: General Criteria for Trauma Centers

Level I Capable of providing total care for every aspect of injury—from prevention to rehabilitation. Elements include 24 hour inhouse coverage by general surgeons and prompt availability of care in specialties (e.g., neurosurgery and plastic 

surgery). Provides leadership in prevention and operates an organized teaching and research effort to help direct new 

innovations in trauma care. Admits a certain volume of patients each year (e.g., at least 1,200 trauma patients). 

Level II Meets the same clinical care requirements as a level I center, including 24-hour immediate coverage by general 

surgeons. Can initiate care for all injured patients. Does not have the leadership, teaching, or research requirements of a 

level I trauma center.

Level III Can provide prompt assessment, resuscitation, surgery, intensive care, and stabilization of injured patients and 

emergency operations. Has transfer agreements in place for patients who need more comprehensive care at a level I or 

II trauma center. Can provide complete clinical care for most minor to moderately injured patients. Elements include 24-

hour immediate coverage by emergency medicine physicians and the prompt availability of general surgeons.

Level IV Can provide advanced trauma life support prior to transferring patients to a higher level trauma center. Provides 

evaluation, stabilization, and diagnostic capabilities for injured patients. Elements include basic emergency department 

facilities and 24-hour laboratory coverage.

Level V Can provide initial evaluation, stabilization, and diagnostic capabilities and can prepare patients for transfer to centers 

with higher levels of care. Elements include basic emergency department facilities, available trauma nurse and physician 

available upon patient arrival, and after-hour protocols if the facility is not open 24 hours a day.

Sources: American College of Surgeons Committee on Trauma (ACS-COT) and American Trauma Society. | GAO-17-334

Note: These general criteria for levels I through IV are adapted from the resources identified in the 

2014 edition of the ACS-COT publication Resources for the Optimal Care of the Injured Patient. The 

criteria for level V trauma centers are as described by the American Trauma Society. For the 

purposes of this report, w e classified level I and II trauma centers as “high-level” trauma centers and 

level III trauma centers as “mid-level” trauma centers. We did not classify or analyze data related to 

level IV and V trauma centers.

Types of trauma centers. There are two types of trauma centers—

pediatric and adult. Some trauma centers are only an adult trauma center, 

some are only a pediatric trauma center, and some are both.13 Pediatric 

 12These guidelines are outlined in the publication Resources for the Optimal Care of 

Injured Patients. In addition to publishing these guidelines, ACS-COT also has a program 

to verify the presence of those resources for both adult and pediatric trauma centers. The 

ACS-COT verification program verifies level I and II centers for pediatrics and levels I, II, 

and III centers for adults. Trauma centers are “designated” by the appropriate authority in 

their state or local area. A trauma center can be both a “designated” center and a 

“verified” trauma center. If the trauma center is verified it means that the center has gone 

through the voluntary ACS-COT verification process.

13A single facility that is both an adult trauma center and a pediatric trauma center is 

called a mixed trauma center. A mixed trauma center can have separate adult and 

pediatric designations or ACS-COT verification at different levels. For example, a trauma 

center could be designated as a level center I for adults and as a level II center for 

pediatrics.
Page 8 GAO-17-334 Pediatric Trauma Centers

trauma centers have dedicated resources to treat injured children and can 

be either stand-alone children’s hospitals or distinct units within larger 

hospitals.

A pediatric trauma center must meet all the same requirements that an 

adult trauma center must meet, as well as additional requirements.14 For 

example, according to ACS-COT guidelines,

• a level I pediatric trauma center must have at least two surgeons who 

are board certified in pediatric surgery and must admit 200 or more 

injured children younger than 15 annually; and

• a level II pediatric trauma center must have at least one boardcertified pediatric surgeon and must admit 100 or more injured 

children younger than 15 annually.15

Pediatric trauma centers are expected to provide trauma care for the 

most severely injured children and have a leadership role in education, 

research, and planning with other trauma centers and non-trauma center 

hospitals in their geographic area with regards to care for injured children.

ACS-COT recommends that pediatric trauma centers be used to the 

fullest extent feasible to treat traumatically injured children; however, due 

to the limited number and geographic distribution of these centers, ACSCOT recognizes that adult trauma centers or non-trauma centers must 

provide initial care for injured children in areas where specialized pediatric 

resources are not available. Research shows that even in states that 

designate trauma centers, nearly half of injured children—45 percent—

are treated at non-trauma centers.16 Many of these non-trauma centers 

where injured children receive treatment do not treat a high volume of 

 14Most states only designate level I and level II pediatric trauma centers, but there are 

some states that designate level III pediatric trauma centers. The ACS-COT voluntary 

verification program verifies level I and II pediatric trauma centers.

15Adult trauma centers may have some of the dedicated resources to treat injured 

children, although not at the same level as a pediatric trauma center. For ACS-COT 

verification, ACS-COT requires any adult trauma center that admits 100 or more injured 

children younger than 15 years old annually to meet additional criteria demonstrating their 

capability to care for injured children. For example, at these centers trauma surgeons 

must be credentialed for pediatric trauma care by the hospital’s credentialing body and 

there must be appropriate resuscitation equipment available. 

16M. Segui-Gomez et al., “Pediatric trauma care: an overview of pediatric trauma systems 

and their practices in 18 US states,” Journal of Pediatric Surgery, Vol. 38, No. 8. (2003).
Page 9 GAO-17-334 Pediatric Trauma Centers

pediatric patients and may not have the equipment recommended for 

treating children. The National Pediatric Readiness Project’s 2013 

assessment of over 4,100 hospitals across the United States found that 

about 69 percent of hospitals see fewer than 14 children per day and that 

at least 15 percent of hospitals lacked one or more specific pieces of 

equipment recommended for treating children.17

Within trauma systems, coordinated trauma care activities occur across a 

broad continuum, ranging from injury prevention activities and prehospital care to hospital-based trauma care and rehabilitation (see fig. 1). 

Trauma care is an essential component of emergency care, which 

encompasses all services involved in emergency medical care—both 

injury and illness. A comprehensive trauma system may involve public 

health officials and departments, emergency medical services personnel, 

emergency departments and trauma centers, stakeholder and advocacy 

groups, and families, among others. Such a system typically organizes 

the delivery of trauma care across the continuum at the local, regional, 

state, or national level.

Figure 1: Continuum of Trauma Care Activities

 17The 4,100 hospitals that responded to the assessment represented 83 percent of all 

hospital emergency departments across the United States. See M. Gausche-Hill, et al., 

“National Assessment,” 527; 531.

Trauma Systems: 

Continuum of Trauma 

Care Activities and the 

Federal Role
Page 10 GAO-17-334 Pediatric Trauma Centers

Responsibility for developing and operating trauma systems and the 

broader emergency care efforts of which they are a part primarily rests at 

the state and local level, with some support from federal programs. 

Generally, federal involvement in trauma care has addressed trauma care 

system development or research. For example, the Department of Health 

and Human Services (HHS) Secretary can make grants and enter into 

cooperative agreements and contracts to conduct and support research, 

training, evaluations, and demonstration projects related to trauma care 

and to foster the development of trauma care systems.18 Additionally, in 

2006, HHS’ Health Resources and Services Administration (HRSA) 

released the Model Trauma System Planning and Evaluation document, a 

guide for trauma system development across the United States. The 

guide has helped provide a foundation to create and maintain systems of 

trauma care for communities, regions, and states.

We found that 57 percent of children in the United States lived within 30 

miles of a high-level pediatric trauma center during the period 2011-2015. 

Some of the studies we reviewed suggest that children treated at 

pediatric trauma centers have a lower risk of mortality compared to 

children treated at other types of facilities, while other studies found no 

difference in mortality.

 18Trauma Care Systems Planning and Development Act of 1990, Pub L. No. 101-590, § 3, 

104 Stat. 2915, 2915-2928 (1990) (codified, as amended, at 42 U.S.C. § 300d).

Over Half of the 

Nation’s Children Live 

within 30 Miles of a 

High-Level Pediatric 

Trauma Center, and 

Studies Differ on How 

Well Such Centers 

Work to Lower 

Mortality
Page 11 GAO-17-334 Pediatric Trauma Centers

Our analysis of data from the American Trauma Society and the Census 

Bureau’s American Community Survey shows that 57 percent, or 41.9 

million, of the estimated 73.7 million children in the United States lived 

within 30 miles of a high-level pediatric trauma center during the period 

2011-2015. These centers have the dedicated resources necessary to 

treat all injuries, regardless of severity. Among states, the proportion of 

children who lived within 30 miles of a high-level pediatric trauma center 

varied widely, ranging from no children in eight states to more than 90 

percent of children in four states (see fig. 2).19

 

19See appendix II for the location of the 136 high-level pediatric trauma centers across the 

United States in 2015. These centers include stand-alone children’s hospitals and centers 

co-located with adult trauma centers.

An Estimated 57 Percent 

of Children Lived within 30 

Miles of a High-Level 

Pediatric Trauma Center 

during the Period 2011-

2015, Although the 

Percentage Varied by 

State
Page 12 GAO-17-334 Pediatric Trauma Centers

Figure 2: Estimated Percentage of Children Who Lived within 30 Miles of a High-Level Pediatric Trauma Center, by State, 

2011-2015

Note: Child population estimates are based on the U.S. Census Bureau’s American Community 

Survey data 5-year estimates during the period 2011-2015. To identify trauma center locations, w e 

used 2015 data from the Trauma Information Exchange Program of the American Trauma Society. 

High-level pediatric trauma center refers to level I and level II pediatric trauma centers. In 2015, there 

w ere 136 high-level pediatric trauma centers in the United States.
Page 13 GAO-17-334 Pediatric Trauma Centers

While an estimated 41.9 million children lived within 30 miles of a highlevel pediatric trauma center, an estimated 31.8 million children did not. In 

areas without high-level pediatric trauma centers, children may have to 

rely on adult trauma centers with the resources to treat injured patients, 

even though these facilities are not specialized to treat children. When we 

consider both adult and pediatric trauma centers, the percentage of 

children living within 30 miles of the nearest high-level trauma center 

increases to 80 percent. When we consider all high- and mid-level trauma 

centers, the percentage of children living within 30 miles of one of these 

facilities increases to 88 percent, or 65.1 million. The proportion of 

children who lived within 30 miles of high- or mid-level trauma centers 

during the period 2011-2015 varied by state (see fig. 3).20

 20See appendix III for a detailed state by state table of the estimated percentage of 

children who lived within 30 miles of a high- or mid-level trauma center.
Page 14 GAO-17-334 Pediatric Trauma Centers

Figure 3: Estimated Percentage of Children Who Lived within 30 Miles of a High- or 

Mid-Level Trauma Center, by State, 2011-2015
Page 15 GAO-17-334 Pediatric Trauma Centers

Note: Child population estimates are based on the U.S. Census Bureau’s American Community 

Survey data during the period 2011-2015. To identify trauma center locations, w e used 2015 data 

from the Trauma Information Exchange Program of the American Trauma Society. In 2015, there 

w ere 136 high-level pediatric trauma centers and 524 high-level adult trauma centers–283 of these 

high level adult trauma centers w ere verified by the American College of Surgeons Committee on 

Trauma (ACS-COT). There w ere a total of 465 mid-level adult trauma centers and 10 mid-level 

pediatric trauma centers. Sixty-seven of those mid-level adult trauma centers w ere verified by ACSCOT.

The findings from our analysis of children’s proximity to trauma centers 

are similar to the findings from other assessments of access to trauma 

care for all U.S. residents (adults and children). For example, one study 

found that in 2005, about 84 percent of residents could reach a high-level 

trauma center within an hour, and about 89 percent could reach a high- or 

mid-level trauma center in this time.21

Five of the studies we reviewed, including studies based on national data, 

suggest that children treated at pediatric trauma centers have a lower risk 

of mortality compared to children treated at other types of facilities. Three 

studies, which each analyzed data from a different state, found no 

significant differences in mortality.22 In addition, seven studies examined 

other outcome measures, such as imaging use or the rates of certain 

surgical procedures for severely injured children. However, some of the 

studies we reviewed and stakeholders we interviewed suggested that 

data on pediatric outcomes is limited and that more information is needed 

on outcomes other than mortality for children treated at pediatric trauma 

centers. More information is needed, in part, because mortality can be a 

limited measure since overall mortality is low among severely injured 

children.

Mortality at pediatric trauma centers compared to other types of 

facilities. Five of the studies that we reviewed show that children treated 

at pediatric trauma centers had a lower risk of mortality compared with 

 21C. C. Branas et al., “Access to Trauma Centers in the United States.” JAMA, vol. 293, 

no. 21 (2005). 

22In total, we reviewed 18 studies that used various study designs and study populations. 

Eight of the 18 studies analyzed data that compared the mortality risk for children treated 

at pediatric trauma centers to the mortality risk for children treated at other types of 

facilities. However, there were also 6 studies that analyzed mortality data but made other 

comparisons (e.g., outcomes between pediatric trauma centers at different levels). Three 

studies were literature reviews of pediatric trauma outcomes, and 1 study examined an 

outcome other than mortality. Some studies examined both mortality and other outcomes. 

This includes 6 of the 7 studies that examined outcomes other than mortality.

Some Studies Suggest 

that Children Treated at 

Pediatric Trauma Centers 

Have a Lower Risk of 

Mortality, While 

Information on Other 

Outcomes Is Limited
Page 16 GAO-17-334 Pediatric Trauma Centers

children treated at adult trauma centers or children transferred to a 

pediatric trauma center for treatment after initial treatment at another 

facility.23 For example, a 2015 study that examined hospitalizations 

nationwide among children ages 18 and under found that children treated 

at pediatric trauma centers had a lower risk of mortality compared with 

children treated at adult trauma centers or mixed trauma centers.24

Another study from 2016 that examined hospitalizations nationwide for 

injured adolescents aged 15 to 19 had a similar finding.25 A third study, 

from 2008, found that treatment in a pediatric trauma center compared to 

an adult trauma center was associated with an almost 8 percent reduction 

in the likelihood of mortality among pediatric trauma patients in Florida.26

 23In addition, two other studies compared mortality for children treated at adult trauma 

centers to adult trauma centers with added qualifications in pediatrics. One study found 

lower mortality at the adult trauma centers with added qualifications in pediatrics, while the 

other study, which only focused on children with brain injuries, found no significant 

difference in mortality. At the time these studies were performed, any adult trauma center 

that admitted 100 or more injured children younger than 15 each year that met additional 

criteria demonstrating some capability to treat injured children were referred to as “adult 

trauma centers, with added qualifications in pediatrics”. T. A. Oyetunji et al., “Treatment 

Outcomes of Injured Children at Adult Level 1 Trauma Centers: Are there Benefits from 

Added Specialized Care?” American Journal of Surgery, vol. 201, no. 4 (2011) and F. 

Ovalle Jr. et al., “Outcomes of Pediatric Severe Traumatic Brain Injury Patients Treated in 

Adult Trauma Centers with and without Added Qualifications in Pediatrics — United 

States, 2009.” Injury Epidemiology, vol. 1, no. 1 (2014).

24A mixed trauma center is a hospital that has both pediatric and adult trauma units. C. 

Sathya et al., “Mortality among Injured Children Treated at Different Trauma Center 

Types,” JAMA Surgery, vol. 150, no. 9 (2015). To examine the association between 

trauma center type and in-hospital mortality, this study reported odds ratios rather than a 

percentage difference in mortality. The crude mortality rates were 2.3 percent for children 

treated at adult trauma centers, 1.8 percent for children treated at mixed trauma centers, 

and 0.6 percent for children treated at pediatric trauma centers. 

25R. B. Webman et al., “Association between Trauma Center Type and Mortality among 

Injured Adolescent Patients,” JAMA Pediatrics, vol. 170, no. 8 (2016). 

26E. E. Pracht et al., “Do Pediatric Patients with Trauma in Florida have Reduced Mortality 

Rates when Treated in Designated Trauma Centers?” Journal of Pediatric Surgery, vol. 

43, no. 1 (2008). In addition to the studies in our review that compared mortality between 

facility types, there were three studies that examined what was in the literature about 

mortality. One study found that severely injured children treated at pediatric trauma 

centers had improved outcomes compared to those treated at adult trauma centers, while 

the other two studies found that the literature did not provide a definitive answer about 

which type of facility had the best outcomes. C. Ochoa et al., “Prior Studies Comparing

Outcomes from Trauma Care at Children’s Hospitals Versus Adult Hospitals,” The Journal 

of Trauma, vol. 63, no. 6 Suppl. (2007); M. Petrosyan et al., “Disparities in the Delivery of 

Pediatric Trauma Care,” The Journal of Trauma, vol. 67, no. 2 Suppl. (2009); and A. 

McCarthy et al., “Paediatric Trauma Systems and their Impact on the Health Outcomes of 

Severely Injured Children: An Integrative Review,” Injury-International Journal of the Care 

of the Injured, vol. 47, no. 3 (2016). 
Page 17 GAO-17-334 Pediatric Trauma Centers

Finally, two studies examined whether there were differences in 

outcomes based on whether children were transported directly to a 

pediatric trauma center following injury.27 Both studies found that after 

adjusting for injury severity, mortality was lower for children who were 

taken directly to a pediatric trauma center compared with children who 

were initially taken to a local hospital.28

In contrast, three of the studies we reviewed did not find a significant 

difference in the risk of mortality for children treated at pediatric trauma 

centers compared to children treated at adult trauma centers.29 All three 

of these studies were state-level analyses rather than analyses based on 

a national sample. For example, two studies, which each examined data 

for adolescents from a single state, did not identify significant differences 

in mortality among adolescents treated at pediatric and adult trauma 

 27J. F. Anders et al., “Comparison of Outcomes for Children with Cervical Spine Injury 

Based on Destination Hospital from Scene of Injury,” Academic Emergency Medicine, vol. 

21, no. 1 (2014) and F. O. Odetola et al., “Source of Admission and Outcomes for 

Critically Injured Children in the Mountain States,” Archives of Pediatrics & Adolescent 

Medicine, vol. 164, no. 3 (2010). Anders et al. reported an odds ratio that indicated that 

after adjusting for injury severity patients taken directly to a pediatric trauma center were 

more likely to have a normal outcome than to die or have a persistent neurologic deficit. 

The study did not report a percentage difference in mortality. Odetola et al. found that after 

adjusting for injury severity and for the time elapsed since injury before admission to the 

trauma center among other factors, transferred patients had a 3-fold higher incident rate of 

death compared to children who were directly admitted. 

28In addition, another study found a 37 percent lower pediatric injury-related mortality rate 

in states with an ACS-COT verified level I pediatric trauma center compared to states 

without a pediatric trauma center or states with only adult trauma centers. We did not 

count this study as one of the five studies that found lower mortality risk because it was a 

population-based study that did not use patient data on outcomes from different facility 

types. Instead, it compared injury-related mortality rates from each state to the types of 

trauma centers available in each state. See D. M. Notrica et al., “Pediatric Trauma 

Centers: Correlation of ACS-Verified Trauma Centers with CDC Statewide Pediatric 

Mortality Rates,” Journal of Trauma and Acute Care Surgery, vol. 73, no. 3 (2012).

29We also identified one study that compared outcomes among pediatric trauma centers 

of different levels rather than between pediatric trauma centers and adult trauma centers. 

This study found no statistically significant difference in mortality between children treated 

at level I and level II pediatric trauma centers. See S. Miyata et al., “Should all Severely 

Injured Pediatric Patients be Treated at Pediatric Level I Trauma Centers? A National 

Trauma Data Bank Study,” American Surgeon, vol. 81, no. 10 (2015). According to the 

authors, no difference may have been found because despite certain differences between 

level I and II pediatric trauma centers (e.g., in the number of pediatric surgeons or other 

pediatric specialists), the standards of care at level I and II pediatric trauma centers are 

identical.
Page 18 GAO-17-334 Pediatric Trauma Centers

centers.30 While the third study found no difference in mortality among 

children treated at pediatric and adult trauma centers, it also found that 

children treated at trauma centers had a 0.79 percentage point decrease 

in mortality compared to children treated at non-trauma hospitals.31

Data on other outcomes. Seven studies examined outcomes other than 

mortality, but according to some of the studies we reviewed and 

stakeholders we interviewed, more information is needed on outcomes 

other than mortality for children treated at pediatric trauma centers. 

Further, as some studies note, mortality can be a limited measure for 

determining quality of care or a trauma center’s contribution to survival, 

because overall mortality is low among severely injured children.32 One 

2015 study found that adding a pediatric trauma center in Delaware 

decreased the frequency of pediatric splenectomies—a procedure that 

removes a child’s spleen.33 Another study found that pediatric trauma 

centers performed less imaging than adult trauma centers when treating 

severely injured adolescents.34

Information on other outcomes was limited. One study from 2016 that we 

reviewed noted that in the pediatric trauma literature there are no 

 30A. E. Walther et al., “Teen Trauma without the Drama: Outcomes of Adolescents 

Treated at Ohio Adult Versus Pediatric Trauma Centers,” Journal of Trauma and Acute 

Care Surgery, vol. 77, no. 1 (2014) and K. Matsushima et al., “Injured Adolescents, Not 

just Large Children: Difference in Care and Outcome between Adult and Pediatric Trauma 

Centers,” American Surgeon, vol. 79, no. 3 (2013).

31N. E. Wang et al., “The Effect of Trauma Center Care on Pediatric Injury Mortality in 

California, 1999 to 2011,” Journal of Trauma and Acute Care Surgery, vol. 75, no. 4 

(2013). The authors noted that pediatric subspecialty care may have benefits, including 

possible mortality benefits that the authors were not able to identify with the analytic 

methods they used. They further noted that their findings demonstrate that trauma-specific 

care of any kind (adult or pediatric) can improve patient outcomes

32For example, in one nationwide study of 175,585 children with blunt or penetrating 

trauma who were hospitalized at a trauma center, the crude mortality rate was 1.6 

percent. 

33To preserve splenic function and prevent sepsis, non-operative management of splenic 

injuries is considered the standard of care for pediatric trauma patients as it is associated 

with shorter hospital stays and lower mortality. See E. Murphy, et al. “The Pediatric 

Trauma Center and the Inclusive Trauma System: Impact on Splenectomy Rates.” Journal 

of Trauma and Acute Care Surgery, vol. 78, no. 5 (2015).

34The authors of this study noted that experts recommend careful use of imaging for 

children to minimize children’s exposure to radiation and reduce their risk of cancer. A. E. 

Walther et al., “Teen Trauma,” 113-114.
Page 19 GAO-17-334 Pediatric Trauma Centers

longitudinal studies on the long-term effects—both physical and 

psychological—of trauma on children.35 In addition, another study we 

reviewed indicated that the selection of outcome measures for analysis 

was constrained by what was available in the dataset used for the 

study.36 One stakeholder we interviewed told us that mortality is one of 

the few outcomes related to pediatric trauma that is captured in 

databases, because most trauma registries and other databases were 

initially developed to capture data for adult patients.37 Moreover, a few 

stakeholders told us that the pediatric trauma system is not as well 

developed as the adult trauma system and that both pediatric trauma care 

and research have tended to occur in isolation. One of these stakeholders 

said that because of this fragmentation, it has been difficult for 

researchers to use or build on the outcome measures that other 

researchers have developed in their work.38

Hospital-based pediatric trauma care activities are supported primarily 

through grants from two agencies within HHS—HRSA and the National 

Institutes of Health (NIH). Officials from these agencies reported that 

activities related to pediatric trauma care are coordinated through an 

interagency group focused broadly on emergency care, as well as 

through arrangements between individual agencies.

 35A. McCarthy et al., “Integrative Review,” 583.

36F. Ovalle Jr. et al., “Outcomes of Pediatric Severe Traumatic Brain Injury,” 9. 

37According to the ACS-COT, a trauma registry is a file of uniform data elements that 

trauma centers should collect and analyze. The data collected includes descriptions of the 

injury event, demographics, prehospital information, diagnosis, care, outcomes, and costs 

of treatment of injured patients.

38According to one stakeholder, there is a new effort underway through the Emergency 

Medical Services for Children Innovation and Improvement Center to identify and develop 

key pediatric measures, although the effort is in its very early stages. For more information 

about the Center see the next section of our report.

Two Agencies 

Support HospitalBased Pediatric 

Trauma Care 

Activities and 

Coordinate Some 

Efforts through an 

Interagency Group
Page 20 GAO-17-334 Pediatric Trauma Centers

Two agencies within HHS—HRSA and NIH—have grant programs and 

other activities that support hospital-based pediatric trauma care (see 

table 2).

Table 2: Key Federal Activities Related to Hospital-Based Pediatric Trauma Care 

Name Type of Activity Activity Summary

Health Resources and Services Administration (HRSA): Emergency Medical Services for Children (EMSC) Program

State Partnership Grant Program This program aims to ensure pediatric emergency care is integrated into the 

larger emergency medical services system. Program performance measures 

include improving pediatric trauma care. HRSA had a total of 58 grantees 

under this program in fiscal year 2016.

Targeted Issues Grant Program This program supports innovation and increasing quality in pediatric 

emergency care. The grants focus on implementing research or cross-cutting 

projects on a larger scale. HRSA had a total of 5 grantees under this program 

in fiscal year 2016.

State Partnership 

Regionalization of Care

Grant Program This program aims to develop systems of care models to improve pediatric 

emergency care capacity in rural and tribal areas. HRSA had a total of 3 

grantees under this program in fiscal year 2016.

Pediatric Emergency Care 

Applied Research Network

Multi-Institutional 

Research Network

EMSC funds the infrastructure for this multi-institutional clinical research effort 

which aims to conduct meaningful and rigorous multi-institutional research into 

the prevention and management of illness and injuries in children. The effort 

includes 18 emergency departments and 9 pre-hospital emergency medical 

services affiliates. 

National Pediatric Readiness 

Project

Quality Improvement 

Initiative

This collaborative quality improvement initiative aims to ensure that all U.S. 

emergency departments have the essential guidelines and resources in place 

to provide effective emergency care to children. In 2013, the project assessed 

over 4,100 emergency departments on how prepared they were to treat 

children. The next phase aims to develop tools and resources to address gaps 

identified in the data. 

EMSC Innovation and 

Improvement Center

Program 

Support/Quality 

Improvement Initiative

The EMSC Innovation and Improvement Center, established in 2016, supports 

the grantees and initiatives listed above by providing expertise and fostering 

collaboration and innovation. For example, in its main initiative, a collaborative 

that aims to help states that are developing a program to identify and 

categorize emergency departments that have the resources to care for 

children, officials from 6 states serve as mentors to help 12 additional states 

develop programs.

National Institutes of Health (NIH): Pediatric Trauma and Critical Illness Branch

Pediatric Trauma Research 

and Training Program

Scientific Program 

Area

This program supports investigator-initiated research and training aimed at 

advancing the science of trauma, injury prevention, and care for pediatric 

populations. The program supports research that addresses the full continuum 

of care and has a goal of reducing morbidity and mortality in children. 

Two Federal Agencies 

Support Hospital-Based 

Pediatric Trauma Activities 

Primarily through Grants, 

While Other Efforts 

Broadly Address 

Emergency Care
Page 21 GAO-17-334 Pediatric Trauma Centers

Name Type of Activity Activity Summary

Eunice Kennedy Shriver 

National Institute of Child 

Health and Human 

Development Consortium for 

Research on Pediatric 

Trauma and Injury Prevention

Grant Program This grant program operates under the support of the Pediatric Trauma 

Research and Training Program. The goal of this grant program is to create a 

consortium of collaborative and multidisciplinary research teams that will 

identify and address gaps in research on pediatric trauma and injury 

prevention. While applications could be submitted beginning in December 

2014, no projects have been funded as of January 2017. 

Pediatric Critical Care 

Research and Training 

Program

Scientific Program 

Area

This program supports research and training opportunities to inform the 

practice of health care providers who stabilize, diagnose, and manage the care 

of critically ill children. The research focuses on investigating the safety and 

effectiveness of treatment and management for all sorts of pediatric critical 

illnesses and injuries (e.g., sepsis and traumatic brain injury). 

Collaborative Pediatric Critical 

Care Research Network

Multi-Institutional 

Research Network

This network operates under the support of the Pediatric Critical Care 

Research and Training Program. The goal of this network is to develop an 

infrastructure for collaborative clinical trials and meaningful descriptive studies 

in pediatric critical care medicine.

Source: GAO Analysis of HRSA and NIH information. | GAO-17-334

Within HRSA, the Emergency Medical Services for Children (EMSC) 

program, established in 1984, provides funding to states and academic 

medical institutions. It does so primarily through six grant programs and 

cooperative agreements that aim to enhance the capacity of emergency 

care—including hospital-based trauma care—to address the needs of 

children. The program’s annual appropriation is authorized at $20.2 

million per fiscal year from fiscal years 2015 through 2019.39 According to 

HRSA officials, EMSC is the only federal program that focuses 

specifically on improving emergency care for children.

Within NIH, the Pediatric Trauma and Critical Illness Branch supports 

research and training focused on preventing, treating, and reducing all 

forms of childhood trauma, injury, and critical illnesses. According to NIH 

officials, the Branch—which is part of the Eunice Kennedy Shriver 

National Institute of Child Health and Human Development—was 

established in 2012 to help unify research in pediatric trauma. Our 

analysis of data on all NIH-funded research in fiscal year 2015 shows that

the Branch provided nearly $9 million in funding for 32 grants related to 

injuries.

Beyond these two agencies, a few other federal efforts more broadly 

address emergency care, including trauma care. While they are not 

focused on pediatric trauma care, these efforts may indirectly address the 

needs of pediatric populations. For example, the Emergency Care 

 3942 U.S.C. § 300w-9.
Page 22 GAO-17-334 Pediatric Trauma Centers

Coordination Center within the HHS Office of the Assistant Secretary for 

Preparedness and Response (ASPR) aims to strengthen the day-to-day 

emergency care system to better prepare the nation for times of crisis and 

to support the federal coordination of in-hospital emergency medical care 

activities.40 Agency officials reported that the Center was funded at 

$820,000 per fiscal year in fiscal years 2015 and 2016. According to 

officials, the Center recently worked on two initiatives related to trauma—

preparing a report requested by Congress on the nation’s capacity to 

respond to mass casualty events and issuing a request for proposals to 

award a contract for the development of an inventory of emergency 

departments, trauma centers, and burn centers and their capabilities 

across the United States.

Recent federal funding to specifically support hospital-based trauma care 

activities or to develop trauma care systems has been limited as well. The 

Patient Protection and Affordable Care Act both continued existing and 

established new discretionary trauma care grant programs to help 

develop trauma care systems.41 However, according to HHS officials, no 

appropriations were made for these new programs and no grants have 

been made under these new authorities.

 40According to its charter, the Emergency Care Coordination Center was established to 

fulfill Homeland Security Presidential Directive #21 and in response to a series of three 

emergency care reports that the Institute of Medicine issued in 2006. 

41For example, the Patient Protection and Affordable Care Act amended and reauthorized 

the EMSC program and created a new emergency and trauma care program to improve 

regional coordination of emergency services.. Pub. L. No. 111-148, §§ 3504, 5603, 124 

Stat. 119, 518-521, 679 (2010). For additional information see C. Stephen Redhead and 

Elayne J. Heisler, Public Health, Workforce, Quality, and Related Provisions in the ACA: 

Summary and Timeline, R41278 (Washington, D.C.: Congressional Research Service, 

May 17, 2013).
Page 23 GAO-17-334 Pediatric Trauma Centers

HRSA and NIH officials reported that activities related to hospital-based 

trauma care and other emergency care, including pediatrics, are 

coordinated through an interagency group and through arrangements 

between individual agencies (see table 3).42 Both HRSA and NIH 

representatives are executive committee members of the Council on 

Emergency Medical Care, a federal interagency group led by ASPR’s 

Emergency Care Coordination Center, a center specially created as the 

policy lead for emergency care activities across the federal government. 

ASPR officials told us that the Council on Emergency Medical Care is the 

central meeting place for agencies across the federal government on 

issues related to emergency care, including pediatric care.43 HRSA and 

NIH officials reported using a variety of arrangements to collaborate with 

other federal agencies on hospital based pediatric trauma, such as 

supporting a program liaison position within another agency, establishing 

interagency agreements, and presenting at conferences and meetings.

 42In prior work, we found that agencies used collaborative mechanisms, such as 

interagency groups, for multiple purposes, including information sharing and 

communication and policy development. See GAO, Managing for Results: Key 

Considerations for Implementing Interagency Collaborative Mechanisms, GAO-12-1022 

(Washington, D.C.: Sept. 27, 2012).

43Both ASPR and HRSA officials also serve on the Federal Interagency Committee for 

Emergency Medical Services, which was established to ensure coordination among 

federal agencies on pre-hospital emergency and trauma care. 

Federal Activities Related 

to Hospital-Based 

Pediatric Trauma Care 

and Other Emergency 

Care Are Coordinated 

through an Interagency 

Group and Arrangements 

between Agencies
Page 24 GAO-17-334 Pediatric Trauma Centers

Table 3: Examples of Hospital-Based Pediatric Trauma Care-Related Coordination Efforts through Interagency Group and 

Arrangements between Agencies

Coordination Effort Description

Agency for Healthcare Research 

and Quality

According to Health Resources and Services Administration (HRSA) officials, the Emergency 

Medical Services for Children (EMSC) program coordinates with the Agency for Health Care 

Research and Quality for data on hospital and emergency room utilization that can be used to 

examine trends in pediatric mortality. The officials told us that these data, obtained annually 

through an interagency agreement, are used for program planning.

Council on Emergency Medical 

Care

This interagency group aims to coordinate emergency care activities across the federal 

government through information sharing and policy development. It meets on a quarterly basis. 

Membership includes representatives from several agencies in the Department of Health and 

Human Services (HHS), Department of Defense, Department of Homeland Security, Department 

of Transportation, Executive Office of the President, and the Department of Veterans Affairs. The 

group is tasked with (1) identifying national issues in emergency and trauma care; (2) working to 

find synergy across participating agencies; and (3) advising the Emergency Care Coordination 

Center within HHS’s Office of the Assistant Secretary for Preparedness and Response (ASPR) on 

the next steps and priorities for the federal government in emergency and trauma care. 

Department of Defense Uniformed 

Services University of the Health 

Sciences

Officials from the EMSC program and subject matter experts from the Uniformed Services 

University of the Health Sciences are working together to develop a virtual pediatric trauma center 

framework, an online training resource for nurses and doctors. HRSA officials stated that the 

framework would help address challenges faced by providers in rural areas who do not regularly 

treat pediatric trauma patients.

Indian Health Service HRSA officials reported that the EMSC program works in partnership with the Indian Health 

Service to engage tribal health facilities in the National Pediatric Readiness Project. HRSA and 

the Indian Health Service have an interagency agreement, which includes support to disseminate 

and promote the use of needed guidelines identified by the Pediatric Readiness assessment and 

to facilitate collaboration between Indian Health Service facilities and state EMSC program staff.

National Institutes of Health (NIH) 

Office of Emergency Care 

Research

An official from this office, the NIH center responsible for coordinating all NIH emergency care 

research and research training, told us that recent efforts to support research that integrates 

civilian and military trauma have not focused on pediatric populations to avoid duplicating the 

work of the Pediatric Emergency Care Applied Research Network.

NIH Pediatric Trauma and Critical 

Illness Branch

HRSA and NIH officials told us that while the EMSC program funds the infrastructure for the 

Pediatric Emergency Care Applied Research Network, the Pediatric Trauma and Critical Illness 

Branch is a large source of the funding for the clinical research that the Network undertakes. 

HRSA officials also reported that they participated in the strategic planning process and in efforts 

to identify research priorities for the NIH Pediatric Trauma and Critical Illness Branch.

Source: GAO Analysis of ASPR, HRSA, and NIH Information. | GAO-17-334

We provided a draft of this report to HHS for comment. The department 

provided technical comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of HHS and 

Agency Comments
Page 25 GAO-17-334 Pediatric Trauma Centers

other interested parties. In addition, the report will be available at no 

charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or crossem@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix IV.

Marcia Crosse

Director, Health Care
Appendix I: Training and Resources Available 

to Physicians and Nurses for Pediatric Trauma 

Care

Page 26 GAO-17-334 Pediatric Trauma Centers

Various types of training and resources are available for physicians and 

nurses on the delivery of pediatric trauma care. The training and 

resources are provided by stakeholder groups, such as professional, 

research and advocacy organizations. The training and resources from 

these groups supplement any training that physicians and nurses may 

receive during medical or nursing school or during any residencies or 

fellowships that may include or be completely focused on pediatric care.1

The available training includes standardized courses that stakeholder 

groups have developed as well as more ad-hoc training on pediatric 

trauma care topics of interest. Stakeholder groups also have developed 

resources on pediatric trauma care that physicians and nurses can 

access and consult when needed. The resources available include both 

policy statements that detail the infrastructure or resources needed to 

provide pediatric trauma care at the facility-level and other more 

individualized and clinical practice resources for physicians and nurses 

about the delivery of pediatric trauma care.

To identify examples of the training and resources available to physicians 

and nurses on the delivery of pediatric trauma care, we interviewed 

stakeholder group representatives or received written responses from the 

following stakeholder groups: the American Academy of Pediatrics, the 

American Association of Neurological Surgeons/Congress of Neurological 

Surgeons, the American College of Emergency Physicians, the American 

College of Surgeons, the Childress Institute for Pediatric Trauma, the 

Emergency Nurses Association, the Pediatric Orthopaedic Society of 

North America, the Pediatric Trauma Society, and the Society of Trauma 

Nurses. We selected the groups to represent the perspectives of trauma 

care physicians and nurses, pediatric specialists, and research and 

advocacy organizations involved in or focusing on hospital-based 

pediatric trauma care. We asked all stakeholder groups a series of openended questions and, to the extent possible, corroborated statements 

with information available on stakeholder group websites.

Many of the stakeholder groups we interviewed have developed 

standardized training courses on the evaluation, management, and 

 1For example, surgeons that specialize in neurosurgery go through 7 years of residency 

training. All neurosurgery residents must be involved with ten pediatric neurosurgical 

cases that result in surgery and those who want to specialize in trauma care or pediatric 

neurosurgery must also complete a sub-specialization fellowship, which furthers exposes 

them to pediatric trauma care cases.

Appendix I: Training and Resources 

Available to Physicians and Nurses for 

Pediatric Trauma Care

Training
Appendix I: Training and Resources Available 

to Physicians and Nurses for Pediatric Trauma 

Care

Page 27 GAO-17-334 Pediatric Trauma Centers

treatment of trauma patients. In addition to standardized courses, 

stakeholder groups also offer other training opportunities related to 

pediatric trauma care on an ad-hoc basis (see table 4).

Table 4: Description of Courses and Examples of Other Training Opportunities Available to Physicians and Nurses on the 

Delivery of Trauma Care 

Courses

Course Name Sponsor Course Description Primary Audience 

Pediatric 

Specific (Y/N)

Advanced Pediatric Life 

Support 

American Academy of 

Pediatrics and American 

College of Emergency 

Physicians

Course on the assessment and 

management of critically ill and injured 

children in the emergency department.

Physicians, nurses 

and other health 

care personnel

Y

Advanced Trauma Care 

for Nursesa

Society of Trauma 

Nurses

Two-day course that teaches established 

standards on trauma care and practical 

lifesaving skills through lectures and 

corresponding skill stations and 

simulations.

Nurses N

Advanced Trauma Life 

Supporta American College of Surgeons Committee on 

Trauma (ACS-COT)

Two to two-and-a-half day course that 

provides training in the immediate 

management of trauma patients, including 

the assessment of a patient’s condition, 

resuscitation and stabilization, and 

determining whether a patient’s needs 

exceed a facility’s capacity. 

Physicians N

Emergency Nursing 

Pediatric Course 

Emergency Nurses 

Association 

Two-day interactive course, focused on 

pediatric emergency care (both medical 

emergencies and trauma care).

Nurses and other 

health care 

personnel

Y

Pediatric Advanced Life 

Support 

American Heart 

Association and 

American Academy of 

Pediatrics

Classroom-based course that uses videos 

and simulated pediatric emergencies to 

teach how to assess, care for, and 

resuscitate pediatric patients with 

respiratory, shock, and cardiac 

emergencies.

Physicians, nurses, 

and other health 

care personnel 

Y

Rural Trauma Team 

Development Course 

ACS-COT One-day course that emphasizes a team 

approach on the initial evaluation and 

resuscitation of a trauma patient at a rural 

facility that includes interactive lectures 

and team performance scenarios.

Any individual 

involved in the care 

of the injured 

patient, including 

physicians, nurse 

practitioners, 

nurses, and other 

health personnel

N

Trauma Nursing Core 

Course 

Emergency Nurses 

Association

Two-day interactive course with lectures, 

scenario-based skill stations (including a 

pediatric-specific station), and an exam 

that emphasizes the rapid identification of 

injuries and comprehensive assessment.

Nurses and other 

health care 

personnel

N
Appendix I: Training and Resources Available 

to Physicians and Nurses for Pediatric Trauma 

Care

Page 28 GAO-17-334 Pediatric Trauma Centers

Other Training Opportunities

Training Type Examples 

Conferences Stakeholder groups reported offering pediatric trauma-specific content at annual meetings. For example:

• The Society of Trauma Nurses offers a pediatric track at its annual conference and collaborated with 

the Pediatric Trauma Society to offer pre-conference training at the Pediatric Trauma Society’s annual 

conference in 2016.

• The Pediatric Orthopaedic Society of North America annually holds the International Pediatric 

Orthopaedic Symposium in conjunction with the American Academy of Orthopaedic Surgeons. This 

symposium includes several sessions on pediatric trauma including a pre-conference webinar for the 

2016 symposium on acute pediatric skeletal trauma. 

Webinars The Childress Institute for Pediatric Trauma has sponsored webinars on pediatric trauma care covering 

topics such as disaster management, burn care, and extremity injury.

Other continuing 

education 

The American Academy of Pediatrics and the American College of Emergency Physicians offer the 

Pediatrics Review and Education Program: Emergency Medicine continuing medical education course 

biennially. The course provides information on recent developments in the field of pediatric emergency 

medicine, including key developments in the area of pediatric trauma.

Source: GAO analysis of information from stakeholder group representatives and websites. | GAO-17-334

a

The Advanced Trauma Care for Nurses course and the Advanced Trauma Life Support course for 

physicians are often taught concurrently.

These courses are generally available to all providers, but whether a 

provider must take any of these courses depends on the facility or system 

in which the provider works and its specific education or credentialing 

requirements. However, stakeholder representatives stated that these are 

all courses that any provider who treats trauma patients, including 

pediatric patients, generally should, and most likely will, take. For 

example, the American College of Surgeons Committee on Trauma 

(ACS-COT) publication, Resources for Optimal Care of the Injured Patient

states that courses like the Advanced Trauma Life Support course, the 

Trauma Nursing Core Course, and the Advanced Trauma Care for 

Nursing course, among others, have become basic trauma education for 

providers.2 These courses have both classroom-based lectures and 

interactive components. Most of the courses are general trauma courses 

with pediatric elements rather than courses that are specific to pediatric 

trauma. One stakeholder representative noted that all providers should 

learn the baseline principles of trauma care from these courses and then 

build on that baseline to learn principles that are specific to pediatric 

trauma. Representatives from stakeholder groups said that these courses

usually include a lecture and a trauma simulation exercise for a pediatric 

 2One of the criteria used by the ACS-COT to verify a facility as a trauma center at any 

level is to verify that all general surgeons, emergency medicine physicians, and midlevel 

providers on the trauma team at the facility have successfully completed the Advanced 

Trauma Life Support course at least once.
Appendix I: Training and Resources Available 

to Physicians and Nurses for Pediatric Trauma 

Care

Page 29 GAO-17-334 Pediatric Trauma Centers

patient, even if the overall focus of the course is on emergency or trauma 

care for the general adult patient population. For example, 

representatives from the Emergency Nurses Association told us that the 

Trauma Nursing Core Course includes a participant skill station that is 

specific to pediatric trauma. In addition, the manual for this course 

includes a chapter on pediatric trauma.

In addition to training, stakeholder groups have also developed resources 

for physicians and nurses related to pediatric trauma. The resources that 

these groups have developed, often in collaboration with each other, 

include 1) policy statements detailing the system-level infrastructure that

must be in place to ensure that providers and facilities are prepared to 

care for injured children; and 2) other more individualized clinical 

resources, such as checklists, forums, and journal articles, that 

physicians and nurses can access to improve their individual knowledge 

and readiness to treat pediatric patients (see table 5).

Table 5: Examples of Resources Available to Physicians and Nurses on Pediatric Trauma

Examples of Policy Statements:

Statement Name (Year) and Authors Description 

Management of Pediatric Trauma (2016)

American Academy of Pediatrics, Pediatric 

Trauma Society, and Society of Trauma Nurses

Joint policy statement with several recommendations on pediatric trauma including, 

among other things,that

• Children’s needs should be integrated into trauma systems and disaster 

planning,

• States should identify which facilities have the resources needed to care for 

injured children,

• Evidence-based protocols should be developed for key aspects of care for 

injured children, and

• Physicians and nurses must have continuing trauma education citing the 

Advanced Trauma Life Support course from the American College of 

Surgeons and the trauma nursing courses that the Society of Trauma Nurses 

and Emergency Nurses Association offer.

Guidelines for Care of Children in the Emergency 

Department (2009)

American Academy of Pediatrics, American 

College of Emergency Physicians, and 

Emergency Nurses Associationa

Joint policy statement outlining the resources and infrastructure that hospital 

emergency departments need to be prepared to serve critically injured or ill 

pediatric patients. One area highlighted is provider skills, knowledge, and training 

and the expectation that all emergency departments should have the infrastructure 

in place to ensure that physicians, nurses, and other health care providers have the 

necessary training and skills to treat all pediatric patients. 

Definitions and Assessment Approaches for 

Emergency Medical Services for Children (2016)

Fuchs. S, Terry M, Adelgais K, et al.b

Statement outlining the consensus of several organizations on the common 

terminology and components of the assessment and treatment approach for 

pediatric patients who are critically ill and injured. 

Resources
Appendix I: Training and Resources Available 

to Physicians and Nurses for Pediatric Trauma 

Care

Page 30 GAO-17-334 Pediatric Trauma Centers

Other Resource Types Examples of Resource Type Use

Clinical Resources - Documents The Pediatric Trauma Society posts member-submitted examples of clinical 

resources on its website. The posted resources provide examples of clinical 

practice guidelines that members have used as a framework for the evaluation and 

treatment of certain diagnoses or conditions. Resources are posted for head and 

facial trauma and cervical spine injuries, among other things.

Clinical Resources - Videos The Pediatric Orthopaedic Society of North America offers POSNAcademy on its 

website. It is peer reviewed video learning specific to pediatric orthopedic issues, 

which are issues related to bones, joints, and muscles. Trauma is one of the key 

areas with videos available on the treatment of specific types of pediatric trauma 

involving musculoskeletal injuries.

Checklists The American Academy of Pediatrics, American College of Emergency Physicians, 

Emergency Nurses Association, and others developed a checklist for providers in 

emergency departments to use to determine whether their emergency department 

is prepared to care for children. The checklist is based on the joint policy statement 

“Guidelines for Care of Children in the Emergency Department.”

Online Forums The Emergency Nurses Association has ENA Connect, an online forum where 

members can share best practices, discuss various topics, or ask questions 

pertaining to pediatric trauma care and other issues.

Articles Published In Stakeholder Group Journals The Society of Trauma Nurses periodically devotes a special edition of the Journal 

of Trauma Nursing to pediatrics and also publishes articles in the journal 

throughout the year that are specific to trauma in the pediatric population. 

Source: GAO analysis of information from stakeholder group representatives and websites. | GAO-17-334

a

The Guidelines for Care of Children in the Emergency Department has also been endorsed by many 

other organizations, including the Society of Trauma Nurses and the American College of Surgeons.

b

This article is a consensus statement authored by a task force on pediatric life support. Groups w ith 

representatives on the task force include the American Academy of Pediatrics, the Emergency 

Nurses Association, the American College of Surgeons Committee on Trauma, the American College 

of Emergency Physicians, and many other groups such as those representing pre-hospital providers. 

See S. Fuchs et al., “Definitions and Assessment Approaches for Emergency Medical Services for 

Children,” Pediatrics, vol. 138, no. 6 (2016).
Appendix II: Location of High-Level Pediatric 

Trauma Centers, United States, 2015

Page 31 GAO-17-334 Pediatric Trauma Centers

Figure 4: Location of High-Level Pediatric Trauma Centers, United States, 2015

Note: To identify trauma center locations, w e used 2015 data from the Trauma Information Exchange 

Program of the American Trauma Society. “High-level pediatric trauma center” refers to level I and 

level II pediatric trauma centers. In 2015, there w ere 136 high-level pediatric trauma centers in the 

United States.

Appendix II: Location of High-Level Pediatric 

Trauma Centers, United States, 2015
Appendix III: Estimated Percentage of Children 

Who Lived within 30 Miles of a High- or MidLevel Trauma Center, Detailed Tables by State, 

2011-2015

Page 32 GAO-17-334 Pediatric Trauma Centers

Table 6: Estimated Child Population and Percentage of Children Who Lived within 30 Miles of a High- or Mid-Level Trauma 

Center, Detailed Tables by State, 2011-2015

High Level

Pediatric Trauma Center

High Level Adult

or Pediatric Trauma Center

High- or Mid-Level Adult

or Pediatric Trauma Center

State

Est. Child

Population

<10

miles

10-30 

miles

>30

miles

<10

miles

10-30 

miles

>30 

miles

<10 

miles

10-30 

miles

>30 

miles

All States 73,682,658 26.7 30.2 43.1 48.9 31.2 19.9 59.8 28.6 11.6

AK 187,960 - - 100.0 33.9 6.9 59.1 33.9 6.9 59.1

AL 1,111,974 13.0 20.6 66.5 28.7 39.6 31.8 67.3 30.1 2.7

AR 707,831 10.7 14.6 74.7 19.4 23.4 57.2 56.3 28.8 14.9

AZ 1,617,889 22.1 40.9 37.1 57.5 23.3 19.2 62.5 20.4 17.1

CA 9,173,992 40.9 31.8 27.3 62.7 27.9 9.4 67.1 27.1 5.8

CO 1,241,825 31.8 25.7 42.5 69.6 18.4 12.0 82.7 11.7 5.6

CT 784,736 31.8 59.7 8.5 69.6 23.8 6.6 72.5 27.3 0.2

DC 111,305 100.0 - - 100.0 - - 100.0 - -

DE 204,154 34.8 25.1 40.1 52.7 11.1 36.3 83.0 17.0 -

FL 4,041,002 13.8 24.3 61.9 51.8 39.9 8.3 51.8 39.9 8.3

GA 2,491,080 11.3 39.2 49.5 41.9 38.4 19.8 43.2 38.9 18.0

HI 308,197 - - 100.0 36.2 33.2 30.6 51.8 47.3 1.0

IA 726,810 19.5 18.8 61.7 32.3 23.8 43.9 52.9 30.4 16.8

ID 429,438 - 2.5 97.5 19.7 37.3 43.0 33.1 41.3 25.7

IL 3,023,734 28.0 31.4 40.6 74.5 15.5 10.0 74.7 15.7 9.6

IN 1,586,651 25.0 30.0 45.1 31.1 34.4 34.4 34.2 40.3 25.5

KS 723,546 26.6 25.3 48.1 46.3 19.4 34.3 51.8 24.2 24.0

KY 1,018,630 22.1 28.0 49.8 22.8 29.9 47.3 25.1 35.6 39.3

LA 1,114,559 - - 100.0 31.7 19.9 48.4 31.7 20.9 47.4

MA 1,397,629 38.1 54.0 7.9 43.7 49.3 7.0 58.2 37.4 4.4

MD 1,348,280 35.2 46.6 18.2 48.0 37.4 14.6 52.4 44.4 3.3

ME 262,217 - - 100.0 26.1 40.6 33.3 28.3 43.9 27.8

MI 2,249,652 33.2 36.1 30.6 58.3 26.8 14.9 59.7 26.0 14.3

MN 1,280,609 36.0 30.1 34.0 44.6 29.5 25.9 65.7 24.4 9.9

MO 1,400,595 18.5 28.8 52.8 48.5 23.4 28.2 57.2 26.3 16.5

MS 736,138 - 6.7 93.3 22.5 28.2 49.3 44.2 35.7 20.1

MT 224,558 - - 100.0 29.9 6.3 63.8 44.2 15.9 40.0

NC 2,283,835 13.8 33.9 52.3 28.8 40.3 30.9 37.3 41.6 21.2

ND 162,770 19.3 2.5 78.2 51.5 5.4 43.1 51.5 6.4 42.1

NE 465,021 35.9 8.8 55.3 55.7 13.8 30.5 65.5 19.5 15.0

NH 271,688 2.2 6.6 91.1 23.4 48.6 28.0 62.9 33.7 3.4

Appendix III: Estimated Percentage of 

Children Who Lived within 30 Miles of a 

High- or Mid-Level Trauma Center, Detailed 

Tables by State, 2011-2015
Appendix III: Estimated Percentage of Children 

Who Lived within 30 Miles of a High- or MidLevel Trauma Center, Detailed Tables by State, 

2011-2015

Page 33 GAO-17-334 Pediatric Trauma Centers

High Level

Pediatric Trauma Center

High Level Adult

or Pediatric Trauma Center

High- or Mid-Level Adult

or Pediatric Trauma Center

State

Est. Child

Population

<10

miles

10-30 

miles

>30

miles

<10

miles

10-30 

miles

>30 

miles

<10 

miles

10-30 

miles

>30 

miles

NJ 2,023,313 36.8 48.7 14.4 69.9 28.3 1.8 69.9 29.3 0.7

NM 506,207 - - 100.0 26.4 17.5 56.1 46.5 22.9 30.6

NV 661,681 54.7 18.1 27.2 71.0 20.2 8.9 72.5 18.6 8.9

NY 4,251,773 68.4 16.1 15.5 76.0 16.7 7.3 77.2 16.2 6.6

OH 2,656,019 34.3 37.3 28.4 48.5 37.4 14.1 60.8 33.0 6.3

OK 947,895 17.1 15.6 67.3 32.1 25.3 42.6 61.2 26.8 12.0

OR 860,348 - - 100.0 48.5 28.1 23.4 62.7 30.7 6.7

PA 2,722,234 29.8 42.6 27.6 55.0 35.5 9.5 55.9 37.1 7.1

RI 215,019 61.9 35.1 3.0 61.9 35.1 3.0 61.9 38.1 0.1

SC 1,081,833 5.2 14.8 80.0 29.6 51.4 19.0 54.1 39.0 6.8

SD 207,718 24.3 5.4 70.4 38.1 8.2 53.7 45.4 13.2 41.5

TN 1,490,321 16.4 21.0 62.7 29.5 37.3 33.2 33.1 38.1 28.7

TX 7,058,802 20.3 43.4 36.3 34.3 39.9 25.8 68.8 22.3 8.9

UT 897,106 13.8 47.4 38.8 56.7 24.5 18.8 67.8 23.3 8.9

VA 1,864,755 11.7 29.6 58.6 43.3 43.8 12.9 50.4 38.0 11.6

VT 123,271 2.8 9.7 87.6 21.0 31.2 47.8 21.0 40.3 38.7

WA 1,596,652 24.7 36.8 38.6 39.6 38.9 21.5 78.2 16.1 5.7

WI 1,309,323 25.4 22.8 51.8 41.5 40.5 18.0 65.0 29.7 5.3

WV 382,286 4.1 7.0 88.9 19.0 35.4 45.6 35.0 40.5 24.5

WY 137,797 - - 100.0 29.2 1.2 69.6 53.9 7.3 38.8

Sources: GAO analysis of American Trauma Society and U.S. Census Bureau data. | GAO-17-334

Note: Child population estimates are based on the U.S. Census Bureau’s American Community 

Survey data 5-year estimates during the period 2011-2015. To identify trauma center locations, w e 

used 2015 data from the Trauma Information Exchange Program of the American Trauma Society. 

We refer to level I and level II pediatric and adult trauma centers as “high-level” trauma centers and 

level III pediatric and adult trauma centers as “mid-level” trauma centers.

“-” indicates that no children are in this category.
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 34 GAO-17-334 Pediatric Trauma Centers

Marcia Crosse, (202) 512-7114, crossem@gao.gov

In addition to the contact named above, Karin Wallestad, Assistant 

Director, Alison Goetsch, Analyst-in-Charge, and Summar Corley made 

key contributions to this report. Also contributing were Leia Dickerson, 

Krister Friday, Giselle Hicks, Vikki Porter, and Jennifer Whitworth.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100886)
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