Pediatric Trauma Centers: Availability, Outcomes, and Federal Support Related to Pediatric Trauma Care
Released: 2017-04-26T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: 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.

section_title: What GAO Found
paragraphs: 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.

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.

section_title: Letter
paragraphs: 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— providers, equipment, and expertise—needed to care for children with  severe physical injuries.

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.  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. 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. 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  (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. 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. 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. In this report, we 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.  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 peer- reviewed, 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  into our report relevant information on pediatric trauma outcomes that  representatives identified.

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.

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.
subsections: section_title: Background
paragraphs: 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.
subsections: section_title: Resources to Address Injured Children’s Unique Needs
paragraphs: 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.

section_title: Trauma Centers
paragraphs: 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  Committee on Trauma (ACS-COT). Table 1 summarizes the general  criteria for trauma centers based on the ACS-COT guidelines.

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. Pediatric  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. 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 board- certified pediatric surgeon and must admit 100 or more injured  children younger than 15 annually.

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, ACS- COT 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. Many of these non-trauma centers  where injured children receive treatment do not treat a high volume of  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.

section_title: Trauma Systems: Continuum of Trauma Care Activities and the Federal Role
paragraphs: Within trauma systems, coordinated trauma care activities occur across a  broad continuum, ranging from injury prevention activities and pre- hospital 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.

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. 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.

section_title: 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
paragraphs: 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.
subsections: section_title: 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
paragraphs: 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).

While an estimated 41.9 million children lived within 30 miles of a high- level 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).

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.

section_title: Some Studies Suggest that Children Treated at Pediatric Trauma Centers Have a Lower Risk of Mortality, While Information on Other Outcomes Is Limited
paragraphs: 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. 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  children treated at adult trauma centers or children transferred to a  pediatric trauma center for treatment after initial treatment at another  facility. 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.  Another study from 2016 that examined hospitalizations nationwide for  injured adolescents aged 15 to 19 had a similar finding. 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.

Finally, two studies examined whether there were differences in  outcomes based on whether children were transported directly to a  pediatric trauma center following injury. 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.

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. 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  centers. 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.

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. 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. Another study found that pediatric trauma  centers performed less imaging than adult trauma centers when treating  severely injured adolescents.

Information on other outcomes was limited. One study from 2016 that we  reviewed noted that in the pediatric trauma literature there are no  longitudinal studies on the long-term effects—both physical and  psychological—of trauma on children. 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. 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. 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.

section_title: Two Agencies Support Hospital- Based Pediatric Trauma Care Activities and Coordinate Some Efforts through an Interagency Group
paragraphs: 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.
subsections: section_title: Two Federal Agencies Support Hospital-Based Pediatric Trauma Activities Primarily through Grants, While Other Efforts Broadly Address Emergency Care
paragraphs: Two agencies within HHS—HRSA and NIH—have  grant programs and  other activities that support hospital-based pediatric trauma care (see  table 2).

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. 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 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. 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. However, according to HHS officials, no  appropriations were made for these new programs and no grants have  been made under these new authorities.

section_title: Federal Activities Related to Hospital-Based Pediatric Trauma Care and Other Emergency Care Are Coordinated through an Interagency Group and Arrangements between Agencies
paragraphs: 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). 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. 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.

section_title: Agency Comments
paragraphs: 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  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.

section_title: Appendix I: Training and Resources Available to Physicians and Nurses for Pediatric Trauma Care
paragraphs: 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.  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 open- ended questions and, to the extent possible, corroborated statements  with information available on stakeholder group websites.
subsections: section_title: Training
paragraphs: Many of the stakeholder groups we interviewed have developed  standardized training courses on the evaluation, management, and  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).

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. 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 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.

section_title: Resources
paragraphs: 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).

section_title: Appendix II: Location of High-Level Pediatric Trauma Centers, United States, 2015

section_title: 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
subsections: section_title: Pediatric Trauma Center

section_title: Pediatric Trauma Center

section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: 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.

Fast facts: More children die of injury each year than from all other causes combined. When children are severely injured in an event such as a car crash, where do they go to get care?

Although most traumatic injuries are treated in hospital emergency departments, hospitals may not have the resources needed to treat injured children. For example, they may lack specially sized medical equipment. Pediatric trauma centers, however, have these resources.

We found that 57 percent of the nation's 74 million children lived within 30 miles of a pediatric trauma center that can treat pediatric injuries, regardless of severity.

Question-summary annotations: questions: question: To what extent do children in the Uniter States have access to a pediatric trauma center?
answer: 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.

question: How does the lack of pediatric trauma centers affect injured children?
answer: 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.

question: What does GAO found out from reviewing studies?
answer: 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.
child_questions: question: What did GAO suggest after review the studies and interviews with stakeholders?
answer: 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.

questions: question: What agencies support hospital-based pediatric trauma care?
answer: 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.
child_questions: question: How do  these programs support hospital-based pediatric trauma care?
answer: 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.

question: What has GAO found about the care?
answer: 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.
child_questions: question: How are these activities coordinated through an interagency group and arrangements among agencies?
answer: 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.

questions: question: What does this report examine?
answer: 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.

question: What did GAO conclude from analyzing the data?
answer: 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.
child_questions: question: What else did GAO review?
answer: 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.