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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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). 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.

Summary: 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. 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.