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.