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Urban vs rural pediatric trauma in Alberta: where can we focus on prevention?
Journal of Pediatric Surgery (2010) 45, 908–911
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Urban vs rural pediatric trauma in Alberta: where can we focus on prevention? Dana Mihalicz, Leah Phillips, Ioana Bratu ⁎ Faculty of Medicine, Department of Pediatric General Surgery, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada T6G 2B7 Received 24 January 2010; accepted 2 February 2010
Key words: Rural pediatric; Trauma prevention; Alberta
Abstract Purpose: Understanding differences between rural and urban pediatric trauma is important in establishing preventative strategies specific to each setting. Methods: Data were extracted from a Provincial Pediatric Trauma Registry on pediatric patients (0-17 years) with Injury Severity Scores (ISS) 12 or more, treated from 1996 to 2006 at 5 major trauma centers in the province. Urban and rural patients were compared with respect to demographic data, as well as injury type and severity. Statistical analysis was made using SPSS software (SPSS Inc, Chicago, Ill) by χ2, Fisher's Exact test, or t test with P b .05 considered significant. Results: Of n = 2660, 63.3% rural patients predominate; mean ISS was 22.5. However, rural patients had more severe injuries (ISS, 23.2 vs 21.8; P b .0001). Blunt trauma was the most common mechanism overall (urban, 89.6%; rural, 93.2%), with most being motor vehicle accidents (MVAs). Significantly, more penetrating trauma occurred in the urban setting (5.4% vs 2.6%; P b .0001). Intent injuries were more common in the urban setting (15.2% vs 5.5%). Of the patients, 89.2% survived the trauma. However, urban patients had a higher rate of death than rural ones (13.0% vs 10.5%; P b .05). Conclusion: Despite the finding that rural patients sustained more severe injuries, overall survival was actually better when compared with urban patients. Most injuries were blunt trauma, suggesting road safety should be the main target in prevention strategies. Intent injuries were much higher in the urban group, thus, a need to target violence in urban prevention strategies. © 2010 Elsevier Inc. All rights reserved.
Trauma is the number one cause of mortality in the pediatric patient [1]. An increase in mortality has been described in rural pediatric trauma patients when compared with urban pediatric trauma patients [2]. A number of possible explanations have been described to explain this discrepancy, including a lack of advanced prehospital care in rural areas [3,4], a lack of access to dedicated pediatric
Presented at the 41st Annual Meeting of the Canadian Association of Paediatric Surgeons, Halifax, Nova Scotia, Canada, October 1-3, 2009. ⁎ Corresponding author. Tel.: +1 780 407 1182; fax: +1 780 407 2004. E-mail address: [email protected] (I. Bratu). 0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.02.022
intensive care units (ICUs) [5], and rural patients sustaining more severe injuries [6]. However, no direct comparisons have been made between urban and rural pediatric trauma patients with respect to demographic factors, types, and severity of injuries or outcomes. Understanding these differences is important in establishing preventative strategies specific to each setting.
1. Method This 10-year (1996-2006) retrospective study examined all patients 17 years or younger, residing in the province of
Urban vs rural pediatric trauma in Alberta
909
Alberta, who sustained injuries with Injury Severity Scores (ISS) of 12 or higher and who were treated at one of the 5 major trauma centers in the province. Data were extracted from the Alberta Pediatric Trauma Database, which collects data from all of the 5 major trauma centers in Alberta (3 of level I or II trauma centers in one city, and 2 of level 1 or 2 trauma centers in the second city), on all patients who sustained injuries with an ISS of 12 or higher. Each site has an abstractor with defined categories of data to be collected in a timely manner. Urban trauma cases were defined as those that occurred within the municipal city limits of Edmonton or Calgary, and rural cases were defined as all others. Urban and rural patients were compared with respect to demographic data, as well as injury type and severity. Statistical analysis was made using SPSS software by χ2, Fisher's Exact test, or Student's t test with P ≤ .05 considered significant.
2. Results Between 1996 and 2006, there were a total of 2910 pediatric patients with an ISS of 12 or higher; however, 250 of these did not have data regarding the place of injury. Tables 1 to 3 outline the results. A total of 2660 patients were included in the statistical analysis, with 1685 (63.3%) of these classified as rural and 975 (36.7%) as urban. Males were more often injured (65.8%) than females (34.2%), and the mean patient age was 11 years. No significant difference Table 1 Comparison of urban and rural pediatric trauma in one province Urban (n = 975) Age (y) 0-1 102 2-5 130 6-11 227 12-17 516 Sex Male 657 Female 318 ISS 12-20 559 21-30 291 31-40 73 41-50 39 N50 13 ICU length of stay (d) 0 564 1-7 340 8-14 45 15-21 14 22-28 8 N28 4
Urban (%)
Rural (n = 1685)
Rural (%)
10.46 13.33 23.28 52.92
132 225 342 986
7.83 13.35 20.30 58.52
67.38 32.62
1092 593
64.81 35.19
57.33 29.85 7.49 4.00 1.33
875 547 118 120 25
51.93 32.46 7.00 7.12 1.48
57.85 34.87 4.62 1.44 0.82 0.41
825 683 104 30 20 23
48.96 40.53 6.17 1.78 1.19 1.36
Table 2
Comparison of urban and rural pediatric trauma
Place of injury Farm/mine/industry Recreation Road/street Other Unknown Intent injury No Yes Vehicle type Car, truck, bus Bicycle or pedestrian Boat, plane, train All-terrain vehicles, motorbike, Ski-doo Other
Urban (n = 975)
Urban (%)
6 126 466 96 40
0.62 12.92 47.19 9.85 4.10
826 149 n = 466 240
84.72 15.28
212
45.49
51.50
0
Rural (n = 1685) 135 235 809 151 65
8.01 13.95 47.89 8.96 3.86
1593 92 n = 1035 638
0
Rural (%)
94.54 5.46 61.64
188
18.16
5
0.48
21
4.50
177
17.10
2
0.43
27
2.61
was found between urban and rural groups for these factors. As age increased, the frequency of injury increased dramatically, with patients aged 12 to 17 years accounting for 56.5% of all injuries. The least injured age group was between 0 and 1 year, accounting for only 8.8% of total injuries. Age categories were chosen according to motor (preambulatory or ambulatory), cognitive (concrete and abstract thinking), and behavioral development. Blunt trauma was the most common mechanism overall (urban, 89.6% vs rural, 93.2%) but significantly more penetrating trauma occurred in the urban setting (5.4% vs 2.9%; P b .0001). Intent injuries, defined as suicide, homicide, child abuse, and assault were much more common in the urban setting, accounting for 15.3% of all injuries, compared with 5.5% in the rural setting (P b .0001). Fortyseven percent of injuries in both groups occurred on a road or street, whereas a larger proportion of injuries in the urban group occurred at home compared with the rural group (24.7% vs 17.3%). Of the injuries on the street/road and those that involved vehicles of any sort, 45.5% of the urban
Table 3
Treating hospital and origin of trauma
Hospital
Urban (n)
Urban (%)
Rural (n)
Rural (%)
1 2 3 4 5 Total
377 168 53 375 2 975
38.7 17.2 5.4 38.5 0.2 100
426 188 48 1019 4 1685
25.3 11.2 2.8 60.5 0.2 100
910 group and only 18.2% of the rural group were either pedestrian or bicycle related. Of note, 17.1% of the rural events involved all-terrain vehicles, snowmobiles, or motorcycles, compared with 4.5% of urban cases. The use of personal protective devices such as seat belts and helmets was not consistently reported. However, in the 1196 cases in which it was documented, only half (614) were used at the time of the trauma. The median ISS overall was 19, with a range of 12 to 75. Urban patients tended to have slightly less severe injuries, with an ISS of 21.8 as compared with rural patients, who had a mean ISS of 23.2 (P b .001). Table 2 shows the distribution of pediatric trauma to the 5 major trauma centers in either of the 2 cities. A significant proportion of trauma occurred at rural locations that were then transferred to 1 of the 5 major trauma centers in the province. Most patients (2356; 88.6%) survived the trauma event, but urban patients experienced higher rates of mortality than rural patients (13% vs 10.5%; P b .05). Greater than 57% of urban patients did not require ICU, whereas more than 51% of rural patients did get admitted to the ICU. Ultimately, 1913 (81.2%) of the survivors were discharged home, of whom 87 (3.7%) required support services at home. Urban patients tended to have a higher rate of discharge home (87.1% vs 77.6%). Significantly more rural patients required transfer to an additional acute care facility (134; 8.9% vs 11; 1.3%) or rehabilitation facility (186; 12.3% vs 73; 8.6%) after hospital stay. Chronic care facilities were only used in 2 cases (both of urban origin), and foster care was the ultimate disposition of 25 children (15 urban and 10 rural). Of the 304 patients who died, 79 (26%) died in the emergency department, whereas 205 (67.4%) died in the ICU. Significant differences were found in these groups as 53 urban patients (41.7%) died in emergency department as compared with 26 rural patients (14.7%; P b .0001). In the ICU, 67 (52.8%) of the urban patients died, compared with 138 (78%; P b .0001) of the rural patients. Overall, a minority of deaths occurred in the operating room (15; 4.9%), involving 6 (4.7%) urban and 9 (5.1%) rural patients, respectively.
3. Discussion In 1996, the population of Alberta was 2,696,821, with an urban population of 62.5%. By 2006, this population grew 22% to 3,290,350 with urbanites accounting for 56.2% of the population [7]. As the population expanded over the 10 years, so did the number of injures in children by 28.4%, accounting for an increase of 218 to 280 cases per year. Although less than half of the population of Alberta resides in rural areas, more than half of the injuries occur there. Coordinated prehospital emergency services with an air ambulance greatly improve transport times to 1 of the 5 major trauma centers in the province.
D. Mihalicz et al. Significantly more urban patients died after their trauma despite that their injuries tended to be less severe than that of the rural patients. Nevertheless, one may argue that the difference between 13% and 10.5% survival is not clinically relevant and that ISS is only one indicator of injury severity [8]. However, it is clinically and socially tragic that almost 1 in 10 children who sustain a significant trauma with an ISS of 12 or higher may have a fatal outcome. Urban patients had a higher rate of being discharged home, with rural patients requiring care from an additional care center. This may be because patients living outside urban areas are often transferred back to a center within their own region once tertiary care is no longer needed. This is an important point to emphasize to health care planners to allocate proper funds for pediatric trauma development and programs at peripheral hospitals, especially in the context of rehabilitation and home environment adaptation. Unfortunately, the trauma database lacks information on the outcome of rehabilitation, activity of daily living, and school performance after injury, which may ultimately prove to be the most important long-term outcomes. Intent injuries were much more common in the urban group than the rural group. This is consistent with other studies evaluating violent pediatric deaths and firearm injuries [9]. Gausche et al [10] demonstrated an increased incidence of child abuse and homicide in urban California compared with rural areas. However, violent injuries cannot be viewed as purely an urban problem. Firearm injuries have been reported to be higher in some rural areas when compared with their adjacent urban areas [3]. A large proportion of these injuries are because of suicide [3], whereas in urban areas, assault is often the culprit [9]. It is important to be cognizant of these differences and the possibility that the same prevention programs for urban firearm injuries may be ineffective for rural children [3]. Greater than half of all injuries in both the urban and rural groups were a result of motor vehicle collisions. This is consistent with the 2008 World Health Organization report that demonstrated road injuries as the leading cause of death in children aged 15 to 19 years and the second leading cause of death in children aged 5 to 14 years [1]. Prevention strategies should be largely focused on this area, and the government has implemented some of the proven strategies to reduce injuries, including graduated driver's licenses and zero alcohol tolerance in the probationary period. Interestingly, a national consensus is often difficult to obtain on what may appear to be a straightforward universal prevention strategy. For example, although there is legislation regarding the use of car seats for infants, not all provinces have legislation regarding the use of booster seats in older children [11]. Without booster seats, children are at higher risk for solid organ, spinal, and head injuries should a collision occur [12]. Legally mandating the use of these restraints may lower the incidence of severe injuries. Trauma involving bicycles and pedestrians were very common in this cohort, especially in the urban area.
Urban vs rural pediatric trauma in Alberta Dedicated bicycle lanes on major roads in conjunction with reflective personal gear may prevent some of these injuries. Furthermore, increased education on bicycle safety for children, and perhaps increased bicycle awareness for drivers, may be of added benefit. Of particular danger, especially in rural areas, is the common use of motorized vehicles such as all-terrain vehicles and snowmobiles [13]. Although there is substantial evidence describing the danger these types of vehicles pose to children [14], changing the attitudes of adults and parents can be difficult. It has been proven that educational strategies alone are not enough to change behavior, and therefore, more comprehensive strategies must be used to further reduce the incidence [1]. Most riders are self-taught with no formal training and only minimal assistance from other riders. Underage alcohol consumption may also compound risktaking behavior and cloud judgment. Mandatory licensing with training courses and a minimum age limit may help to make people aware of the risks of unsafe driving and how to prevent injuries. Moreover, these guidelines may prevent young children from operating a vehicle they cannot safely drive. Focus groups also revealed that increased personal and parental liability may provide the incentive necessary to reduce unsafe driving behavior [1]. An important goal of any prevention program should be to make safety habits social norms. In literature surrounding the prevention of smoking and alcohol and substance abuse, it has been shown that social reinforcement and social norms are more powerful in creating behavior modification than the awareness programs alone [15]. There are several limitations to our study. Our data only include patients who were admitted to 1 of the 5 major trauma centers. Rural patients who were perhaps too severely injured to be transported or those who did not survive transportation to a tertiary center may not have been included, thus, rendering the exact number of rural mortalities inaccurate. This may also account for the finding that in cases of death, urban patients tended to die in the emergency department, whereas rural patients tended to die in the ICU. Other limitations of the study are related to the constraints of the database itself and the potentially subjective data accrual. Also, we only evaluated patients with an ISS of 12 or higher, possibly excluding other injury patterns that may help differentiate between the urban and rural groups. Unfortunately, the trauma database did not include data on socioeconomic status, which can have a large impact on the incidence of injury [16].
911 Nevertheless, despite these constraints, one cannot refute the serious impact of pediatric trauma with its rural and urban pattern of injury variation and our need to use focused preventive strategies.
References [1] World Health Organization. World report on child injury prevention; 2008. p. 50-150. [2] Halldorsson JG, Flekkoy KM, Gudmundsson KR, et al. Urban-rural differences in pediatric traumatic head injuries: a prospective nationwide study. Neuropsychiat Dis Treat 2007;3:935-41. [3] Svenson JE, Spurlock C, Nypaver M. Pediatric firearm-related fatalities—not just an urban problem. Arch Pediatr Adolesc Med 1996;150:583-7. [4] Gauschne M, Seidel JS, Henderson DP, et al. Pediatric deaths and emergency medical services (EMS) in urban and rural areas. Pediatr Emerg Care 1989;5:158-61. [5] Odetola FO, Miller WC, Davis MM, et al. The relationship between the location of pediatric intensive care unit facilities and child death from trauma: a county-level ecological study. J Pediatr 2005;147: 74-7. [6] Svenson JE, Spurlock C, Nypaver M. Factors associated with the higher traumatic death rate among rural children. Ann Emerg Med 1996;27:625-32. [7] Statistics Canada. Census. Available at: http://www12.statcan.gc.ca/ census-recensement/index-eng.cfm. Accessed July 15, 2009. [8] Burd RS, Madigan D. The impact of injury coding schemes on predicting hospital mortality after pediatric injury. Acad Emerg Med 2009;16:639-45. [9] Nance ML, Denysenko L, Durbin D, et al. The rural-urban continuum. Variability in statewide serious firearm injuries in children and adolescents. Arch Pediatr Adolesc Med 2002;156:781-5. [10] Gausche M, Seidel JS, Henderson DP, et al. Violent death in the pediatric age group: Rural and urban differences. Pediatr Emerg Care 1989;14:388-92. [11] Safe Kids Canada. Car seat and booster seat legislation chart. Available at: http://www.safekidscanada.ca/SKCPublicPolicyAdvocacy/ custom/BoosterSeatLegislationChart.pdf. Accessed November 8, 2009. [12] Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA 2003;289:2835-40. [13] Aitken ME, Graham CJ, Killingsworth JB, et al. All-terrain vehicle injury in children: strategies for prevention. Inj Prev 2004;10:303-7. [14] Trauma Committee of the Canadian Association of Pediatric Surgeons of Canada. Canadian Association of Pediatric Surgeons' position statement on the use of all-terrain vehicles by children and youth. J Pediatr Surg 2008;43:938-9. [15] Rundall TG, Bruvold WH. A meta-analysis of school-based smoking and alcohol use prevention programs. Health Educ Q 1988;15: 317-34. [16] Birken CS, Parkin PC, To T, et al. Trends in rates of death from unintentional injuries among Canadian children in urban areas: influence of socioeconomic status. CMAJ 2006;175:867-8.
www.elsevier.com/locate/jpedsurg
Urban vs rural pediatric trauma in Alberta: where can we focus on prevention? Dana Mihalicz, Leah Phillips, Ioana Bratu ⁎ Faculty of Medicine, Department of Pediatric General Surgery, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada T6G 2B7 Received 24 January 2010; accepted 2 February 2010
Key words: Rural pediatric; Trauma prevention; Alberta
Abstract Purpose: Understanding differences between rural and urban pediatric trauma is important in establishing preventative strategies specific to each setting. Methods: Data were extracted from a Provincial Pediatric Trauma Registry on pediatric patients (0-17 years) with Injury Severity Scores (ISS) 12 or more, treated from 1996 to 2006 at 5 major trauma centers in the province. Urban and rural patients were compared with respect to demographic data, as well as injury type and severity. Statistical analysis was made using SPSS software (SPSS Inc, Chicago, Ill) by χ2, Fisher's Exact test, or t test with P b .05 considered significant. Results: Of n = 2660, 63.3% rural patients predominate; mean ISS was 22.5. However, rural patients had more severe injuries (ISS, 23.2 vs 21.8; P b .0001). Blunt trauma was the most common mechanism overall (urban, 89.6%; rural, 93.2%), with most being motor vehicle accidents (MVAs). Significantly, more penetrating trauma occurred in the urban setting (5.4% vs 2.6%; P b .0001). Intent injuries were more common in the urban setting (15.2% vs 5.5%). Of the patients, 89.2% survived the trauma. However, urban patients had a higher rate of death than rural ones (13.0% vs 10.5%; P b .05). Conclusion: Despite the finding that rural patients sustained more severe injuries, overall survival was actually better when compared with urban patients. Most injuries were blunt trauma, suggesting road safety should be the main target in prevention strategies. Intent injuries were much higher in the urban group, thus, a need to target violence in urban prevention strategies. © 2010 Elsevier Inc. All rights reserved.
Trauma is the number one cause of mortality in the pediatric patient [1]. An increase in mortality has been described in rural pediatric trauma patients when compared with urban pediatric trauma patients [2]. A number of possible explanations have been described to explain this discrepancy, including a lack of advanced prehospital care in rural areas [3,4], a lack of access to dedicated pediatric
Presented at the 41st Annual Meeting of the Canadian Association of Paediatric Surgeons, Halifax, Nova Scotia, Canada, October 1-3, 2009. ⁎ Corresponding author. Tel.: +1 780 407 1182; fax: +1 780 407 2004. E-mail address: [email protected] (I. Bratu). 0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.02.022
intensive care units (ICUs) [5], and rural patients sustaining more severe injuries [6]. However, no direct comparisons have been made between urban and rural pediatric trauma patients with respect to demographic factors, types, and severity of injuries or outcomes. Understanding these differences is important in establishing preventative strategies specific to each setting.
1. Method This 10-year (1996-2006) retrospective study examined all patients 17 years or younger, residing in the province of
Urban vs rural pediatric trauma in Alberta
909
Alberta, who sustained injuries with Injury Severity Scores (ISS) of 12 or higher and who were treated at one of the 5 major trauma centers in the province. Data were extracted from the Alberta Pediatric Trauma Database, which collects data from all of the 5 major trauma centers in Alberta (3 of level I or II trauma centers in one city, and 2 of level 1 or 2 trauma centers in the second city), on all patients who sustained injuries with an ISS of 12 or higher. Each site has an abstractor with defined categories of data to be collected in a timely manner. Urban trauma cases were defined as those that occurred within the municipal city limits of Edmonton or Calgary, and rural cases were defined as all others. Urban and rural patients were compared with respect to demographic data, as well as injury type and severity. Statistical analysis was made using SPSS software by χ2, Fisher's Exact test, or Student's t test with P ≤ .05 considered significant.
2. Results Between 1996 and 2006, there were a total of 2910 pediatric patients with an ISS of 12 or higher; however, 250 of these did not have data regarding the place of injury. Tables 1 to 3 outline the results. A total of 2660 patients were included in the statistical analysis, with 1685 (63.3%) of these classified as rural and 975 (36.7%) as urban. Males were more often injured (65.8%) than females (34.2%), and the mean patient age was 11 years. No significant difference Table 1 Comparison of urban and rural pediatric trauma in one province Urban (n = 975) Age (y) 0-1 102 2-5 130 6-11 227 12-17 516 Sex Male 657 Female 318 ISS 12-20 559 21-30 291 31-40 73 41-50 39 N50 13 ICU length of stay (d) 0 564 1-7 340 8-14 45 15-21 14 22-28 8 N28 4
Urban (%)
Rural (n = 1685)
Rural (%)
10.46 13.33 23.28 52.92
132 225 342 986
7.83 13.35 20.30 58.52
67.38 32.62
1092 593
64.81 35.19
57.33 29.85 7.49 4.00 1.33
875 547 118 120 25
51.93 32.46 7.00 7.12 1.48
57.85 34.87 4.62 1.44 0.82 0.41
825 683 104 30 20 23
48.96 40.53 6.17 1.78 1.19 1.36
Table 2
Comparison of urban and rural pediatric trauma
Place of injury Farm/mine/industry Recreation Road/street Other Unknown Intent injury No Yes Vehicle type Car, truck, bus Bicycle or pedestrian Boat, plane, train All-terrain vehicles, motorbike, Ski-doo Other
Urban (n = 975)
Urban (%)
6 126 466 96 40
0.62 12.92 47.19 9.85 4.10
826 149 n = 466 240
84.72 15.28
212
45.49
51.50
0
Rural (n = 1685) 135 235 809 151 65
8.01 13.95 47.89 8.96 3.86
1593 92 n = 1035 638
0
Rural (%)
94.54 5.46 61.64
188
18.16
5
0.48
21
4.50
177
17.10
2
0.43
27
2.61
was found between urban and rural groups for these factors. As age increased, the frequency of injury increased dramatically, with patients aged 12 to 17 years accounting for 56.5% of all injuries. The least injured age group was between 0 and 1 year, accounting for only 8.8% of total injuries. Age categories were chosen according to motor (preambulatory or ambulatory), cognitive (concrete and abstract thinking), and behavioral development. Blunt trauma was the most common mechanism overall (urban, 89.6% vs rural, 93.2%) but significantly more penetrating trauma occurred in the urban setting (5.4% vs 2.9%; P b .0001). Intent injuries, defined as suicide, homicide, child abuse, and assault were much more common in the urban setting, accounting for 15.3% of all injuries, compared with 5.5% in the rural setting (P b .0001). Fortyseven percent of injuries in both groups occurred on a road or street, whereas a larger proportion of injuries in the urban group occurred at home compared with the rural group (24.7% vs 17.3%). Of the injuries on the street/road and those that involved vehicles of any sort, 45.5% of the urban
Table 3
Treating hospital and origin of trauma
Hospital
Urban (n)
Urban (%)
Rural (n)
Rural (%)
1 2 3 4 5 Total
377 168 53 375 2 975
38.7 17.2 5.4 38.5 0.2 100
426 188 48 1019 4 1685
25.3 11.2 2.8 60.5 0.2 100
910 group and only 18.2% of the rural group were either pedestrian or bicycle related. Of note, 17.1% of the rural events involved all-terrain vehicles, snowmobiles, or motorcycles, compared with 4.5% of urban cases. The use of personal protective devices such as seat belts and helmets was not consistently reported. However, in the 1196 cases in which it was documented, only half (614) were used at the time of the trauma. The median ISS overall was 19, with a range of 12 to 75. Urban patients tended to have slightly less severe injuries, with an ISS of 21.8 as compared with rural patients, who had a mean ISS of 23.2 (P b .001). Table 2 shows the distribution of pediatric trauma to the 5 major trauma centers in either of the 2 cities. A significant proportion of trauma occurred at rural locations that were then transferred to 1 of the 5 major trauma centers in the province. Most patients (2356; 88.6%) survived the trauma event, but urban patients experienced higher rates of mortality than rural patients (13% vs 10.5%; P b .05). Greater than 57% of urban patients did not require ICU, whereas more than 51% of rural patients did get admitted to the ICU. Ultimately, 1913 (81.2%) of the survivors were discharged home, of whom 87 (3.7%) required support services at home. Urban patients tended to have a higher rate of discharge home (87.1% vs 77.6%). Significantly more rural patients required transfer to an additional acute care facility (134; 8.9% vs 11; 1.3%) or rehabilitation facility (186; 12.3% vs 73; 8.6%) after hospital stay. Chronic care facilities were only used in 2 cases (both of urban origin), and foster care was the ultimate disposition of 25 children (15 urban and 10 rural). Of the 304 patients who died, 79 (26%) died in the emergency department, whereas 205 (67.4%) died in the ICU. Significant differences were found in these groups as 53 urban patients (41.7%) died in emergency department as compared with 26 rural patients (14.7%; P b .0001). In the ICU, 67 (52.8%) of the urban patients died, compared with 138 (78%; P b .0001) of the rural patients. Overall, a minority of deaths occurred in the operating room (15; 4.9%), involving 6 (4.7%) urban and 9 (5.1%) rural patients, respectively.
3. Discussion In 1996, the population of Alberta was 2,696,821, with an urban population of 62.5%. By 2006, this population grew 22% to 3,290,350 with urbanites accounting for 56.2% of the population [7]. As the population expanded over the 10 years, so did the number of injures in children by 28.4%, accounting for an increase of 218 to 280 cases per year. Although less than half of the population of Alberta resides in rural areas, more than half of the injuries occur there. Coordinated prehospital emergency services with an air ambulance greatly improve transport times to 1 of the 5 major trauma centers in the province.
D. Mihalicz et al. Significantly more urban patients died after their trauma despite that their injuries tended to be less severe than that of the rural patients. Nevertheless, one may argue that the difference between 13% and 10.5% survival is not clinically relevant and that ISS is only one indicator of injury severity [8]. However, it is clinically and socially tragic that almost 1 in 10 children who sustain a significant trauma with an ISS of 12 or higher may have a fatal outcome. Urban patients had a higher rate of being discharged home, with rural patients requiring care from an additional care center. This may be because patients living outside urban areas are often transferred back to a center within their own region once tertiary care is no longer needed. This is an important point to emphasize to health care planners to allocate proper funds for pediatric trauma development and programs at peripheral hospitals, especially in the context of rehabilitation and home environment adaptation. Unfortunately, the trauma database lacks information on the outcome of rehabilitation, activity of daily living, and school performance after injury, which may ultimately prove to be the most important long-term outcomes. Intent injuries were much more common in the urban group than the rural group. This is consistent with other studies evaluating violent pediatric deaths and firearm injuries [9]. Gausche et al [10] demonstrated an increased incidence of child abuse and homicide in urban California compared with rural areas. However, violent injuries cannot be viewed as purely an urban problem. Firearm injuries have been reported to be higher in some rural areas when compared with their adjacent urban areas [3]. A large proportion of these injuries are because of suicide [3], whereas in urban areas, assault is often the culprit [9]. It is important to be cognizant of these differences and the possibility that the same prevention programs for urban firearm injuries may be ineffective for rural children [3]. Greater than half of all injuries in both the urban and rural groups were a result of motor vehicle collisions. This is consistent with the 2008 World Health Organization report that demonstrated road injuries as the leading cause of death in children aged 15 to 19 years and the second leading cause of death in children aged 5 to 14 years [1]. Prevention strategies should be largely focused on this area, and the government has implemented some of the proven strategies to reduce injuries, including graduated driver's licenses and zero alcohol tolerance in the probationary period. Interestingly, a national consensus is often difficult to obtain on what may appear to be a straightforward universal prevention strategy. For example, although there is legislation regarding the use of car seats for infants, not all provinces have legislation regarding the use of booster seats in older children [11]. Without booster seats, children are at higher risk for solid organ, spinal, and head injuries should a collision occur [12]. Legally mandating the use of these restraints may lower the incidence of severe injuries. Trauma involving bicycles and pedestrians were very common in this cohort, especially in the urban area.
Urban vs rural pediatric trauma in Alberta Dedicated bicycle lanes on major roads in conjunction with reflective personal gear may prevent some of these injuries. Furthermore, increased education on bicycle safety for children, and perhaps increased bicycle awareness for drivers, may be of added benefit. Of particular danger, especially in rural areas, is the common use of motorized vehicles such as all-terrain vehicles and snowmobiles [13]. Although there is substantial evidence describing the danger these types of vehicles pose to children [14], changing the attitudes of adults and parents can be difficult. It has been proven that educational strategies alone are not enough to change behavior, and therefore, more comprehensive strategies must be used to further reduce the incidence [1]. Most riders are self-taught with no formal training and only minimal assistance from other riders. Underage alcohol consumption may also compound risktaking behavior and cloud judgment. Mandatory licensing with training courses and a minimum age limit may help to make people aware of the risks of unsafe driving and how to prevent injuries. Moreover, these guidelines may prevent young children from operating a vehicle they cannot safely drive. Focus groups also revealed that increased personal and parental liability may provide the incentive necessary to reduce unsafe driving behavior [1]. An important goal of any prevention program should be to make safety habits social norms. In literature surrounding the prevention of smoking and alcohol and substance abuse, it has been shown that social reinforcement and social norms are more powerful in creating behavior modification than the awareness programs alone [15]. There are several limitations to our study. Our data only include patients who were admitted to 1 of the 5 major trauma centers. Rural patients who were perhaps too severely injured to be transported or those who did not survive transportation to a tertiary center may not have been included, thus, rendering the exact number of rural mortalities inaccurate. This may also account for the finding that in cases of death, urban patients tended to die in the emergency department, whereas rural patients tended to die in the ICU. Other limitations of the study are related to the constraints of the database itself and the potentially subjective data accrual. Also, we only evaluated patients with an ISS of 12 or higher, possibly excluding other injury patterns that may help differentiate between the urban and rural groups. Unfortunately, the trauma database did not include data on socioeconomic status, which can have a large impact on the incidence of injury [16].
911 Nevertheless, despite these constraints, one cannot refute the serious impact of pediatric trauma with its rural and urban pattern of injury variation and our need to use focused preventive strategies.
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