A growing number of adult trauma center hospitals are seeking American College of Surgeons (ACS) verification as Level II pediatric trauma centers. As someone who has cared for injured children for most of my career, I see this as a great trend and one that makes sense for several reasons.
First and foremost, it’s the right thing to do for our young patients. The majority of injured children are treated in adult trauma centers. Doing what’s best for pediatric patients should be a goal for all trauma centers, so it makes sense that adult centers that serve a large pediatric population seek to comply with ACS pediatric verification criteria — the gold standard for the care of injured children.
Second, if your verified adult trauma center already admits a significant number of injured children and is in compliance with Resources for Optimal Care of the Injured Patient (the “Orange Book”), pediatric trauma verification may be closer than you think.
Here’s what I mean: The Orange Book requires adult trauma centers that admit more than 100 injured children per year to demonstrate commitment and competency in pediatric trauma care. Specific requirements include credentialing trauma surgeons for pediatric trauma (CD 2-23) and having a pediatric emergency department area, a pediatric intensive care area, and a pediatric-specific trauma performance improvement and patient safety program (CD 2-24).
For a verified adult trauma center, these criteria already require a significant commitment of time and resources. So it may make sense to “take the extra step” and receive full pediatric trauma center verification to better serve these patients and the community.
Misconceptions about pediatric trauma verification
But along with these reasons to verify pediatric trauma centers, there are a number of common misconceptions.
One misconception is about volume requirements. The annual volume threshold for Level II pediatric verification is 100 admitted patients under the age of 15. However, unlike adult trauma verification, there is no Injury Severity Score (ISS) requirement associated with this threshold. An adult center that admits 100 injured children regardless of injury severity can request to be verified as a Level II pediatric trauma center.
The biggest misconception, however, is about verification requirements. Many trauma program leaders believe that pediatric verification is achieved simply by complying with the criteria in Chapter 10 (“Pediatric Trauma Care”) of the Orange Book. This is only partly true. While Chapter 10 presents pediatric-specific requirements for trauma verification, it does not contain the full range of pediatric trauma standards. In reality, a verified pediatric trauma program must meet the standards of the entire Orange Book.
To put it a different way, in order to be verified for pediatric trauma, a hospital must build a standalone pediatric trauma program that meets the entire range of Orange Book criteria utilizing a pediatric focus. For example, Chapter 3 requires trauma programs to take part in training prehospital personnel and help develop prehospital care protocols (CD 3–1). This requirement is not in Chapter 10, but any trauma center that wants pediatric verification must fulfill it from a pediatric perspective.
It’s worth noting that the ACS survey for pediatric verification follows the same format as the adult verification survey. That means when you prepare for a pediatric site visit, you need to start at page 1 of the Orange Book and work your way to the very last page.
I had the opportunity to work with an incredibly talented team to establish the first ACS-verified pediatric Level II trauma program in an adult Level I trauma center in the Rocky Mountain Region. Based on this experience, I have identified six things that outside reviewers need to validate in your center for it to earn pediatric trauma verification:
1. Pediatric-specific trauma protocols
To achieve pediatric trauma center verification from the ACS, an adult trauma program should have a complete set of trauma protocols developed specifically for children. Simply adding a “pediatric addendum” to an adult trauma protocol generally does not qualify.
For example, the ACS will not accept an adult massive transfusion protocol with a note at the end about adjusting blood volumes for different pediatric age groups.
A pediatric trauma protocol must go through the same multidisciplinary, collaborative development process as an adult protocol. Pediatric protocols also require separate approvals, with sign-off from the hospital CEO or chief medical officer in addition to the pediatric trauma medical director (TMD).
2. Separate pediatric trauma staff
According to the Orange Book, all Level I and II pediatric trauma centers must have a dedicated pediatric trauma program manager (CD 10-3).
- For Level I verification, the pediatric trauma program manager (TPM) must be dedicated full-time to the pediatric trauma service.
- For Level II verification, the pediatric TPM can be dedicated part-time to the pediatric trauma service. He or she may also serve as the injury prevention coordinator or the pediatric registrar (but not both).
What this does not mean — and it’s easy to go down this road — is that the Level II pediatric TPM can also be the IP coordinator and the pediatric registrar plus be given additional non-trauma roles and responsibilities.
It is critical that the pediatric TPM not be saddled with multiple responsibilities close to the trauma scope, but not within the trauma service. Meeting performance improvement expectations alone (concurrent, continuous tracking, trending and coordinating care with adequate documentation) requires multiple working hours every week.
In addition, the hospital must work collaboratively with the pediatric TMD and pediatric TPM to provide pediatric-specific credentialing and education for program staff. For the hospital, this represents a financial commitment. It includes credentialing physicians for pediatric trauma care, providing nurses with pediatric trauma certification courses, and maintaining a commitment to ongoing pediatric trauma education.