The characteristics of patients and hospital procedures for pediatric trauma in Saint Petersburg

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Abstract


This study presents health statistics for a specialized trauma department in a large pediatric hospital in St. Petersburg. Data relating to patients treated in the trauma department for any injuries and with injuries of the musculoskeletal system were analyzed separately. Injuries of the musculoskeletal system, accounted for 67.3% of all children hospitalized in the trauma department. We also identified patients with injuries of the musculoskeletal system who were treated in non-specialized departments of the hospital (accounting for 4.1% of patients in these departments). Detailed characteristics of the pediatric trauma departments, the characteristics of children hospitalized with injuries of the musculoskeletal system, methods for diagnosis, treatment, and rehabilitation are described. The challenges of rehabilitation for children with injuries and the need to increase the hospital capacity are also described.

Background

Pediatric trauma remains a critical medical and social problem in society due to the high frequency of injuries and their influence on child mortality and disability rates. It is the second most common contributor to child morbidity rate, accounting for 6%-8% of the pediatric population [1]. A lot of researchers note high indices of pediatric injuries in big cities where there are areas with heavy vehicular traffic [2-4]. In the hierarchy of primary pediatric incapacitation, diseases and consequences of musculoskeletal injuries account for 11.2% of the total number of childhood disabilities [5,6].

Inpatient specialized care is one of the most resource-intensive types of medical care; therefore, the analysis of its condition, while considering regional characteristics, may be a basis for the development of guidelines directed towards improving specialized care for children.

The objective of this study is to develop guidelines for the improvement of inpatient pediatric trauma care in patients with musculoskeletal injuries in Saint Petersburg.

During the study, the following objectives were set:

1. To analyze official state statistical data:

  • On the level of traumatism as a whole and musculoskeletal traumatism in dynamics
  • To determine children’s need for inpatient treatment (index of selection for hospitalization)
  • To assess the provision of trauma beds to children
  • To assess the working results of trauma departments (trauma beds) in pediatric hospitals in Saint Petersburg.

2. To evaluate the pediatric department of Pediatric City Hospital no. 1:

  • To study the age and sex structure of its trauma patients.
  • To classify patients based on the nature and localization of the injury.
  • To study the duration and outcomes of treatment.

3. To analyze some characteristics of rehabilitation in children with musculoskeletal injuries in inpatient conditions and determine approaches for improving rehabilitation for such children.

Materials and methods

Statistical form no. 57 “Information on injuries, poisonings and some other consequences of external reasons”, f. 47 “Information on chain and activity of medical institutions”, f. 30 “Information on medical institution” and f. 14 “Information on hospital activity”) in dynamics from 2010 to 2014, data on the patients with injuries who received treatment in specialized departments of SBIH “Pediatric City Hospital no. 1.” In this study, the following methods of statistical data processing were used: definition of indices of authenticity and significance of their differences, time series analyses (visibility index), relation criteria (of Spearman rank correlation).

Results

Traumatism index (categories S00-T98 in International Clasification of Diseases-10 [ICD-10]) 

in the study period varied from 161.8 to 178.1 per 1,000 children (aged 0-17 years). It includes injuries, poisonings, burns and freezing injuries, and adverse effects of atmospheric phenomena. We were especially interested in musculoskeletal injuries. They include (from form no. 57):

  • Minor injuries.
  • Open wounds.
  • Upper limb fractures.
  • Lower limb fractures.
  • Vertebral and trunk fractures.
  • Dislocations, sprains of capsular-ligament joint apparatus.
  • Crush injuries and traumatic amputations.

Of the total number of injuries and accidents in children in 2014, 86.7% were musculoskeletal injuries.

The most severe pediatric injuries are treated as inpatient conditions. The percentage of injured or poisoned pediatric patients who needed hospitalization and other external interventions fluctuated from 15% to 17% over the 5-year study period (or 263 patients per 10,000 children in 2013). Among children hospitalized with injuries and accidents, 40.3% (106 ± 1.3 per 10,000 children) had musculoskeletal injuries.

Some children from rural areas are also admitted to city hospitals in Saint Petersburg; they comprised 3.2%-4.7% of the total study population during the study period. Therefore, we excluded children from rural areas from our calculations of the index of hospitalization frequency (Table 1).

During the previous 5 years, the number of trauma beds remained almost unchanged, whereas the number of patients who occupied these beds increased by a total of 26.3%, 20.4% of whom, were city residents. Thus, hospitalization frequency depends not only on the number of special beds but also on other factors, as confirmed by the Spearman rank-order correlation coefficient (ρ = +0.5), which explains why there is only a moderate correlation between the capacity (beds) and the number of patients.

The indices of trauma bed performance are very important for the characterization and assessment of inpatient care (Table 2).

The provision of trauma beds decreased from 3.1 to 2.7 per 10,000 children; however, these differences are statistically insignificant (t = 1.3). Simultaneously, in 2014, both the admission rate of city children to trauma departments (116 ± 1.3 per 10,000 children) and the rate of the urban children who have been cured in that year (117 ± 1.4 per 10,000 children) remained quite high, utilization of inpatient trauma care per 10,000 children accounted for a minimum of −787.3 bed-days; bed occupancy has reduced by 286.3 days compared with that in the previous 3 years, and, average duration of patient’s staying on the bed has reduced almost by 20% compared with 2013. Moreover, 416 patients received treatment or aftercare as outpatients. In the same year, the turnover of pediatric trauma beds increased by 17.4% compared with that from 2010. The average downtime of trauma beds from 2013 to 2014 remained at an insignificant level of 1.7 days. Considering the sanitary code for pediatric hospitals with a high number of surgical patients, this index should be considered very low.

We studied the scope of patients in trauma departments of pediatric hospitals, as well as timeframes and outcomes for their treatment. As an example, we took the year 2013. In total, 19,213 children with injuries and consequences of external interventions were hospitalized, and they spent 131,122 bed-days as inpatients. Thus, the average treatment duration for this group of patients was 6.8 bed-days per patient. The overwhelming majority of patients from the studied group were discharged either when they were in satisfactory or improved condition. Hospital fatalities accounted for 0.08% of the study population; almost 2/3 of the fatalities were from intracranial injuries and poisonings.

In the form no. 14 of statutory reports, only the aggregate data on all fractures are presented. In 2013, fractures accounted for 29.7% of all injuries and/or poisonings in children. The average treatment duration for fractures in city hospitals accounted for 9.2 bed-days. There were no hospital fatalities in the fracture group.

Aside for statistical data analysis, we conducted an intensive study on some aspects of inpatient care for children with musculoskeletal injuries in a large city hospital. The trauma department in the studied pediatric hospital has 40 beds, with 30 beds allocated for trauma and 10 beds for rehabilitation patients. The trauma department staff consists of three doctors, one of whom is the head. All the doctors have the highest qualifications for their field of specialty.

The main performance indices for the trauma department during the 5-year study period are presented in Table 3. Changes in these indices were assessed using a visibility index, calculated as a percentage of the data for each year with the 2010 making up 100%.

On the basis of the data in Table 3, we can suppose that the trauma department’s workload increased with every year. For example, the number of patients discharged in 2014 exceeds the number of patients discharged in 2010 by more than 20%, with a “smooth” increase in the number of discharged patients observed each year, i.e., intensification of the department activity gradually occurred, which is also confirmed by other performance indices of the department. For example, the bed turnover in the department was almost 25% larger in 2014 than in 2010, and it also gradually increases every year. The average duration of patient treatment almost coincides with average city indices in the corresponding years. In addition, the average number of days the beds are occupied per year (bed-occupancy days) has exceded the standards for pediatric hospitals within the previous 2 years and accounted for 335 and 356.3 days in 2014 and 2015, respectively. This is clear evidence of work overload in the trauma department. At the same time, intensification of the department’s workload is also associated with the application of new methods and technologies, aftercare for certain groups of outpatients, and timely direction of some patients to rehabilitation, as well as with some other organizational, clinical, and medical-demographical factors.

The age distributions of children admitted to the trauma department were as follows: 0.4%, 5%, 14.8%, 58.6%, and 21.2% of the children were aged < 1, 1-2, 3-6, 7-14, and 15-17 years old, respectively. Thus, in the trauma department, 73.4% of patients were children aged 3-14 years old and 21.2 %were in their mid to late teens (15-17 years old). School-age patients (those aged 7-17 years) accounted for 79.8%, i.e., 4/5 of all the patients.

Obviously, the main marker which defines both therapeutic and diagnostic strategy and which influenced the indices of the department’s performance is the distribution of children based on the type and localization of the disease. Patients with musculoskeletal injuries accounted for 67.3% of all children admitted to the trauma department.

Figure 1 presents the structure of musculoskeletal injuries grouped according to diagnoses.

Some patients with musculoskeletal injuries were treated in other departments (i.e., not in the trauma department) of our pediatric hospital. There was an average of 54 such patients per year. They received treatment in the infectious disease, surgical, urological, hematological, and burns departments, and they accounted for 4.1% of all the patients with injuries. For these patients, musculoskeletal injuries were concomitant diseases, and the average duration of their treatment was 1.5-3-fold longer than the average treatment duration for patients in whom the injury was the main diagnosis. Patients were most commonly admitted to the surgical and infectious disease departments (23 and 15 patients, respectively).

Among patients who received treatment in non-major departments, the proportion of patients who had upper and lower limb fractures, vertebral fractures, and open wounds and/or vessel injuries were 85.2%, 9.2%, 3.7%, and 1.9%, respectively. While the number of such patients in our study is small, a detailed characteristic of these patients would necessitate a continuation of the study. However, it is evident that in planning the workload of the trauma department, it is necessary to consider that some pediatric patients with injuries receive treatment in non-major departments, which requires additional time for consultations, examination, and specialized treatment.

The indices of average treatment duration are important, and sometimes crucial, for planning the workload of the inpatient trauma department. Among all the children admitted to the trauma department with musculoskeletal injuries, the most common are upper limb fractures, minor injuries, and lower limb fractures (41%, 22.9 %, and 12.3% of patients, respectively; Table 4).

The average duration of hospitalization was 6.2 days. Long-term average timeframes of inpatient treatment were 11.3, 9.0, and 8.5 days for femoral, tibial, and vertebral and trunk fractures, respectively.

The most common treatment procedures performed in the pediatric trauma department were closed reduction with pin fixation (osteosynthesis; 59.3% of all procedures) and major operations on bones and joints (13.5%). Patients underwent surgery for the following indications: hand (14.7%), pelvic (42.9%), and femoral fractures (20.6%). In 2014, arthroendoscopies and arthrotomies were performed in 2.6% and 0.85% of patients in trauma departments, respectively.

While inpatient treatment is important, it is just the primary stage in the complex treatment of patients with injuries. The second and, in many traumatologists’ opinion, most important stage of treatment is the rehabilitation of patients in outpatient, inpatient, or sanatorium institutions.

According to order no. 1705n of the Health Ministry of the Russian Federation as of December 29, 2012, there are three stages of medical rehabilitation according to the severity of the patient’s clinical condition:

the first stage of medical rehabilitation is provided during the acute period of the clinical course or injury in resuscitation and intensive care departments,

the second stage is the early rehabilitation period of the clinical course or injury in inpatient conditions of medical institutions, and

the third stage is the early and late rehabilitation period, a period of residual signs of the clinical course in departments (rooms) of rehabilitation, physiotherapy, therapeutic exercises, reflexotherapy, and manual therapy.

At the study hospital, there are 10 rehabilitation beds in the trauma department where 315 patients with musculoskeletal injuries received remedial treatment within a year. Some patients with musculoskeletal injuries, after treatment in the trauma inpatient department, receive rehabilitation in a sanatorium (for example, “Ogonek”) and some receive aftercare in children’s polyclinics or rehabilitation facilities (budget and commercial ones).

Patients with more severe conditions definitely go through the inpatient stage, as detailed by the structure and timeframes of rehabilitation in the hospital (Table 5).

Unfortunately, there are no integral statistics on the patients who underwent rehabilitation; hopefully, the presented data may serve as guidelines in organizing such medical care.

The indices presented in Table 5 cannot be taken as a model for rehabilitation work with children who have had musculoskeletal injuries. There are no clear indices for directing treated patients in trauma departments to remedial treatment. No clear algorithms have been established for specific types of injury, and no recommended timeframes for treatment have been instituted. Because of this, issues of need, space, scope, and timeframes of rehabilitation for children with musculoskeletal injuries become extremely urgent and require profound scientific and practical solutions.

Conclusions

In the last 5 years, the number of trauma beds and their use for the provision care for the pediatric population has undergone little change, whereas the intensity of trauma bed occupancy has significantly increased. The number of patients placed into these beds has increased by 26.3%, the average duration of patients’ hospitalization has reduced, trauma bed turnover has increased by 17.4%, and the planned standard of bed occupancy per year has been exceeded. At the same time, 3.2%-4.7% of the patients were children from rural areas. Moreover, some patients had musculoskeletal injuries as concomitant diseases and received treatment in other departments and required consultations, recommendations, and systematic observations from traumatologists. Timeframes and algorithms for the remedial treatment of patients with musculoskeletal injuries were insufficient. It is necessary to create a unified state (budget or CMI program) system of rehabilitation for children with traumatic injuries, especially musculoskeletal injuries, with clear indications and aggregate indices for rehabilitation of one or another group of patients.

Information on funding and conflict of interests

The study was conducted with support of FSBI “The Turner Scientific and Research Institute for Children’s Orthopedics”; First Pavlov State Medical University of Saint Petersburg; Pediatric City Hospital No.1, of Saint Petersburg. The authors state that there is no potential conflicts of interests related to publication of this article.

Alexei G Baindurashvili

The Turner Scientific and Research Institute for Children’s Orthopedics

Author for correspondence.
Email: fake@eco-vector.com

Russian Federation MD, PhD, professor. Professor of the chair of Public Health and Health Care System with the economics course and Health Administration. First Pavlov State Medical University of Saint Petersburg.

Klara I Shapiro

First Pavlov State Medical University of Saint Petersburg

Email: fake@eco-vector.com

Russian Federation MD, PhD, professor. Professor of the chair of Public Health and Health Care System with the economics course and Health Administration. First Pavlov State Medical University of Saint Petersburg.

Anatoliy V Kagan

Pediatric City Hospital No.1

Email: fake@eco-vector.com

Russian Federation MD, PhD, professor, Head doctor of the City Children's Hospital No. 1. Head of the department of Pediatric Surgery of the First Pavlov State Medical University of Saint Petersburg.

Alexander N Vishniakov

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: van287641@gmail.com

Russian Federation MD, clinical resident of the The Turner Scientific and Research Institute for Children’s Orthopedics

Sergey V Fedorov

Pediatric City Hospital No.1

Email: fake@eco-vector.com

Russian Federation MD, chief of the traumatic department of the City Children's Hospital No 1.

Lyudmila A Drozhzhina

First Pavlov State Medical University of Saint Petersburg

Email: fake@eco-vector.com

Russian Federation MD, PhD, assistant professor of physical therapy and physical therapies. First Pavlov State Medical University of Saint Petersburg.

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Copyright (c) 2016 Baindurashvili A.G., Shapiro K.I., Kagan A.V., Vishniakov A.N., Fedorov S.V., Drozhzhina L.A.

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