Prehospital time and mortality in pediatric trauma.

PURPOSE: The "Golden Hour" of transportation to a hospital has long been accepted as a central principal of trauma care. However, this has not been studied in pediatric populations. We assessed for non-linearity of the relationship between prehospital time and mortality in pediatric trauma patients, redefining the threshold at which reducing this time led to more favorable outcomes. METHODS: We performed an analysis of the 2017-2018 American College of Surgeons Trauma Quality Improvement Program, including trauma patients age < 18 years. We examined the association between prehospital time and odds of in-hospital mortality using linear, polynomial, and restricted cubic spline (RCS) models, ultimately selecting the non-linear RCS model as the best fit. RESULTS: 60,670 patients were included in the study, of whom 1525 died and 3074 experienced complications. Prolonged prehospital time was associated with lower mortality and fewer complications. Both models demonstrated that mortality risk was lowest at 45-60 min, after which time was no longer associated with reduced probability of mortality. CONCLUSIONS: The demonstration of a non-linear relationship between pre-hospital time and patient mortality is a novel finding. We highlight the need to improve prehospital treatment and access to pediatric trauma centers while aiming for hospital transportation within 45 min.

Factors associated with follow-up outside a transplant center among pediatric kidney transplant recipients.

BACKGROUND: Transfer of follow-up care after pediatric kidney transplantation (KTx) may jeopardize quality of care and patient outcomes. We sought to determine if minority status and socioeconomic factors were associated with increased likelihood of follow-up outside a transplant center, and whether this transition of care was associated with worse long-term graft and patient survival. METHODS: We performed an analysis of the United Network for Organ Sharing database, including children age < 18 years who received a kidney transplant between 2003 and 2018. Survival analysis (conditional on survival with functioning graft to 1 year) was performed using a Cox proportional hazards model where transfer of care (place of follow-up recorded as any setting other than a transplant center) was entered as a time-varying covariate. RESULTS: The study included 10,293, of whom 2083 received care outside of a transplant center during follow-up. Medicare coverage, but not minority race/ethnicity or socioeconomic status, was associated with increased likelihood of follow-up outside a transplant center. Follow-up outside a transplant center was associated with a 10% increased hazard of death or graft failure (hazard ratio: 1.10; 95% confidence interval: 1.004, 1.21; p = 0.041). CONCLUSION: Follow-up outside of a transplant center increased risk of poor outcomes, though the likelihood of receiving care outside a transplant center did not vary by race/ethnicity or socioeconomic status. Our results highlight the need to improve continuity of care after KTx and to further understand the mechanisms leading to poor survival rates among minority populations. A higher resolution version of the Graphical abstract is available as Supplementary information.