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.

3. Separate pediatric trauma committees

As with care protocols, a pediatric trauma program must have separate, pediatric-specific committees dedicated to performance improvement and patient safety (PIPS) and pediatric peer review. These Type I criteria are key to a well-functioning program with good outcomes.

Pediatric PIPS and peer review meetings have the same physician liaison attendance requirements as adult committee meetings. Meeting must be chaired by the pediatric TMD, and diligence is required to make these meetings a success.

To facilitate attendance, schedule adult and pediatric committee meetings back-to-back, since the liaisons are often the same physicians. However, make sure there are separate agendas for each meeting, documented beginning and adjournment times, and adequate time to run both meetings effectively.

If the adult PIPS meeting is scheduled first, it should include a recurring yet brief agenda slot for the pediatric TMD and pediatric TPM. During this time, any issues related to verification can be brought forward, plus other pediatric trauma items that require attention by staff who may not routinely attend the pediatric PIPS meeting.

4. Meaningful specialist commitment to pediatric trauma

Specialist involvement is key to the success of any trauma program. For a pediatric trauma program, it’s critical to secure meaningful commitment.

One of the bigger challenges is neurosurgery support. For pediatric Level II verification, the ACS requires at least one board-certified or board-eligible neurosurgeon who has “demonstrated interests and skills” in pediatric trauma care (CD 10-14).

It is important to realize that neurosurgery coverage for a verified adult Level I or II program does not always translate into the interest and ability to cover emergent pediatric neurosurgical trauma, especially for very young patients (age 0 to 5 years). Having commitment “on paper” is not enough. During a site visit, ACS reviewers will want to see evidence of strong neurosurgery participation in the pediatric trauma program.

Another area to pay close attention to is critical care. According to the Orange Book, the surgical director of the pediatric intensive care unit (PICU) should be board-certified in surgical critical care. Notice there is a little leeway here — board certification is a should, not a must. However, you must be able to demonstrate that the PICU director works collaboratively with the pediatric TMD to develop pediatric trauma care protocols.

During the verification survey, expect review of these documents and verification that PICU protocols are being followed. When not followed, the reviewers will want to see how the situation was handled in the PIPS process. Again, verification is not about what’s on paper, it’s about how programs are concurrently and continuously monitoring and improving care of the injured patient.

5. Organized pediatric programs

According to the Orange Book, verified pediatric trauma centers must have the following programs: pediatric rehabilitation, child life and family support programs, pediatric social work, pediatric injury prevention, community outreach, education and child protective services.

The programs required for pediatric verification must be true programs. They can be small in terms of the number of dedicated staff, but they have to be organized and verifiable during the survey and, in particular, case review.

For example, the injury prevention program of a Level II pediatric trauma center might be run entirely by the pediatric TPM. However, the activities of this program must be driven by pediatric registry data and adequately documented. The expectation is the trauma center has an organized approach to preventing the pediatric injuries in the area or community it serves.

Structure and upfront commitment are important. For instance, documented education program activities should show the center’s commitment to serving as a pediatric trauma care resource to the local and regional area. This commitment is sometimes difficult to secure in non-academic settings. The education component should be managed and negotiated up-front in the verification journey, especially if the hospital would like physicians to provide off-site lectures or education.

Child life is another area that calls for planning and structure. It requires a specialist-run program — not just volunteers with toys. There seems to be a lot of misunderstanding about this specialty and its truly beneficial contributions to pediatric care. Certified Child Life Specialists are required to have at least a bachelor’s or master’s degree in a related field of study, complete a lengthy clinical internship, and pass a national certification exam. (More information about the specialty is available from the Association of Child Life Professionals.)

6. Verifiable commitment to child abuse protection

Adult trauma centers pursuing pediatric verification often underestimate their tremendous responsibility for identifying and managing victims of child neglect and abuse.

According to Child Maltreatment 2015, a report from the U.S. Department of Health & Human Services:

• Approximately 683,000 children were reported victims of abuse or neglect in 2015 — an estimated 3.8% increase from 2011.
• Approximately 3,358,000 children received a child protective services investigation response or alternative response in 2015 — up 9.0% from 2011.
• Three-quarters (75.3%) of victims were neglected, 17.2% were physically abused and 8.4% were sexually abused.
• An estimated 1,670 children died of abuse or neglect in 2015 — a rate of 2.25 per 100,000 children in the national population.
• Nearly three-quarters (74.8%) of all child fatalities were younger than 3 years old, and four-fifths (77.7%) of child fatalities involved at least one parent.

What will you say when ACS reviewers ask to see your child protective services program? The answer cannot be, “We call the police and county CPS.” Again, with pediatric trauma center verification comes great responsibility and advocacy. Pediatric trauma centers must develop an organized and effective approach to identifying, diagnosing and treating victims of child neglect and abuse. They must also work collaboratively with law enforcement and the justice system on the behalf of victimized children.

So where do you begin? Child protective services programs are well defined by the Children’s Hospital Association (CHA) in Defining the Children’s Hospital Role in Child Maltreatment. This resource outlines what a child protection team should offer in terms of infrastructure, staffing, functions and systems. For Level I or II pediatric trauma centers, the CHA recommends developing and maintaining a medically directed child protection team at either the “Advanced” or “Center of Excellence” level.

Up your game

Generally, the lower the age of the patient, the higher the uneasiness of healthcare providers when treating patients. But that is precisely the reason adult trauma centers should “up their game” by seeking pediatric trauma verification.

Developing a pediatric trauma program can be expensive, because the ACS requires a verifiable commitment to creating a standalone program. But the reward for this investment is having the ability to provide injured children with the best care possible.

Stephanie Haley-Andrews, RN is the director of trauma and EMS for the Healthcare Corporation of America’s Continental Division. Before joining HCA, Stephanie worked for 20 years in academic adult Level I and pediatric Level I and II trauma centers. She is also a pediatric trauma site surveyor for the State of Washington. She can be reached at SHA@EliteTrauma.com.