O3321: Interhospital Transport of Young Children with Nonaccidental Trauma: A Single-Center Experience

Background: Nonaccidental trauma (NAT) is a leading cause of trauma mortality in young children and is often unrecognized. While delayed recognition is reported to affect nearly 20% of NAT cases, we hypothesize that the subset of children requiring secondary transfer to a pediatric trauma center are an even more vulnerable population. We aim to describe our institutional experience with such critically ill young children transferred for evaluation at our Level 1 Pediatric Trauma Center.

Methods: We retrospectively reviewed the charts of children ≤2 years old admitted to our institution’s pediatric ICU between 7/1/2016 and 6/30/2023 with an ICD9/ICD10 code consistent with head trauma and consulted by the child protective services team, and we subsequently identified those transferred from a referring facility. Among this cohort, we categorized those with a discharge diagnosis of NAT vs. accidental trauma (AT). Demographics and data pertaining to the initial presentation, transport, and hospital course were compared between the NAT and AT groups. Data was compared with the Mann-Whitney U test post hoc.

Results: Of 183 included patients, 66 (36.1%) presented at our institution’s pediatric ED, whereas 117 (63.9%) were transferred from another institution. Among the transferred children, 55 (47%) had a discharge diagnosis of NAT and 62 (53%) of AT (Table 1). Demographics, prehospital characteristics, and transport logistics were not different between groups. However, when compared with the AT group, the NAT group had higher pediatric transport triage tool (PT3) scores (median [IQR]: 2 [0-5.5] vs. 1 [0-2], p=0.014), and post-transfer, had significantly longer ICU stays and overall hospitalizations (p=0.028, p=0.004 respectively). Children with NAT were also less likely than those with AT to be discharged home and required further placement with inpatient rehabilitation or foster care (p < 0.001, p=0.004 respectively). Injury location was found to be significantly different between groups: 43 (78.2%) children with confirmed NAT had injuries in zip codes with high social vulnerability vs. 28 (45.2%) children with AT (p < 0.001). Importantly, only 36.4% of the NAT group had a suspicion for NAT pre-transfer, leading to potential delays in NAT recognition for 63.6% of NAT group. Other referral diagnoses included intracranial hemorrhage, trauma, neurologic complaints, arrest, and infection (Table 2).

Conclusion: Our data suggest that young children who ultimately have confirmed NAT at the time of discharge may be sicker at the time of their initial presentation at the referring institution, more frequently sustain injuries in zip codes of high social vulnerability, and are most often unrecognized pre-transfer. Moreover, patients transferred with NAT have longer hospitalizations and more complicated dispositions at the time of discharge. Some of this information can be used to raise clinical suspicion for NAT and guide transport recommendations to higher level of care.