Developing a pediatric trauma system in Tuscany, Italy: a case study in transformative change.

BACKGROUND: Trauma is the leading cause of death and disability in Italy among patients aged between 1 year and 19 years. To transform its fragmented regional pediatric trauma system to a more organized and efficient spoke and hub model, Tuscany has developed a partnership with physicians from the United States to facilitate the process and to implement a series of strategic system changes to create the first pediatric trauma center in Italy. METHODS: After establishing a multidisciplinary and institutional task force, a rigorous needs assessment was conducted to evaluate resources and develop a strategic timeline with specific project goals. Once an intensive educational program was completed, a series of system changes were made in Tuscany to create a full-service pediatric trauma center. Once accomplished, regional changes were enacted to divert the most severely injured children to the new center. RESULTS: In <3 years, a full-service pediatric trauma center was developed and ingratiated into the adult trauma system. All these changes were achieved through relentless administrative support, creation of a strong sense of urgency, and empowerment of innovators and early adopters to effect change. CONCLUSION: Through a comprehensive process including early extensive system analysis leading to educational interventions and organizational changes, the Anna Meyer Children's Hospital has developed the first Italian pediatric trauma center.

Cervical spine injuries in children, part I: mechanism of injury, clinical presentation, and imaging.

BACKGROUND: Cervical spine injuries are difficult to diagnose in children. They tend to occur in different locations than in adults, and they are more difficult to identify based on history or physical examination. As a result, children are often subjected to radiographic examinations to rule out cervical spine injury. OBJECTIVES: This two-part series will review the classic cervical spine injuries encountered in children based on age and presentation. Part I will discuss the mechanisms of injury, clinical presentations, and the use of different imaging modalities, including X-ray studies and computed tomography (CT). Part II discusses management of these injuries and special considerations, including the role of magnetic resonance imaging, as well as injuries unique to children. DISCUSSION: Although X-ray studies have relatively low risks associated with their use, they do not identify all injuries. In contrast, CT has higher sensitivity but has greater radiation, and its use is more appropriate in children over 8 years of age. CONCLUSION: With knowledge of cervical spine anatomy and the characteristic injuries seen at different stages of development, emergency physicians can make informed decisions about the appropriate modalities for diagnosis of pediatric cervical spine injuries.

Cervical spine injuries in children, part II: management and special considerations.

BACKGROUND: The diagnosis and management of cervical spine injury is more complex in children than in adults. OBJECTIVES: Part I of this series stressed the importance of tailoring the evaluation of cervical spine injuries based on age, mechanism of injury, and physical examination findings. Part II will discuss the role of magnetic resonance imaging (MRI) as well as the management of pediatric cervical spine injuries in the emergency department. DISCUSSION: Children have several common variations in their anatomy, such as pseudosubluxation of C2-C3, widening of the atlantodens interval, and ossification centers, that can appear concerning on imaging but are normal. Physicians should be alert for signs or symptoms of atlantorotary subluxation and spinal cord injury without radiologic abnormality when treating children with spinal cord injury, as these conditions have significant morbidity. MRI can identify injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal X-ray study or CT scan. CONCLUSION: With knowledge of these variations in pediatric anatomy, emergency physicians can appropriately identify injuries to the cervical spine and determine when further imaging is needed.

Building a trauma center and system in Tuscany, Italy.

BACKGROUND: Growing evidence supports the premise that adult trauma centers lower the risk of death for severely injured patients. The same principles have been applied to the pediatric population and mounting research suggests that, as in the adult population, gravely injured children have better outcomes at pediatric trauma centers where personnel trained and experienced in the specific needs and unique physiology of injured children provide care. As in the United States, acute traumatic injury represents an important public healthcare concern to the Tuscan regional government whose goal is to maximize clinical outcomes within available resources. In order to address this problem, the Tuscan regional government has created a new and innovative collaboration between the Meyer Pediatric Hospital/University of Florence School of Medicine and the Children's Hospital Boston/Harvard Medical School to build a pediatric trauma center and regional pediatric trauma referral system. GOALS AND OBJECTIVES: This long-term international initiative will seek to develop a demonstration model for pediatric trauma care that may later be replicated elsewhere. The initial goals of the project will focus on expanding the role of the pediatricians working in the emergency department to include the acute care of medical, surgical, orthopedic and multiple trauma patients. This new configuration will closely resemble the single provider model of emergency medical care commonly utilized in the United States. During this transition period to a more broadly trained emergency physician, a multi-disciplinary trauma team will be created and pediatric trauma clinical practice guidelines will be introduced into the emergency department and inpatient care units. Systems measurements will be achieved through a comprehensive quality improvement and risk management program. Ultimately, all Tuscan regional pediatric major trauma will be consolidated at the Meyer Pediatric Hospital in Florence.