Quality of initial trauma care in paediatrics

array:24 ["pii" => "S234128791730193X" "issn" => "23412879" "doi" => "10.1016/j.anpede.2017.02.008" "estado" => "S300" "fechaPublicacion" => "2017-12-01" "aid" => "2221" "copyright" => "Asociación Española de Pediatría" "copyrightAnyo" => "2016" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2017;87:337-42" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1195 "formatos" => array:3 [ "EPUB" => 135 "HTML" => 701 "PDF" => 359 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1695403317300516" "issn" => "16954033" "doi" => "10.1016/j.anpedi.2017.02.007" "estado" => "S300" "fechaPublicacion" => "2017-12-01" "aid" => "2221" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2017;87:337-42" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2644 "formatos" => array:3 [ "EPUB" => 199 "HTML" => 1710 "PDF" => 735 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "ORIGINAL" "titulo" => "Calidad asistencial en la atención inicial al trauma pediátrico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "337" "paginaFinal" => "342" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Quality of initial trauma care in paediatrics" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Vicente Ibáñez Pradas, Rut Pérez Montejano" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Vicente" "apellidos" => "Ibáñez Pradas" ] 1 => array:2 [ "nombre" => "Rut" "apellidos" => "Pérez Montejano" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S234128791730193X" "doi" => "10.1016/j.anpede.2017.02.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234128791730193X?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403317300516?idApp=UINPBA00005H" "url" => "/16954033/0000008700000006/v1_201711281432/S1695403317300516/v1_201711281432/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341287917300212" "issn" => "23412879" "doi" => "10.1016/j.anpede.2017.02.002" "estado" => "S300" "fechaPublicacion" => "2017-12-01" "aid" => "2212" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2017;87:343-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2138 "formatos" => array:3 [ "EPUB" => 216 "HTML" => 1322 "PDF" => 600 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original Article" "titulo" => "Neopterin levels and systemic inflammatory response syndrome in pediatric critically ill patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "343" "paginaFinal" => "349" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Niveles de neopterina y síndrome de respuesta inflamatoria sistémica en pacientes críticos pediátricos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2611 "Ancho" => 3417 "Tamanyo" => 272167 ] ] "descripcion" => array:1 [ "en" => "Correlation of basal neopterin and length of stay in PICU, hours of MV and VIS." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raquel Gil-Gómez, Javier Blasco-Alonso, Pilar Sánchez-Yáñez, Vanessa Rosa-Camacho, Guillermo Milano" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Raquel" "apellidos" => "Gil-Gómez" ] 1 => array:2 [ "nombre" => "Javier" "apellidos" => "Blasco-Alonso" ] 2 => array:2 [ "nombre" => "Pilar" "apellidos" => "Sánchez-Yáñez" ] 3 => array:2 [ "nombre" => "Vanessa" "apellidos" => "Rosa-Camacho" ] 4 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Milano" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S169540331730036X" "doi" => "10.1016/j.anpedi.2016.11.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S169540331730036X?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287917300212?idApp=UINPBA00005H" "url" => "/23412879/0000008700000006/v1_201711281541/S2341287917300212/v1_201711281541/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341287917301928" "issn" => "23412879" "doi" => "10.1016/j.anpede.2017.02.007" "estado" => "S300" "fechaPublicacion" => "2017-12-01" "aid" => "2217" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2017;87:330-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1840 "formatos" => array:3 [ "EPUB" => 118 "HTML" => 1294 "PDF" => 428 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Construction of a diagnostic prediction model of severe bacterial infection in febrile infants under 3 months old" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "330" "paginaFinal" => "336" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Creación de un modelo probabilístico de diagnóstico de infección bacteriana grave en lactantes febriles de 0 a 3 meses de vida" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1891 "Ancho" => 1621 "Tamanyo" => 125191 ] ] "descripcion" => array:1 [ "en" => "Comparative ROC curve for SBI (cut-off point, 80)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Enrique Villalobos Pinto, Marciano Sánchez-Bayle" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Enrique" "apellidos" => "Villalobos Pinto" ] 1 => array:2 [ "nombre" => "Marciano" "apellidos" => "Sánchez-Bayle" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1695403317300474" "doi" => "10.1016/j.anpedi.2017.02.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403317300474?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287917301928?idApp=UINPBA00005H" "url" => "/23412879/0000008700000006/v1_201711281541/S2341287917301928/v1_201711281541/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original Article" "titulo" => "Quality of initial trauma care in paediatrics" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "337" "paginaFinal" => "342" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Vicente Ibáñez Pradas, Rut Pérez Montejano" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Vicente" "apellidos" => "Ibáñez Pradas" "email" => array:1 [ 0 => "ibanez_vic@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rut" "apellidos" => "Pérez Montejano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Pediátricos, Servicio de Anestesiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Calidad asistencial en la atención inicial al trauma pediátrico" ] ] "textoCompleto" => "IntroductionInjury is the leading cause of death for children over a year of age in developed countries. More than 8.7 million children are treated in emergency departments for injury each year, with more than 7000 deaths a year, and improving injury care is a public health priority.<a class="elsevierStyleCrossRef" href="#bib0095">1</a> Spain does not have a national injury register, although there is one at the European level (The European Injury Database).<a class="elsevierStyleCrossRef" href="#bib0100">2</a> In the absence of official data, save for the death records offered by the Instituto Nacional de Estadística (National Institute of Statistics), 2 studies conducted in different paediatric hospitals have offered an equally worrisome approximation, estimating that for every death there are 160 hospital admissions and 2600 visits to emergency departments.<a class="elsevierStyleCrossRefs" href="#bib0105">3–5</a>Spain does not have specific referral centres for paediatric trauma care, so these patients are usually managed at the scene of the accident by the advance life support (ALS) ambulance teams, or at the nearest hospital or primary care centre, which exposes health professionals in these facilities to patients with life-threatening conditions with whom they rarely come into contact. Adding to this low incidence, the care provided in the first few minutes has an impact on the final outcome in what has come to be known as the “golden hour”, so that appropriate medical intervention is of vital importance. The Advanced Trauma Life Support (ATLS) protocol is the gold standard for the management of trauma patients since it was first adopted in the 1980s by the American College of Surgeons as a training programme for trauma care.<a class="elsevierStyleCrossRef" href="#bib0120">6</a> This protocol offers an intervention algorithm that is similar to that of paediatric CPR (ABCDE for trauma) and standardises the actions to be taken in the first moments of care.The paediatric version of this course was introduced in Spain in 1987 by the Sociedad Española de Cirugía Pediátrica (Spanish Society of Paediatric Surgery) in the form of the AITP course (atención inicial al trauma pediátrico, or initial care for paediatric trauma), which reproduces the standardised training of the ATLS, adapting it to the paediatric population.<a class="elsevierStyleCrossRef" href="#bib0125">7</a> The course consists of a distance portion and a face-to-face portion in which students engage in various skill stations in a simulation environment and take a final test with actors in character. This course has been taught in our hospital since 2004, and more than 500 professionals have been trained to date, physicians as well as nurses, employed in both hospital and out-of-hospital settings (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The aim of this study was to assess the quality of the initial care provided to patients brought to a tertiary care level hospital as an indirect measure of the increase in the number of professionals trained in trauma care.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Materials and methodsWe conducted a retrospective study of patients admitted to the paediatric intensive care unit (PICU) with traumatic injuries. We selected 2 historic cohorts that corresponded to a first period comprehending the 4 years preceding the implementation of the training courses (2001–2004, group 1) and a second period that included the last 4 years of activity (2012–2015, group 2). The AITP course is open to all health professionals and is offered twice a year in classes of 25 students each (originally 20). It includes a distance education portion in which students are given a manual with the theoretical contents, and a face-to-face portion delivered over two days. The face-to-face portion includes a brief review of the theory as well as training at the different skill stations, which cover the full range of interventions and decisions involved in the care of these patients: basic and advanced airway management, peripheral catheter placement, treatment of immediately life-threatening injuries in anaesthetised experimental animals (tension pneumothorax, massive haemothorax, cardiac tamponade), cervical collar placement and immobilisation of patient for transport, extrication, interpretation of radiologic tests and patient classification and triage. In addition to individual training, performance as part of a team is evaluated by practicing scenarios of accidents with multiple victims. The course ends with a theoretical exam and a practical exam with actors (children in character) in which the student has to demonstrate the acquired skills by managing a variety of clinical scenarios.In addition to demographic characteristics, the variables under study included the mechanism of injury, the team that provided initial care, the Glasgow Coma Score (GCS) at the time of initial care and the paediatric trauma score (PTS).To assess the quality of initial trauma care, we evaluated 4 clinical indicators that are commonly used in studies of this type<a class="elsevierStyleCrossRefs" href="#bib0130">8,9</a> and that reflect the adherence to interventions considered indispensable in trauma care: use of a cervical collar, establishment of vascular access, orotracheal intubation in patients with a GCS of 8 or less, and placement of a gastric tube in patients with severe trauma (PTS≤8). We also included a fifth indicator that counted the number of interventions performed out of the first 4 recommended interventions: cervical immobilisation, oxygen administration, peripheral catheter placement and administration of intravenous fluids.We collected the data from emergency department discharge summaries for patients managed in hospitals, or from the patient care reports that must be completed by ALS ambulance teams documenting the performed interventions.To analyse the data, we compared categorical variables by means of the chi-square test or the Fisher exact test. We compared continuous variables using the Student t test or the Mann–Whitney U test based on whether the variable followed a normal distribution. We set the level of significance at the conventional p-value of less than 0.05 to define statistical significance.ResultsThe study sample consisted of 218 patients: 105 patients in group 1 (2001–2004 period) and 113 in group 2 (2012–2015 period). The number of admissions to the PICU due to severe trauma remained stable through both periods, with a mean of 26 admissions a year and a range of 20–32 admissions.The comparison of both groups revealed a similar distribution by sex and age, with the characteristic predominance of the male sex in trauma patients (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The groups were not comparable in terms of the mechanisms of injury, trauma care team or proportion of severely injured patients. In recent years, there has been a decrease in the number of patients injured in road accidents while riding a vehicle and an increase in unintentional falls and bicycle accidents, as well as a decrease in the number of cases managed by mobile ALS teams and an increase in the cases treated in lower-level health care facilities. We also found a decreased frequency of patients in a coma (GCS≤8) or with severe trauma (PTS≤8), which was probably related to the decreased incidence of high-energy injuries.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>When it came to the quality of care, while the percentage of adherence to the quality indicators increased in nearly all (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), the difference was only statistically significant in the use of measures for cervical spine control (p=0.01), with a near-significant p-value for the establishment of peripheral vascular access (p=0.054). The indicator with the least improvement was the use of gastric tubes for decompression (p=0.14), although its proportion had doubled in group 2 (from 12% to 24%).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>We also found no statistically significant differences in the “number of initial interventions” indicator, with a similar proportion of patients in who no intervention was performed during initial care (19% in group 1, 11% in group 2). This variable exhibited a statistically significant negative correlation with both the GCS (r=−0.40; p=0.0001) and the PTS (r=−0.357; p=0.0001), so that the more the number of interventions decreased, the better the mental status of the patient or the lesser the apparent severity. We only calculated this indicator in patients for who enough information was available on the 4 interventions under study, and therefore it was the indicator that was most affected by missing data. In group 1, we calculated it based on 101 cases (96% of the sample), whereas in group 2 we calculated it based on 97 cases (85% of the sample). An additional analysis that presupposed that the appropriate interventions had been performed in cases with missing data (worst case analysis) gave similar results, with maintenance of the inverse correlation of the GCS and the PTS with the number of performed interventions (r=−0.41; p=0.01 for GCS; r=−0.34; p=0.01 for PTS).Most patients in who the initial care interventions were not performed presented with traumatic brain injury (TBI) associated with skull fracture and complicated by bleeding (subdural or epidural haematoma, intracerebral or subarachnoid haemorrhage).DiscussionIt is well known that simulation-based training programmes are a very useful tool for the development of skills and habits that would be difficult to achieve in health problems with a low prevalence and a high mortality,<a class="elsevierStyleCrossRef" href="#bib0140">10</a> as is the case of traumatic injury. Our data revealed that in recent years, most of these patients were managed in hospitals with a low level of care, possibly as a result of the decrease in traffic accidents, which means that any professional serving the paediatric population could face such a case. There are few data on the impact of training courses in clinical practice. Evaluations conducted in simulation environments<a class="elsevierStyleCrossRefs" href="#bib0135">9,11</a> tend to show an improvement of parameters in post-training evaluations compared to pre-training, but it would not be realistic to expect the same degree of improvement in a real-world environment. Two previous studies have investigated the correlation between training and real practice in Spain, one in the paediatric population conducted in the Hospital Gregorio Marañón,<a class="elsevierStyleCrossRef" href="#bib0125">7</a> and another in adults conducted in several hospitals in Catalonia (TRAUMACAT project).<a class="elsevierStyleCrossRef" href="#bib0130">8</a> The study on the paediatric population focused exclusively in the care provided by mobile ALS teams, and found improvement in every indicator, which probably reflected the greater specialisation of these teams in the care of these patients. The study on the adult population assessed performance in emergency department bays, although 75% of the sample had been transported and therefore received initial care from ALS ambulance teams, and the study was limited to victims of high-energy accidents.When it comes to the indicators used for quality assessment, several authors have remarked on the difficulty of establishing global standards for data auditing.<a class="elsevierStyleCrossRef" href="#bib0150">12</a> Mortality is not considered an appropriate indicator, as many injuries carry a low risk of death yet a high risk of disability, leading to the proposal of other indicators, such as the presence of shock, sepsis, ventilator-associated pneumonia or undue delays in care,<a class="elsevierStyleCrossRef" href="#bib0155">13</a> although these indicators also assess the quality of in-hospital and not only of out-of-hospital care. The indicators we used for out-of-hospital care in our study were based on the interventions proposed by the AITP management algorithm, although other protocols may be implemented based on the age of the patient or different training programmes. Thus, the protocol established by the Cincinnati Children's Hospital, designed for groups (teams), takes into account variables such as the time elapsed to initiation of electrocardiographic monitoring, and the ATLS, geared towards the adult population, assesses the presence of a heart rate of less than 100bpm as an indicator of haemodynamic stability prior to transfer to radiology, a situation that cannot be extrapolated to the paediatric population.In our series, gastric tube placement in severely injured patients was the indicator in which there was the least improvement, possibly because it is perceived as an aggressive intervention in paediatric patients, especially in the absence of changes in the level of consciousness, a circumstance that has already been identified in similar studies.<a class="elsevierStyleCrossRef" href="#bib0160">14</a> As for the “number of interventions performed,” the fact that it is negatively correlated to signs of neurologic involvement is important, as it denotes an erroneous perception of risk in these patients. The implementation of the trauma algorithm should not be based on the Glasgow Coma Score, but on the medical history of the patient. It is important to remember that while a low GCS is a risk factor for the presence of intra-abdominal injury, a high score does not rule it out, or that paediatric patients can continue to be haemodynamically stable for hours despite rupture of a solid organ. No intervention or a single intervention was performed in 30% of patients in group 1 and 25% of patients in group 2 during initial care. A more detailed analysis of the diagnoses of these patients at the time of admission to the PICU revealed a predominance of TBI associated with skull fracture and complicated by haemorrhage (subdural or epidural haematoma, subarachnoid haemorrhage), but there were also patients with solid organ rupture or multiple fractures, including pelvic fracture. Therefore, the best possible care is to adhere to the trauma care protocol until performance of diagnostic tests is completed and the patient can be classified appropriately.The availability of a simulation training programme in a given region does not imply that the quality of pre-hospital care is any better compared to other areas,<a class="elsevierStyleCrossRef" href="#bib0165">15</a> and furthermore, a direct association between the care provided by professionals trained in trauma management and improved outcomes has not been established to date,<a class="elsevierStyleCrossRef" href="#bib0170">16</a> mainly due to a lack of rigorous studies. Nevertheless, training by means of simulation has been proven to increase individual confidence and skills in the management of complex medical situations. Although it has been estimated that students of these courses retain their knowledge for a period of 6 years,<a class="elsevierStyleCrossRef" href="#bib0175">17</a> it is probably unrealistic to depend solely on such courses to achieve an overall improvement in outcomes. Complementary strategies, such as the one developed in the TRAUMACAT programme, which combines educational talks with the distribution of informational posters in the emergency care area, or the use of a checklist in the care of trauma patients,<a class="elsevierStyleCrossRef" href="#bib0180">18</a> may contribute to reduce the number of tasks that are not performed during initial care.Last of all, we ought to note some of the limitations of the study associated with its retrospective design. First of all, we were unable to establish a direct association between training courses and the analysed data, as it was not possible to determine whether the health professional (or professionals) that delivered care had been trained in trauma management, and only 50% of our students were employed in the catchment area of the hospital. Considering that our hospital is the only hospital in the province with a trauma centre, it is reasonable to assume that the data we collected was appropriate for the assessment of the level of training in our region.Secondly, there was a patient selection bias, as we only analysed data for patients admitted to the PICU, excluding the rest of hospitalised patients that stayed in the ward. The sample we used has characteristics that are common in trauma care studies, and the inclusion of patients admitted to hospital but that did not need admission to PICU would have been a source of bias of a different kind, as we would have only analysed patients admitted to our hospital, excluding those admitted to lower-level facilities, which would diminish the external validity of the results.Lastly, we should highlight that the two groups were not comparable, so the univariate analysis may have been affected by intervening variables, as well as by the small sample size for some of the study variables when we restricted the analysis to subgroups of patients with a GCS or PTS of 8 or less. We cannot exclude the possibility that the size of the compared groups was responsible for results not being statistically significant despite the absolute increase in the percentage of adherence to 4 out of the 5 analysed indicators.In conclusion, our results show an increased proportion of trauma cases managed in non-specialty hospitals along with a decrease in trauma severity. The implementation of AITP training courses has not translated to an overall improvement in quality indicators for the care of patients managed at a tertiary care hospital, with the exception of specific interventions, such as the use of a cervical collar. Training courses should be combined with other resources, such as the dissemination of outcomes, the use of checklists or other reinforcing measures to achieve the systematic implementation of currently recommended protocols.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres947371" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec919839" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres947372" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec919838" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-11-10" "fechaAceptado" => "2017-02-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec919839" "palabras" => array:5 [ 0 => "Injuries" 1 => "Advanced trauma life support care" 2 => "Trauma centres" 3 => "Patient simulation" 4 => "Quality of healthcare" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec919838" "palabras" => array:5 [ 0 => "Lesiones" 1 => "Soporte vital avanzado en trauma" 2 => "Centro de trauma" 3 => "Simulación con pacientes" 4 => "Calidad asistencial" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionTrauma care in Spain is not provided in specific centres, which means that health professionals have limited contact to trauma patients. After the setting up of a training programme in paediatric trauma, the aim of this study was to evaluate the quality of the initial care provided to these patients before they were admitted to the paediatric intensive care unit (PICU) of a third level hospital (trauma centre), as an indirect measurement of the increase in the number of health professionals trained in trauma. Materials and methodsTwo cohorts of PICU admissions were reviewed, the first one during the four years immediately before the training courses started (Group 1, period 2001–2004), and the second one during the 4 years (Group 2, period 2012–2015) after nearly 500 professionals were trained. A record was made of the injury mechanism, attending professional, Glasgow coma score (GCS), and paediatric trauma score (PTS). Initial care quality was assessed using five indicators: use of cervical collar, vascular access, orotracheal intubation if GCS≤8, gastric decompression if PTS≤8, and number of actions carried out from the initial four recommended (neck control, provide oxygen, get vascular access, provide IV fluids). Compliance was compared between the 2 periods. A p<0.05 was considered statistically significant. ResultsA total of 218 patient records were analysed, 105 in Group 1, and 113 in Group 2. The groups showed differences both in injury mechanism and in initial care team. A shift in injury mechanism pattern was observed, with a decrease in car accidents (28% vs 6%; p<0.0001). Patients attended to in low complexity hospitals increased from 29.4% to 51.9% (p=0.008), and their severity decreased when assessed using the GCS≤8 (29.8% vs 13.5%; p=0.004), or PTS≤8 (48.5% vs 29.7%; p=0.005). As regards quality indicators, only the use of neck collar improved its compliance (17.3–32.7%; p=0.01). Patients who received no action in the initial care remained unchanged (19% vs 11%%; p=0.15). ConclusionsAlthough there are limited improvements, the setting up of a training programme has not translated into better initial care for trauma patients in our area of influence. Trauma training should be complemented with other support measures in order to achieve a systematic application of the trauma care principles." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEn nuestro país la asistencia al trauma no se presta en centros específicos, lo que expone a los profesionales sanitarios a un contacto esporádico con este tipo de pacientes. El objetivo de este estudio es evaluar la calidad de la asistencia inicial prestada a los pacientes antes de su ingreso en la Unidad de Cuidados Intensivos Pediátricos (UCIP) de un centro de tercer nivel tras el inicio de un programa formativo en trauma pediátrico, como medida indirecta del aumento de profesionales con formación específica. Material y métodosSe seleccionaron 2 cohortes de pacientes correspondientes a los ingresos en UCIP por trauma durante los 4 años previos al inicio de los cursos de formación (grupo 1, periodo 2001–2004) y durante los 4 últimos años (grupo 2, periodo 2012–2015), tras haber formado a cerca de 500 profesionales. Se registró el mecanismo lesional, equipo que presta la asistencia inicial, puntuación en el score de Glasgow (GCS) en la atención inicial, y puntuación en el índice de trauma pediátrico (ITP) en la atención inicial. La calidad de la asistencia se evaluó mediante 5 indicadores: uso de collarín cervical, obtención de una vía venosa, intubación orotraqueal si GCS≤8, sondaje gástrico si ITP≤8, y número de actuaciones realizadas entre las primeras 4 medidas recomendadas (control cervical, administración de oxígeno, canalización de vía periférica y administración de fluidos). Se comparó el porcentaje de cumplimiento de los indicadores en ambos periodos. Una p<0,05 fue considerada estadísticamente significativa. ResultadosSe analizó a 218 pacientes; 105 en el grupo 1 y 113 en el grupo 2. Los grupos mostraron diferencias tanto en el mecanismo lesional como en el equipo que presta la asistencia inicial. En los últimos años se aprecia una disminución de los accidentes de tráfico (28% vs. 6%; p: 0,0001), así como un aumento de los casos atendidos en centros de baja complejidad (29,4% vs. 51,9%; p: 0,008). También disminuyeron los pacientes en coma (29,8% vs. 13,5%; p: 0,004) o con trauma grave (48,5% vs. 29,7%; p: 0,005). De los indicadores analizados solo se observó mejoría en el uso de collarín cervical (17,3% vs. 32,7%; p: 0,01), sin modificarse el porcentaje de pacientes en los que no se realiza ninguna acción en la asistencia inicial (19% vs. 11%; p: 0,15). ConclusionesAunque con mejoras aisladas, el desarrollo de un programa formativo específico no se ha traducido en una mejora global de la calidad asistencial en este tipo de pacientes. La formación en trauma debe complementarse con medidas de refuerzo para conseguir una aplicación sistemática del algoritmo de actuación." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ibáñez Pradas V, Pérez Montejano R. Calidad asistencial en la atención inicial al trauma pediátrico. An Pediatr (Barc). 2017;87:337–342." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Previous presentation: This study was presented at the Jornada Conmemorativa of the XXV Curso de AITP-Valencia: Avanzando en la formación del politrauma pediátrico. March 3, 2016; Valencia, Spain." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mobile critical care physician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mobile critical care nurse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 (13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatrics/paediatric surgery resident \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">170 (34.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatrician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (18.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital nurse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 (11.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Traumatologist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric surgeon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family physician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Plastic surgeon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">493 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1604461.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of students by specialty (March 2004–March 2016)." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 N=105 n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 N=113 n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Sex</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 (64.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 (66.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="center" valign="middle">0.80</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (35.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (33.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Mechanism of injury</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unintentional fall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 (39) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="8" align="center" valign="middle">0.0001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fall from height \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Motor vehicle (rider) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Motor vehicle (pedestrian) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (15.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bicycle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (7.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Crushing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (7.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Direct hit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (5.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Care team</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trauma centre. Emergency department \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (13.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (7.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="6" align="center" valign="middle">0.008</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trauma centre. PICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (29.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 (51.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Primary Care Centre \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intensive Care ambulance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (36) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Basic Life Support (BLS). Ambulance without medical staff (nurse or physician) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Severity</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with GCS≤8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (29.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (13.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with PTS<8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (48.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (29.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1604459.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD)</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.2 (4.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6 (4.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glasgow Coma Score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.5 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.08 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric Trauma Score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.9 (3.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3 (3.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1604458.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the study sample." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">p \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n (%)</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peripheral catheter placement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 (75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94 (85.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.054 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use of cervical collar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (17.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (32.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Orotracheal intubation (OTI) if GCS≤8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (54.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastric intubation in case of severe trauma (PTS≤8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (24.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Number of initial interventions from the following</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cervical spine control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxygen administration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peripheral vascular catheter placement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Administration of IV fluids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (19.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (11.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="5" align="left" valign="middle">0.15</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (8.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (13.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (33.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (26.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (21.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (10.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (20.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1604460.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Initial care quality indicators." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Epub ahead of print]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A national analysis of pediatric trauma care utilization and outcomes in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.R. Myers" 1 => "C.C. Branas" 2 => "B. French" 3 => "M.L. Nance" 4 => "B.G. Carr" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PEC.0000000000000902" "Revista" => array:3 [ "tituloSerie" => "Pediatr Emerg Care" "fecha" => "2016" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21252817" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0100" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "The European Injury Database. Bruselas: Comisión Europea [Updated in 2014; accessed 28.03.17]. Available from: <a href="http://ec.europa.eu/health/data_collection/databases/idb_en">http://ec.europa.eu/health/data_collection/databases/idb_en</a>." ] ] ] 2 => array:3 [ "identificador" => "bib0105" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Accidental injury in children: hospital trauma records in a Spanish population" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Concheiro" 1 => "C. Luances" 2 => "J.M. Quintillá" 3 => "L. Delgado" 4 => "J. Pou" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/17457300601170216" "Revista" => array:6 [ "tituloSerie" => "Int J Inj Contr Saf Promot" "fecha" => "2007" "volumen" => "14" "paginaInicial" => "125" "paginaFinal" => "127" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17510850" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0110" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gravedad de los accidentes infantiles: mortalidad y secuelas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Casaní Martínez" 1 => "M. Suárez-Varela" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Pediatr" "fecha" => "2001" "volumen" => "57" "paginaInicial" => "235" "paginaFinal" => "242" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0115" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Accidentes infantiles. Epidemiología y prevención" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Pou Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "JANO" "fecha" => "2008" "volumen" => "1684" "paginaInicial" => "35" "paginaFinal" => "37" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0120" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolution and development of the Advanced Trauma Life Support (ATLS) protocol: a historical perspective" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.S. Radvinsky" 1 => "R.S. Yoon" 2 => "P.J. Schmitt" 3 => "C.J. Prestigiacomo" 4 => "K.G. Swan" 5 => "F.A. Liporace" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3928/01477447-20120327-07" "Revista" => array:6 [ "tituloSerie" => "Orthopedics" "fecha" => "2012" "volumen" => "35" "paginaInicial" => "305" "paginaFinal" => "311" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22495839" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0125" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Registro de trauma pediátrico: análisis de 1.200 casos" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Navascués" 1 => "J. Soleto" 2 => "J. Cerdá" 3 => "G. Barrientos" 4 => "R. Sánchez" 5 => "R. Romero" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cir Pediatr" "fecha" => "1998" "volumen" => "11" "paginaInicial" => "151" "paginaFinal" => "160" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9927766" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0130" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impacto de los programas de formación en la asistencia al niño traumatizado" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Navascués" 1 => "J. Soleto" 2 => "R. Romero" 3 => "M.A. García Casillas" 4 => "E. Hernández" 5 => "O. Sánchez-París" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cir Pediatr" "fecha" => "2004" "volumen" => "17" "paginaInicial" => "28" "paginaFinal" => "32" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15002722" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0135" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estudio para la mejoría de la atención hospitalaria inicial del paciente politraumatizado: proyecto TRAUMACAT" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Navarro" 1 => "M. Koo" 2 => "C. Orrego" 3 => "J.M. Muñoz-Vives" 4 => "M. Rivero" 5 => "S. Montmany" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2014" "volumen" => "143" "numero" => "Suppl. 1" "paginaInicial" => "25" "paginaFinal" => "31" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0140" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluación de la actuación de los pediatras de atención primaria en un escenario simulado de trauma pediátrico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Civantos Fuentes" 1 => "A. Rodríguez Núñez" 2 => "J.A. Iglesias Vázquez" 3 => "L. Sánchez Santos" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Pediatr (Barc)" "fecha" => "2012" "volumen" => "77" "paginaInicial" => "203" "paginaFinal" => "207" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0145" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.A. Falcone Jr." 1 => "M. Daugherty" 2 => "L. Schweer" 3 => "M. Patterson" 4 => "R.L. Brown" 5 => "V.F. Garcia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jpedsurg.2008.02.033" "Revista" => array:6 [ "tituloSerie" => "J Pediatr Surg" "fecha" => "2008" "volumen" => "43" "paginaInicial" => "1065" "paginaFinal" => "1071" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18558184" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0150" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "¿Están cambiando nuestros paradigmas en la enfermedad traumática?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. Alted López" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Intensiva" "fecha" => "2015" "volumen" => "39" "paginaInicial" => "375" "paginaFinal" => "382" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0155" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Application of international classification injury severity score to national surgical quality improvement program defines pediatric trauma performance standards and drives performance improvement" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.J. Tepas" 1 => "B.G. Celso" 2 => "C.L. Leaphart" 3 => "D. Graham" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0b013e3181a5f03c" "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "2009" "volumen" => "67" "paginaInicial" => "185" "paginaFinal" => "189" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19590333" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0160" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Importancia de la evaluación inicial en los traumatismos graves en la infancia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.J. Peláez Mata" 1 => "A. Medina Villanueva" 2 => "S. García Saavedra" 3 => "S. Prieto Espuñes" 4 => "J.A. Concha Torre" 5 => "S. Menéndez Cuervo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cir Pediatr" "fecha" => "2005" "volumen" => "18" "paginaInicial" => "17" "paginaFinal" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15901103" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0165" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mapping the use of simulation in prehospital care – a literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Abelsson" 1 => "I. Rystedt" 2 => "B.O. Suserud" 3 => "L. Lindwall" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1757-7241-22-22" "Revista" => array:5 [ "tituloSerie" => "Scand J Trauma Resusc Emerg Med" "fecha" => "2014" "volumen" => "22" "paginaInicial" => "22" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24678868" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0170" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advanced trauma life support training for hospital staff" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Jayaraman" 1 => "D. Sethi" 2 => "P. Chinnock" 3 => "R. Wong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2014" "volumen" => "8" "paginaInicial" => "Cd004173" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0175" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Attrition of cognitive and trauma management skills after the Advanced Trauma Life Support (ATLS) course" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Ali" 1 => "R. Cohen" 2 => "R. Adam" 3 => "T.J. Gana" 4 => "I. Pierre" 5 => "E. Ali" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "1996" "volumen" => "40" "paginaInicial" => "860" "paginaFinal" => "866" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8656470" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0180" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of a checklist on advanced trauma life support task performance during pediatric trauma resuscitation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.C. Kelleher" 1 => "E.A. Carter" 2 => "L.J. Waterhouse" 3 => "S.E. Parsons" 4 => "J.L. Fritzeen" 5 => "R.S. Burd" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/acem.12487" "Revista" => array:6 [ "tituloSerie" => "Acad Emerg Med" "fecha" => "2014" "volumen" => "21" "paginaInicial" => "1129" "paginaFinal" => "1134" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25308136" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "titulo" => "Acknowledgments" "texto" => "We thank the AITP-Valencia group." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008700000006/v1_201711281541/S234128791730193X/v1_201711281541/en/main.assets" "Apartado" => array:4 [ "identificador" => "26005" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008700000006/v1_201711281541/S234128791730193X/v1_201711281541/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234128791730193X?idApp=UINPBA00005H"]

Statistics

Original Article

Quality of initial trauma care in paediatrics

Calidad asistencial en la atención inicial al trauma pediátrico

Vicente Ibáñez Pradasa,

Corresponding author

ibanez_vic@hotmail.com

Corresponding author.

, Rut Pérez Montejanob

a Servicio de Cirugía Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, Spain

b Unidad de Cuidados Intensivos Pediátricos, Servicio de Anestesiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain

Read

4980

Times
was read the article

2108

Total PDF

2872

Total HTML

Share statistics

 array:24 [
  "pii" => "S234128791730193X"
  "issn" => "23412879"
  "doi" => "10.1016/j.anpede.2017.02.008"
  "estado" => "S300"
  "fechaPublicacion" => "2017-12-01"
  "aid" => "2221"
  "copyright" => "Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a"
  "copyrightAnyo" => "2016"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "fla"
  "cita" => "An Pediatr &#40;Barc&#41;. 2017;87:337-42"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 1195
    "formatos" => array:3 [
      "EPUB" => 135
      "HTML" => 701
      "PDF" => 359
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S1695403317300516"
      "issn" => "16954033"
      "doi" => "10.1016/j.anpedi.2017.02.007"
      "estado" => "S300"
      "fechaPublicacion" => "2017-12-01"
      "aid" => "2221"
      "copyright" => "Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "fla"
      "cita" => "An Pediatr &#40;Barc&#41;. 2017;87:337-42"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 2644
        "formatos" => array:3 [
          "EPUB" => 199
          "HTML" => 1710
          "PDF" => 735
        ]
      ]
      "es" => array:12 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">ORIGINAL</span>"
        "titulo" => "Calidad asistencial en la atenci&#243;n inicial al trauma pedi&#225;trico"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "337"
            "paginaFinal" => "342"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Quality of initial trauma care in paediatrics"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Vicente Ib&#225;&#241;ez Pradas, Rut P&#233;rez Montejano"
            "autores" => array:2 [
              0 => array:2 [
                "nombre" => "Vicente"
                "apellidos" => "Ib&#225;&#241;ez Pradas"
              ]
              1 => array:2 [
                "nombre" => "Rut"
                "apellidos" => "P&#233;rez Montejano"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S234128791730193X"
          "doi" => "10.1016/j.anpede.2017.02.008"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234128791730193X?idApp=UINPBA00005H"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403317300516?idApp=UINPBA00005H"
      "url" => "/16954033/0000008700000006/v1_201711281432/S1695403317300516/v1_201711281432/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2341287917300212"
    "issn" => "23412879"
    "doi" => "10.1016/j.anpede.2017.02.002"
    "estado" => "S300"
    "fechaPublicacion" => "2017-12-01"
    "aid" => "2212"
    "copyright" => "Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "An Pediatr &#40;Barc&#41;. 2017;87:343-9"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2138
      "formatos" => array:3 [
        "EPUB" => 216
        "HTML" => 1322
        "PDF" => 600
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
      "titulo" => "Neopterin levels and systemic inflammatory response syndrome in pediatric critically ill patients"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "343"
          "paginaFinal" => "349"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Niveles de neopterina y s&#237;ndrome de respuesta inflamatoria sist&#233;mica en pacientes cr&#237;ticos pedi&#225;tricos"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0025"
          "etiqueta" => "Figure 5"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr5.jpeg"
              "Alto" => 2611
              "Ancho" => 3417
              "Tamanyo" => 272167
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Correlation of basal neopterin and length of stay in PICU&#44; hours of MV and VIS&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Raquel Gil-G&#243;mez, Javier Blasco-Alonso, Pilar S&#225;nchez-Y&#225;&#241;ez, Vanessa Rosa-Camacho, Guillermo Milano"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Raquel"
              "apellidos" => "Gil-G&#243;mez"
            ]
            1 => array:2 [
              "nombre" => "Javier"
              "apellidos" => "Blasco-Alonso"
            ]
            2 => array:2 [
              "nombre" => "Pilar"
              "apellidos" => "S&#225;nchez-Y&#225;&#241;ez"
            ]
            3 => array:2 [
              "nombre" => "Vanessa"
              "apellidos" => "Rosa-Camacho"
            ]
            4 => array:2 [
              "nombre" => "Guillermo"
              "apellidos" => "Milano"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S169540331730036X"
        "doi" => "10.1016/j.anpedi.2016.11.011"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S169540331730036X?idApp=UINPBA00005H"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287917300212?idApp=UINPBA00005H"
    "url" => "/23412879/0000008700000006/v1_201711281541/S2341287917300212/v1_201711281541/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2341287917301928"
    "issn" => "23412879"
    "doi" => "10.1016/j.anpede.2017.02.007"
    "estado" => "S300"
    "fechaPublicacion" => "2017-12-01"
    "aid" => "2217"
    "copyright" => "Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "An Pediatr &#40;Barc&#41;. 2017;87:330-6"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 1840
      "formatos" => array:3 [
        "EPUB" => 118
        "HTML" => 1294
        "PDF" => 428
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Construction of a diagnostic prediction model of severe bacterial infection in febrile infants under 3 months old"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "330"
          "paginaFinal" => "336"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Creaci&#243;n de un modelo probabil&#237;stico de diagn&#243;stico de infecci&#243;n bacteriana grave en lactantes febriles de 0 a 3 meses de vida"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 1891
              "Ancho" => 1621
              "Tamanyo" => 125191
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparative ROC curve for SBI &#40;cut-off point&#44; 80&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Enrique Villalobos Pinto, Marciano S&#225;nchez-Bayle"
          "autores" => array:2 [
            0 => array:2 [
              "nombre" => "Enrique"
              "apellidos" => "Villalobos Pinto"
            ]
            1 => array:2 [
              "nombre" => "Marciano"
              "apellidos" => "S&#225;nchez-Bayle"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S1695403317300474"
        "doi" => "10.1016/j.anpedi.2017.02.003"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403317300474?idApp=UINPBA00005H"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287917301928?idApp=UINPBA00005H"
    "url" => "/23412879/0000008700000006/v1_201711281541/S2341287917301928/v1_201711281541/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
    "titulo" => "Quality of initial trauma care in paediatrics"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "337"
        "paginaFinal" => "342"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Vicente Ib&#225;&#241;ez Pradas, Rut P&#233;rez Montejano"
        "autores" => array:2 [
          0 => array:4 [
            "nombre" => "Vicente"
            "apellidos" => "Ib&#225;&#241;ez Pradas"
            "email" => array:1 [
              0 => "ibanez&#95;vic&#64;hotmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Rut"
            "apellidos" => "P&#233;rez Montejano"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Servicio de Cirug&#237;a Pedi&#225;trica&#44; Hospital Universitario y Polit&#233;cnico La Fe&#44; Valencia&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Unidad de Cuidados Intensivos Pedi&#225;tricos&#44; Servicio de Anestesiolog&#237;a&#44; Hospital Universitario y Polit&#233;cnico La Fe&#44; Valencia&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Calidad asistencial en la atenci&#243;n inicial al trauma pedi&#225;trico"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Injury is the leading cause of death for children over a year of age in developed countries&#46; More than 8&#46;7 million children are treated in emergency departments for injury each year&#44; with more than 7000 deaths a year&#44; and improving injury care is a public health priority&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> Spain does not have a national injury register&#44; although there is one at the European level &#40;The European Injury Database&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> In the absence of official data&#44; save for the death records offered by the Instituto Nacional de Estad&#237;stica &#40;National Institute of Statistics&#41;&#44; 2 studies conducted in different paediatric hospitals have offered an equally worrisome approximation&#44; estimating that for every death there are 160 hospital admissions and 2600 visits to emergency departments&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Spain does not have specific referral centres for paediatric trauma care&#44; so these patients are usually managed at the scene of the accident by the advance life support &#40;ALS&#41; ambulance teams&#44; or at the nearest hospital or primary care centre&#44; which exposes health professionals in these facilities to patients with life-threatening conditions with whom they rarely come into contact&#46; Adding to this low incidence&#44; the care provided in the first few minutes has an impact on the final outcome in what has come to be known as the &#8220;golden hour&#8221;&#44; so that appropriate medical intervention is of vital importance&#46; The Advanced Trauma Life Support &#40;ATLS&#41; protocol is the gold standard for the management of trauma patients since it was first adopted in the 1980s by the American College of Surgeons as a training programme for trauma care&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> This protocol offers an intervention algorithm that is similar to that of paediatric CPR &#40;ABCDE for trauma&#41; and standardises the actions to be taken in the first moments of care&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The paediatric version of this course was introduced in Spain in 1987 by the Sociedad Espa&#241;ola de Cirug&#237;a Pedi&#225;trica &#40;Spanish Society of Paediatric Surgery&#41; in the form of the AITP course &#40;atenci&#243;n inicial al trauma pedi&#225;trico&#44; or initial care for paediatric trauma&#41;&#44; which reproduces the standardised training of the ATLS&#44; adapting it to the paediatric population&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> The course consists of a distance portion and a face-to-face portion in which students engage in various skill stations in a simulation environment and take a final test with actors in character&#46; This course has been taught in our hospital since 2004&#44; and more than 500 professionals have been trained to date&#44; physicians as well as nurses&#44; employed in both hospital and out-of-hospital settings &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The aim of this study was to assess the quality of the initial care provided to patients brought to a tertiary care level hospital as an indirect measure of the increase in the number of professionals trained in trauma care&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a retrospective study of patients admitted to the paediatric intensive care unit &#40;PICU&#41; with traumatic injuries&#46; We selected 2 historic cohorts that corresponded to a first period comprehending the 4 years preceding the implementation of the training courses &#40;2001&#8211;2004&#44; group 1&#41; and a second period that included the last 4 years of activity &#40;2012&#8211;2015&#44; group 2&#41;&#46; The AITP course is open to all health professionals and is offered twice a year in classes of 25 students each &#40;originally 20&#41;&#46; It includes a distance education portion in which students are given a manual with the theoretical contents&#44; and a face-to-face portion delivered over two days&#46; The face-to-face portion includes a brief review of the theory as well as training at the different skill stations&#44; which cover the full range of interventions and decisions involved in the care of these patients&#58; basic and advanced airway management&#44; peripheral catheter placement&#44; treatment of immediately life-threatening injuries in anaesthetised experimental animals &#40;tension pneumothorax&#44; massive haemothorax&#44; cardiac tamponade&#41;&#44; cervical collar placement and immobilisation of patient for transport&#44; extrication&#44; interpretation of radiologic tests and patient classification and triage&#46; In addition to individual training&#44; performance as part of a team is evaluated by practicing scenarios of accidents with multiple victims&#46; The course ends with a theoretical exam and a practical exam with actors &#40;children in character&#41; in which the student has to demonstrate the acquired skills by managing a variety of clinical scenarios&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In addition to demographic characteristics&#44; the variables under study included the mechanism of injury&#44; the team that provided initial care&#44; the Glasgow Coma Score &#40;GCS&#41; at the time of initial care and the paediatric trauma score &#40;PTS&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">To assess the quality of initial trauma care&#44; we evaluated 4 clinical indicators that are commonly used in studies of this type<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#44;9</span></a> and that reflect the adherence to interventions considered indispensable in trauma care&#58; use of a cervical collar&#44; establishment of vascular access&#44; orotracheal intubation in patients with a GCS of 8 or less&#44; and placement of a gastric tube in patients with severe trauma &#40;PTS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#41;&#46; We also included a fifth indicator that counted the number of interventions performed out of the first 4 recommended interventions&#58; cervical immobilisation&#44; oxygen administration&#44; peripheral catheter placement and administration of intravenous fluids&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We collected the data from emergency department discharge summaries for patients managed in hospitals&#44; or from the patient care reports that must be completed by ALS ambulance teams documenting the performed interventions&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">To analyse the data&#44; we compared categorical variables by means of the chi-square test or the Fisher exact test&#46; We compared continuous variables using the Student t test or the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test based on whether the variable followed a normal distribution&#46; We set the level of significance at the conventional <span class="elsevierStyleItalic">p</span>-value of less than 0&#46;05 to define statistical significance&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The study sample consisted of 218 patients&#58; 105 patients in group 1 &#40;2001&#8211;2004 period&#41; and 113 in group 2 &#40;2012&#8211;2015 period&#41;&#46; The number of admissions to the PICU due to severe trauma remained stable through both periods&#44; with a mean of 26 admissions a year and a range of 20&#8211;32 admissions&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The comparison of both groups revealed a similar distribution by sex and age&#44; with the characteristic predominance of the male sex in trauma patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The groups were not comparable in terms of the mechanisms of injury&#44; trauma care team or proportion of severely injured patients&#46; In recent years&#44; there has been a decrease in the number of patients injured in road accidents while riding a vehicle and an increase in unintentional falls and bicycle accidents&#44; as well as a decrease in the number of cases managed by mobile ALS teams and an increase in the cases treated in lower-level health care facilities&#46; We also found a decreased frequency of patients in a coma &#40;GCS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#41; or with severe trauma &#40;PTS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#41;&#44; which was probably related to the decreased incidence of high-energy injuries&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">When it came to the quality of care&#44; while the percentage of adherence to the quality indicators increased in nearly all &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; the difference was only statistically significant in the use of measures for cervical spine control &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; with a near-significant <span class="elsevierStyleItalic">p</span>-value for the establishment of peripheral vascular access &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;054&#41;&#46; The indicator with the least improvement was the use of gastric tubes for decompression &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;14&#41;&#44; although its proportion had doubled in group 2 &#40;from 12&#37; to 24&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">We also found no statistically significant differences in the &#8220;number of initial interventions&#8221; indicator&#44; with a similar proportion of patients in who no intervention was performed during initial care &#40;19&#37; in group 1&#44; 11&#37; in group 2&#41;&#46; This variable exhibited a statistically significant negative correlation with both the GCS &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;40&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; and the PTS &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;357&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#44; so that the more the number of interventions decreased&#44; the better the mental status of the patient or the lesser the apparent severity&#46; We only calculated this indicator in patients for who enough information was available on the 4 interventions under study&#44; and therefore it was the indicator that was most affected by missing data&#46; In group 1&#44; we calculated it based on 101 cases &#40;96&#37; of the sample&#41;&#44; whereas in group 2 we calculated it based on 97 cases &#40;85&#37; of the sample&#41;&#46; An additional analysis that presupposed that the appropriate interventions had been performed in cases with missing data &#40;worst case analysis&#41; gave similar results&#44; with maintenance of the inverse correlation of the GCS and the PTS with the number of performed interventions &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;41&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01 for GCS&#59; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;34&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01 for PTS&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Most patients in who the initial care interventions were not performed presented with traumatic brain injury &#40;TBI&#41; associated with skull fracture and complicated by bleeding &#40;subdural or epidural haematoma&#44; intracerebral or subarachnoid haemorrhage&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">It is well known that simulation-based training programmes are a very useful tool for the development of skills and habits that would be difficult to achieve in health problems with a low prevalence and a high mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> as is the case of traumatic injury&#46; Our data revealed that in recent years&#44; most of these patients were managed in hospitals with a low level of care&#44; possibly as a result of the decrease in traffic accidents&#44; which means that any professional serving the paediatric population could face such a case&#46; There are few data on the impact of training courses in clinical practice&#46; Evaluations conducted in simulation environments<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9&#44;11</span></a> tend to show an improvement of parameters in post-training evaluations compared to pre-training&#44; but it would not be realistic to expect the same degree of improvement in a real-world environment&#46; Two previous studies have investigated the correlation between training and real practice in Spain&#44; one in the paediatric population conducted in the Hospital Gregorio Mara&#241;&#243;n&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> and another in adults conducted in several hospitals in Catalonia &#40;TRAUMACAT project&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> The study on the paediatric population focused exclusively in the care provided by mobile ALS teams&#44; and found improvement in every indicator&#44; which probably reflected the greater specialisation of these teams in the care of these patients&#46; The study on the adult population assessed performance in emergency department bays&#44; although 75&#37; of the sample had been transported and therefore received initial care from ALS ambulance teams&#44; and the study was limited to victims of high-energy accidents&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">When it comes to the indicators used for quality assessment&#44; several authors have remarked on the difficulty of establishing global standards for data auditing&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> Mortality is not considered an appropriate indicator&#44; as many injuries carry a low risk of death yet a high risk of disability&#44; leading to the proposal of other indicators&#44; such as the presence of shock&#44; sepsis&#44; ventilator-associated pneumonia or undue delays in care&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> although these indicators also assess the quality of in-hospital and not only of out-of-hospital care&#46; The indicators we used for out-of-hospital care in our study were based on the interventions proposed by the AITP management algorithm&#44; although other protocols may be implemented based on the age of the patient or different training programmes&#46; Thus&#44; the protocol established by the Cincinnati Children&#39;s Hospital&#44; designed for groups &#40;teams&#41;&#44; takes into account variables such as the time elapsed to initiation of electrocardiographic monitoring&#44; and the ATLS&#44; geared towards the adult population&#44; assesses the presence of a heart rate of less than 100<span class="elsevierStyleHsp" style=""></span>bpm as an indicator of haemodynamic stability prior to transfer to radiology&#44; a situation that cannot be extrapolated to the paediatric population&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our series&#44; gastric tube placement in severely injured patients was the indicator in which there was the least improvement&#44; possibly because it is perceived as an aggressive intervention in paediatric patients&#44; especially in the absence of changes in the level of consciousness&#44; a circumstance that has already been identified in similar studies&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> As for the &#8220;number of interventions performed&#44;&#8221; the fact that it is negatively correlated to signs of neurologic involvement is important&#44; as it denotes an erroneous perception of risk in these patients&#46; The implementation of the trauma algorithm should not be based on the Glasgow Coma Score&#44; but on the medical history of the patient&#46; It is important to remember that while a low GCS is a risk factor for the presence of intra-abdominal injury&#44; a high score does not rule it out&#44; or that paediatric patients can continue to be haemodynamically stable for hours despite rupture of a solid organ&#46; No intervention or a single intervention was performed in 30&#37; of patients in group 1 and 25&#37; of patients in group 2 during initial care&#46; A more detailed analysis of the diagnoses of these patients at the time of admission to the PICU revealed a predominance of TBI associated with skull fracture and complicated by haemorrhage &#40;subdural or epidural haematoma&#44; subarachnoid haemorrhage&#41;&#44; but there were also patients with solid organ rupture or multiple fractures&#44; including pelvic fracture&#46; Therefore&#44; the best possible care is to adhere to the trauma care protocol until performance of diagnostic tests is completed and the patient can be classified appropriately&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The availability of a simulation training programme in a given region does not imply that the quality of pre-hospital care is any better compared to other areas&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> and furthermore&#44; a direct association between the care provided by professionals trained in trauma management and improved outcomes has not been established to date&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> mainly due to a lack of rigorous studies&#46; Nevertheless&#44; training by means of simulation has been proven to increase individual confidence and skills in the management of complex medical situations&#46; Although it has been estimated that students of these courses retain their knowledge for a period of 6 years&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> it is probably unrealistic to depend solely on such courses to achieve an overall improvement in outcomes&#46; Complementary strategies&#44; such as the one developed in the TRAUMACAT programme&#44; which combines educational talks with the distribution of informational posters in the emergency care area&#44; or the use of a checklist in the care of trauma patients&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> may contribute to reduce the number of tasks that are not performed during initial care&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Last of all&#44; we ought to note some of the limitations of the study associated with its retrospective design&#46; First of all&#44; we were unable to establish a direct association between training courses and the analysed data&#44; as it was not possible to determine whether the health professional &#40;or professionals&#41; that delivered care had been trained in trauma management&#44; and only 50&#37; of our students were employed in the catchment area of the hospital&#46; Considering that our hospital is the only hospital in the province with a trauma centre&#44; it is reasonable to assume that the data we collected was appropriate for the assessment of the level of training in our region&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Secondly&#44; there was a patient selection bias&#44; as we only analysed data for patients admitted to the PICU&#44; excluding the rest of hospitalised patients that stayed in the ward&#46; The sample we used has characteristics that are common in trauma care studies&#44; and the inclusion of patients admitted to hospital but that did not need admission to PICU would have been a source of bias of a different kind&#44; as we would have only analysed patients admitted to our hospital&#44; excluding those admitted to lower-level facilities&#44; which would diminish the external validity of the results&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Lastly&#44; we should highlight that the two groups were not comparable&#44; so the univariate analysis may have been affected by intervening variables&#44; as well as by the small sample size for some of the study variables when we restricted the analysis to subgroups of patients with a GCS or PTS of 8 or less&#46; We cannot exclude the possibility that the size of the compared groups was responsible for results not being statistically significant despite the absolute increase in the percentage of adherence to 4 out of the 5 analysed indicators&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results show an increased proportion of trauma cases managed in non-specialty hospitals along with a decrease in trauma severity&#46; The implementation of AITP training courses has not translated to an overall improvement in quality indicators for the care of patients managed at a tertiary care hospital&#44; with the exception of specific interventions&#44; such as the use of a cervical collar&#46; Training courses should be combined with other resources&#44; such as the dissemination of outcomes&#44; the use of checklists or other reinforcing measures to achieve the systematic implementation of currently recommended protocols&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:10 [
        0 => array:3 [
          "identificador" => "xres947371"
          "titulo" => "Abstract"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "abst0005"
              "titulo" => "Introduction"
            ]
            1 => array:2 [
              "identificador" => "abst0010"
              "titulo" => "Materials and methods"
            ]
            2 => array:2 [
              "identificador" => "abst0015"
              "titulo" => "Results"
            ]
            3 => array:2 [
              "identificador" => "abst0020"
              "titulo" => "Conclusions"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec919839"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres947372"
          "titulo" => "Resumen"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "abst0025"
              "titulo" => "Introducci&#243;n"
            ]
            1 => array:2 [
              "identificador" => "abst0030"
              "titulo" => "Material y m&#233;todos"
            ]
            2 => array:2 [
              "identificador" => "abst0035"
              "titulo" => "Resultados"
            ]
            3 => array:2 [
              "identificador" => "abst0040"
              "titulo" => "Conclusiones"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec919838"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Materials and methods"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflicts of interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-11-10"
    "fechaAceptado" => "2017-02-15"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec919839"
          "palabras" => array:5 [
            0 => "Injuries"
            1 => "Advanced trauma life support care"
            2 => "Trauma centres"
            3 => "Patient simulation"
            4 => "Quality of healthcare"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec919838"
          "palabras" => array:5 [
            0 => "Lesiones"
            1 => "Soporte vital avanzado en trauma"
            2 => "Centro de trauma"
            3 => "Simulaci&#243;n con pacientes"
            4 => "Calidad asistencial"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Trauma care in Spain is not provided in specific centres&#44; which means that health professionals have limited contact to trauma patients&#46; After the setting up of a training programme in paediatric trauma&#44; the aim of this study was to evaluate the quality of the initial care provided to these patients before they were admitted to the paediatric intensive care unit &#40;PICU&#41; of a third level hospital &#40;trauma centre&#41;&#44; as an indirect measurement of the increase in the number of health professionals trained in trauma&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Two cohorts of PICU admissions were reviewed&#44; the first one during the four years immediately before the training courses started &#40;Group 1&#44; period 2001&#8211;2004&#41;&#44; and the second one during the 4 years &#40;Group 2&#44; period 2012&#8211;2015&#41; after nearly 500 professionals were trained&#46; A record was made of the injury mechanism&#44; attending professional&#44; Glasgow coma score &#40;GCS&#41;&#44; and paediatric trauma score &#40;PTS&#41;&#46; Initial care quality was assessed using five indicators&#58; use of cervical collar&#44; vascular access&#44; orotracheal intubation if GCS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#44; gastric decompression if PTS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#44; and number of actions carried out from the initial four recommended &#40;neck control&#44; provide oxygen&#44; get vascular access&#44; provide IV fluids&#41;&#46; Compliance was compared between the 2 periods&#46; A <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered statistically significant&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 218 patient records were analysed&#44; 105 in Group 1&#44; and 113 in Group 2&#46; The groups showed differences both in injury mechanism and in initial care team&#46; A shift in injury mechanism pattern was observed&#44; with a decrease in car accidents &#40;28&#37; vs 6&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Patients attended to in low complexity hospitals increased from 29&#46;4&#37; to 51&#46;9&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008&#41;&#44; and their severity decreased when assessed using the GCS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8 &#40;29&#46;8&#37; vs 13&#46;5&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#44; or PTS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8 &#40;48&#46;5&#37; vs 29&#46;7&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41;&#46; As regards quality indicators&#44; only the use of neck collar improved its compliance &#40;17&#46;3&#8211;32&#46;7&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; Patients who received no action in the initial care remained unchanged &#40;19&#37; vs 11&#37;&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;15&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Although there are limited improvements&#44; the setting up of a training programme has not translated into better initial care for trauma patients in our area of influence&#46; Trauma training should be complemented with other support measures in order to achieve a systematic application of the trauma care principles&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En nuestro pa&#237;s la asistencia al trauma no se presta en centros espec&#237;ficos&#44; lo que expone a los profesionales sanitarios a un contacto espor&#225;dico con este tipo de pacientes&#46; El objetivo de este estudio es evaluar la calidad de la asistencia inicial prestada a los pacientes antes de su ingreso en la Unidad de Cuidados Intensivos Pedi&#225;tricos &#40;UCIP&#41; de un centro de tercer nivel tras el inicio de un programa formativo en trauma pedi&#225;trico&#44; como medida indirecta del aumento de profesionales con formaci&#243;n espec&#237;fica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se seleccionaron 2 cohortes de pacientes correspondientes a los ingresos en UCIP por trauma durante los 4 a&#241;os previos al inicio de los cursos de formaci&#243;n &#40;grupo 1&#44; periodo 2001&#8211;2004&#41; y durante los 4 &#250;ltimos a&#241;os &#40;grupo 2&#44; periodo 2012&#8211;2015&#41;&#44; tras haber formado a cerca de 500 profesionales&#46; Se registr&#243; el mecanismo lesional&#44; equipo que presta la asistencia inicial&#44; puntuaci&#243;n en el score de Glasgow &#40;GCS&#41; en la atenci&#243;n inicial&#44; y puntuaci&#243;n en el &#237;ndice de trauma pedi&#225;trico &#40;ITP&#41; en la atenci&#243;n inicial&#46; La calidad de la asistencia se evalu&#243; mediante 5 indicadores&#58; uso de collar&#237;n cervical&#44; obtenci&#243;n de una v&#237;a venosa&#44; intubaci&#243;n orotraqueal si GCS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#44; sondaje g&#225;strico si ITP<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#44; y n&#250;mero de actuaciones realizadas entre las primeras 4 medidas recomendadas &#40;control cervical&#44; administraci&#243;n de ox&#237;geno&#44; canalizaci&#243;n de v&#237;a perif&#233;rica y administraci&#243;n de fluidos&#41;&#46; Se compar&#243; el porcentaje de cumplimiento de los indicadores en ambos periodos&#46; Una p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 fue considerada estad&#237;sticamente significativa&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se analiz&#243; a 218 pacientes&#59; 105 en el grupo 1 y 113 en el grupo 2&#46; Los grupos mostraron diferencias tanto en el mecanismo lesional como en el equipo que presta la asistencia inicial&#46; En los &#250;ltimos a&#241;os se aprecia una disminuci&#243;n de los accidentes de tr&#225;fico &#40;28&#37; vs&#46; 6&#37;&#59; p&#58; 0&#44;0001&#41;&#44; as&#237; como un aumento de los casos atendidos en centros de baja complejidad &#40;29&#44;4&#37; vs&#46; 51&#44;9&#37;&#59; p&#58; 0&#44;008&#41;&#46; Tambi&#233;n disminuyeron los pacientes en coma &#40;29&#44;8&#37; vs&#46; 13&#44;5&#37;&#59; p&#58; 0&#44;004&#41; o con trauma grave &#40;48&#44;5&#37; vs&#46; 29&#44;7&#37;&#59; p&#58; 0&#44;005&#41;&#46; De los indicadores analizados solo se observ&#243; mejor&#237;a en el uso de collar&#237;n cervical &#40;17&#44;3&#37; vs&#46; 32&#44;7&#37;&#59; p&#58; 0&#44;01&#41;&#44; sin modificarse el porcentaje de pacientes en los que no se realiza ninguna acci&#243;n en la asistencia inicial &#40;19&#37; vs&#46; 11&#37;&#59; p&#58; 0&#44;15&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Aunque con mejoras aisladas&#44; el desarrollo de un programa formativo espec&#237;fico no se ha traducido en una mejora global de la calidad asistencial en este tipo de pacientes&#46; La formaci&#243;n en trauma debe complementarse con medidas de refuerzo para conseguir una aplicaci&#243;n sistem&#225;tica del algoritmo de actuaci&#243;n&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ib&#225;&#241;ez Pradas V&#44; P&#233;rez Montejano R&#46; Calidad asistencial en la atenci&#243;n inicial al trauma pedi&#225;trico&#46; An Pediatr &#40;Barc&#41;&#46; 2017&#59;87&#58;337&#8211;342&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleBold">Previous presentation&#58;</span> This study was presented at the Jornada Conmemorativa of the XXV Curso de AITP-Valencia&#58; Avanzando en la formaci&#243;n del politrauma pedi&#225;trico&#46; March 3&#44; 2016&#59; Valencia&#44; Spain&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mobile critical care physician&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mobile critical care nurse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatrics&#47;paediatric surgery resident&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">170 &#40;34&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatrician&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital nurse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56 &#40;11&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Traumatologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric surgeon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family physician&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Plastic surgeon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">493&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1604461.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of students by specialty &#40;March 2004&#8211;March 2016&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>105<br><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>113<br><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;64&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;66&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="center" valign="middle">0&#46;80</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;35&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;33&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Mechanism of injury</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unintentional fall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="8" align="center" valign="middle">0&#46;0001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fall from height&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Motor vehicle &#40;rider&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Motor vehicle &#40;pedestrian&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bicycle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;7&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;11&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Crushing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Direct hit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;5&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Care team</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Trauma centre&#46; Emergency department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;13&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="6" align="center" valign="middle">0&#46;008</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Trauma centre&#46; PICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;29&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56 &#40;51&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Primary Care Centre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intensive Care ambulance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Basic Life Support &#40;BLS&#41;&#46; Ambulance without medical staff &#40;nurse or physician&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Severity</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Patients with GCS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;29&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;13&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Patients with PTS<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;48&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;29&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1604459.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;6 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glasgow Coma Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;5 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;08 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric Trauma Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;9 &#40;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3 &#40;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1604458.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the study sample&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Peripheral catheter placement</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94 &#40;85&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;054&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Use of cervical collar</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;17&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;32&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Orotracheal intubation &#40;OTI&#41; if GCS</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8804;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">8</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;54&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Gastric intubation in case of severe trauma &#40;PTS</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8804;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">8&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;24&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Number of initial interventions from the following</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cervical spine control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Oxygen administration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Peripheral vascular catheter placement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Administration of IV fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;19&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;11&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="5" align="left" valign="middle">0&#46;15</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;8&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;13&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;33&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;26&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;21&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;20&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1604460.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Initial care quality indicators&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:18 [
            0 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "&#91;Epub ahead of print&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A national analysis of pediatric trauma care utilization and outcomes in the United States"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;R&#46; Myers"
                            1 => "C&#46;C&#46; Branas"
                            2 => "B&#46; French"
                            3 => "M&#46;L&#46; Nance"
                            4 => "B&#46;G&#46; Carr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/PEC.0000000000000902"
                      "Revista" => array:3 [
                        "tituloSerie" => "Pediatr Emerg Care"
                        "fecha" => "2016"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21252817"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "The European Injury Database&#46; Bruselas&#58; Comisi&#243;n Europea &#91;Updated in 2014&#59; accessed 28&#46;03&#46;17&#93;&#46; Available from&#58; <a href="http://ec.europa.eu/health/data_collection/databases/idb_en">http&#58;&#47;&#47;ec&#46;europa&#46;eu&#47;health&#47;data&#95;collection&#47;databases&#47;idb&#95;en</a>&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Accidental injury in children&#58; hospital trauma records in a Spanish population"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Concheiro"
                            1 => "C&#46; Luances"
                            2 => "J&#46;M&#46; Quintill&#225;"
                            3 => "L&#46; Delgado"
                            4 => "J&#46; Pou"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1080/17457300601170216"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Inj Contr Saf Promot"
                        "fecha" => "2007"
                        "volumen" => "14"
                        "paginaInicial" => "125"
                        "paginaFinal" => "127"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17510850"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gravedad de los accidentes infantiles&#58; mortalidad y secuelas"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46; Casan&#237; Mart&#237;nez"
                            1 => "M&#46; Su&#225;rez-Varela"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Esp Pediatr"
                        "fecha" => "2001"
                        "volumen" => "57"
                        "paginaInicial" => "235"
                        "paginaFinal" => "242"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Accidentes infantiles&#46; Epidemiolog&#237;a y prevenci&#243;n"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46; Pou Fern&#225;ndez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "JANO"
                        "fecha" => "2008"
                        "volumen" => "1684"
                        "paginaInicial" => "35"
                        "paginaFinal" => "37"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evolution and development of the Advanced Trauma Life Support &#40;ATLS&#41; protocol&#58; a historical perspective"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D&#46;S&#46; Radvinsky"
                            1 => "R&#46;S&#46; Yoon"
                            2 => "P&#46;J&#46; Schmitt"
                            3 => "C&#46;J&#46; Prestigiacomo"
                            4 => "K&#46;G&#46; Swan"
                            5 => "F&#46;A&#46; Liporace"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3928/01477447-20120327-07"
                      "Revista" => array:6 [
                        "tituloSerie" => "Orthopedics"
                        "fecha" => "2012"
                        "volumen" => "35"
                        "paginaInicial" => "305"
                        "paginaFinal" => "311"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22495839"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Registro de trauma pedi&#225;trico&#58; an&#225;lisis de 1&#46;200 casos"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Navascu&#233;s"
                            1 => "J&#46; Soleto"
                            2 => "J&#46; Cerd&#225;"
                            3 => "G&#46; Barrientos"
                            4 => "R&#46; S&#225;nchez"
                            5 => "R&#46; Romero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Cir Pediatr"
                        "fecha" => "1998"
                        "volumen" => "11"
                        "paginaInicial" => "151"
                        "paginaFinal" => "160"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9927766"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impacto de los programas de formaci&#243;n en la asistencia al ni&#241;o traumatizado"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Navascu&#233;s"
                            1 => "J&#46; Soleto"
                            2 => "R&#46; Romero"
                            3 => "M&#46;A&#46; Garc&#237;a Casillas"
                            4 => "E&#46; Hern&#225;ndez"
                            5 => "O&#46; S&#225;nchez-Par&#237;s"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Cir Pediatr"
                        "fecha" => "2004"
                        "volumen" => "17"
                        "paginaInicial" => "28"
                        "paginaFinal" => "32"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15002722"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Estudio para la mejor&#237;a de la atenci&#243;n hospitalaria inicial del paciente politraumatizado&#58; proyecto TRAUMACAT"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Navarro"
                            1 => "M&#46; Koo"
                            2 => "C&#46; Orrego"
                            3 => "J&#46;M&#46; Mu&#241;oz-Vives"
                            4 => "M&#46; Rivero"
                            5 => "S&#46; Montmany"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "2014"
                        "volumen" => "143"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "25"
                        "paginaFinal" => "31"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluaci&#243;n de la actuaci&#243;n de los pediatras de atenci&#243;n primaria en un escenario simulado de trauma pedi&#225;trico"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46; Civantos Fuentes"
                            1 => "A&#46; Rodr&#237;guez N&#250;&#241;ez"
                            2 => "J&#46;A&#46; Iglesias V&#225;zquez"
                            3 => "L&#46; S&#225;nchez Santos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
                        "fecha" => "2012"
                        "volumen" => "77"
                        "paginaInicial" => "203"
                        "paginaFinal" => "207"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46;A&#46; Falcone Jr&#46;"
                            1 => "M&#46; Daugherty"
                            2 => "L&#46; Schweer"
                            3 => "M&#46; Patterson"
                            4 => "R&#46;L&#46; Brown"
                            5 => "V&#46;F&#46; Garcia"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jpedsurg.2008.02.033"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr Surg"
                        "fecha" => "2008"
                        "volumen" => "43"
                        "paginaInicial" => "1065"
                        "paginaFinal" => "1071"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18558184"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#191;Est&#225;n cambiando nuestros paradigmas en la enfermedad traum&#225;tica&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "E&#46; Alted L&#243;pez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2015"
                        "volumen" => "39"
                        "paginaInicial" => "375"
                        "paginaFinal" => "382"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Application of international classification injury severity score to national surgical quality improvement program defines pediatric trauma performance standards and drives performance improvement"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;J&#46; Tepas"
                            1 => "B&#46;G&#46; Celso"
                            2 => "C&#46;L&#46; Leaphart"
                            3 => "D&#46; Graham"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TA.0b013e3181a5f03c"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "2009"
                        "volumen" => "67"
                        "paginaInicial" => "185"
                        "paginaFinal" => "189"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19590333"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Importancia de la evaluaci&#243;n inicial en los traumatismos graves en la infancia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;J&#46; Pel&#225;ez Mata"
                            1 => "A&#46; Medina Villanueva"
                            2 => "S&#46; Garc&#237;a Saavedra"
                            3 => "S&#46; Prieto Espu&#241;es"
                            4 => "J&#46;A&#46; Concha Torre"
                            5 => "S&#46; Men&#233;ndez Cuervo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Cir Pediatr"
                        "fecha" => "2005"
                        "volumen" => "18"
                        "paginaInicial" => "17"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15901103"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mapping the use of simulation in prehospital care &#8211; a literature review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Abelsson"
                            1 => "I&#46; Rystedt"
                            2 => "B&#46;O&#46; Suserud"
                            3 => "L&#46; Lindwall"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1757-7241-22-22"
                      "Revista" => array:5 [
                        "tituloSerie" => "Scand J Trauma Resusc Emerg Med"
                        "fecha" => "2014"
                        "volumen" => "22"
                        "paginaInicial" => "22"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24678868"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Advanced trauma life support training for hospital staff"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46; Jayaraman"
                            1 => "D&#46; Sethi"
                            2 => "P&#46; Chinnock"
                            3 => "R&#46; Wong"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2014"
                        "volumen" => "8"
                        "paginaInicial" => "Cd004173"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Attrition of cognitive and trauma management skills after the Advanced Trauma Life Support &#40;ATLS&#41; course"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Ali"
                            1 => "R&#46; Cohen"
                            2 => "R&#46; Adam"
                            3 => "T&#46;J&#46; Gana"
                            4 => "I&#46; Pierre"
                            5 => "E&#46; Ali"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "1996"
                        "volumen" => "40"
                        "paginaInicial" => "860"
                        "paginaFinal" => "866"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8656470"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of a checklist on advanced trauma life support task performance during pediatric trauma resuscitation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D&#46;C&#46; Kelleher"
                            1 => "E&#46;A&#46; Carter"
                            2 => "L&#46;J&#46; Waterhouse"
                            3 => "S&#46;E&#46; Parsons"
                            4 => "J&#46;L&#46; Fritzeen"
                            5 => "R&#46;S&#46; Burd"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/acem.12487"
                      "Revista" => array:6 [
                        "tituloSerie" => "Acad Emerg Med"
                        "fecha" => "2014"
                        "volumen" => "21"
                        "paginaInicial" => "1129"
                        "paginaFinal" => "1134"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25308136"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:3 [
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0115" class="elsevierStylePara elsevierViewall">We thank the AITP-Valencia group&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/23412879/0000008700000006/v1_201711281541/S234128791730193X/v1_201711281541/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "26005"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Original Articles"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008700000006/v1_201711281541/S234128791730193X/v1_201711281541/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234128791730193X?idApp=UINPBA00005H"
]

Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2017.02.008

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	4	9	13
2024 October	29	32	61
2024 September	43	46	89
2024 August	61	48	109
2024 July	33	24	57
2024 June	45	22	67
2024 May	40	41	81
2024 April	50	32	82
2024 March	30	26	56
2024 February	37	31	68
2024 January	31	25	56
2023 December	23	14	37
2023 November	19	25	44
2023 October	24	21	45
2023 September	25	21	46
2023 August	24	19	43
2023 July	34	28	62
2023 June	27	25	52
2023 May	38	19	57
2023 April	35	15	50
2023 March	90	19	109
2023 February	32	12	44
2023 January	20	22	42
2022 December	71	27	98
2022 November	77	26	103
2022 October	48	36	84
2022 September	53	25	78
2022 August	47	46	93
2022 July	47	30	77
2022 June	64	30	94
2022 May	39	33	72
2022 April	34	34	68
2022 March	40	41	81
2022 February	38	22	60
2022 January	50	29	79
2021 December	47	41	88
2021 November	49	43	92
2021 October	60	65	125
2021 September	32	51	83
2021 August	25	56	81
2021 July	19	36	55
2021 June	29	44	73
2021 May	47	59	106
2021 April	111	54	165
2021 March	39	48	87
2021 February	21	17	38
2021 January	30	26	56
2020 December	26	33	59
2020 November	31	20	51
2020 October	28	15	43
2020 September	24	29	53
2020 August	24	32	56
2020 July	24	44	68
2020 June	23	24	47
2020 May	33	19	52
2020 April	17	17	34
2020 March	22	9	31
2020 February	18	13	31
2020 January	25	16	41
2019 December	41	13	54
2019 November	15	9	24
2019 October	21	13	34
2019 September	31	10	41
2019 August	42	21	63
2019 July	21	16	37
2019 June	18	17	35
2019 May	24	32	56
2019 April	34	27	61
2019 March	25	18	43
2019 February	31	22	53
2019 January	24	21	45
2018 December	24	22	46
2018 November	65	37	102
2018 October	109	33	142
2018 September	50	12	62
2018 August	2	0	2
2018 July	1	0	1
2018 June	2	0	2
2018 May	3	0	3
2018 April	17	0	17
2018 March	25	0	25
2018 February	16	0	16
2018 January	24	0	24
2017 December	1	0	1
2017 November	0	18	18
2017 October	0	1	1

Show all

Indexed in:

Follow us:

Subscribe:

Statistics

Indexed in:

Follow us:

Subscribe:

Statistics

Subscribe to our newsletter