PROJECT SUMMARY Unintentional injury is the leading cause of death among children in the United States. Several studies demonstrate decreased mortality when severely injured children are transported to high-level (levels 1 and 2) and designated pediatric trauma centers, compared with low-level (levels 3 or greater) and non-trauma centers. Field trauma triage aims to identify patients who require high-level trauma center resources, with 95% sensitivity and 65% specificity goals set by the American College of Surgeons Committee on Trauma (ACSCOT). The ACSCOT and the Centers for Disease Control and Prevention (CDC) publish field triage criteria, which are widely used by emergency medical service (EMS) agencies nationally. These criteria were developed and updated through expert consensus primarily for adults, and have been shown to undertriage severely injured children, with a reported sensitivity as low as 65%. In a 2020 systematic review, the Pediatric Trauma Society Research Committee stated the data supporting field triage criteria are “minimal and of low quality,” specifically calling for new research to establish individual criteria and combinations of criteria to determine where an injured child should be transported. While the need for refined pediatric field triage criteria is clear, progress has been limited by the lack of large-scale, linked prehospital and outcome data and implementation failures including missing and inaccurate physiologic measurements (e.g. blood pressure and mental status), and overreliance on provider judgement as the sole determinant of trauma center need. To address these gaps and improve the prehospital triage of injured children, we will perform a descriptive analysis of undertriage of children in 7 states using AHRQ Healthcare Cost and Utilization (HCUP) databases, derive and validate refined pediatric field triage using predictive modeling of a robust population-based dataset containing prehospital and outcome data from Los Angeles County, and conduct a mixed-methods study evaluating implementation outcomes of the refined criteria in an urban EMS system. This proposal directly addresses AHRQ priority populations including pediatric, minority, rural, and low-income, and is directly responsive to AHRQ research priorities of improving health care patient safety by identifying potential harm from and disparities in undertriage, designing and evaluating interventions to improve patient safety, and harnessing data (including HCUP databases) to improve health care quality and patient outcomes. Successful completion of this work will advance this field of study by describing the potential health impact of accurate field triage, establishing preliminary implementation outcomes in preparation for a large, hybrid effectiveness- implementation trial to evaluate the refined criteria, and identifying key barriers to prehospital care of injured children to inform future adaptations and implementation strategies. During this award, I will obtain the training, mentorship, and experience in large-scale data analytics, predictive modeling, and D&I science necessary to become an independent health services researcher focused on improving emergency care for children.

PROJECT NARRATIVE Severely injured children have better health outcomes when they are transported to high-level trauma centers. Current national field trauma triage guidelines, which have been widely adopted by emergency medical services (EMS) systems nationally, do not accurately identify children in need of trauma center resources. We will describe the potential health impact of accurate field triage through a descriptive analysis of undertriage of children in 7 states using AHRQ Healthcare Cost and Utilization (HCUP) databases, derive and validate refined pediatric field triage using predictive modeling of a robust population-based dataset, and conduct a mixed methods study evaluating implementation outcomes of the refined criteria in an urban EMS system, with the ultimate goal of matching injury severity with appropriate resources to improve patient outcomes.