Trauma is one of the most frequent causes of death in childhood [1]. The World Health Organization reports that unintentional injuries result in the deaths of 830,000 children per year [2]. Pediatric major trauma is one of the most frequent presentations in the resuscitation bay of pediatric emergency departments (PEDs) [3–6]. Pediatric trauma care is a critical aspect of specialized medical practice and demands tailored strategies to ensure optimal patient outcomes. In industrialized countries, trauma care is delivered by specialized, multidisciplinary teams [7,8]. Allocation of team roles may vary depending on jurisdiction, scope of practice, institution, and tradition. In 2014, Switzerland recognized pediatric emergency medicine (PEM) as a subspecialty [9]. This recognition led to the amalgamation of medical and surgical departments to provide unified pediatric emergency care, in line with global standards [4]. In Switzerland, the governance of highly specialized medicine (HSM), which includes pediatric major trauma care, is coordinated at the national level with the aim of optimizing care delivery and resource allocation. Eight pediatric trauma centers (PTCs) are authorized to treat seriously injured children with acute life-threatening injuries [10], and these institutions must fulfill specific infrastructural, organizational, geographical, and logistical requirements. Globally, multidisciplinary pediatric trauma care is highly variable and depends on patient volume, individual experience, and local infrastructure [11]. PTC outcomes are significantly better than those of general trauma centers, including having lower mortality rates and fewer complications [12]. Several Swiss PTCs have separately published their data [3,5,13]. The framework for adult trauma care has been delineated elsewhere [14]. To conduct an overview of pediatric trauma care, a national online survey was conducted among all PTCs. The survey was conducted to explore and analyze pediatric trauma care practices in specialized medical centers across Switzerland. This report presents the findings. The objective of this review was to acquire insights into interdisciplinary approaches, trauma team activation (TTA) methods, patient management strategies, and communication modalities. The findings can help facilitate assessment of the need for and feasibility of implementing a national pediatric trauma data collection initiative in Switzerland.

All Swiss PTCs responded from May to July 2020, resulting in a response rate of 100%. All PEDs are run by pediatricians subspecializing in PEM. Seven out of eight PEDs are integrated, which means that patients are first seen by pediatric emergency physicians rather than pediatricians or surgeons. Three PTCs are independent children’s hospitals; the other PTCs are integrated pediatric hospitals (Fig. 1, Table 1).

The results of this survey provide an overview of the management of pediatric trauma care at all accredited PTCs in Switzerland, with a focus on TTA, trauma reception, and team composition.

The modes of TTA vary widely, with activation by individual phone calls being the most frequent. Likewise, activation criteria vary somewhat. In all but one center, the default trauma team leaders are nonsurgeons.

Globally, pediatric trauma volumes are at an insignificant level in many centers [11]. However, PTCs apparently have better outcomes than adult or combined trauma centers [12]. Published pediatric trauma volumes at individual centers are evidently lower in Europe at level I PTCs [3,5,16] than overseas [17]. That finding aligns with those of this survey and of local Swiss studies [3–5].

However, the volume of TTAs may not correspond to trauma severity, as even severely injured children may present as walk-in patients with their caregivers [5]. This study shows that TTA criteria differ at Swiss trauma centers. The accuracy of appropriate TTA may depend on communication between prehospital crews and receiving clinicians and on institutional policies (e.g., trauma arrival by helicopter as an automatic TTA trigger). Previous studies have addressed the dilemma of overtriage and undertriage in pediatric trauma and the resulting problems in resource allocation [7,18]. Ultimately, refining the criteria for TTA for both adults and children remains an ongoing challenge; the ideal criteria have yet to be determined [11,19].

This study revealed that the anesthesiologist is the default choice for pediatric airway management at all institutions. The trauma team leader role varies; however, in most centers surveyed, the role is held by either senior PEM physicians or senior PICU physicians, who primarily oversee initial stabilization and continuous evaluation. This finding aligns with those of previous studies that reported no difference in patient outcome regardless of whether the trauma team leader was a surgeon or nonsurgeon [20]. These data suggest that the pediatric surgeon's role is mainly to address and manage life-threatening injuries in the resuscitation bay and after transfer to the operating room.

The responses indicate that the role of trainee doctors is key in managing departmental flow, especially when resources are committed to resuscitation efforts. The role is crucial for maintaining the care of all patients presenting to the PED. Ensuring prudent resource allocation and avoiding overtriage is vital to preventing risks to low-acuity patients. It highlights the importance of precise prehospital communication.

The number of PICU beds differs among centers but approximates the numbers cited in prior research and in the data of the Swiss Society for Intensive Care Medicine [21,22]. Internationally, the rationale for the existence of eight pediatric centers in a country such as Switzerland, with a population of 9 million, may be debatable, especially when compared with, for example, Victoria, Australia, which has an area six times larger, a population of 6 million, and only one PTC [23]. However, the Swiss Alpine region (58% of territory, 23% above 2,000-m elevation) presents both topographical and meteorological obstacles that complicate access for road-ambulance and helicopter emergency services operating under visual flight rules [24]. Historically, the Swiss healthcare system has been characterized by fragmentation that mirrors the country's federal structure and the variety of cultures and languages [25]. Because the number of TTAs frequently exceeds the number of actual major trauma cases, some PTCs receive low numbers of severe cases. This may warrant discussion on the benefit of consolidating PTCs. Whether the limited exposure to pediatric major trauma cases can be effectively offset by collaboration with adult services remains uncertain.

Similar variation in trauma management has been observed outside Switzerland. A survey of French level I PTCs reported significant heterogeneity in trauma management practices, with variations in trauma reception locations and involvement of adult physicians and surgeons in pediatric trauma resuscitation [26]. Although data from North America are abundant with more standardized protocols [12], trauma management practices and systems are highly diverse elsewhere [27].

This study had several limitations. In the absence of a national trauma registry, the numbers of trauma activations are self-reported by the respondents of the centers. Since May 2020, when the survey was conducted, time has elapsed, and the number of ICU beds and TTAs may have changed. Furthermore, the number of physical beds may not reflect the actual capacity due to staffing issues. Although the survey achieved a 100% response rate, the small size of the country naturally limited the sample size. Moreover, because this was a national survey, its results are not internationally generalizable.

The establishment of a pediatric trauma registry in Switzerland would provide a centralized database of pediatric major trauma cases and enable the collection of standardized data on injury mechanisms, patterns, severity, and outcomes [5,23]. The first update in 13 years to the Swiss HSM plan now requires each center to submit to authorities a minimal dataset for pediatric major trauma [28]. Many PTCs face numerous operational challenges, including resource allocation and funding, staff training and retention, coordination and communication inefficiencies, and geographic and environmental barriers. Overcoming these challenges through standardized protocols and enhanced resource allocation may help improve pediatric trauma care globally.

This report provides an overview of pediatric trauma care practices in the emergency departments of PTCs in Switzerland. It also highlights the national variability in TTA methods, criteria, pediatric trauma volumes, and team compositions. Despite the inherent limitations of self-reported data and the small national sample size, the findings illuminate the complexities and challenges of delivering pediatric trauma care. Future research should aim to overcome the limitations of this study, potentially through the establishment of national trauma registries, to provide more robust data for trauma prevention and improvement of pediatric trauma care.