Background and aims:​ The importance and safety of non-operative management in splenic injury has been established in children and adults. However, international evidence shows when children are managed in adult centres, operation rates are higher than established benchmarks, while when adolescents are managed in paediatric centres, operation rates meet paediatric benchmarks. In New South Wales, splenic injury management in children (0-16 years) at a population level and factors associated with variation in management, have not been studied. Additionally, management in young adults (17- 25 years) has not been examined in this distinct cohort. This work fills these gaps in knowledge.

Methods:​ Three studies were undertaken to investigate the management of splenic injury in children and young adults. The first two used linked administrative data to compare splenic injury management of (a) children 0-16 years and (b) young people 17-25 years, between different hospital types (Study 1), and different age groups (Study 2). For the final study, a survey of NSW surgeons and a mixed methods approach underpinned by behaviour change theory, were used to gain insight regarding surgeon level factors impacting management of splenic injury.

Results:​ This work confirmed management outside paediatric trauma centres for children, and age over 16 years, influenced variations in management. A high level of optimism amongst adult surgeons regarding their capacity to care for children was found. However, adult and paediatric surgeons take different management approaches, especially in complex cases. These differences align with the differences in published North American adult and paediatric guidelines, and appear motivated by surgeon training, experience, professional situation and trauma system opportunities.

Conclusion:​ While paediatric surgeons in NSW have wholeheartedly adopted non-operative management, outside paediatric centres, paediatric operation rates do not meet established benchmarks. In addition, they rise significantly in young adults, with few identifiable patient factors unique to this age group accounting for this. Survey results reveal a need to increase surgeon motivation to offer non-operative management away from paediatric trauma centres and among young people generally, to reduce unwarranted variations in management. Revised guidelines and attention to training and support provided to surgeons in adult centres, as well as addressing NSW trauma system factors contributing to current practices may help achieve this.