Trauma center designation: initial impact on trauma-related mortality

Assessment of Ohio's adult and pediatric legislatively mandated prehospital trauma triage criteria

BACKGROUND

The study objective was to validate prehospital indicators mandated by the Ohio legislature.

METHOD

The design was a retrospective case review using adult and pediatric tools developed to assess prehospital documentation of anatomic and physiologic indicators of significant trauma.

RESULTS

There were 400 adult records with Glasgow Coma Score, the most frequently cited (23.5%). Fifty-four percent of the adult cases had at least 1 item checked. There were 104 pediatric cases reviewed, where 49% of the cases had at least 1 indicator checked.

CONCLUSIONS

The mandated trauma indicators appear to be valid measures for use in trauma research.

The influence of insurance status on the transfer of femoral fracture patients to a level-I trauma center

BACKGROUND

The aim of the present study was to evaluate transfer patterns and insurance status for patients with a femoral fracture who were definitively managed within a six-hospital health-care system. We hypothesized that insurance status significantly influenced transfer of these patients to the level-I trauma center and that the level-I center provided definitive care for a disproportionate percentage of uninsured femoral fracture patients.

METHODS

The present retrospective cohort study was performed within a six-hospital health-care system. The system comprises a single American College of Surgeons-designated level-I trauma center and five nondesignated community hospitals. We identified 243 patients with 251 femoral shaft fractures that had been definitively treated with intramedullary nail fixation within the system. From the health-care system billing database and trauma registries, we obtained diagnosis and procedure codes, insurance status, and trauma center transfer data. Differences in the proportions of uninsured and insured patients were calculated.

RESULTS

One hundred and seventy-two (71%) of the 243 patients who were definitively managed within our health-care system initially had been taken to the regional level-I center, and thirty-eight patients (16%) had been transferred to the trauma center. Of the thirty-eight patients who had been transferred, eighteen (47%) had met appropriate transfer criteria. Of the twenty patients with an isolated femoral fracture who had been transferred from hospitals with regular orthopaedic coverage, four (20%) had met appropriate transfer criteria. Twenty-two (58%) of the thirty-eight patients who had been transferred were uninsured, and all thirty-three patients who had not been transferred were insured (p = 0.0008); this observation remained when controlling for injury severity and available orthopaedic coverage (p < 0.0001). The proportion of insured patients definitively managed at the trauma center (52%) differed significantly from the proportion of insured patients definitively managed at the community hospitals (100%) (p < 0.0001).

CONCLUSIONS

The majority (71%) of the patients with a femoral fracture who had been managed definitively within our health-care system, regardless of injury severity, had been taken directly to the trauma center. This finding suggests over-triage, which errs on the side of patient well-being. Because there was a significant difference in insurance status between patients who had been transferred to the level-I center and those who had not been transferred as well as between patients who had been definitively managed at the level-I center and those who had been managed in community hospitals, it can be assumed that insurance status as well as injury severity and orthopaedic surgeon availability influence the decision to transfer femoral fracture patients to a level-I trauma center.

Incidence and outcome of traumatic brain injury in an urban area in Western Europe over 10 years

INTRODUCTION

Valid epidemiological data on incidence and outcome of traumatic brain injury (TBI) show great variability. A study on incidence, severity and outcome of TBI was conducted in an urban area of one million inhabitants.

MATERIALS AND METHODS

130,000 prehospital emergencies were screened for TBI.

INCLUSION CRITERIA

Glasgow Coma Scale (GCS) score <or=8 and/or Abbreviated Injury Scale for head injuries (AIS(head)) score >or=2 with confirmed TBI via appropriate diagnostics.

RESULTS

Annual incidence was 7.3/100,000. Overall mortality rate was 45.8%: 182 (28%) were prehospital deaths, 116 (17.8%) patients died in hospital. Two hundred and fourteen of 352 (60.8%) surviving patients were sufficiently rehabilitated at discharge [Glasgow Outcome Scale (GOS) score = 1], but 138 patients (39.2%) survived with persisting deficits. GOS was associated with initial GCS and AIS(head).

CONCLUSION

The incidence of TBI was lower compared to the literature. The overall mortality was high, especially prehospital and early in-hospital mortality rates.

Prioritizing the organization and management of intensive care services in the United States: the PrOMIS Conference

OBJECTIVE

Adult critical care services are a large, expensive part of U.S. health care. The current agenda for response to workforce shortages and rising costs has largely been determined by members of the critical care profession without input from other stakeholders. We sought to elicit the perceived problems and solutions to the delivery of critical care services from a broad set of U.S. stakeholders.

DESIGN

A consensus process involving purposive sampling of identified stakeholders, preconference Web-based survey, and 2-day conference.

SETTING

Participants represented healthcare providers, accreditation and quality-oversight groups, federal sponsoring institutions, healthcare vendors, and institutional and individual payers.

SUBJECTS

We identified 39 stakeholders for the field of critical care medicine. Thirty-six (92%) completed the preconference survey and 37 (95%) attended the conference.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants expressed moderate to strong agreement with the concerns identified by the critical care professionals and additionally expressed consternation that the critical care delivery system was fragmented, variable, and not patient-centered. Recommended solutions included regionalizing the adult critical care system into "tiers" defined by explicit triage criteria and professional competencies, achieved through voluntary hospital accreditation, supported through an expanded process of competency certification, and monitored through process and outcome surveillance; implementing mechanisms for improved communication across providers and settings and between providers and patients/families; and conducting market research and a public education campaign regarding critical care's promises and limitations.

CONCLUSIONS

This consensus conference confirms that agreement on solutions to complex healthcare delivery problems can be achieved and that problem and solution frames expand with broader stakeholder participation. This process can be used as a model by other specialties to address priority setting in an era of shifting demographics and increasing resource constraints.

Towards Regionalized Care of Severe Orthopedic Injuries: A Survey on Non-university Hospitals in Finland

INTRODUCTION

The principles of a designated trauma system and regionalization of trauma care exist in very limited areas in Finland. In this study, we obtained information on the current personal opinions of orthopedicsin-chief (OICs) and surgeons-in-chief (SICs) towards regionalization of severe orthopedic trauma care in Finland.

MATERIALS AND METHODS

A questionnaire was sent to OICs and SICs working in 36 primary and secondary hospitals providing acute surgical care asking to give their personal opinions whether certain severe orthopedic injuries should be managed in their hospitals or be referred.

RESULTS

The overall response rate was 49/67 (73%). In general, SICs tended to be more reluctant to refer patients to higher level facilities. Both OICs and SICs were more willing to refer spinal and pelvic injuries than complicated long bone fractures.

CONCLUSIONS

There seems to be major differences in personal views on referral policy between OICs and SICs. This information is useful prior to discussions by the professional organizations, hospitals, and the government in establishing a modern orthopedic trauma system in Finland.

The impact of trauma centre accreditation on patient outcome

Trauma centre accreditation originated as a North American initiative in the 1970's with the aim of standardising and improving care for injured patients. This system of grading a hospital's ability to receive serious trauma has subsequently spread, most notably to Australasia. Many studies have focussed on determing whether this accreditation results in improved patient outcomes. We review the evidence to date, which suggests significant mortality reductions albeit from mainly Class III studies and reflect on the future sustainability of this initiative given mounting financial pressures.

Improving outcomes in a regional trauma system: impact of a level III trauma center

BACKGROUND

Trauma systems decrease morbidity and mortality of injured populations, and each component contributes to the final outcome. This study evaluated the association between a referring hospital's trauma designation and the survival and resource utilization of patients transferred to a level I trauma center.

METHODS

Data from the Registry of the American College of Surgeons on patients transferred to a level I trauma center during a 7-year period were subdivided into 3 categories: group 1 = level III-designated trauma center; group 2 = potential level III trauma centers; and group 3 = other transferring hospitals. Trauma and Injury Severity Score methodology was used to provide a probability estimate of survival adjusted for the effect related to injury severity, physiologic host factors, and age. A W statistic was calculated for each type of referring hospital so that comparisons between observed survival and predicted survival could be measured. Differences in W, length of stay, intensive care unit days, and ventilator days were examined using general linear models.

RESULTS

Patients transferred to a level I from a level III trauma center (group 1) were more seriously injured (P < .0001) and had improved survival (P < .0018) compared with those transferred from nondesignated hospitals (groups 2 and 3). Patients transferred from large nondesignated hospitals (group 2) had outcomes similar to patients transferred from all other hospitals (group 3). Level I hospital resource utilization did not show significant differences based on referring hospital type.

COMMENTS

Outcomes of patients in a trauma system are associated with trauma-center designation of the referring hospitals.

Analysis of trends in the Florida Trauma System (1991-2003): changes in mortality after establishment of new centers

BACKGROUND

This study analyzes trends in hospitalization and outcome for adult, elderly, and pediatric trauma victims in the Florida Trauma System (FTS) from 1991 to 2003, during which time the number of centers nearly doubled from 11 to 20.

METHODS

Administrative data was queried for all admissions with at least one trauma related discharge. Patients were stratified by age as pediatric (age, 0 to 15 years), adult (age, 16 to 64 years), or elderly (age, >64 years). Volume of admissions, severity, and mortality were analyzed over time. A logistic regression model was used to test the existence of an organizational experience curve after the designation of a new trauma center.

RESULTS

Injury-related hospitalizations increased for the elderly, stayed the same for adults, and declined for children. As the system matured, a larger percentage of victims, particularly the most severely injured, were triaged to trauma centers, indicating more effective triage. In contrast to adults and pediatric patients, the majority of elderly trauma victims were managed at non-trauma centers. The trauma mortality rate per 1,000 population among the elderly increased during the study period (P < .01). Multivariate analysis indicated that for adult and pediatric victims it took up to 3 years after the designation of trauma center status before the odds of mortality reached parity with that of established centers.

CONCLUSIONS

The FTS has grown with its population and has matured to treat a larger percentage of trauma victims. Trauma victims transported to established trauma centers (4+ years) have a survival advantage compared to their counterparts transported to newly created centers. The reduction in the odds of mortality does not occur immediately after trauma center designation.

The impact of trauma activations on the care of emergency department patients with potential acute coronary syndromes

STUDY OBJECTIVE

Trauma systems improve the care of trauma patients; however, it is possible that prioritizing the emergency care of trauma patients might adversely affect other potentially ill patients requiring the same resources. We seek to determine whether the presence of a concurrent trauma activation negatively affects processes of care and outcomes for patients with potential acute coronary syndromes.

METHODS

Patients who presented to the emergency department (ED) with a potential acute coronary syndrome from July 2003 to June 2004 were stratified according to whether they presented concurrently with a trauma activation. Structured data collection included demographics, medical history, and daily tracking of inhospital course. Thirty-day follow-up was performed. The main outcome was a composite of inhospital cardiovascular complications and 30-day death and myocardial infarction. Secondary outcomes were time from triage to ECG acquisition, transfer to an evaluation room, return of laboratory results, disposition decision, and actual disposition.

RESULTS

Patients who presented concurrently with (n=357) or not concurrently with (n=1,235) a trauma activation were similar with respect to demographic characteristics, cardiac risk factors, and TIMI risk score. The unadjusted incidence of 30-day adverse cardiovascular events between potential acute coronary syndrome patients who presented with and without a concurrent trauma activation was 6.2% versus 3.6% (unadjusted odds ratio 1.74 [95% confidence interval (CI) 1.03 to 2.93]). After adjustment for measures of patient acuity (triage classification, TIMI risk score) and ED volume (total patient care hours and ED activity), concurrent trauma activation was independently associated with increased rate of 30-day cardiovascular complications (odds ratio 1.72; 95% CI 1.01 to 2.92).

CONCLUSION

The presence of a concurrent trauma activation at the time of presentation of a patient with potential acute coronary syndrome was associated with an increased incidence of 30-day adverse cardiovascular events. Although trauma activations improve the care of trauma patients, they may be associated with a negative impact on the care of other patients requiring contemporaneous resources.

Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations

OBJECTIVES

To describe the organization and distribution of intensive care unit (ICU) patients and services in the United States and to determine ICU physician staffing before the publication and dissemination of the Leapfrog Group ICU physician staffing recommendations.

DESIGN AND SETTING

Stratified, weighted survey of ICU directors in the United States, performed as part of the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS) study. Using lenient definitions, we defined an ICU as "high intensity" if > or =80% of patients were cared for by a critical care physician (intensivist) and defined an ICU as compliant with Leapfrog if it was both high-intensity and providing some form of in-house physician coverage during all hours.

SUBJECTS

Three hundred ninety-three ICU directors.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We obtained a 33.5% response rate (393/1,173). We estimated there were 5,980 ICUs in the United States, caring for approximately 55,000 patients per day, with at least one ICU in all acute care hospitals. The predominant reasons for admission were respiratory insufficiency, postoperative care, and heart failure. Most ICUs were combined medical-surgical ICUs (n = 3,865; 65%), were located in nonteaching, community hospitals (n = 4,245; 71%), and were in hospitals of <300 beds (n = 3,710; 62%). One in four ICUs were high-intensity (n = 1,578; 26%), half had no intensivist coverage (n = 3,183; 53%), and the remainder had at least some intensivist presence (n = 1,219; 20%). High-intensity units were more common in larger hospitals (p = .001) and in teaching hospitals (p < .001) and more likely to be surgical (p < .001) or trauma ICUs (p < .001). Few ICUs had any in-house physician coverage outside weekday daylight hours (20% during weekend days, 12% during weeknights, and 10% during weekend nights). Only 4% (n = 255) of all adult ICUs in the United States appeared to meet the full Leapfrog standards (a high-intensity ICU staffing pattern plus dedicated attending coverage during daytime plus dedicated coverage by any physician during nighttime).

CONCLUSIONS

ICU services are widely distributed but heterogeneously organized in the United States. Although high-intensity ICUs have been associated previously with improved outcomes, they were infrequent in our study, especially in smaller hospitals, and virtually no ICU met the Leapfrog standards before their dissemination. These findings highlight the considerable challenge to any efforts designed to promote either 24-hr physician coverage or high-intensity model organization.

A Systematic Review and Meta-Analysis Comparing Outcome of Severely Injured Patients Treated in Trauma Centers Following the Establishment of Trauma Systems

BACKGROUND

The establishment of trauma systems was anticipated to improve overall survival for the severely injured patient. We systematically reviewed the published literature to assess if outcome from severe traumatic injury is improved for patients following the establishment of a trauma system.

METHODS

A systematic literature review of all population-based studies that evaluated trauma system performance was conducted. A qualitative analysis of each study's design and methodology and a meta-analysis was performed to evaluate the evidence to date of trauma system effectiveness.

RESULTS

A search of the literature yielded 14 published articles. Trauma systems demonstrated improved odds of survival in 8 of the 14 reports. The overall quality-weighted odds ratio was 0.85 lower mortality following trauma system implementation.

CONCLUSIONS

The results of the meta-analysis showed a 15% reduction in mortality in favor of the presence of a trauma system. Evaluation of trauma system effectiveness must remain an uncompromising commitment to optimal outcome for the injured patient.

Relationship Between American College of Surgeons Trauma Center Designation and Mortality in Patients with Severe Trauma (Injury Severity Score > 15)

BACKGROUND

We studied the association of the American College of Surgeons (ACS) trauma center designation and mortality in adult patients with severe trauma (Injury Severity Score > 15). ACS designation of trauma centers into different levels requires substantial financial and human resources commitments. There is very little work published on the association of ACS trauma center designation and outcomes in severe trauma.

STUDY DESIGN

National Trauma Data Bank study including all adult trauma admissions (older than 14 years of age) with Injury Severity Score (ISS) > 15. The relationship between ACS level of trauma designation and survival outcomes was evaluated after adjusting for age, mechanism of injury, ISS, hypotension on admission, severe liver trauma, aortic, vena cava, iliac vascular, and penetrating cardiac injuries.

RESULTS

A total of 130,154 patients from 256 trauma centers met the inclusion criteria. Adjusted mortality in ACS-designated Level II centers and undesignated centers was notably higher than in Level I centers (adjusted odds ratio, 1.14; 95% CI, 1.09-120; p < 0.0001 and adjusted odds ratio, 1.09; CI, 1.05-1.13; p < 0.0001, respectively).

CONCLUSIONS

Severely injured patients with ISS > 15 treated in ACS Level I trauma centers have considerably better survival outcomes than those treated in ACS Level II centers.

The effect of trauma center designation and trauma volume on outcome in specific severe injuries

OBJECTIVE

The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries.

BACKGROUND

Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated.

METHODS

The National Trauma Data Bank study, which included patients >14 years of age and had injury severity score (ISS) >15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and II trauma centers and between centers within the same level designation but different volumes of severe trauma (<240 vs > or =240 trauma admissions with ISS >15 per year). The outcomes were adjusted for age (<65 > or =65), gender, mechanism of injury, hypotension on admission, and ISS (< or =25 and >25).

RESULTS

A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71-0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44-0.69; P < 0.001) than level II centers. Subgroup analysis showed that cardiovascular injuries (N = 2004) and grades IV-V liver injuries (N = 1415) had a significantly better survival in level I than level II trauma centers (adjusted P = 0.017 and 0.023, respectively). Overall, there was a significantly better functional outcome in level I centers (adjusted P < 0.001). Subgroup analysis showed level I centers had significantly better functional outcomes in complex pelvic fractures (P < 0.001) and a trend toward better outcomes in the rest of the subgroups. The volume of trauma admissions with ISS >15 (<240 vs > or =240 cases per year) had no effect on outcome in either level I or II centers.

CONCLUSIONS

Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation.

Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study

BACKGROUND

Case fatality rates after all types of blunt injury have not improved since 1994 in England and Wales, possibly because not all patients with severe head injury are treated in a neurosurgical centre. Our aims were to investigate the case fatality trends in major trauma patients with and without head injury, and to establish the effect of neurosurgical care on mortality after severe head injury.

METHODS

We analysed prospectively collected data from the Trauma Audit and Research Network database for patients presenting between 1989 and 2003. Mortality and odds of death adjusted for case mix were compared for patients with and without head injury, and for those treated in a neurosurgical versus a non-neurosurgical centre.

FINDINGS

Patients with head injury (n=22,216) had a ten-fold higher mortality and showed less improvement in the adjusted odds of death since 1989 than did patients without head injury (n=154,231). 2305 (33%) of patients with severe head injury (presenting between 1996 and 2003) were treated only in non-neurosurgical centres; such treatment was associated with a 26% increase in mortality and a 2.15-fold increase (95% CI 1.77-2.60) in the odds of death adjusted for case mix compared with patients treated at a neurosurgical centre.

INTERPRETATION

Since 1989 trauma system changes in England and Wales have delivered greater benefit to patients without head injury. Our data lend support to current guidelines, suggesting that treatment in a neurosurgical centre represents an important strategy in the management of severe head injury.

The association between trauma system and trauma center components and outcome in a mature regionalized trauma system

BACKGROUND

Regionalized trauma systems have been shown repeatedly to improve the outcome of seriously injured patients. However, we do not have data regarding which components of these systems have the most impact on outcome and to what degree. The objective of this study was to understand the association between various components that make up a trauma system and outcome.

METHODS

Surveys were administered to trauma directors at 59 hospitals in the province of Quebec, Canada. Data from the surveys were then linked with specific outcome variables obtained from a regionalized trauma database. Specific outcomes were assigned to trauma system- and in-hospital-based components after controlling for injury severity.

RESULTS

Over 4.8 years, 72,073 patients met inclusion criteria. Components found to affect survival after risk adjustment were prehospital notification (OR, 0.61; 95% CI, 0.39-0.94) and the presence of a performance improvement program in that hospital (OR, 0.44; 95% CI, 0.20-0.94). Increased patient volume was associated with a reduction in risk-adjusted mortality (OR, 0.98; 95% CI, 0.97-0.99). Tertiary trauma centers were also associated with a reduction in risk-adjusted mortality compared with both secondary and primary centers (OR, 0.68; 95% CI, 0.48-0.99).

CONCLUSIONS

Improvements in outcome in a regionalized trauma system are secondary to a combination of elements, as well as to the interplay of these elements on each other. Prehospital notification protocols and performance improvement programs appear to be most associated with decreased risk-adjusted odds of death.

Monitoring performance: longterm impact of trauma verification and review

BACKGROUND

This study documents how the verification process at a Level I pediatric trauma center affected patient care through changes in care indicators (CIs) from predesignation through four postverification time frames. An important component of any verification program is its effectiveness, not only at the time of verification but during the time between "examinations." To date, few data exist describing the interval periods and the progression and maturation of a trauma program after initial verification.

STUDY DESIGN

Forty-seven distinct CIs were monitored monthly through data generated from the trauma registry. Six distinct time periods were identified. PRE (January, June, October 1997), trauma care without monitoring; VER (November 1999 to September 2000), preparation for verification; and four postverification periods: P1 (January to June 2001), P2 (July to December 2001), P3 (January to June 2002), and P4 (July to September 2002).

RESULTS

Between 1997 and 2002, trauma admissions increased from 200 per year to 313 per year. Mortality rate and Injury Severity Score distributions remained unaltered. Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (<120 minutes) improved in each study section and remained high during the postverification time period. There was a strong pair-wise correlation (p < 0.005, Cronbach alpha 0.8) between CNS charting and acquisition of head CAT scans. Pediatric ICU duration of stay increased in both the (summer) P2 and P4 time periods. Prehospital and emergency department fluid monitoring remained unsatisfactory.

CONCLUSIONS

Statistically significant changes in patient care indicators were noted to improve during the trauma center designation process, and other key deficiencies were identified and addressed. Maintaining these improvements requires constant monitoring or performance may revert below accepted levels.

Developing Australia's first statewide trauma registry: what are the lessons?

Trauma registries, like disease registries, provide an important analysis tool to assess the management of patient care. Trauma registries are well established and relatively common in the USA and have been used to change legislation, promote trauma prevention and to evaluate trauma system effectiveness. In Australia, the first truly statewide trauma registry was established in Victoria in 2001 with an estimated capture of 1700 major trauma cases annually. The Victorian State Trauma Registry, managed by the Victorian State Trauma Outcomes Registry and Monitoring (VSTORM) group, was established in response to a ministerial review of trauma and emergency services undertaken in 1997 to advise the Victorian Government on a best practice model of trauma service provision that was responsive to the particular needs of critically ill trauma patients. This taskforce recommended the establishment of a new system of care for major trauma patients in Victoria and a statewide trauma registry to monitor this new system. The development of the Victorian state trauma registry has shown that there are certain issues that must be resolved for successful implementation of any system-wide registry. This paper describes the issues faced by VSTORM in developing, implementing and maintaining a statewide trauma registry.

Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children's hospital

BACKGROUND

Freestanding children's hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways.

MATERIALS AND METHODS

At a tertiary care children's hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology.

RESULTS

A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score > or =15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07.

CONCLUSIONS

Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.

Implementation of a Trauma Care System: Evolution Through Evaluation

BACKGROUND

The regionalization of trauma services has been implemented in many health care systems and communities over the past 10 to 20 years. As these trauma systems mature and evolve, changes are made to improve the care and efficiency of the system. Trauma care regionalization was introduced in Quebec in 1993. This study looked at the evolution of trauma care in Quebec over the past 13 years, from the preregionalization era to the present.

METHODS

A retrospective review scientifically evaluated a trauma system, the implementation of evidence-based changes, and the efficacy of these changes.

RESULTS

Various changes have been made in the Quebec trauma system since the introduction of regionalization. These changes have led to an incremental decrease in mortality caused by severe trauma from 51.8% in 1992 to 8.6% in 2002.

CONCLUSION

A trauma system is fluid and constantly evolving. Research and constant reevaluation are necessary for continuous evaluation of the system and improvement of its outcomes and efficiency.

Trauma system development in North America

The concepts of organized trauma care, many of which originated in military medicine, have been proven effective in the civilian sector. A formal trauma system includes all phases of care from prehospital through rehabilitation. Although trauma centers assume the leadership role, in a truly inclusive system, all healthcare providers (prehospital providers, community hospitals, and trauma centers) have a defined role in providing care to patients with trauma. As a result, patients receive treatment at the appropriate institution, resources are allocated appropriately, and the clinical outcome is optimized. Such a system ideally is suited to the unique needs of the mass casualty scenario.

Improving care of the critically ill: institutional and health-care system approaches

Institutional and health-care system approaches complement bedside strategies to improve care of the critically ill. Focusing on the USA and the UK, we discuss seven approaches: education (especially of non-clinical managers, policy-makers, and the public), organisational guidelines, performance reporting, financial and sociobehavioural incentives to health-care professionals and institutions, regulation, legal requirements, and health-care system reorganisation. No single action is likely to have sustained effect and we recommend a combination of approaches. Several recent initiatives that hold promise tie performance reporting to financial incentives. Though performance reporting has been hampered by concerns over cost and accuracy, it remains an essential component and we recommend continued effort in this area. We also recommend more public education and use of organisational guidelines, such as admission criteria and staffing levels in intensive care units. Even if these endeavours are successful, with rising demand for services and continuing pressure to control costs, optimum care of the critically ill will not be realised without a fundamental reorganisation of services. In both the USA and UK, we recommend exploration of regionalised care, akin to US state trauma systems, and greater use of physician-extenders, such as nurse practitioners, to provide enhanced access to specialist care for critical illness.

Elderly trauma patients with rib fractures are at greater risk of death and pneumonia

BACKGROUND

The purpose of this study was to show that elderly patients admitted with rib fractures after blunt trauma have increased mortality.

METHODS

Demographic, injury severity, and outcome data on a cohort of consecutive adult trauma admissions with rib fractures to a tertiary care trauma center from April 1, 1993, to March 31, 2000, were extracted from our trauma registry.

RESULTS

Among 4,325 blunt trauma admissions, there were 405 (9.4%) patients with rib fractures; 113 were aged > or = 65. Injuries were severe, with Injury Severity Score (ISS) > or = 16 in 54.8% of cases, a mean hospital stay of 26.8 +/- 43.7 days, and 28.6% of patients requiring mechanical ventilation. Mortality (19.5% vs. 9.3%; p < 0.05), presence of comorbidity (61.1% vs. 8.6%; p < 0.0001), and falls (14.6% vs. 0.7%; p < 0.0001) were significantly higher in patients aged > or = 65 despite significantly lower ISS (p = 0.031), higher Glasgow Coma Scale score (p = 0.0003), and higher Revised Trauma Score (p < 0.0001). After adjusting for severity (i.e., ISS and Revised Trauma Score), comorbidity, and multiple rib fractures, patients aged > or = 65 had five times the odds of dying when compared with those < 65 years old.

CONCLUSION

Despite lower indices of injury severity, even after taking account of comorbidities, mortality was significantly increased in elderly patients admitted to a trauma center with rib fractures.

Lack of change in trauma care in England and Wales since 1994

To demonstrate trends in trauma care in England and Wales from 1989 to 2000.

STUDY POPULATION

Database of the Trauma Audit and Research Network that includes hospital patients admitted for three days or more, those who died, were transferred or admitted to an intensive care or high dependency area.

METHOD

To demonstrate trends in outcome, severity adjusted odds of death per year of admission to hospital were calculated for all hospitals (n=99) and 20 hospitals who had participated since 1989 (adjustments are for Injury Severity Score, age, and Revised Trauma Score). The grade of doctor initially seeing the injured patient in accident and emergency and median prehospital times per year of admission were calculated to demonstrate trends in the process of care. Trend analyses were carried out using simple linear regression (odds ratio versus year).

RESULTS

The analysis shows a significant reduction in the severity adjusted odds of death of 3% per year over the 1989-2000 time period (p=0.001). During the period 1989-1994 the odds of death declined most steeply (on average 6% per year p=0.004). Between 1994 to 2000 no significant change occurred (p=0.35). This pattern was mirrored by the 20 permanent members where the odds of death also declined more steeply over the 1989-1994 period. The percentage of severely injured patients (ISS >15) seen by a consultant increased from 29 to 40 from 1989-1994 but has remained static subsequently. Median prehospital times for severely injured patients have not changed significantly since 1994 (51 to 45 minutes).

CONCLUSION

Most of the case fatality reduction for trauma patients reaching hospital over the 1989-2000 time period occurred before 1995 when there was most marked change in the initial care of severely injured patients.

American College of Surgeons, Committee on Trauma Verification Review: does it really make a difference?

BACKGROUND

Although not directly involved in designation per se, the American College of Surgeons (ACS) Committee on Trauma verification/consultation program in conjunction with has set the national standards for trauma care. This study analyzes the impact of a recent verification process on an academic health center.

METHODS

Performance improvement data were generated monthly from the hospital trauma registry. Forty-seven clinical indicators were reviewed. Three study periods were defined for comparative purposes: PRE (January, June, October 1997), before verification/consultation; CON (April 1999-October 1999), after reorganization; and VER (November 1999-September 2000), from consultation to verification.

RESULTS

Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (< 120 minutes) improved in each study section (PRE, 21%; CON, 48%; VER, 76%). Enhanced nursing documentation correlated with improved clinical care such as early acquisition of head computed axial tomographic scans in neurologic injured patients (PRE, 66%; CON, 97%; VER, 95%). Intensive care unit length of stay (< 7 days) decreased (PRE, 87%; VER, 97.8%). Other transformations included increase in institutional morale with recognition of trauma excellence within the hospital and resurgence of the trauma research programs (60 institutional review board-approved projects).

CONCLUSION

The ACS verification/consultation program had a positive influence on this developing academic trauma program. Preparation for ACS verification/consultation resulted in significant improvements in patient care, enhancement of institutional pride, and commitment to care of the injured patient.

Field triage of trauma patients: improving on the Prehospital Index

The purpose of the present study was to evaluate the predictive ability of the Prehospital Index (PHI) in identifying injury severity and to develop a trauma triage scale that incorporates, along with the PHI, a subset of time independent variables to improve the predictive ability of the PHI-based triage instrument. This study included 1,291 trauma patients treated in Montreal, Canada. The developed trauma triage protocol was based on logistic regression analysis, in which the model that predicts the data best was selected by using Bayesian information criterion. The selected regression model included the variables age, body region injured, mechanism of injury, comorbidity, and PHI. This algorithm was a substantial improvement in detecting major versus non-major injuries (major injury defined based on death, intensive care unit admission, and surgery intervention) over the PHI alone (area under the receiver operating characteristic curve: 0.76 v 0.66, P <.05). Considering time independent variables could lead to better injury triage decisions.

Relative importance of designation and accreditation of trauma centers during evolution of a regional trauma system

BACKGROUND

Improved survival after injury has been demonstrated with trauma system implementation and designation of trauma centers. Local designating health authorities or national verification (United States) or accreditation (Canada) programs audit trauma center performance. The relative importance of designation versus accreditation with respect to improved outcomes is not clear. The purpose of this study was to measure outcomes within a single regional trauma system after designation of trauma centers and to compare outcomes in the one accredited center to the nonaccredited centers.

METHODS

Data from three trauma centers were studied. All were large, university-affiliated regional medical centers, integrated into a regional trauma system and served by a single ambulance service. The study period was 1992 to 1999, immediately after trauma center designation in 1991. The British Columbia Trauma Registry was used to identify trauma patients, mechanism of injury, length of stay, case mix, case volume, acuity, pediatric caseload, and proportion of transfers at each center. A questionnaire was circulated to each hospital to determine the level of institutional support and programmatic development for trauma. The Trauma Registry was used to calculate z scores (TRISS methodology) for each center and TRISS-adjusted mortality odds ratios between institutions. Differences in covariables were controlled for in subgroup analysis.

RESULTS

Two centers (hospitals A and C) had a high trauma caseload; one (hospital B) had a small and diminishing caseload. Only one center (hospital A) developed a trauma program consistent with Canadian accreditation criteria; z scores for center A were consistently better than at hospital B or C and survival odds ratios were significant. This finding applied to the total trauma population, blunt adult trauma patients (whether or not transfers and hip fracture patients were excluded), and in the more severely injured blunt trauma subgroups. There were no differences between hospitals for the relatively small number of patients with penetrating trauma.

CONCLUSION

Differences between hospitals were apparent from the outset of the trauma system. However, designation as a trauma center does not appear to necessarily improve survival in large regional medical centers. Development of a trauma program and commitment to meeting national guidelines through the accreditation process does appear to be associated with improved outcome after injury.

Reporting data following major trauma and analysing factors associated with outcome using the new Utstein style recommendations

STUDY OBJECTIVE

To collect and present retrospectively the recommended core data from the Utstein style, analyse factors associated with outcome in major trauma, and discuss the value of the Utstein style definition of major trauma.

DESIGN

A retrospective trauma cohort study.

SETTING

A Norwegian trauma system with a 1200 bed combined local and referral trauma hospital without a formal trauma registry, covering a population of approximately 2.0 million.

PARTICIPANTS

3391 injured patients admitted 12 months from January 15, 1996.

MAIN OUTCOME MEASURES

Recommended core data from the Utstein style, and factors associated with outcome defined as in-hospital death within 30 days.

RESULTS

225 patients had an injury severity score (ISS)>15. In each of the 225 patients, we were able to obtain at least 47% of the recommended core data. Age >70 years, fall as a mechanism of injury, and a Trauma Score (TS)< or =14 were significantly associated with poor outcome. Of 22 with no major trauma (ISS<16), two died in hospital and 20 had an intensive care unit stay of more than 2 days.

CONCLUSION

We found it difficult to collect retrospectively the recommended core data of the Utstein style. Age and physiological alterations (TS) were significantly related to outcome. The recommended definition of major trauma (ISS>15) did not cover all life-threatening injuries. The implementation of trauma registries based on the Utstein style recommendations could facilitate system evaluation and comparison, but definitions and categorizations should be further developed. Efforts should be made to reduce the number of core data.

Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome

OBJECTIVE

The purpose of this study was to assess the impact on patient outcome and hospital performance of preparing for and achieving American College of Surgeons (ACS) Level I trauma verification.

METHODS

The center was a previously designated state regional trauma center located adjacent to a major metropolitan area. Preparation for ACS verification began in early 1996 and was completed in early 1998. Final verification took place in April 1999. Data were analyzed before (1994) and after (1998) the process. There was a marked increase in administrative support with trauma named one of the hospital's six centers of excellence. Two full-time board-certified trauma/critical care surgeons were added to the current six trauma surgeons. Their major focus was trauma care. Trauma support staff was also increased with case managers, a trauma nurse practitioner, additional trauma registrars, and administrative support staff. Education and continuous quality improvement were markedly expanded starting in 1996.

RESULTS

There were 1,098 trauma patients admitted in 1994, and 1,658 in 1998. Overall mortality decreased (1994, 7.38%; 1998, 5.37%; p < 0.05). There was a marked decrease in mortality for severely injured (Injury Severity Score > 30) patients (1994, 44% mortality [38 of 86]; 1998, 27% [22 of 80]; p < 0.04). Average length of stay also decreased (1994, 12.22 days; 1998, 9.87 days; p < 0.02). This yielded an estimated cost savings for 1998 of greater than $4,000 per patient (total saving estimate of $7.4 million).

CONCLUSION

Trauma system improvement as related to achieving ACS Level I verification appeared to have a positive impact on survival and patient care. There were cost savings realized that helped alleviate the added expense of this system improvement. The process of achieving ACS Level I verification is worthwhile and can be cost effective.

Outcome analysis of Pennsylvania trauma centers: factors predictive of nonsurvival in seriously injured patients

BACKGROUND

The purpose of this study was to evaluate the impact of five trauma center characteristics on survival outcome in nine serious injury categories.

METHODS

A retrospective analysis of prospectively collected data from 1992 to 1996 on patients older than 14 years of age from 24 accredited trauma centers in Pennsylvania was performed. Trauma center characteristics selected for evaluation were level of accreditation, volume of trauma admissions, presence of in-house trauma surgeons, presence of a surgical residency program, and presence of an on-site medical school. Each of these characteristics was evaluated to determine its impact on survival in the selected serious injuries. A logistic regression model was then created to evaluate the most seriously injured patients as defined by A Severity Characterization of Trauma score of < 0.50. On the basis of the logistic regression model, odd ratios were calculated treating low volume as a significant risk factor for mortality.

RESULTS

Of the 88,723 patients meeting registry criteria, 13,942 met the serious injury criteria. Independent analysis suggested that accreditation was beneficial regardless of level, volume of patients treated had a direct impact on survival outcome, and the presence of a surgical residency program may confer survival benefit. Of the 13,942 patients with serious injuries, those with A Severity Characterization of Trauma score of < 0.5 were selected for evaluation by logistic regression (n = 3,562). The logistic regression model, however, showed that only volume of patients treated had a consistent association with improved survival. Odds ratio analysis revealed low volume as a significant risk factor for mortality in seven of the nine injuries studied.

CONCLUSION

In this analysis, only volume of patients treated had a direct impact on survival outcome. Accreditation, regardless of level, appears to be beneficial.

Traumatic brain injury

The decrease in mortality and improved outcome for patients with severe traumatic brain injury over the past 25 years can be attributed to the approach of "squeezing oxygenated blood through a swollen brain". Quantification of cerebral perfusion by monitoring of intracranial pressure and treatment of cerebral hypoperfusion decrease secondary injury. Before the patient reaches hospital, an organised trauma system that allows rapid resuscitation and transport directly to an experienced trauma centre significantly lowers mortality and morbidity. Only the education of medical personnel and the institution of trauma hospital systems can achieve further improvements in outcome for patients with traumatic brain injuries.

The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Trauma systems

Published case series and cohort comparison studies of patients treated in regions where planned trauma systems are in place compared to regions without trauma systems, or before and after instituting a trauma system, conclude that mortality is reduced after major trauma in patients treated in a trauma system. For optimal care of neurotrauma, neurosurgeons should be involved in the planning and implementation of trauma systems and in support of a system once it is in place.

Systematic review of trauma system effectiveness based on registry comparisons

BACKGROUND

Trauma registries offer distinct advantages and disadvantages when assessing the effectiveness of trauma systems. Detailed injury data and statistical comparisons that use TRISS methodology and the Major Trauma Outcome Study norms provide advantages over population-based or preventable death studies. However, miscodings and registry differences in injury severity coding limit the validity and generalizability of findings. The purpose of this study was to identify these strengths and weaknesses and to determine whether registry studies provide evidence of trauma system efficacy.

METHODS

A systematic review of published literature assessing trauma systems effectiveness by using registry-based data.

RESULTS

Eight of 11 articles reviewed provided comparable data and consistently demonstrated a 15 to 20% reduction in the risk of death comparing trauma system outcomes to Major Trauma Outcome Study norms.

CONCLUSION

These studies provide evidence of the effectiveness of trauma systems. However, future studies that use trauma registries would be strengthened by including both prehospital and postdischarge trauma deaths, standardizing trauma registry inclusion criteria and developing a contemporary national reference norm for trauma outcome.

Trauma center maturation: quantification of process and outcome

BACKGROUND AND OBJECTIVE

The regional trauma system with the trauma center as its center is a model for health care networks. However, trauma center maturation has not been defined in the literature. The authors' hypothesis was that maturation of the trauma center would affect quantitatively both process and patient outcome.

MATERIALS AND METHODS

A total of 15,303 trauma patients were admitted from 1987 to 1995. Annual admissions increased from 813 to 2669. Resources were generated as patient volume increased. Time to the operating room, length of stay, and complications were determined. TRISS methodology was used to calculate z scores and w values to compare actual with predicted mortality rates.

RESULTS

Time to the operating room for laparotomy decreased from 62+/-73 to 35+/-47 minutes, from 32+/-32 to 20+/-17 minutes in hypotensive patients, and for craniotomy decreased from 88+/-54 to 67+/-49 minutes. The incidence of infectious, airway, neurologic, orthopedic, respiratory, gastrointestinal, and procedure-related complications declined significantly. Z scores and w values increased for penetrating and blunt injuries. Deaths for patients with ISS >15 declined significantly. Hospital length of stay decreased for all ranges of injury severity.

CONCLUSIONS

As the trauma center matured, the process of delivering patient care became more efficient. The result was improved survival, fewer complications, and a shorter length of stay.

Trauma care regionalization: a process-outcome evaluation

BACKGROUND

Regionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients.

METHODS

This was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III).

RESULTS

A total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers.

CONCLUSION

This study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

Defining excess resource utilization and identifying associated factors for trauma victims

BACKGROUND

Trauma system evaluation addresses aspects of the process, structure, and outcomes of trauma care. This approach may not identify all opportunities for trauma system improvement. Hospital length of stay (LOS) represents a meaningful measure of resource utilization and may help focus efforts to improve care. The purpose of this study is to estimate expected hospital LOS after trauma and determine the consequences of excessive LOS.

METHODS

Patients admitted during a 2-year period (January 1, 1993 to December 31, 1994) were retrospectively reviewed, and expected LOS was estimated. Excess LOS was defined as an observed LOS > or =100% of expected. Injuries, complications, and American College of Surgeons' Committee on Trauma audit filters were compared between the groups.

RESULTS

Observed LOS exceeded expected by 100% or more for 568 of 5,226 patients (10.9%), and most survived (98.3%). Complications predicted excess LOS, whereas audit filters did not. Median costs for these 568 patients were $30,315 and totaled 30% of the expenditures for the entire cohort of 5,226 patients.

CONCLUSION

Prolonged LOS represents an adverse outcome. Estimation of LOS and evaluation of outliers represents an important method for the evaluation of care within established trauma systems and centers.

Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims

OBJECTIVE

Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system.

DESIGN

A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team.

SETTING

A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States.

SUBJECTS

Pediatric trauma victims identified as critically injured (designated as "trauma one") and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team.

INTERVENTIONS

A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as "trauma one") is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes.

OUTCOME MEASURES

Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation of z score.

RESULTS

Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 +/- 2 vs 21 +/- 4 minutes), operating room (63 +/- 16 vs 623 +/- 27 minutes) and total time in the ED (85 +/- 8 vs 821 +/- 9 minutes). Calculation of z score showed that survival for the control group was not different from the reference population (z = -0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102).

CONCLUSION

Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.