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Norton TW, Zhou M, Rupp K, Wang M, Paxton R, Rehman N, He JC. Impact of lower level trauma center proliferation on patient outcomes. Surg Open Sci 2024; 18:78-84. [PMID: 38435487 PMCID: PMC10905033 DOI: 10.1016/j.sopen.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/08/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
Background In attempt to increase trauma system coverage, our state added 21 level 3 (L3TC) and level 4 trauma centers (L4TC) to the existing 7 level 1 trauma centers from 2008 to 2012. This study examined the impact of adding these lower-level trauma centers (LLTC) on patient outcomes. Methods Patients in the state trauma registry age ≥ 15 from 2007 to 2012 were queried for demographic, injury, and outcome variables. These were compared between 2007 (PRE) and 2008-2012 (POST) cohorts. Multivariate logistic regression was performed to assess independent predictors of mortality. Subgroup analyses were performed for Injury Severity Score (ISS) ≥15, age ≥ 65, and trauma mechanisms. Results 143,919 adults were evaluated. POST had significantly more female, geriatric, and blunt traumas (all p < 0.001). ISS was similar. Interfacility transfers increased by 10.2 %. Overall mortality decreased by 0.6 % (p < 0.001). Multivariate logistic regression analysis showed that being in POST was not associated with survival (OR: 1.07, CI: 0.96-1.18, p = 0.227). Subgroup analyses showed small reductions in mortality, except for geriatric patients. After adjusting for covariates, POST was not associated with survival in any subgroup, and trended toward being a predictor for death in penetrating traumas (OR: 1.23; 1.00-1.53, p = 0.059). Conclusions Unregulated proliferation of LLTCs was associated with increased interfacility transfers without significant increase in trauma patients treated. LLTC proliferation was not an independent protector against mortality in the overall cohort and may worsen mortality for penetrating trauma patients. Rather than simply increasing the number of LLTCs within a region, perhaps more planned approaches are needed. Key message This is, to our knowledge, the first work to study the effect of rapid lower level trauma center proliferation on patient outcomes. The findings of our analysis have implications for strategic planning of future trauma systems.
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Affiliation(s)
- Taylor W. Norton
- Department of Surgery, University of Arizona College of Medicine, Phoenix, United States of America
| | - Michael Zhou
- Department of Surgery, University of Arizona College of Medicine, Phoenix, United States of America
| | - Kelsey Rupp
- Department of Surgery, University of Arizona College of Medicine, Phoenix, United States of America
| | - Michele Wang
- Department of Surgery, University of Arizona College of Medicine, Phoenix, United States of America
| | - Rebecca Paxton
- Department of Surgery, University of Arizona College of Medicine, Phoenix, United States of America
| | - Nisha Rehman
- Department of Surgery, University of Arizona College of Medicine, Phoenix, United States of America
| | - Jack C. He
- Department of Surgery, University of Arizona College of Medicine, Phoenix, United States of America
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Zhou J, Wang T, Belenkiy I, Hardcastle TC, Rouby JJ, Jiang B. Management of severe trauma worldwide: implementation of trauma systems in emerging countries: China, Russia and South Africa. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:286. [PMID: 34372903 PMCID: PMC8352140 DOI: 10.1186/s13054-021-03681-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/06/2021] [Indexed: 12/04/2022]
Abstract
As emerging countries, China, Russia, and South Africa are establishing and/or improving their trauma systems. China has recently established a trauma system named “the Chinese Regional Trauma Care System” and covered over 200 million populations. It includes paramedic-staffed pre-hospital care, in-hospital care in certified trauma centers, trauma registry, quality assurance, continuous improvement and ongoing coverage of the entire Chinese territory. The Russian trauma system was formed in the first decade of the twenty-first century. Pre-hospital care is region-based, with a regional coordination center that determines which team will go to the scene and the nearest hospital where the victim should be transported. Physician-staffed ambulances are organized according to three levels of trauma severity corresponding to three levels of trauma centers where in-hospital care is managed by a trauma team. No national trauma registry exists in Russia. Improvements to the Russian trauma system have been scheduled. There is no unified trauma system in South Africa, and trauma care is organized by public and private emergency medical service in each province. During the pre-hospital care, paramedics provide basic or advanced life support services and transport the patients to the nearest hospital because of the limited number of trauma centers. In-hospital care is inclusive with a limited number of accredited trauma centers. In-hospital care is managed by emergency medicine with multidisciplinary care by the various specialties. There is no national trauma registry in South Africa. The South African trauma system is facing multiple challenges. An increase in financial support, training for primary emergency trauma care, and coordination of private sector, need to be planned.
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Affiliation(s)
- Jing Zhou
- National Center for Trauma Medicine, Trauma Center, Department of Orthopedics and Traumatology, Peking University People's Hospital, Beijing, China
| | - Tianbing Wang
- National Center for Trauma Medicine, Trauma Center, Department of Orthopedics and Traumatology, Peking University People's Hospital, Beijing, China
| | - Igor Belenkiy
- Department of the Trauma and Orthopedics, Pavlov First Saint-Petersburg State Medical University, St. Petersburg, Russia.,Department of Trauma and Orthopedics , St. Petersburg I. I. Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, Russia
| | - Timothy Craig Hardcastle
- Trauma and Burns Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.,Department of Surgery, Nelson R Mandela School of Clinical Medicine, UKZN, Durban, South Africa
| | - Jean-Jacques Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Sorbonne University, La Pitié-Salpêtrière Hospital, Assistance-Publique-Hôpitaux-de-Paris, Paris, France.
| | - Baoguo Jiang
- National Center for Trauma Medicine, Trauma Center, Department of Orthopedics and Traumatology, Peking University People's Hospital, Beijing, China.
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Truong EI, Ho VP, Tseng ES, Ngana C, Curtis J, Curfman ET, Claridge JA. Is more better? Do statewide increases in trauma centers reduce injury-related mortality? J Trauma Acute Care Surg 2021; 91:171-177. [PMID: 33843835 PMCID: PMC8487036 DOI: 10.1097/ta.0000000000003178] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Trauma centers are inconsistently distributed throughout the United States. It is unclear if new trauma centers improve care and decrease mortality. We tested the hypothesis that increases in trauma centers are associated with decreases in injury-related mortality (IRM) at the state level. METHODS We used data from the American Trauma Society to geolocate every state-designated or American College of Surgeons-verified trauma center in all 50 states and the District of Columbia from 2014 to 2018. These data were merged with publicly available IRM data from the Centers for Disease Control and Prevention. We used geographic information systems methods to map and study the relationships between trauma center locations and state-level IRM over time. Regression analysis, accounting for state-level fixed effects, was used to calculate the effect of total statewide number of trauma center on IRM and year-to-year changes in statewide trauma center with the IRM (shown as deaths per additional trauma center per 100,000 population, p value). RESULTS Nationwide between 2014 and 2018, the number of trauma center increased from 2,039 to 2,153. Injury-related mortality also increased over time. There was notable interstate variation, from 1 to 284 trauma centers. Four patterns in statewide trauma center changes emerged: static (12), increased (29), decreased (5), or variable (4). Of states with trauma center increases, 26 (90%) had increased IRM between 2014 and 2017, while the remaining 3 saw a decline. Regression analysis demonstrated that having more trauma centers in a state was associated with a significantly higher IRM rate (0.38, p = 0.03); adding new trauma centers was not associated with changes in IRM (0.02, p = 0.8). CONCLUSION Having more trauma centers and increasing the number of trauma center within a state are not associated with decreases in state-level IRM. In this case, more is not better. However, more work is needed to identify the optimal number and location of trauma centers to improve IRM. LEVEL OF EVIDENCE Epidemiologic, level III; Care management, level III.
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Affiliation(s)
- Evelyn I. Truong
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Esther S. Tseng
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Colette Ngana
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Jacqueline Curtis
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Eric T. Curfman
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Jeffrey A. Claridge
- Department of Surgery, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
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Takahashi Y, Sato S, Yamashita K, Matsumoto N, Nozaki Y, Hirao T, Tajima G, Inokuma T, Yamano S, Takahashi K, Miyamoto T, Inoue K, Osaki M, Tasaki O. Effects of a trauma center on early mortality after trauma in a regional city in Japan: a population-based study. Trauma Surg Acute Care Open 2019; 4:e000291. [PMID: 31245618 PMCID: PMC6560472 DOI: 10.1136/tsaco-2018-000291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Although the effects of the trauma center(TC) were researched in several studies, there have been few studies on changes in the regional mortality due to the implementation of a TC. An emergency medical center (EMC) and TC were implemented at Nagasaki University Hospital (NUH) for the first time in the Nagasaki medical region of Japan in April 2010 and October 2011, respectively, and they have cooperated with each other in treating trauma patients. The purpose of this study was to investigate the effects on the early mortality at population level of a TC working in cooperation with an EMC. Methods This is a retrospective study using standardized regional data (ambulance service record) in Nagasaki medical region from April 2007 through March 2017. We included 19,045 trauma patients directly transported from the scene. The outcome measures were prognosis for one week. To examine the association between the implementation of the EMC and TC and mortality at a region, we fit adjusted logistic regression models. Results The number of patients of each fiscal year increased from 1492 in 2007 to 2101 in 2016. The number of all patients transported to NUH decreased until 2009 to 70, but increased after implementation of the EMC and TC. Overall mortality of all patients in the region improved from 2.3% in 2007 to 1.0% in 2016. In multivariate logistic regression model, odds ratio of death was significantly smaller at 2013 and thereafter if the data from 2007 to 2011 was taken as reference. Conclusions Implementation of the EMC and TC was associated with early mortality in trauma patients directly transported from the scene by ambulance. Our analysis suggested that the implementation of EMC and TC contributed to the improvement of the early mortality at a regional city with 500000 populations. Level of evidence Level III.
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Affiliation(s)
- Yuji Takahashi
- Department of Emergency Medicine, Unit of Clinical Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.,Inoue Hospital, Nagasaki, Japan
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Kazunori Yamashita
- Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Naoya Matsumoto
- Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Yoshihiro Nozaki
- Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Tomohito Hirao
- Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Goro Tajima
- Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Takamitsu Inokuma
- Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Shuhei Yamano
- Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Kensuke Takahashi
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan.,Department of Infectious Diseases, Nagasaki University Hospital, Nagasaki, Japan
| | - Takashi Miyamoto
- Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
| | | | - Makoto Osaki
- Department of Orthopaedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Osamu Tasaki
- Department of Emergency Medicine, Unit of Clinical Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.,Acute & Critical Care Center, Nagasaki University Hospital, Nagasaki, Japan
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Trauma Ecosystems: The Impact of Too Many Trauma Centers. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0231-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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David JS, Bouzat P, Raux M. Evolution and organisation of trauma systems. Anaesth Crit Care Pain Med 2019; 38:161-167. [DOI: 10.1016/j.accpm.2018.01.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/12/2018] [Accepted: 01/22/2018] [Indexed: 01/07/2023]
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The trauma ecosystem: The impact and economics of new trauma centers on a mature statewide trauma system. J Trauma Acute Care Surg 2017; 82:1014-1022. [PMID: 28328670 DOI: 10.1097/ta.0000000000001442] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Florida serves as a model for the study of trauma system performance. Between 2010 and 2104, 5 new trauma centers were opened alongside 20 existing centers. The purpose of this study was to explore the impact of trauma system expansion on system triage performance and trauma center patients' profiles. METHODS A statewide data set was queried for all injury-related discharges from adult acute care hospitals using International Classification of Diseases, Ninth Revision (ICD-9) codes for 2010 and 2014. The data set, inclusion criteria, and definitions of high-risk injury were chosen to match those used by the Florida Department of Health in its trauma registry. Hospitals were classified as existing Level I (E1) or Level II (E2) trauma centers and new E2 (N2) centers. RESULTS Five N2 centers were established 11.6 to 85.3 miles from existing centers. Field and overall trauma system triage of high-risk patients was less accurate with increased overtriage and no change in undertriage. Annual volume at N2 centers increased but did not change at E1 and E2 centers. In 2014, Patients at E1 and E2 centers were slightly older and less severely injured, while those at N2 centers were substantially younger and more severely injured than in 2010. The injured patient-payer mix changed with a decrease in self-pay and commercial patients and an increase in government-sponsored patients at E1 and E2 centers and an increase in self-pay and commercial patients with a decrease in government-sponsored patients at N2 centers. CONCLUSION Designation of new trauma centers in a mature system was associated with a change in established trauma center demographics and economics without an improvement in trauma system triage performance. These findings suggest that the health of an entire trauma system network must be considered in the design and implementation of a regional trauma system. LEVEL OF EVIDENCE Therapeutic/care management study, level IV; epidemiological, level IV.
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Pracht EE, Langland-Orban B, Ryan JL. The Probability of Hospitalizations for Mild-to-Moderate Injuries by Trauma Center Ownership Type. Health Serv Res 2017; 53:35-48. [PMID: 28074471 DOI: 10.1111/1475-6773.12646] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To corroborate anecdotal evidence with systematic evidence of a lower threshold for admission among for-profit hospitals. DATA SOURCES The study used Florida emergency department and hospital discharge datasets for 2012 to 2014. The treatment variable of interest was for-profit-designated trauma center status. The dependent variable indicated whether a patient with mild-to-moderate injuries was admitted after presenting as a trauma alert and then discharged to home. A separate analysis was conducted of discharges that had a 1-day length of stay. STUDY DESIGN Generalized estimation equations with logistic distribution models were used to control for the confounding influences and developed for four groups of patients: ICISS = 1 (no probability of mortality), ICISS ≥ 0.99, ICISS ≥ 0.95, and ICISS ≥ 0.85 (zero to 15 percent probability of mortality, which includes all mild and moderate injury patients). PRINCIPAL FINDINGS For the ICISS = 1 and ICISS ≥ 0.99 models, the centers' for-profit status was the most important predictor. In the ICISS ≥ 0.95 and ICISS ≥ 0.85 models, injury type played a more important role, but for-profit status remained important. For patients with a 1-day stay, for-profit status was associated with an even higher probability of hospitalization. CONCLUSIONS Considerable differences exist between for-profit and not-for-profit trauma centers concerning hospitalization among the study population, which may be explained by supplier-induced demand.
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Affiliation(s)
- Etienne E Pracht
- Department of Health Policy and Management, College of Public Health, University of South Florida, Tampa, FL
| | - Barbara Langland-Orban
- Department of Health Policy and Management, College of Public Health, University of South Florida, Tampa, FL
| | - Jessica L Ryan
- Department of Health Policy and Management, College of Public Health, University of South Florida, Tampa, FL
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Azami-Aghdash S, Sadeghi-Bazargani H, Shabaninejad H, Abolghasem Gorji H. Injury epidemiology in Iran: a systematic review. J Inj Violence Res 2017; 9:852. [PMID: 28039683 PMCID: PMC5279990 DOI: 10.5249/jivr.v9i1.852] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 11/16/2016] [Indexed: 12/13/2022] Open
Abstract
Background: Injuries are the second greatest cause of mortality in Iran. Information about the epidemiological pattern of injuries is effective in decision-making. In this regard, the aim of the current study is to elaborate on the epidemiology of injuries in Iran through a systematic review. Methods: Required data were collected searching the following key words and their Persian equivalents; trauma, injury, accident, epidemiology, prevalence, pattern, etiology, risk factors and Iran. The following databases were searched: Google Scholar, PubMed, Scopus, MagIran, Iranian scientific information database (SID) and Iran Medex. Some of the relevant journals and web sites were searched manually. The lists of references from the selected articles were also investigated. We have also searched the gray literature and consulted some experts. Results: Out of 2747 retrieved articles, 25 articles were finally included in the review. A total of 3234481 cases have been investigated. Mean (SD) age among these cases was 30 (17.4) years. The males comprised 75.7% of all the patients. Only 31.1% of patients were transferred to hospital by ambulance. The most common mechanism of injuries was road traffic accidents (50.1%) followed by falls (22.3%). In road traffic accidents, motorcyclists have accounted for the majority of victims (45%). Roads were the most common accident scene for the injuries (57.5%). The most common injuries were to the head and neck. (47.3%). The mean (SD) Injury Severity Score (ISS) was 8.1(8.6%). The overall case-fatality proportion was 3.8% and 75% of all the mortalities related to road traffic accidents. Conclusions: The main priorities in reducing the burden of injuries include: the young, male target group, improving pre-hospital and ambulance services, preventing road traffic accidents, improving road safety and the safety of motorcyclists (compulsory helmet use, safer vehicles, dedicated motorcycle lanes).
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Affiliation(s)
| | | | | | - Hassan Abolghasem Gorji
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
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Pracht EE, Tepas JJ, Celso BG, Langland-Orban B, Flint L. Survival Advantage Associated with Treatment of Injury at Designated Trauma Centers. Med Care Res Rev 2016; 64:83-97. [PMID: 17213459 DOI: 10.1177/1077558706296241] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This article analyzes the effectiveness of designated trauma centers in Florida concerning reduction in the mortality risk of severely injured trauma victims. A bivariate probit model is used to compute the differential impact of two alternative acute care treatment sites. The alternative sites are defined as (1) a nontrauma center (NC) or (2) a designated trauma center (DTC). An instrumental-variables method was used to adjust for prehospital selection bias in addition to the influence of age, gender, race, risk of mortality, and type of injury. Treatment at a DTC was associated with a reduction of 0.13 in the probability of mortality.
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Evolution of Patient Outcomes Over 14 Years in a Mature, Inclusive Canadian Trauma System. World J Surg 2015; 39:1397-405. [DOI: 10.1007/s00268-015-2977-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Coniglio R, M. Caputo L, D. Sanddal N, Salottolo K, Sabin M, W. Bourg P, W. Mains C. Integrating care: the experience of a US healthcare organization. Leadersh Health Serv (Bradf Engl) 2014. [DOI: 10.1108/lhs-01-2013-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The purpose of this paper is to describe an American healthcare organization's experience creating the first multi-facility trauma system managed by a private, nonprofit organization.
Design/methodology/approach
– A leadership structure was established to initiate the first steps of system development, followed by needs assessments that identified key components essential to creating the interconnected system. The key components were applied as a result of evidence-based system development. After system implementation, early benefits were explored.
Findings
– Data collection and research, prehospital support, system-wide quality improvement, rural outreach, communication, and system evaluation were identified as key components essential to creating an interconnected trauma system. The system currently connects 12 trauma centers throughout the state of Colorado while working within the parameters of an established statewide system. Early benefits included improved designation review results, the utilization of system-wide best practice protocols, a rich trauma registry, and closer relations with rural, out-of-network facilities.
Practical implications
– This study describes the process undertaken to implement a unique medical system that provides regionalized care and complements an existing statewide trauma system. The authors hope their experience may serve as a roadmap for healthcare professionals wishing to develop an integrated, patient-centered model of care.
Originality/value
– The development of this multi-facility trauma system within a private, not-for-profit healthcare organization is the first of its kind.
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15
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Pracht E. Inpatient hospital outcomes following injury in Suriname: lessons for prevention. Glob Health Promot 2014; 21:29-39. [PMID: 24449798 DOI: 10.1177/1757975913509655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traumatic injury is an important and indiscriminant contributor to mortality. Hypothesizing that outcomes from severe injuries do not vary by demographic factors or socioeconomic status, this research analyzed the relationship between race, ethnicity, injury characteristics, and fatality following hospitalization in Suriname. Data were obtained for all hospital episodes in 2008 from the only hospital within the greater Paramaribo area that provides emergency department services. A logistic regression was used to analyze the subset of 544 non-elderly adult trauma victims to assess the contribution of patient demographics and anatomic injury severity to outcome, which was defined as mortality during acute hospitalization. The specific demographics included were patient age, gender, race, and insurance status. Injury severity was measured using the International Classification Injury Severity Score. The results indicate that age, insurance status, injury type, and injury severity were significant predictors for survival. While the uninsured experienced a higher rate of mortality, the model suggests this result is not due to physiologic reasons but behavioral and socioeconomic. The higher mortality is driven by greater injury severity, which increases not only the mortality rate but also the cost of care. Injury severity itself, independent of all other factors, is the most important contributor. The results suggest that a reduction of 10% in injury severity, around the mean, would reduce the probability of mortality by 70%. This suggests that targeting risk-taking behavior, perhaps relating to compliance with safety practices (e.g. seat belt and helmet laws), driver education, and road safety measures can play important roles in reducing mortality and morbidity from injury in Suriname.
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Sela HY, Einav S. Injury in motor vehicle accidents during pregnancy: a pregnant issue. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.10.68] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2013; 73:S345-50. [PMID: 23114492 DOI: 10.1097/ta.0b013e318270191f] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Aging patients constitute an increasing proportion of patients treated at trauma centers. Previous and existing guidelines addressing care of the injured elder have not adequately addressed emerging data regarding optimal means for undertaking triage decisions, correcting coagulopathy, and the limitations of supraphysiologic resuscitation. METHODS More than 400 MEDLINE citations published between the years 2000 and 2008 were identified and screened. A total of 90 references were selected for the evidentiary table followed by consensus-based discussions regarding the level of evidence and the strength of recommendations that could be derived from the related findings of the individual studies. RESULTS In general, a lower threshold for trauma activation should be used for injured patients aged 65 years or older who are evaluated at trauma centers. Furthermore, elderly patients with at least one body system with an AIS score of 3 or higher or a base deficit of -6 or less should be treated at trauma centers, preferably in intensive care units staffed by surgeon-intensivists. In addition, all elderly patients who receive daily therapeutic anticoagulation should have appropriate assessment of their coagulation profile and cross-sectional imaging of the brain as soon as possible after admission where appropriate. In patients aged 65 years or older with a Glasgow Coma Scale (GCS) score less than 8, if substantial improvement in GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions. CONCLUSION Effective evidence-based care of aging patients necessitates aggressive triage, correction of coagulopathy, and limitation of care when clinical evidence points toward an overwhelming likelihood of poor long-term prognosis.
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Abstract
Infrastructure, processes of care and outcome measurements are the cornerstone of quality care for pediatric trauma. This review aims to evaluate current evidence on system organization and concentration of pediatric expertise in the delivery of pediatric trauma care. It discusses key quality indicators for all phases of care, from pre-hospital to post-discharge recovery. In particular, it highlights the importance of measuring quality of life and psychosocial recovery for the injured child.
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Affiliation(s)
- Amelia J Simpson
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
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Factors associated with the interfacility transfer of the pediatric trauma patient: implications for prehospital triage. Pediatr Emerg Care 2012; 28:905-10. [PMID: 22929144 DOI: 10.1097/pec.0b013e318267ea61] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The goal of this study was to identify prehospital factors associated with increased likelihood of interfacility transfer of pediatric trauma patients. Such factors might serve as a basis for improvements in future field pediatric trauma triage guidelines. METHODS This was a retrospective cohort study of children aged 12 years or younger with blunt, penetrating, or thermal injuries who were transported by ground emergency medical services from the scene to the emergency department of a Level I, II, or III trauma center within the Denver metropolitan area from January 1, 2000, to December 31, 2008. Characteristics predicting subsequent interfacility transfer to a pediatric trauma center (PTC) were assessed. RESULTS A total of 1673 patients were included in the analysis. Variables hypothesized to be most commonly associated with interfacility transfer were age, sex, mechanism of injury, body region of injury, and Glasgow Coma Scale score. The cohort included 1079 males and 593 females. Logistic regression analysis yielded the following as significant predictors of transfer: younger age (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.15-1.25), lower Glasgow Coma Scale score (OR, 1.08; 95% CI, 1.01-1.16), the presence of burns (OR, 37.52; 95% CI, 7.3-191.7), non-accidental trauma (OR, 6.09; 95% CI, 2.44-15.25), falls (OR, 1.62; 95% CI, 1.06-2.48), other motor vehicle-related incidents (OR, 2.37; 95% CI, 1.08-5.19), abdominal injury (OR, 5.39; 95% CI, 2.31-12.55), head/neck injury (OR, 7.89; 95% CI, 4.21-14.77), limb injury (OR, 5.31; 95% CI, 2.78-10.16), and multiple injuries (OR, 13.01; 95% CI, 5.0-33.8). CONCLUSIONS Factors highly associated with transfer of an injured child from a non-PTC to a PTC included younger age, burns, non-accidental trauma, head/neck injury, and multiple injuries in younger children. Further investigation is warranted to determine whether these factors may have applicability in future improvements in field pediatric trauma patient triage guidelines.
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Survival advantage for elderly trauma patients treated in a designated trauma center. ACTA ACUST UNITED AC 2011; 71:69-77. [PMID: 21818016 DOI: 10.1097/ta.0b013e31820e82b7] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND This article analyzes the effectiveness of designated trauma centers (DTCs) in Florida concerning reduction in the mortality risk of severely injured elderly trauma victims. METHODS Inpatient hospital data collected by the Agency for Health Care Administration were used to identify elderly trauma patients. An instrumental variables method was used to adjust for prehospital selection bias in addition to the influence of age, gender, race, risk of mortality, comorbidities, and type of injury. The model was estimated using a bivariate probit full information maximum likelihood model to determine the impact of triage to a trauma center as opposed to a nontrauma hospital. RESULTS After adjusting for confounding influences, treatment at a DTC was associated with a statistically significant reduction of 0.072, 0.040, and 0.036 in the probability of mortality for patients in the age groups 65 years to 74 years, 75 years to 84 years, and ≥ 85 years, respectively. CONCLUSIONS Treatment of severely injured elderly trauma patients in DTCs is associated with statistically significant gains in the probability of survival.
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Leung GKK, Chang A, Cheung FC, Ho HF, Ho W, Hui SM, Kam CW, Lai A, Lam KW, Leung M, Liu SH, Lo CB, Mok F, Rainer TH, Shen WY, So FL, Wong G, Wu A, Yeung J, Yuen WK. The First 5 Years Since Trauma Center Designation in the Hong Kong Special Administrative Region, People's Republic of China. ACTA ACUST UNITED AC 2011; 70:1128-33. [DOI: 10.1097/ta.0b013e3181fd5d62] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Abstract
BACKGROUND Older injured persons are frequently undertriaged, increasing the risk for preventable mortality and morbidity in an already-vulnerable population. Changes made in 2006 to the American College of Surgeons Committee on Trauma (ACS-COT) Field Triage Decision Scheme might improve triage accuracy for this population. OBJECTIVE This study examined triage accuracy before and after the 2006 revisions. METHODS This secondary analysis of 2004, 2007, and 2008 data from the National Automotive Sampling System Crashworthiness Data System included persons aged 55 years and older who were transported to a hospital and had a maximum injury severity of uninjured or an Abbreviated Injury Scale score of 1 to 5. Trauma center and non-trauma center admission was a proxy for triage accuracy. Frequencies, means, standard deviations, sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) were calculated. RESULTS Although triage accuracy has improved from 2004 to 2008, the undertriage rate still remains higher than the ACS-COT target of 5-10%. Overtriage rates have remained slightly above or within an acceptable range, suggesting that gains in triage accuracy have not unduly overburdened trauma centers. Both PPV and NPV have improved since 2004. CONCLUSIONS There is a positive trend in triage accuracy for older injured persons since 2004. Ongoing funding, continued trauma system development with more training emphasis on scene evaluation of older adults, and the use of the ACS-COT triage decision scheme are essential for further improvement of triage accuracy. More research is needed to identify and validate additional triage criteria that are sensitive to severe injuries in older persons.
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Affiliation(s)
- Linda J Scheetz
- Department of Nursing, State University of New York, New Paltz, New Paltz, NY 12561, USA.
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Caterino JM, Valasek T, Werman HA. Identification of an age cutoff for increased mortality in patients with elderly trauma. Am J Emerg Med 2010; 28:151-8. [PMID: 20159383 DOI: 10.1016/j.ajem.2008.10.027] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 10/15/2008] [Accepted: 10/17/2008] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES The chosen age cutoff for considering patients with trauma to be "elderly" has ranged from 55 to 80 years in trauma guidelines and studies. The goal of this study was to identify at what age mortality truly increases for older victims of trauma. METHODS We performed a cross-sectional study of the Ohio Trauma Registry, a statewide database of all injured patients who died or were admitted for more than 48 hours to both trauma and nontrauma centers. Patients 16 years or older entered into the registry between January 1, 2003, and December 31, 2006, were included. Inhospital mortality rates were obtained and stratified by 5-year age intervals and by injury severity score (ISS). Rates between age groups were compared using logistic regression to identify significant differences in mortality. RESULTS Included were 75 658 patients. In logistic regression, patients 70 to 74 years of age had significantly greater mortality than all younger age groups when stratified by ISS (P < or = .001-.004). When considering other 5-year age groups as referent (40-44, 45-49, 50-54, 55-59, 60-64, 65-69 years old), no other group was associated with significantly increased mortality, as compared to younger groups (P > .05 for all). CONCLUSION Patients 70 to 74 years of age have significantly greater mortality than all younger age groups when stratified by ISS. Age cutoffs based on younger ages are not associated with significant increases in mortality. An age of 70 years should be considered as an appropriate cutoff for considering a patient to be elderly in future studies of trauma and development of geriatric trauma triage criteria.
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Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA.
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Application of International Classification Injury Severity Score to National Surgical Quality Improvement Program defines pediatric trauma performance standards and drives performance improvement. ACTA ACUST UNITED AC 2009; 67:185-8; discussion 188-9. [PMID: 19590333 DOI: 10.1097/ta.0b013e3181a5f03c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program is becoming a core methodology to define performance as a ratio of observed to expected events. We hypothesized that application of this using International Classification of Injury Severity Score (ICISS) for individual patient risk stratification to a group of hospitals contributing data to the National Pediatric Trauma Registry (NPTR) would apply objective evidence of actual injuries to define an expected standard and identify performance outliers. METHODS Using a blinded code, children entered into phase III of the NPTR were aggregated by treating hospital. Individual patient ICISS survival probability (Ps) were calculated using survival risk ratios (SRR) derived from the phase II NPTR dataset (n = 53,253). For each center, sample size, observed mortality, and ICISS Ps were calculated. Probability of mortality (Pm) was computed as 1 - Ps. Logistic regression was used to develop a predictive model for mortality. Logit transformation of Pm was performed to adjust for the skew of minor injury in children and reduce overestimation of low Pm fatalities. Mean Pm was computed for each center and multiplied by its volume to determine expected frequency. Observed to expected ratio (O/E) and 95% confidence interval were calculated to define expected performance and outliers above or below 1 SD of the mean O/E. RESULTS Patients treated at 30 pediatric trauma centers (mean volume = 451 +/- 258/patients per center) were evaluated. Mean O/E was 1.001 with SD = 0.404. Twenty-two centers fell within the reference range; O/E of 12 centers exceeded 1, suggesting performance below expectation. Trauma center volume, as reflected by sample, did not correlate to O/E performance. CONCLUSIONS Application of ICISS Ps from a national pediatric benchmark population simplifies determination of expected mortality necessary to compute the expected component of National Surgical Quality Improvement Program. Analysis of these ratios of expected to observed mortality demonstrates variance among centers, defines performance against peers using the same benchmarks, and can drive performance improvement based on the objective evidence of injury diagnoses actually encountered.
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Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatr Surg 2008; 43:212-21. [PMID: 18206485 DOI: 10.1016/j.jpedsurg.2007.09.047] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 09/02/2007] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purposes of the study were to compare the survival associated with treatment of seriously injured patients with pediatric trauma in Florida at designated trauma centers (DTCs) with nontrauma center (NCs) acute care hospitals and to evaluate differences in mortality between designated pediatric and nonpediatric trauma centers. METHODS Trauma-related inpatient hospital discharge records from 1995 to 2004 were analyzed for children aged from 0 to 19 years. Age, sex, ethnicity, injury mechanism, discharge diagnoses, and severity as defined by the International Classification Injury Severity Score were analyzed, using mortality during hospitalization as the outcome measure. Children with central nervous system, spine, torso, and vascular injuries and burns were evaluated. Instrumental variable analysis was used to control for triage bias, and mortality was compared by probabilistic regression and bivariate probit modeling. Children treated at a DTC were compared with those treated at a nontrauma center. Within the population treated at a DTC, those treated at a DTC with pediatric capability were compared with those treated at a DTC without additional pediatric capability. Models were analyzed for children aged 0 to 19 years and 0 to 15 years. RESULTS For the 27,313 patients between ages 0 and 19 years, treatment in DTCs was associated with a 3.15% reduction in the probability of mortality (P < .0001, bivariate probit). The survival advantage for children aged 0 to 15 years was 1.6%, which is not statistically significant. Treatment of 16,607 children in a designated pediatric DTC, as opposed to a nonpediatric DTC, was associated with an additional 4.84% reduction in mortality in the 0- to 19-year age group and 4.5% in the 0 to 15 years group (P < .001, bivariate probit). CONCLUSIONS Optimal care of the seriously injured child requires both the extensive and immediate resources of a DTC as well as pediatric-specific specialty support.
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