Trauma center designation: initial impact on trauma-related mortality

National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions

INTRODUCTION

Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken.

METHODS

Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes.

RESULTS

One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation.

CONCLUSIONS

Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.

Current patterns of trauma center proliferation have not led to proportionate improvements in access to care or mortality after injury: An ecologic study

BACKGROUND

Timely access to high-level (I/II) trauma centers (HLTCs) is essential to minimize mortality after injury. Over the last 15 years, there has been a proliferation of HLTC nationally. The current study evaluates the impact of additional HLTC on population access and injury mortality.

METHODS

A geocoded list of HLTC, with year designated, was obtained from the American Trauma Society, and 60-minute travel time polygons were created using OpenStreetMap data. Census block group population centroids, county population centroids, and American Communities Survey data from 2005 and 2020 were integrated. Age-adjusted nonoverdose injury mortality was obtained from CDC Wide-ranging Online Data for Epidemiologic Research and the Robert Wood Johnson Foundation. Geographically weighted regression models were used to identify independent predictors of HLTC access and injury mortality.

RESULTS

Over the 15-year (2005-2020) study period, the number of HLTC increased by 31.0% (445 to 583), while population access to HLTC increased by 6.9% (77.5-84.4%). Despite this increase, access was unchanged in 83.1% of counties, with a median change in access of 0.0% (interquartile range, 0.0-1.1%). Population-level age-adjusted injury mortality rates increased by 5.39 per 100,000 population during this time (60.72 to 66.11 per 100,000). Geographically weighted regression controlling for population demography and health indicators found higher median income and higher population density to be positively associated with majority (≥50%) HLTC population coverage and negatively associated with county-level nonoverdose mortality.

CONCLUSION

Over the past 15 years, the number of HLTC increased 31%, while population access to HLTC increased only 6.9%. High-level (I/II) trauma center designation is likely driven by factors other than population need. To optimize efficiency and decrease potential oversupply, the designation process should include population level metrics. Geographic information system methodology can be an effective tool to assess optimal placement.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Could the Injury Severity Score be a new indicator for surgical treatment in patients with traumatic splenic injury?

Purpose

The purpose of this study was to determine whether a higher Injury Severity Score (ISS) could serve as an indicator of splenectomy in patients with traumatic splenic lacerations.

Methods

A total of 256 cases of splenic laceration were collected from January 1, 2005 to December 31, 2018. After the application of exclusion criteria, 105 were eligible for this study. Charts were reviewed for demographic characteristics, initial vital signs upon presentation to the emergency room, Glasgow Coma Scale, computed tomography findings, ISS, and treatment strategies. The cases were then divided into nonsplenectomy and splenectomy groups for analysis.

Results

When analyzed with the chi-square test and t-test, splenectomy was associated with a systolic blood pressure lower than 90 mmHg, a Glasgow Coma Scale score lower than 13, active bleeding found on computed tomography, a splenic laceration grade greater than or equal to 4, and an ISS greater than 15 at presentation. However, in multivariate logistic regression analysis, only active bleeding on computed tomography showed a statistically significant relationship (P=0.014).

Conclusions

Although ISS failed to show a statistically significant independent relationship with splenectomy, it may still play a supplementary role in traumatic splenic injury management.

Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine

OBJECTIVES

The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions.

DATA SOURCES AND STUDY SELECTION

Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product.

DATA EXTRACTION AND SYNTHESIS

The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations.

CONCLUSIONS

Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.

A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care

BACKGROUND

There are well-documented disparities in outcomes for injured Black and Hispanic patients in the United States. However, patient level characteristics cannot fully explain the differences in outcomes and system-level factors, including the trauma center designation of the hospital to which a patient presents, may contribute to their worse outcomes. We aim to determine if Black and Hispanic patients are more likely to be undertriaged, compared with white patients.

METHODS

This is a retrospective, cross-sectional, population-based study that uses data from the 2014 Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases. We included data from all states with available State Inpatient Databases data that included both race and hospital characteristics needed for analysis (n = 18). Logistic regression was used to identify predictors of severely injured (Injury Severity Score ≥16) patients being brought to a trauma center.

RESULTS

We identified 70,970 severely injured trauma patients with complete data. Non-Hispanic White represented 74.1% of the study population, 9.8% were non-Hispanic Black, and 9.7% were Hispanic. After adjustment for other demographic and injury characteristics, Non-Hispanic Black and Hispanic patients were more likely to be undertriaged, compared with white patients (odds ratio, 1.20; 95% confidence interval, 1.12-1.29 and odds ratio, 1.39; 95% confidence interval, 1.29-1.48, respectively). Male sex and older age were associated with higher odds of undertriage, whereas urban residence, high injury severity, and penetrating injury were associated with lower odds of undertriage.

CONCLUSIONS

Severely injured Black and Hispanic trauma patients are more likely to be undertriaged than otherwise similar white patients. The factors that contribute to racial and ethnic disparities in receiving trauma center care need to be identified and addressed to provide equitable trauma care.

The Effect of a Multidisciplinary Trauma Team Leader Paradigm at a Tertiary Trauma Center: 10-Year Experience

Background

To illustrate the impact of the implementation of a multidisciplinary TTL program in 2005 on the mortality of trauma patients in a level 1 trauma center as well as admission rates and length of stay.

Methods

Retrospective observational study of all trauma patients included in the provincial trauma database at the Montreal General Hospital between 1998 and 2015. The primary outcome studied was in-hospital mortality. The secondary outcomes studied were hospital and intensive care unit (ICU) rates of admission and hospital and ICU length of stay.

Results

24,107 patients were included. We observed a statistically significant reduction in mortality of 1.25% or a relative reduction of 16% (p value = 0.0058; rate ratio 0.844 (95% CI 0.747-0.952)). ICU admissions were also significantly reduced where we observed a statistically significant absolute reduction of 4.46% or a relative reduction of 14% (p value = 8.38 × 10^-7; rate ratio 0.859 (95% CI 0.808-0.912)). The ICU length of stay was increased by 0.91 days or 19.03% (p value = 0.016 (95% CI 0.167-1.655)). There was no observed change in overall length of stay (13.97 days pre-TTL and 12.91 post-TTL (p value = 0.13; estimate -1.053 (95% CI -2.424-0.318))).

Conclusions

This article suggests that multidisciplinary TTL model may be beneficial in the care of trauma patients. Further subgroup analysis may help determine which patients could benefit more.

Association Between Trauma Center Level and Outcomes of Adult Patients with Motorcycle Crash-Related Injuries in the United States

BACKGROUND

Motorcycle crash-related injury mechanism is a criterion in the Centers for Disease Control and Prevention field triage guidelines of injured patients, with a recommendation to transport affected patients to a trauma center need not be the highest level.

OBJECTIVE

This study examines the evidence behind this recommendation because severe injuries can result from motorcycle crashes and patients can benefit from treatment at higher-level trauma centers.

METHODS

This retrospective cohort study used the National Trauma Data Bank 2015 dataset. We conducted descriptive analyses (univariate and bivariate) followed by adjusted multivariate analysis to examine the association between trauma center designation levels and survival to hospital discharge.

RESULTS

A total of 28,821 patients with motorcycle injuries were included. Most patients were men (n = 25,361; 88%) and aged between 16 and 64 years (n = 26,989; 93.6%). Survival rates were higher in level II (n = 10,658; 95.3%) and III (n = 2,129; 95.5%) trauma centers compared to level I centers (n = 14,498; 94.6%). After adjusting for confounders, decreased survival to hospital discharge was noted for patients treated at level III trauma centers compared to those at level I centers (odds ratio 0.543; 95% confidence interval 0.390-0.729). No difference in survival was noted between level I and II centers.

CONCLUSIONS

Patients with motorcycle crash-related injuries treated at higher-level trauma center (I or II) had increased survival. This warrants a re-evaluation and adjustment of the field triage criterion for such patients. Examining the evidence behind field triage guidelines in trauma systems is needed for improved patient outcomes.

The Effect of Trauma Care on the Temporal Distribution of Homicide Mortality in Jefferson County, Alabama

The distribution of time from acute traumatic injury to death has three peaks: immediate (less than or equal to one hour), early (6 to 24 hours), and late (days to weeks). It has been suggested that coordinated trauma care dampens the late peak; however, this research may be more reflective of unintentional than intentional deaths. This study examines whether a coordinated trauma system (TS) alters the temporal distribution for assault-related deaths. Data were obtained from homicides examined by the Jefferson County Coroner's/Medical Examiner's Office from 1987 to 2008. Homicides were categorized—based on year of death—as occurring in the presence of no TS, during TS implementation, in the early years of the TS, or in a mature TS. The temporal distribution of homicide mortality was compared among TS categories using a χ2 test. A Cox Markov multistate model was used to estimate proportional changes in the temporal distribution of death adjusted for assault mechanism. With a TS, after adjusting for assault mechanism, a lower proportion of homicide victims survived through the first hour (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.54 to 1.03) and from one to six hours (HR, 0.68; 95% CI, 0.49 to 0.96). Additionally, the presence of a TS was associated with a proportional decrease in deaths after 24 hours ( P = 0.0005). These results suggest that a trauma system is effective in preventing late homicide deaths; however, other means of preventing death (such as violence prevention programs) are needed to decrease the burden of immediate homicide-related deaths.

A public-private collaborative model for a trauma program implementation: findings from a prospective trauma registry at 14 hospitals in Buenos Aires, Argentina

INTRODUCTION

Trauma is a leading cause of mortality and comprises an important cause of functional impairment among young people worldwide. The trauma registry (TR) is an integral component of modern comprehensive trauma care systems. Nevertheless, TRs have not been yet established in most developing countries. The objective of this study was to summarize the challenges, results, and lessons learned from a trauma program including initial results from a TR at tertiary-care public hospitals of Buenos Aires, Argentina.

MATERIAL AND METHODS

This is a descriptive study of the implementation of a trauma program in 14 hospitals and analysis of the initial results in the period between January 2010 and December 2018, using data from Fundación Trauma TR. Patients fitting injury definition that remained in hospital for more than 23 h were included. Injured patients were divided by age groups. Data on patients' demographics, mechanism of injury and severity, complications, treatments, and in-hospital mortality were analyzed between groups. A descriptive analysis is presented.

RESULTS

There were 29,970 trauma cases during the study period. Median age was 23 years (RIC 12, 39) with a 2.4:1 male-to-female ratio. Road traffic injuries (RTI) were the leading mechanism (30.8%) of admission and head was the most frequently injured body region (33.2%). Two-thirds of RTIs were motorcycle-related. Overall in-hospital mortality was 6.1%. Intentional self-harm in adult males and burns in adult females had the highest mortality rates (17.6% and 17.9%, respectively).

CONCLUSIONS AND DISCUSSION

The implementation of a trauma program within a public-private collaborative program in a resource-limited environment is feasible. The hospital-based TR can be used as a tool for injury surveillance, monitoring of the quality of trauma care, development of a trauma system, and to guide public health policies.

Effects of a trauma center on early mortality after trauma in a regional city in Japan: a population-based study

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.

Effects of Trauma Center Establishment on the Clinical Characteristics and Outcomes of Patients with Traumatic Brain Injury : A Retrospective Analysis from a Single Trauma Center in Korea

Objective

To investigate the effects of trauma center establishment on the clinical characteristics and outcomes of trauma patients with traumatic brain injury (TBI).

Methods

We enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma.

Results

Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit (ICU) admissions (p=0.001), and the emergency room stay time (p<0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment.

Conclusion

We confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary.

The Impact of Enhanced Intensive Care on Outcome of Major Trauma Patients in a Regional Hospital in Hong Kong

Objectives

To describe an updated epidemiology of major trauma cases presenting to a regional hospital in Hong Kong and to analyse the impact of enhanced intensive care on the outcome of major trauma patients.

Methods

This was a retrospective comparative study. In late 2004, we amended our trauma care system with enhancement of intensive care in the management of major trauma patients. An 18-month period was chosen before and after the amendment respectively and patients' data and crude mortality rate between the two periods were compared. Stratified analyses based on mechanism of injury, injury severity and physiological parameters were also performed. Finally, a TRISS analysis was included.

Results

Altogether 163 and 155 patients were included in our study from the two periods respectively. The majority involved blunt injury and one third of them had injury severity score (ISS) greater than 15. Road traffic accidents and fall from height remained as the two leading causes of major trauma. The median length of stay in the intensive care unit increased for one day (p<0.01) in the later period but the median total length of stay in hospital remained the same. The mortality rate decreased from 10.4% to 9.7% (p=0.82).

Conclusion

With enhanced intensive care, there is an apparent decrease in mortality of major trauma patients but its significance needs to be determined with a larger scale study.

Survival Advantage Associated with Treatment of Injury at Designated Trauma Centers

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.

Early impact of American College of Surgeons-verification at a level-1 pediatric trauma center

PURPOSE

The purpose of this study was to determine the early impact of American College of Surgeons (ACS)-level-1 verification at an established pediatric trauma center.

METHODS

Following IRB approval, we conducted a retrospective review of all trauma patients treated at a level-1 state-designated pediatric trauma center, comparing 2years before (2009-2010) and 2years after ACS-verification (mid-2012-mid-2014). Statistical significance was defined as p<0.05.

RESULTS

Before verification, 2105 trauma patients were admitted to our institution compared to 2248 patients admitted after ACS-verification. Overall, there were no differences in mean age or injury severity score (ISS). Hospital and pediatric intensive care unit (PICU) length of stay (LOS), ventilator days, and mortality were also unchanged. Through incorporation of clinical pathways, the number of PICU admissions decreased significantly from 17.2% to 13.7%. Morbidity in the form of hospital-acquired conditions (HACS) also decreased following verification, most notably through reduction in pneumonias. Decubitus ulcers and nosocomial infections reached their nadir by 2014. Hospital readmission rates also decreased.

CONCLUSIONS

ACS-verification at a level-1 pediatric trauma center is associated with an immediate benefit to patient outcomes. Enhanced tracking and institutional policy changes resulted in fewer HACS. Further cost-saving and improved outcomes because of ACS-verification may be amplified over time.

Preventable deaths and potentially preventable deaths. What are our errors?

BACKGROUND

A variety of systems have been applied to identify and address errors in the management of multiple trauma patients. This lack of standardisation represents a serious problem.

OBJECTIVES

Detect preventable and potentially preventable deaths, and classify all the errors with universal language.

METHODS

We studied all trauma patients over 16 admitted to the critical care unit or who died before. In multidisciplinary sessions we decided which deaths were preventable, potentially preventable and non preventable. Guided by ATLS protocols, we detected errors in their management that were classified using the taxonomy of Joint Commission.

RESULTS

We registered 1236 trauma patients (ISS 20.77). Of the 115 trauma deaths, 19 were preventable or potentially preventable deaths. We recorded 130 errors in all deaths, 46 of them in preventable or potentially preventable deaths. Using our own classification, the main errors were delay in starting correct treatment or performance of CT in hemodynamically unstable patients. Using the taxonomy of Joint Commission, the main type error was clinical, during the intervention: the delay in initiating correct treatment. Mistakes were made in the emergency department by medical specialists. The incidence of therapeutic and diagnostic errors was similar. The main cause of error was human failure, specifically 'rule-based' errors

CONCLUSIONS

Measuring and recording the results is the first step on the way to improving the quality of care for trauma patients. A common language like the taxonomy of Joint Commission will help standardise patient safety data, thus improving the recording of incidents and their analysis and treatment.

Impact of ATLS training on preventable and potentially preventable deaths

BACKGROUND

Multiple trauma continues to have a high incidence worldwide. Trauma is the leading cause of death among people between the ages of 10 and 40. The Advanced Trauma Life Support (ATLS) is the most widely accepted method for the initial control and treatment of multiple trauma patients. It is based on the following hypothesis: The application of the ATLS program may reduce preventable or potentially preventable deaths in trauma patients.

MATERIALS AND METHODS

The present article reports a retrospective study based on the records of prospectively evaluated trauma patients between January 2007 and December 2012. Trauma patients over the age of 18 admitted to the critical care unit or patients who died before hospital admission were included. A multidisciplinary committee looked for errors in the management of each patient and classified deaths into preventable, potentially preventable, or nonpreventable. We recorded the number of specialists at our center who had received training in the ATLS program.

RESULTS

A total of 898 trauma patients were registered. The mean injury severity score was 21 (SD 15), and the mortality rate was 10.7 % (96 cases). There were 14 cases (14.6 %) of preventable or potentially preventable death. The main errors were delay in initiating suitable treatment and performing a computed tomography scan in cases of hemodynamic instability, followed by initiation of incorrect treatment or omission of an essential procedure. As the number of ATLS-trained professionals increases, the rates of potentially preventable or preventable death fall.

CONCLUSIONS

Well-founded protocols such as the ATLS can help provide the preparation health professionals need. In our hospital environment, ATLS training has helped to reduce preventable or potentially preventable mortality among trauma patients.

An analysis of the effectiveness of a state trauma system: treatment at designated trauma centers is associated with an increased probability of survival

BACKGROUND

States struggle to continue support for recruitment, funding and development of designated trauma centers (DTCs). The purpose of this study was to evaluate the probability of survival for injured patients treated at DTCs versus nontrauma centers.

METHODS

We reviewed 188,348 patients from the state's hospital discharge database and identified 13,953 severely injured patients admitted to either a DTC or a nontrauma center between 2008 and 2012. DRG International Classification of Diseases-9th Rev. Injury Severity Scores (ICISS), an accepted indicator of injury severity, was assigned to each patient. Severe injury was defined as an ICISS less than 0.85 (indicating ≥15% probability of mortality). Three subgroups of the severely injured patients were defined as most critical, intermediate critical, and least critical. A full information maximum likelihood bivariate probit model was used to determine the differences in the probability of survival for matched cohorts.

RESULTS

After controlling for injury severity, injury type, patient demographics, the presence of comorbidities, as well as insurance type and status, severely injured patients treated at a DTC have a 10% increased probability of survival. The largest improvement was seen in the intermediate subgroup.

CONCLUSION

Treatment of severely injured patients at a DTC is associated with an improved probability of survival. This argues for continued resources in support of DTCs within a defined statewide network.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

To TQIP or Not to TQIP? that is the Question

The Trauma Quality Improvement Program (TQIP) reports a feasible mortality prediction model. We hypothesize that our institutional characteristics differ from TQIP aggregate data, questioning its applicability. We conducted a 2-year (2008 to 2009) retrospective analysis of all trauma activations at a Level 1 trauma center. Data were analyzed using TQIP methodology (three groups: blunt single system, blunt multisystem, and penetrating) to develop a mortality prediction model using multiple logistic regression. These data were compared with TQIP data. Four hundred fifty-seven patients met TQIP inclusion criteria. Penetrating and blunt trauma differed significantly at our institution versus TQIP aggregates (61.9 vs 7.8%; 38.0 vs 92.2%, P < 0.01). There were more firearm mechanisms of injury and less falls compared with TQIP aggregates (28.9 vs 4.2%; 8.5 vs 34.8%, P < 0.01). All other mechanisms were not significantly different. Variables significant in the TQIP model but not found to be predictors of mortality included Glasgow Coma Score motor 2 to 5, systolic blood pressure greater than 90 mmHg, age, initial pulse rate in the emergency department, mechanism of injury, head Abbreviated Injury Score, and abdominal Abbreviated Injury Score. External benchmarking of trauma center performance using mortality prediction models is important in quality improvement for trauma patient care. From our results, TQIP methodology from the pilot study may not be applicable to all institutions.

Selective non-operative management of abdominal gunshot wounds: survey of practise

BACKGROUND

There is a growing body of evidence attesting to the effectiveness and safety of selective non-operative management (SNOM) of abdominal gunshot wounds. However, much of the research which supports this conclusion has originated from a few centres, and the actual utilisation of SNOM by trauma surgeons is not known. We therefore conducted a survey to assess the acceptance of this strategy and evaluate variations in practise.

METHODS

Electronic questionnaire survey of trauma surgeons in the United States of America, Canada, Brazil, and South Africa. Responses were compared using Chi(2) and Fisher's exact tests.

RESULTS

183 replies were received. 105 (57%) respondents practise SNOM of abdominal gunshot wounds, but there are marked regional variations in the acceptance of this strategy (p<0.01). Respondents who had completed trauma (p<0.01) or critical care (p<0.01) fellowships, and those who practise in a higher volume centre (defined as >50 penetrating abdominal injuries seen per year) (p<0.01) are more likely to practise SNOM of gunshot wounds. Most surgeons who practise SNOM regard peritonitis, omental and bowel evisceration, and being unable to evaluate a patient as a contraindication to attempting non-operative management. Almost all regard CT as essential. Respondents' preparedness to consider SNOM is related to injury extent.

CONCLUSIONS

SNOM of abdominal gunshot wounds is practised by trauma surgeons in all four countries surveyed, but is not universally accepted, and there are variations in how it is practised.

Relationship of trauma centre characteristics and patient outcomes: a systematic review

AIMS AND OBJECTIVES

To systematically review the relationship of trauma centre characteristics and trauma patient outcomes.

BACKGROUND

Numerous studies have documented the impact of trauma centre level, trauma centre verification, volume per centre and per surgeon or resource availability on outcomes among trauma patients. However, there continues to be debated about whether trauma care is comparable by these trauma centre characteristics.

DESIGN

Systematic review.

METHODS

Eligible studies were identified via electronic database searches, footnote chasing and contact with clinical experts. Quality of selected studies was assessed in terms of internal and external validity using 14 questions. Two reviewers independently examined titles, abstracts and whether each met the predefined criteria.

RESULTS

A total of 50 studies which met criteria were selected. Ten of 17 articles showed that level I trauma centres had better patient outcomes than level II centres. The achievement of trauma centre verification by American College of Surgeons or State was beneficial to decreasing mortality and length of stay in 9 of 11 studies. High trauma admission volume was beneficial in 8 of 16 studies. The volume per trauma surgeon did not contribute to better patient outcomes in 4 of 5 studies. The availability of in-house trauma surgeon was beneficial to lower mortality and shorter length of stay in only 2 of 9 studies.

CONCLUSION

This review supports that achieving the trauma centre verification by American College of Surgeons or State is definitely beneficial to patient outcomes. However, the benefit of level I centres compared with level II centres, and volume of annual trauma patients to outcomes is still debating. Further prospective study examining this relationship is required.

RELEVANCE TO CLINICAL PRACTICE

Understanding which characteristics of trauma centre provides the best prospect for improved outcomes depending on patient need and resource availability would allow further appreciation of the processes that foster such enhancement.

Prehospital care in patients with severe traumatic brain injury: does the level of prehospital care influence mortality?

INTRODUCTION AND PURPOSE

The controversy between the "scoop and run" versus the "stay and play" approach in severely injured trauma patients has been an ongoing issue for decades. The present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the Netherlands have improved outcome.

METHODS

In this retrospective study, files (n = 60) were analyzed from a prospectively collected database including all patients admitted to one of six hospitals in the Limburg region in the Netherlands with a Glasgow Coma Scale (GCS) score ≤8 on admittance over the period from January 2006 to December 2008. All patients had traumatic brain damage proven on computed tomography (CT) or magnetic resonance imaging (MRI). Relevant prehospital and clinical data from the present cohort were compared to data from a similar study (n = 30) conducted 20 years ago. The primary outcome assessed was mortality.

RESULTS

The two study groups had similar characteristics with regard to the GCS score. In the historic cohort, Basic Life Support (BLS) and the "scoop and run" approach in patients with major traumatic brain injury was common, with an average time on scene of 7.5 min. Currently, prehospital care is performed mainly on the level of prehospital Advanced Life Support (ALS), with the average time on scene being about four times as long as in the historic cohort. However, the overall mortality rate for the current cohort compared to the historic cohort has not changed.

CONCLUSION

Despite more on-site ALS in severely head injured patients nowadays compared to the historic cohort, there was no reduction in mortality.

Are All Level I Trauma Centers Created Equal? A Comparison of American College of Surgeons and State-Verified Centers

Scant literature investigates potential outcome differences between Level I trauma centers. We compared overall survival and survival after acute respiratory distress syndrome (ARDS) in patients admitted to American College of Surgeons (ACS)-verified versus state-verified Level I trauma centers. Using the National Trauma Data Bank Version 7.0, incident codes associated with admission to an ACS-verified facility were extracted and compared with the group admitted to state-verified centers. Overall, there were 382,801 (73.7%) patients admitted to ACS and 136,601 (26.3%) admitted to state centers. There was no adjusted survival advantage after admission to either type (4.9% for ACS vs 4.8% for state centers; 1.014 [95% CI, 0.987 to 1.042], P = 0.311). However, in the 3,088 cases of ARDS, mortality for admission to the ACS centers was 20.3 per cent (451 of 2,220) versus 27.1 per cent (235 of 868) for state centers. Adjusting for injury severity and facility size, admission to an ACS center was associated with a significantly greater survival after ARDS (0.75 [0.654 to 0.860]; P < 0.001). Level I verification does not necessarily imply similar outcomes in all subgroups. Federal oversight may become necessary to ensure uniformity of care, maximizing outcomes across all United States trauma systems. Further study is needed.

Mortality decreases by implementing a level I trauma center in a Dutch hospital

BACKGROUND

Trauma centers are designed to improve survival and outcome of the injured patient. The implementation of these centers in the United States has shown to reduce the number of preventable deaths from serious injuries. This study compares outcomes of trauma patients during two separate time periods in a Dutch Level I trauma center, before and after obtaining the trauma center status.

METHODS

Prospectively, patient data were collected from an automated database in the years 1996 through 1998 (period 1) and 2003 through 2005 (period 2) in the University Medical Center in Utrecht. The patients included and analyzed were adult trauma victims admitted to our trauma center.

RESULTS

A total of 4,069 patients in total were included, 2,348 in period 1 and 1,721 in period 2. Mean age was 45.9 years and 48.1 years, respectively (p < 0.001). Men comprised 62% and 64%, respectively (not significant). After obtaining the trauma center status, more severely injured patients were admitted (mean Injury Severity Score was 9.6 in group 1 vs. 12.4 in group 2, p < 0.001). Adjusted for age and injury severity, the inhospital mortality was lower (odds ratio: 0.606, p < 0.05) in the second group. Adjusted for age, Injury Severity Score, and mortality, the hospital stay was shorter (p < 0.001) in the second group. Fewer patients were admitted to the intensive care unit (p < 0.001), but the length of stay appeared longer (p = 0.055) after trauma center designation.

CONCLUSION

This study implies that the implementation of a trauma center reduces mortality, shortens hospital stay, and decreases the number of intensive care unit admittances in Utrecht, the Netherlands.

Regional Systems of Care for Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post–cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.

The impact of time of admission on major complications and mortality in patients undergoing emergency trauma surgery

BACKGROUND

Previous studies have shown a relationship between time of admission to hospital and mortality rates; however, it is uncertain whether such a relationship exists for patients requiring emergency trauma surgery.

METHODS

We included all trauma patients, except those with moderate to severe burns, who presented to a university-affiliated level 1 trauma center and underwent surgery, from 1995 until 2001 (n = 1044). We conducted univariate and multivariate analyses in which the dependent variables were in-hospital mortality and major complications, and the independent variables were the time of presentation to the trauma centre (nighttime vs. daytime, weekend vs. weekday, month of year, and year), age, sex, injury severity score, type of operative procedure, and total number of operative procedures.

RESULTS

None of the factors related to time of presentation were associated with major complications or mortality. Factors predictive of increased mortality were higher ISS (odds ratio 1.07; 95% confidence interval 1.03-1.08), older age (1.04; 1.03-1.07), operations involving the cardiovascular system (1.7; 1-2.6), "miscellaneous" operative procedures (1.8; 1.1-2.9), and major complications (2.4; 1.4-4.2).

INTERPRETATION

Time of presentation for emergency trauma surgery was not associated with differences in major complications or in mortality.

Assessment of mortality in older trauma patients sustaining injuries from falls or motor vehicle collisions treated in regional level I trauma centers

OBJECTIVE

To compare mortality in elderly trauma patients sustaining fall or motor vehicle collision (MVC) related injuries and who are subsequently treated at regional Level I (tertiary) trauma centers.

SUMMARY BACKGROUND DATA

An increase in the mean age of the Canadian population is leading to a higher proportion of older patients injured in falls who are subsequently treated at Level 1 trauma centers in Quebec. The Level 1 centers were designed to treat younger patients injured in MVCs and violent acts. As a result, discordance may exist between the type of care supplied at these centers and the increased demand for care tailored to older trauma patients.

METHODS

A retrospective cohort study comprised of 4,717 patients over the age of 65; 606 (12.8%) injured in MVCs and 4,111 (87.2%) in falls. The mean (SD) age was 79.6 (8.0) years and 67.9% were female. The mean (SD) Injury Severity Score (ISS) was 10.8 (7.4). Data were obtained from the Quebec Trauma Registry (QTR) for patients treated at 3 Level I trauma centers in the province of Quebec, Canada. The primary outcome measure in this study was mortality.

RESULTS

Being injured in a fall was a strong predictor for mortality, with an odds ratio of 5.11 (95% C.I. = 1.84-14.17, P = 0.002). Additionally, the adjusted mortality rate was 25.3% among fall victims, versus 7.8% for MVC patients. Female gender, older age, higher ISS and an increasing number of injuries were all associated with heightened mortality. In contrast, the number of body regions injured, experiencing complications, sustaining a hip fracture, the Revised Trauma Score, the Prehospital Index and the Charlson (comorbidity) Index had no association with mortality in the Level I centers.

CONCLUSIONS

Elderly patients sustaining fall-related injuries and treated at Level I trauma centers are at risk for excess mortality when compared with those injured in MVCs. Effective and efficient methods for treating this population must be determined.

Can hospital rankings measure clinical and educational quality?

BACKGROUND

A relative dearth of relevant data hampers efforts to demonstrate a link between educational and clinical quality and may preclude residency applicants from identifying programs with the best clinical outcomes. Existing clinical rankings could fill this gap if they are based on sound judgments about quality.

METHOD

To explore the potential of the U.S. News & World Report "America's Best Hospitals" clinical rankings in measuring the quality of clinical and learning environments, the author systematically reviewed the U.S. and Canadian literature for 1975 through 2007 regarding quality indicators and teaching hospitals. Individual data elements of the rankings were examined to assess the extent to which they included accepted measures of clinical performance.

RESULTS

A total of 187 articles met the inclusion criteria of addressing clinical quality criteria relevant to the rankings and quality assessment in teaching hospitals. Statistical examination of the data underlying the rankings and their relationship with measures of educational and clinical quality showed the rankings are largely based on institutional "prestige." Ranked clinical programs and institutions consistently outperform counterparts on available indices, suggesting that the data elements underlying the rankings may provide valid assessments about the quality of care in educational settings.

CONCLUSIONS

Data elements in the rankings can be used to assess clinical and, to a lesser extent, educational quality, but the number of specialties and ranked institutions is too small to have a significant effect on widespread clinical or educational quality, unless ranked institutions serve as sites for the development, study, and dissemination of best practices.

The value of trauma registries

Trauma registries are databases that document acute care delivered to patients hospitalised with injuries. They are designed to provide information that can be used to improve the efficiency and quality of trauma care. Indeed, the combination of trauma registry data at regional or national levels can produce very large databases that allow unprecedented opportunities for the evaluation of patient outcomes and inter-hospital comparisons. However, the creation and upkeep of trauma registries requires a substantial investment of money, time and effort, data quality is an important challenge and aggregated trauma data sets rarely represent a population-based sample of trauma. In addition, trauma hospitalisations are already routinely documented in administrative hospital discharge databases. The present review aims to provide evidence that trauma registry data can be used to improve the care dispensed to victims of injury in ways that could not be achieved with information from administrative databases alone. In addition, we will define the structure and purpose of contemporary trauma registries, acknowledge their limitations, and discuss possible ways to make them more useful.

Facial trauma coverage among level-1 trauma centers of the United States

PURPOSE

A large portion of patients admitted to trauma centers present with isolated or concomitant facial injuries. Multiple surgical specialties including oral and maxillofacial, plastic, and otolaryngology/head and neck surgeons are trained and involved in the management of oral and maxillofacial trauma. The purpose of this study is to evaluate the current distribution of different specialties that cover facial trauma among the leading trauma centers in the United States.

MATERIALS AND METHODS

Based on the number of emergency department admissions, the 5 busiest hospitals for each state within the United States were determined from the American Hospital Association, representing a total of 255 hospital emergency rooms. Seventy-six (N = 76) level-1 trauma centers were identified by directly contacting the hospital facility. Information was requested by mail from the chief of surgery and emergency medicine department regarding the percentage of facial trauma coverage by the different surgical specialties. In addition, the professional societies representing the 3 main specialties: American Association of Oral and Maxillofacial Surgeons (AAOMS), American Association of Plastic Surgeons (AAPS), and the American Academy of Otolaryngologists/Head and Neck Surgeons (AAO-HNS) were contacted to determine an estimate of the number of active members within each specialty.

RESULTS

Information was obtained from 57 (75%) level-1 trauma hospitals. The remaining 19 (25%) hospitals failed to respond to our survey. The distribution of facial trauma coverage by the different specialties was as follows: plastic surgeons, 39.6%; oral and maxillofacial surgeons, 36.6%; otolaryngologists/head and neck surgeons, 23.3%; and other services (general surgery and oculoplastics), 0.5%. According to the respective professional societies contacted, there are approximately 7,003 plastic surgeons, 6,377 oral and maxillofacial surgeons, and 7,720 head and neck surgeons that are practicing members of their respective societies.

CONCLUSION

Treatment of facial trauma is an essential and demanding aspect of all the surgical specialties that provide this service. All major trauma centers require the support of facial trauma specialists for management of these injuries. When considering the ratio of surgeons per specialty and the percentage of facial trauma coverage provided by each specialty, oral and maxillofacial surgeons and plastic surgeons provide the greatest proportion of facial trauma coverage among the level-1 trauma centers that participated in the survey.

Orthopaedic traumatology: the hospital side of the ledger, defining the financial relationship between physicians and hospitals

OBJECTIVE

The purpose of the study was to determine the financial relationship between facility and professional revenue for care delivered by two orthopaedic surgeons in a Level I trauma center for patients with multiple orthopaedic injuries.

DESIGN

Retrospective review of medical and financial records.

SETTING

Level 1 trauma center.

PATIENTS

Adult patients admitted with major multiple orthopaedic trauma were included if they had a significant pelvis/acetabulum injury associated with at least 2 extremity fractures, or if they had 3 or 4 extremities requiring surgical care. All patients had limited injury to other body systems, and all had completed their care related to the injury within the study period. We identified 68 patients who met the inclusion criteria. The mean Injury Severity Score was 22.6 (range, 9 to 57) and the mean New Injury Severity Score was 35.9 (range, 27 to 57).

OUTCOME MEASURES

The trauma center has an integrated economy. The surgeons are employed by the hospital, and the information systems for facility and professional services are shared through a unified business structure. Inpatient hospital charges related to the initial trauma admission and subsequent hospital-based outpatient care were abstracted from the Trendstar billing system. All medical and financial records were reviewed to exclude inpatient hospital charges related to the delivery of care by nonorthopaedic services. Orthopaedic professional fees were abstracted from the Epic billing system used for physician services.

RESULTS

The average facility charge was US$96,000, (range, $20,400 to $334,000, SD = $62,000) and the average orthopaedic professional charge was $24,900 (range, $5,200 to $60,300, SD = $14,000). The total facility charge for the study patients was $5,854,602 and the total orthopaedic professional charge was $1,516,568. The average orthopaedic trauma charge multiplier, the dollars of facility charge created by a single dollar of orthopaedic professional charge, was 3.86, (range, 1.35 to 15.2, SD = 3.0). When differences between collection rates were considered, the net revenue multiplier, the dollars collected by the hospital for facility services generated for each dollar collected by the orthopaedic surgeon, was 7.81.

CONCLUSIONS

The majority of the charges and the net revenue related to the care of trauma patients fall on the hospital side of the ledger. The significant multiplier for orthopaedic care delivered in the inpatient setting increases the value of the orthopaedic traumatology service above and beyond the value of the labor component as reflected by the professional fee. Understanding the value of the multiplier in different clinical situations frames the interdependent relationship between physicians and hospitals. Changes in malpractice coverage, declining professional reimbursement and reported difficulties in securing on-call coverage contribute to an emerging crisis in trauma care. The relationship between facility revenue and professional activity provides a firm basis to negotiate institutional support for orthopaedic traumatology.