The impact of true partnership between a university Level I trauma center and a community Level II trauma center on patient transfer practices

Editor's Choice - Acute Cardiovascular Care Association Position Paper on Intensive Cardiovascular Care Units: An update on their definition, structure, organisation and function

Acute cardiovascular care has progressed considerably since the last position paper was published 10 years ago. It is now a well-defined, complex field with demanding multidisciplinary teamworking. The Acute Cardiovascular Care Association has provided this update of the 2005 position paper on acute cardiovascular care organisation, using a multinational working group. The patient population has changed, and intensive cardiovascular care units now manage a large range of conditions from those simply requiring specialised monitoring, to critical cardiovascular diseases with associated multi-organ failure. To describe better intensive cardiovascular care units case mix, acuity of care has been divided into three levels, and then defining intensive cardiovascular care unit functional organisation. For each level of intensive cardiovascular care unit, this document presents the aims of the units, the recommended management structure, the optimal number of staff, the need for specially trained cardiologists and cardiovascular nurses, the desired equipment and architecture, and the interaction with other departments in the hospital and other intensive cardiovascular care units in the region/area. This update emphasises cardiologist training, referring to the recently updated Acute Cardiovascular Care Association core curriculum on acute cardiovascular care. The training of nurses in acute cardiovascular care is additionally addressed. Intensive cardiovascular care unit expertise is not limited to within the unit's geographical boundaries, extending to different specialties and subspecialties of cardiology and other specialties in order to optimally manage the wide scope of acute cardiovascular conditions in frequently highly complex patients. This position paper therefore addresses the need for the inclusion of acute cardiac care and intensive cardiovascular care units within a hospital network, linking university medical centres, large community hospitals, and smaller hospitals with more limited capabilities.

A prospective evaluation of patients with isolated orthopedic injuries transferred to a level I trauma center

PURPOSE

To assess the indications for, the demographics of, and the appropriateness of patient transfers for orthopedic injuries to a level I trauma center.

MATERIALS AND METHODS

All patients with isolated orthopedic trauma transferred to our level I trauma center (N = 128) by means of a physician-to-physician referral line during the call period of two surgeons were prospectively evaluated between January 1, 2004 and December 31, 2004. The specific indication for transfer, the specialty of the referring physician, the patient diagnosis, the perceived need for tertiary care referral (as assessed by a visual analog scale [VAS] based on the phone conversation with the transferring physician), and patient insurance status were obtained before the transfer. On patient arrival, each of these factors was reassessed for later comparison.

RESULTS

The transferring physician was an emergency department physician in 88 cases (69%), an orthopedic surgeon in 32 cases (25%), and an internist in the other eight cases (6%). In the 77 cases in which we could confirm the presence of an on-call orthopedist, the patient was examined by the orthopedic surgeon before being transferred in only 32 (42%) cases. In 98 cases (76%), the stated indication for transfer was that the case was too complex for care at the referring hospital or that there was a need for a subspecialist. There was no significant difference in pre- versus post-transfer case complexity as assessed by the VAS (P > 0.05). Although the reported insurance data before transfer was inaccurate in 34 patients (27%), the overall payer mixes reported before and after transfers were similar (23% Medicare, 20% HMO/PPO, 14% workers' compensation, 12% uninsured, 5% Medicaid). The insurance type for the transferred patients as a whole was not significantly different from the non-transferred patients treated by our orthopedic trauma service during the same time period (P > 0.05). Twenty transferred patients had a low VAS complexity score (<5), suggesting that their injuries did not necessarily require tertiary care. Fifteen of these 20 had Medicaid, Medicare, or no insurance. This was a significantly different (worse) payer mix than for the typical transferred patient (P < 0.05).

CONCLUSIONS

The need for an increased level of care was the predominant stated reason for patient transfer to our level I trauma center. Nonetheless, the orthopedic surgeon on call did not always examine the patient before transfer. Additionally, patients transferred who had a low level of complexity (those believed not to necessarily require tertiary care) had an insurance status that was worse than that of the typical transferred patient.

Acute traumatic injuries in rural populations

In the United States, injuries are the leading cause of death among individuals aged 1 to 45 years and the fourth leading cause of death overall. Rural populations exhibit disproportionately high injury mortality rates. Deaths resulting from motor vehicle crashes, traumatic occupational injuries, drowning, residential fires, and suicide all increase with increasing rurality. We describe differences in rates and patterns of injury among rural and urban populations and discuss factors that contribute to these differences.

Two major hospitals can share level I status in a rural community setting

BACKGROUND

Even though development of Level I trauma centers is thought to improve outcome of injury treatment, the political barriers in communities where two capable hospitals compete for designation can be formidable. This report documents the initial experience of a Level I trauma center developed in a two-hospital setting whereby each hospital hosted the trauma center on an alternating annual basis.

METHODS

Preliminary efforts began with a community-based report on trauma care to which both hospitals and their associated school of medicine contributed. In addition to confirming need, all parties agreed to develop a single Level I trauma center that would be verified by the appropriate state agency and would receive professional and financial support from all three institutions.

RESULTS

The Southern Illinois Trauma Center began to function on July 1, 1999. Prehospital acceptance of the community agreement has resulted in appropriate triage to the designated hospital in 95% of the 1,000 cases seen annually. Integration of trauma care into the surgical residency program has been valuable both for function of the trauma center and as a teaching enhancement for trauma and critical care as reflected by significantly improved American Board of Surgery In-Training Examination scores. The trauma center is governed by a trauma committee with representation from the three institutions. The percentage of trauma transfers has increased over 3 years from 23% to 28%. Four annual institutional site changeovers have now occurred without incident or disruption of service. The trauma center finances are reviewed by the participants on a biannual basis and have been deemed favorable.

CONCLUSION

The community medical resources are commonly polarized between two large hospitals but need not prevent centralized trauma center development if preagreed community support can be achieved. Annual site change is not an impediment and could be successfully used in other similar communities, provided they are receptive to the concept of sharing Level I trauma center site designation.

Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care

OBJECTIVES

To describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level.

PARTICIPANTS

A multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM).

DATA SOURCES AND SYNTHESIS

Relevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts. Consensus for the final written document was reached through collaboration in meetings and through electronic communication modalities. Literature cited included previously written guidelines from the ACCM, published expert opinion and statements from official organizations, published review articles, and nonrandomized, historical cohort investigations. With this background, the ACCM writing panel described a three-tiered system of intensive care units determined by service-based criteria.

CONCLUSIONS

Guidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.

The Outreach Trauma Program: a model for survival of the academic trauma center

BACKGROUND

In the current health care climate, trauma centers face particular economic challenges. Statewide trauma systems provide a network for referral of critically injured patients to academic Level I trauma centers, but favorable reimbursement in states such as Colorado results in intense competition for patients. We hypothesized that a comprehensive Outreach Trauma Program would facilitate our mission as a key resource facility in our trauma system, and would increase referrals of critically injured patients to our center from outside our metropolitan area.

METHODS

The Colorado statewide trauma system was formalized in 1995; our Outreach program-including providing visiting trauma call, continuing medical education lectures, 24-hour/7-day immediate consultation and transfers, and public relations/marketing-was fully implemented in 1997. We audited our trauma registry from January 1994 to July 2001 to determine the impact on patient volume and acuity as well as academic productivity.

RESULTS

Annual overall trauma admissions have remained stable. Since 1997, high-acuity patients (i.e., Injury Severity Score > 15, intensive care unit admissions, those requiring surgery) have increased 27% to 51%, attributable largely to an approximately 300% increase in high-acuity Outreach patients. In 2000, Outreach patients constituted 8% of our total trauma admissions, but 21% of intensive care unit trauma admissions; notably, they accounted for 25% of our center's trauma charges. Meanwhile, our group's academic productivity has not suffered; in fact, we had 57 publications in 2000, compared with an average of 35 per year from 1993 through 1997.

CONCLUSION

The Outreach Trauma Program has proven clinically, academically, and financially rewarding. Our program may serve as a model whereby academic trauma centers, through a demonstrated commitment to serving the clinical and educational needs of their referral base, can satisfy their mission while ensuring their survival.

Pediatric trauma center criteria: an outcomes analysis

BACKGROUND/PURPOSE

Trauma centers (TC) are certified based on widely accepted criteria. These specific criteria rarely are scrutinized individually. The purpose of this study was to analyze the individual components of a pediatric trauma center for their effect on outcome.

METHODS

Members of the National Pediatric Trauma Registry were queried about the following: (1) separate pediatric emergency department (ED), (2) pediatric intensive care unit (PICU), (3) pediatric intensivist as PICU director, (4) pediatric surgeon as TC director, (5) in-house attending surgeon, (6) in-house pediatric emergency physician, (7) 24-hour operating room, (8) 24-hour computed tomography (CT) scan. Outcomes analyzed included mortality, length of stay, time in ED, days in PICU, and disability. Victims were stratified based on age (<7 or > or = 7 years) and severity of injury (ISS < or = 16, 17-35, > or = 36). Results were compared using Student's t test and chi2 analysis.

RESULTS

A total of 59 of 74 centers responded, 18 were dropped because of low enrollment (mean, 1.6 patients). Questions 3, 4, 6, and 7 were eliminated because of skewed data. An in-house surgeon reduced the amount of time a mildly injured patient (ISS < or = 16) spent in the ED (210 v434 minutes), as did the separate pediatric ED (333 v592 minutes) and pediatric emergency physicians (344 v 507 minutes) in younger patients (> or = 7 years). An in-house surgeon reduced the morality rate in older (> or = 7) severely injured (ISS > or = 36) patients (46.7% v 56.8%; P < .05 for all). No other differences were significant.

CONCLUSIONS

In-house personnel improved efficiency for the less severely injured, and an in-house attending surgeon reduced mortality in the severely injured older patient. None of the other variables were found to have a significant impact on outcome.

Consolidation of trauma programs in the era of large health care delivery networks

OBJECTIVE

To review the development of an integrated trauma program at two separate campuses brought about by the merger of two medical-affiliated hospitals, each with an integrated program and a common trauma administrator, medical director, and educational coordinator. Each campus has an associate trauma medical director for on-site administrative management, a nurse coordinator, and a registrar. The integration resulted in a reduction of 1.5 full-time equivalents and "cost" savings by consolidated use of the helicopter, outreach, prevention, research, and educational programs. Regular "integration meetings," ad hoc committees, and video-linked conferences were used to institute common quality improvement programs, morbidity and mortality discussions, policies, and clinical management protocols. Reaccreditation by an outside agency, elimination of duplicated services, and maintenance of pre-merger clinical volume results.

CONCLUSION

This integrated trauma program may serve as a model in this era of individual hospitals merging into large health care delivery networks.