Availability of trauma specialists in level I and II trauma centers: a national survey

Are trauma research programs in academic and non-academic centers measured by equal standards? A survey of 137 level I trauma centers in the United States

Background

American College of Surgeons level I trauma center verification requires an active research program. This study investigated differences in the research programs of academic and non-academic trauma centers.

Methods

A 28-question survey was administered to ACS-verified level I trauma centers in 11/12/2020–1/7/2021. The survey included questions on center characteristics (patient volume, staff size), peer-reviewed publications, staff and resources dedicated to research, and funding sources.

Results

The survey had a 31% response rate: 137 invitations were successfully delivered via email, and 42 centers completed at least part of the survey. Responding level I trauma centers included 36 (86%) self-identified academic and 6 (14%) self-identified non-academic centers. Academic and non-academic centers reported similar annual trauma patient volume (2190 vs. 2450), number of beds (545 vs. 440), and years of ACS verification (20 vs. 14), respectively. Academic centers had more full-time trauma surgeons (median 8 vs 6 for non-academic centers) and general surgery residents (median 30 vs 7) than non-academic centers. Non-academic centers more frequently ranked trauma surgery (100% vs. 36% academic), basic science (50% vs. 6% academic), neurosurgery (50% vs. 14% academic), and nursing (33% vs. 0% academic) in the top three types of studies conducted. Academic centers were more likely to report non-profit status (86% academic, 50% non-academic) and utilized research funding from external governmental or non-profit grants more often (76% vs 17%).

Conclusions

Survey results suggest that academic centers may have more physician, resident, and financial resources available to dedicate to trauma research, which may make fulfillment of ACS level I research requirements easier. Structural and institutional changes at non-academic centers, such as expansion of general surgery resident programs and increased pursuit of external grant funding, may help ensure that academic and non-academic sites are equally equipped to fulfill ACS research criteria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-021-00309-2.

Effect of Distance to Trauma Centre, Trauma Centre Level, and Trauma Centre Region on Fatal Injuries among Motorcyclists in Taiwan

Background: Studies have suggested that trauma centre-related risk factors, such as distance to the nearest trauma hospital, are strong predictors of fatal injuries among motorists. Few studies have used a national dataset to study the effect of trauma centre-related risk factors on fatal injuries among motorists and motorcyclists in a country where traffic is dominated by motorcycles. This study investigated the effect of distance from the nearest trauma hospital on fatal injuries from two-vehicle crashes in Taiwan from 2017 to 2019. Methods: A crash dataset and hospital location dataset were combined. The crash dataset was extracted from the National Taiwan Traffic Crash Dataset from 1 January 2017 through 31 December 2019. The primary exposure in this study was distance to the nearest trauma hospital. This study performed a multiple logistic regression to calculate the adjusted odds ratios (AORs) for fatal injuries. Results: The multivariate logistic regression models indicated that motorcyclists involved in crashes located ≥5 km from the nearest trauma hospital and in Eastern Taiwan were approximately five times more likely to sustain fatal injuries (AOR = 5.26; 95% CI: 3.69–7.49). Conclusions: Distance to, level of, and region of the nearest trauma centre are critical risk factors for fatal injuries among motorcyclists but not motorists. To reduce the mortality rate of trauma cases among motorcyclists, interventions should focus on improving access to trauma hospitals.

Effect of the COVID-19 pandemic on the ability of level 1 trauma centers to meet American College of Surgeons research requirements

Introduction

The COVID-19 pandemic has had major effects on hospitals' ability to perform scientific research while providing patient care and minimizing virus exposure and spread. Many non-COVID-19 research has been halted, and funding has been diverted to COVID-19 research and away from other areas.

Methods

A 28-question survey was administered to all level 1 trauma centers in the USA that included questions about how the pandemic affected the trauma centers' ability to fulfill the volume and research requirements of level 1 verification by the American College of Surgeons (ACS).

Results

The survey had a 29% response rate (40/137 successful invitations). Over half of respondents (52%) reported reduced trauma admissions during the pandemic, and 7% reported that their admissions dropped below the volume required for level 1 verification. Many centers diverted resources from research during the pandemic (44%), halted ongoing consenting studies (33%), and had difficulty fulfilling research requirements because of competing clinical priorities (40%).

Discussion

Results of this study show a need for flexibility in the ACS verification process during the COVID-19 pandemic, potentially including reduction of the required admissions and/or research publication volumes.

Level of evidence

Level IV, cross-sectional study.

Penetrating Abdominal Aortic Injury: Comparison of ACS-Verified Level-I and II Trauma Centers

OBJECTIVES

Penetrating abdominal aortic injury (PAAI) is a highly acute injury requiring prompt surgical management. When compared to surgeons at level-II trauma centers, surgeons at level-I trauma centers are more likely to take in-house call, and may more often be available within 15 minutes of patient arrival. Thus, we hypothesized that level-I trauma centers would have a lower mortality rate than level-II trauma centers in patients with PAAI.

METHODS

We queried the Trauma Quality Improvement Program database for patients with PAAI, and compared patients treated at American College of Surgeons (ACS)-verified level-I centers to those treated at ACS level-II centers.

RESULTS

PAAI was identified in 292 patients treated at level-I centers and 86 patients treated at level-II centers. Patients treated at the 2 center types had similar median age, injury severity scores and prevalence of diabetes, hypertension, and smoking (p > 0.05). There was no difference in the frequency of additional intra-abdominal vascular injuries (p > 0.05). Median time to hemorrhage control (level-I: 40.8 vs level-II: 49.2 minutes, p = 0.21) was similar between hospitals at the 2 trauma center levels. We found no difference in the total hospital length of stay or post-operative complications (p > 0.05). When controlling for covariates, we found no difference in the risk of mortality between ACS verified level-I and level-II trauma centers (OR:1.01, CI:0.28-2.64, p = 0.99).

CONCLUSION

Though the majority of PAAIs are treated at level-I trauma centers, we found no difference in the time to hemorrhage control, or the risk of mortality in those treated at level-I centers when compared to those treated at level-II trauma centers. This finding reinforces the ACS-verification process, which strives to achieve similar outcomes between level-I and level-II centers.

Assessing trauma care provider judgement in the prediction of need for life-saving interventions

INTRODUCTION

Human judgement on the need for life-saving interventions (LSI) in trauma is poorly studied, especially during initial casualty management. We prospectively examined early clinical judgement and compared clinical experts' predictions of LSI to their later occurrence.

PATIENTS AND METHODS

Within 10-15 min of direct trauma admission, we surveyed the predictions of pre-hospital care providers (PHP, 92% paramedics), trauma centre nurses (RN), and attending or fellow trauma physicians (MD) on the need for LSI. The actual outcomes including fluid bolus, intubation, transfusion (<1h and 1-6h), and emergent surgical interventions were observed. Cohen's kappa statistic (K) and percentage agreement were used to measure agreement among provider responses. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated to compare clinical judgement to actual patient interventions.

RESULTS

Among 325 eligible trauma patient admissions, 209 clinical judgement of LSIs were obtained from all three providers. Cohen's kappa statistic for agreement between pairs of provider groups demonstrated no "disagreement" (K<0) between groups, "fair" agreement for fluid bolus (K=0.12-0.19) and blood transfusion 0-6h (K=0.22-0.39), and "moderate" (K=0.45-0.49) agreement between PHP and RN regarding intubation and surgical interventions, but no "excellent" (K ≥ 0.81) agreement between any pair of provider groups for any intervention. The percentage agreement across the different clinician groups ranged from 50% to 83%. NPV was 90-99% across providers for all interventions except fluid bolus.

CONCLUSIONS

Expert clinical judgement provides a benchmark for the prediction of major LSI use in unstable trauma patients. No excellent agreement exists across providers on LSI predictions. It is possible that quality improvement measures and computer modelling-based decision-support could reduce errors of LSI commission and omission found in resuscitation at major trauma centres and enhance decision-making in austere trauma settings by less well-trained providers than those surveyed.

Clinical outcomes following invasive versus noninvasive preoperative stabilization of closed diaphyseal femur fractures

BACKGROUND

The use of invasive traction (INV-T) to stabilize femur fractures prior to fixation (open reduction and internal fixation, ORIF) remains controversial. Some centers have utilized noninvasive traction (NINV-T) or splinting preoperatively. It is possible that INV-T decreases hemorrhage. However, the use of INV-T in pediatric patients and for femoral neck fractures in adults is associated with worsened outcomes. We hypothesized that there is no difference in the need for transfusion between those who receive INV-T and NINV-T.

METHODS

A retrospective study was performed at two level I and one level II trauma center from January 2006 to December 2009. Patients ≥18 years with a closed diaphyseal femur fracture who underwent ORIF within 48 h of arrival were included. Patients were grouped by method of preoperative fracture stabilization. Primary endpoint was need for transfusion. A power analysis found that 94 patients were needed to detect a 25 % difference with 80 % power.

RESULTS

Fifty-six (22 %) received INV-T and 199 (78 %) received NINV-T stabilization. No significant differences were found between groups in terms of age, injury severity score, or ORIF method. There was no significant difference between the two groups in the hemoglobin value on arrival, preoperative hemoglobin value, or the difference between admission and preoperative hemoglobin values. We did not find a significant difference in the need for red blood cell transfusion between the two groups. There was no difference in length of stay or discharge destination.

CONCLUSION

INV-T is not associated with improved outcomes in adult patients with closed mid-shaft femoral fractures who are operated upon within 48 h of arrival.

Validation and refinement of a rule to predict emergency intervention in adult trauma patients

STUDY OBJECTIVE

Trauma centers use "secondary triage" to determine the necessity of trauma surgeon involvement. A clinical decision rule, which includes penetrating injury, an initial systolic blood pressure less than 100 mm Hg, or an initial pulse rate greater than 100 beats/min, was developed to predict which trauma patients require emergency operative intervention or emergency procedural intervention (cricothyroidotomy or thoracotomy) in the emergency department. Our goal was to validate this rule in an adult trauma population and to compare it with the American College of Surgeons' major resuscitation criteria.

METHODS

We used Level I trauma center registry data from September 1, 1995, through November 30, 2008. Outcomes were confirmed with blinded abstractors. Sensitivity, specificity, and 95% confidence intervals (CIs) were calculated.

RESULTS

Our patient sample included 20,872 individuals. The median Injury Severity Score was 9 (interquartile range 4 to 16), 15.3% of patients had penetrating injuries, 13.5% had a systolic blood pressure less than 100 mm Hg, and 32.5% had a pulse rate greater than 100 beats/min. Emergency operative intervention or procedural intervention was required in 1,099 patients (5.3%; 95% CI 5.0% to 5.6%). The sensitivities and specificities of the rule and the major resuscitation criteria for predicting emergency operative intervention or emergency procedural intervention were 95.6% (95% CI 94.3% to 96.8%) and 56.1% (95% CI 55.4% to 56.8%) and 85.5% (95% CI 83.3% to 87.5%) and 80.9% (95% CI 80.3% to 81.4%), respectively.

CONCLUSION

This new rule was more sensitive for predicting the need for emergency operative intervention or emergency procedural intervention directly compared with the American College of Surgeons' major resuscitation criteria, which may improve the effectiveness and efficiency of trauma triage.

Management of blunt extracranial traumatic cerebrovascular injury: a multidisciplinary survey of current practice

BACKGROUND

Extracranial traumatic cerebrovascular injury (TCVI) is present in 1-3% of all blunt force trauma patients. Although options for the management of patients with these lesions include anticoagulation, antiplatelet agents, and endovascular treatment, the optimal management strategy for patients with these lesions is not yet established.

OBJECTIVE

Multidisciplinary survey of clinicians about current management of TCVI.

METHODS

A six-item multiple-choice survey was sent by electronic mail to a total of 11,784 neurosurgeons, trauma surgeons, stroke neurologists, and interventional radiologists. The survey included questions about their choice of imaging, medical management, and the use of endovascular techniques. Survey responses were analyzed according to stated specialty.

RESULTS

Seven hundred eighty-five (6.7%) responses were received. Overall, a total of 325 (42.8%) respondents favored anticoagulation (heparin and/or warfarin), 247 (32.5%) favored antiplatelet drugs, 130 (17.1%) preferred both anticoagulation and antiplatelet drugs, and 57 (7.5%) preferred stenting and/or embolization. Anticoagulation was the most commonly preferred treatment among vascular surgeons (56.9%), neurologists (50.2%) and neurosurgeons (40.7%), whereas antiplatelet agents were the most common preferred treatment among trauma surgeons (41.5%). Overall, 158 (20.7%) of respondents recommended treatment of asymptomatic dissections and traumatic aneurysms, 211 (27.7%) did not recommend it, and 39.4% recommended endovascular treatment only if there is worsening of the lesion on follow-up imaging.

CONCLUSIONS

These data demonstrate the wide variability of physicians' management of traumatic cerebrovascular injury, both on an individual basis, and between specialties. These findings underscore the need for multicenter, randomized trials in this field.

Night admission to the emergency department: a factor delaying time to surgery in patients with head injury

AIM

To investigate factors influencing time from patient's arrival at the emergency department to surgery in patients with head injury.

BACKGROUND

A better understanding of factors influencing variation in time from patient's arrival at the emergency department to surgery for patients with head trauma could reduce mortality and morbidity associated with injury.

DESIGN

A cross-sectional study of secondary data.

METHODS

The sample represented 493 patients with head injury requiring surgery from the 17 level I and II trauma centres. Data were extracted from the National Trauma Data Bank version 4.0. Two-level hierarchical models were used to analyse data at the patient level while incorporating a unique random effect for each trauma centre. Factors entered in the models included patient characteristics and trauma centre characteristics.

RESULTS

Patients with a Glasgow coma scale score of 3-8 in the first ED assessment had earlier time to surgery compared with those with a Glasgow coma scale of 13-15 (β = -0·31, 95% CI = -0·43-0·18). Patients who arrived at the hospital during the nighttime (6pm-8am) had a significantly delayed time to surgery than those who arrived during the daytime (8am-6pm) (β = -0·15, 95% CI = -0·26 to -0·04).

CONCLUSIONS

The more severely the injured patients were the faster surgery was performed. The time, when patients arrived to the emergency department was found to be a significant factor influencing time to surgery. Patients who arrived at emergency department at night had longer time to surgery than those who arrived during daytime, despite they were more severely head injured than those who arrived during the day.

RELEVANCE TO CLINICAL PRACTICE

When surgical intervention in head-injured patients is anticipated, especially during the night shift, time from patient's arrival at emergency department to surgery should be consistently assessed to identify opportunities for improvement in the structure and process of trauma care.