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Availability of Trauma Specialists in Level I and II Trauma Centers: A National Survey
Abstract
Despite American College of Surgeons Committee on Trauma's criteria, little data exists about the variability of practices in both the composition of trauma teams and timing of specialist availability across trauma centers. The purpose of the study was to determine the availability of trauma team personnel in Level I and II trauma centers across the United States.
Two surveys were developed and mailed to trauma directors and coordinators in 450 centers. Responses were received from 254 directors (56%) and 218 coordinators (48%). The director survey was designed to collect data on trauma team composition and timeliness in response to a hypothetical scenario. The coordinator survey was designed to collect data on trauma center characteristics and general availability of trauma specialists.
Eighty-two percent of Level I and II centers had trauma surgeons available within 15 minutes of and 37% at patient admission. The in-house (IH) centers (60%) had a trauma surgeon at patient admission significantly more than on-call centers did (22%). The specialty surgeons, such as neurosurgeons (73%) and orthopedic surgeons (75%), were mostly available through the on-call system. An IH system, high volumes of trauma patients, and designation by American College of Surgeons were significantly associated with higher likelihood of trauma surgeons physically present at the bedside within 15 minutes.
There was a large variation in the availability of expertise at or shortly after a trauma admission. For centers with low patient volume, early triage, better notification systems based on advanced telecommunication technology, and compensation for IH call may be a solution to better use the trauma surgical specialties.
... The patient cohort studied was representative of the entire trauma center population in respect to the incidence of blood transfusion of 7.4%; this was within the 6-8% incidence of the overall trauma center transfusion rate [28] indicating that the patients studied were similar to that of the overall trauma center population. Not all patients were included since we excluded patients who expired within the first 15 minutes after admission. ...
... In addition we were unable to survey clinician's predictions when there were concerns with interruption of emergency clinical care, especially in the most severely injured and moribund patients, thus resulting in a potential selection bias to the less injured patient with few LSIs. We did not rank the relative importance of LSIs or the occurrence of multiple LSI's, the pulse oximeter PPG analysis algorithm only minutes of patient admission [28], so having survey responses completed by 100% of physician leaders within 15minutes and 80% within 10 minutes would exceed an expected timely survey completion rate at most U.S trauma centers. ...
Early recognition of hemorrhage during the initial resuscitation of injured patients is associated with improved survival in both civilian and military casualties. We tested a transfusion and life-saving intervention (LSI) prediction algorithm in comparison to clinical judgment of expert trauma care providers.
... Trauma care in the platinum ten minutes and golden hour There is ample evidence that prompt attention by well-trained trauma care professionals increase the positive patient outcomes following trauma 16,17 . However, there are many challenges bringing the patients to the attention to trauma care experts within the golden hour (18). The challenges may range from simply geographical, or situation related as in mass disasters where access is limited to unavailability of human resources in ideal levels. ...
Trauma care represents a complex interaction between humans and technology. Historically advancement in trauma care is linked to advancement in technology: it may be improvements in communication, transportation, imaging, etc. On the other hand, advancement in technologies leads to new challenges in trauma care. Using computers in health care is not a new phenomenon. Whatever the advancement in information and communication technology, one of the first applications of technology is in the field of health care. The fourth industrial revolution is changing the lives of people as never before. The Metaverse comprises of technologies of industry 4.0 such as artificial intelligence (AI), AR, VR, telepresence, digital twinning, and block chain, etc. According to broader definitions, the metaverse represents a futuristic virtual world in 3D. Virtual reality is a network of interconnected virtual worlds that can be managed independently. Metaverses, therefore, consist of a multitude of digital universes rather than a single virtual world (1). The science-fiction author Neal Stephenson coined the term metaverse in his novel Snow Crash (1992), in which characters enjoy themselves as digital avatars in the “Metaverse” as an escape from the grim realities of the real world.
... Because of the high bar set for ACS level I verification, these trauma centers serve as comprehensive regional resources that provide the highest level of specialized, immediate trauma care [3][4][5][6]. Level I status has shown to be associated with improved clinical outcomes, including lower mortality rates, lower rates of disability at discharge, and better overall outcomes in severely injured patients, compared to level II-IV centers and undesignated trauma centers [7][8][9][10]. Undergoing the process of transitioning to ACS level I status, including restructuring of the trauma department and greater oversight of patient care, has been shown to lead to improved patient outcomes, including reductions in both mortality and patient length of stay [11]. ...
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.
... 5 Facilities designated as level 1 trauma centers by the American College of Surgeons (ACS) are comprehensive regional resources that provide the highest level of specialized trauma care. [12][13][14] Verification as an adult level 1 trauma center has requirements that include a volume threshold (≥1200 adult trauma admissions, or ≥240 admissions with Injury Severity Score >15, per year), as well as an active and productive research program. 15 The research program requirements include either 20 publications per 3-year review period or a combination of 10 publications and participation in research activities such as lectures at national conferences and leadership in major trauma organizations. ...
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.
... Demographic and clinical characteristics of these patients are shown in Table 1. Mean Injury Severity Scores (ISS) were 13.0 (SD 13.2) [interquartile range, [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Injuries included 19% penetrating injuries and 78% blunt injuries (Table 1). ...
Human judgment on the need for life-saving interventions (LSI) in trauma is poorly studied, especially during initial casualty management. We prospectively examined early clinical judgment and compared clinical experts’ predictions of LSI to their later occurrence.Patients and Methods
Within 10-15 minutes 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 (<1 hour and 1-6 hours), 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 judgment to actual patient interventions.ResultsAmong 325 eligible trauma patient admissions, 209 clinical judgment of LSIs were obtained from all 3 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 0-6 hours (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%-83%. NPV was 90-99% across providers for all interventions except fluid bolus.Conclusions
Expert clinical judgment 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.
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.
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.
The emergency department (ED) is an especially challenging environment in which to consistently make accurate and timely diagnoses, as mistaken or delayed diagnoses can produce severe adverse outcomes to the patient. In addition, missed diagnoses in the ED are of particular concern for the emergency clinician as it became one of the most prevalent type of malpractice claim in many countries [1].
Managing a patient that suffered a skeletal injury in the ED places a great demand on the treatment process because the orthopaedic trauma surgeon may be not available in the hospital all hours. In fact, in many hospitals an emergency room (ER) physician usually conducts the first evaluation of this patient, which seems to be pretty reasonable if some requests are followed.
Demarest et al. proved to be not absolutely necessary for the trauma surgeon to be available in the hospital all hours provided the distance to the hospital is not greater than 15 minutes and an orthopaedic resident is already in the hospital [2]. In another study, Helling et al. found the presence of in-house attending trauma surgeons did not improve management or outcome of critically injured patients, giving the trauma surgeons 20 minutes as the limit to be at the hospital [3]. These results were confirmed by other authors [4,5]. More recently, Kim et al. showed that 82% of level I and II centers across the United States had trauma surgeons available within 15 minutes and that 75% of orthopedic surgeons were mostly available through the on-call system [6].
However, there are some urgent musculoskeletal conditions, like severely injured patients, acute infections, joint dislocations, and older patients sustaining a fracture, that may benefit from an in-house trauma surgeon or, if not readily available in an institution, an ER physician adequately prepared for the prompt management of those patients [4]. In this context, increasing ER physician training in an attempt to mitigate patients’ morbidity and mortality seems to be extremely important as an in-house call policy. Ultimately the ability of the emergency physician to diagnose the skeletal injury may substantially influence patient’s outcome. In addition, the emergency team should be supported by various levels of trainee and/or staff grades.
Emergency orthopaedic care includes acute trauma care and urgent general orthopaedic care delivered in hospital emergency rooms [7]. Treatment of the seriously injured should always be considered a time-critical process. Thus, diagnosis of a critically injured patient must detect life-threatening injuries, complete the diagnostic work-up, and prepare the patient for the next phase of care (operating room or intensive care unit) as rapidly as possible [8]. For those patients, the most important factor that determines one’s probability to survive is often time. Missing, ignoring, or not expediting adequate care can result in disastrous consequences, like loss of life or limb.
On the clinical side, critical skills to manage musculoskeletal injuries must be learned during emergency medicine residency training Gill et al. designed a hands-on orthopaedic rotation for emergency residents in collaboration with the emergency medicine residency program in their first post-graduate year to introduce them to the appropriate evaluation and management of common orthopaedic injuries and conditions [9]. They demonstrated that giving emergency medicine residents a similar opportunity to learn with an orthopaedic surgery resident is a useful model for musculoskeletal education for non-orthopaedic surgery residents [9]. Physicians will perform better when they are trained and interested in a specific area than those not trained, or even not having any particular interest in that specific area [10]. Going a little further, we feel it seems quite reasonable to maintain a continuing education program for the ER physician who initially addresses musculoskeletal injuries.
Lin et al. demonstrated that surgeons committed to the trauma service had less missed injuries in severely injured patients, and it is vital to improve patient safety and quality of care for trauma patients [10].
The overall impression of the hospital care is directly related to improved patient function and quality of life, cost-effectiveness, and reduced risk of mortality [11]. Staff training and education for assessing severely injured patients and creating an open culture with detection and reduction of the potential for error are important and effective strategies in decreasing missed injuries and improving patient safety [10-12]. Today, continuing medical education (CME) is mandated by many regulatory bodies as part of maintenance of competence, accreditation and licensure, either in form of face-to-face learning through courses, conferences, and workshops, or online learning modules [12]. From an orthopaedic perspective, the course must be intended to teach doctors to recognize limb-threatening injuries and referring these patients after resuscitation, initial wound management, and immobilization [13]. Prevention measures and interventions that increase healthcare capacity to manage injuries may be an effective way to decrease morbidity and mortality [14]. Both Quansah et al. and Pringle et al. recommend governments and/or international community support programs to provide CME in trauma care, such as ATLS (or variations) or locally developed courses in low and middle-income countries, which shown to be valuable and effective education tools to all front line trauma care providers [13,14]. Implementation of trauma care managers and nurse coordinators is the cornerstone of quality medical care [15].
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.
Trauma is a major public health issue. The management of seriously injured patients requires the integration of rescue and transport services, resuscitation and reconstructive care in dedicated centers with access to physical and vocational rehabilitation. The management of injury is exceedingly complex and expensive. We are entering a period of uncertainty due to the convergence of decreased reimbursement, more uncompensated care and fewer specialists willing to provide on-call services. The management of injury is costly yet has clear economic benefits based upon the potential to reduce mortality and mitigate disability. Trauma care also is very sustainable under favorable conditions including regionalized systems to support volume-driven proficiency, productive specialist staffing models, an evidence-based approach to technology and a high degree of physician-hospital integration.
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.
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.
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.
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.
The Emergency Medical Treatment and Active Labor Act was meant to provide access to emergency medical care irrespective of financial resources. Yet, many Level I trauma Centers have raised concerns about the financial drivers influencing transfer.
: To study the relationship between insurance status and transfer, we focused on patients with mild head injury to tease apart the medical necessity for transfer from other potential drivers, such as financial factors.
Using the 2002 to 2006 American College of Surgeons National Trauma Databank and Massachusetts General Hospital's Trauma Databank from 1993 to 2009, we conducted a retrospective study and limited our population to patients with mild head injuries and mild to moderate systemic injuries as determined by the Glasgow Coma Scale, Abbreviated Injury Scale, or Injury Severity Score. Statistical analyses were conducted with STATA software.
In a nationalized database, (1) uninsured patients with mild head injury are more likely to be transferred out of a Level II or III facility (adjusted odds ratio [OR]: 2.07; P = .000) compared with privately insured patients and (2) uninsured patients are less likely to be accepted by a Level II or III facility for transfer compared with privately insured patients (adjusted OR: = .143; P = .000l). For transfers received by 1 Level I trauma center (Massachusetts General Hospital), uninsured patients are more likely to be transferred to (1) Massachusetts General Hospital between midnight and 6 am (adjusted OR: 5.201; P = .000) compared with other time periods throughout the day and (2) Massachusetts General Hospital on Sunday (adjusted OR: 1.09; P = .000) compared with other days of the week.
Insurance status appears to influence transfer patterns.
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.
Multidisciplinary survey of clinicians about current management of TCVI.
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.
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.
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.
To investigate factors influencing time from patient's arrival at the emergency department to surgery in patients with head injury.
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.
A cross-sectional study of secondary data.
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.
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).
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.
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.
Rural citizens die more frequently because of trauma than their urban counterparts. Skill maintenance is a potential issue among rural surgeons because of infrequent exposure to severely injured patients. The primary goal was to evaluate the outcomes of multiple injuries patients who required a laparotomy after referral from level III trauma centers.
All severely injured patients (injury severity score >12) referred to a level I trauma center from level III hospitals, during a 48-month period were evaluated. Comparisons between referrals (level III and IV) as well as survivors and nonsurvivors used standard statistical methodology.
One thousand two hundred and thirty patients (35%) were transferred from level III (33%) and level IV (67%) centers (43% underwent an operative procedure). Only 13% required a laparotomy, whereas 87% needed procedures from other subspecialists. Referred patients had a mean injury severity score of 28, length of stay of 28 days, and mortality rate of 26%. More patients arrived hemodynamically unstable from level IV (55%) versus level III (35%) hospitals (p < 0.05). Nonsurvivors from level III centers were more likely to transfer via aircraft (100%) than from level IV hospitals (55%) (p < 0.05). Most (91%) definitive general surgery procedures could have been completed by surgeons at level III centers; however, 90% also had multisystem injuries requiring treatment by other subspecialists.
Most severely injured patient referrals from level III and IV trauma centers in Western Canada are appropriate. The lack of consistent subspecialty coverage mandates most transfers from level III hospitals. This data will be used to engage rural Alberta physicians in an educational outreach program.
As a result of many factors, the availability of neurosurgeons (NS) to care for trauma patients (TP) is increasingly sparse. This has precipitated a crisis in access to neurosurgical support in many trauma systems, often placing undue burden on level I centers. This study examines the profile of head-injured (HI) trauma patients and their actual need for the specific expertise of a neurosurgeon.
The National Trauma Data Bank (NTDB) was queried for specific information relating to the volume, nature, timeliness, and outcome of HI TP. Study patients were identified by reported International Classification of Diseases, 9th Edition (ICD-9) codes denoting open (OHI) or closed head injury (CHI) in isolation or in combination with other injuries.
Total number of NTDB patients studied was 731,823, of which 213,357 (29%) had a reported HI. CHI represented 22% of all TP and 74% of HI. OHI was reported in 8% of all TP and was 26% of HI. Craniotomy (crani) was performed in 3.6% of all HI (1% of all TP). This was in 2.8% of OHI and 2.6% of CHI. Mean Glasgow Coma Scale score (GCS) of crani patients was 9, and 13 for the noncrani group. Subdural hematoma occurred in 18% of HI (5% of TP), with 13% undergoing crani. Epidural hematoma occurred in 10% of HI (3% of all TP), with 17% undergoing crani. Median time to OR for all cranis was 195 minutes (195 for CHI; 183 for OHI). Of all cranis, 6.5% were performed within 1 hour of hospital admission. Intracranial pressure (ICP) monitoring was reportedly used in 0.7% of TP and 2.2% of HI.
Care of TP with HI rarely requires the explicit expertise and immediate presence of a neurosurgeon due to volume and nature of care. HI was diagnosed in <30% of TP reported to the NTDB. Over 95% required nonoperative management alone, with only 1% of all TP and 2%-4% of HI TP requiring crani and/or ICP monitoring. Immediate availability of NS is not essential if a properly trained and credentialed trauma surgeon or other health care provider can appropriately monitor patients for neurologic demise and effect early transfer to a center capable of, and committed to, operative and postoperative neurosurgical care. A subgroup of patients known to have a high propensity for the specific expertise of a neurosurgeon may be able to be identified for direct transport to these committed centers.
Background Although not directly involved in designation per se, the American College of Surgeons (ACS) Committee on Trauma verification/consultation program in conjunction with Resources for Optimal Care of the Injured Patient has set the national standards for trauma care. This study analyzes the impact of a recent verification process on an academic health center. Methods. Performance improvement data were generated monthly from the hospital trauma registry. Forty-seven clinical indicators were reviewed. Three study periods were defined for comparative purposes: PRE (January, June, October 1997), before verification/consultation; CON (April 1999-October 1999), after reorganization; and VER (November 1999-September 2000), from consultation to verification. Results: Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (< 120 minutes) improved in each study section (PRE, 21%; CON, 48%; VER, 76%). Enhanced nursing documentation correlated with improved clinical care such as early acquisition of head computed axial tomographic scans in neurologic injured patients (PRE, 66%; CON, 97%; VER, 95%). Intensive care unit length of stay (< 7 days) decreased (PRE, 87%; VER, 97.8%). Other transformations included increase in institutional morale with recognition of trauma excellence within the hospital and resurgence of the trauma research programs (60 institutional review board-approved projects). Conclusion. The ACS verification/consultation program had a positive influence on this developing academic trauma program. Preparation for ACS veriflcation/consultation resulted in significant improvements in patient care, enhancement of institutional pride, and commitment to care of the injured patient.
and Background Data: As a result of many factors, the availability of neurosurgeons (NS) to care for trauma patients (TP) is increasingly sparse. This has precipitated a crisis in access to neurosurgical support in many trauma systems, often placing undue burden on level I centers. This study examines the profile of head-injured (HI) trauma patients and their actual need for the specific expertise of a neurosurgeon. Methods: The National Trauma Data Bank (NTDB) was queried for specific information relating to the volume, nature, timeliness, and outcome of HI TP. Study patients were identified by reported International Classification of Diseases, 9th Edition (ICD-9) codes denoting open (OHI) or closed head injury (CHI) in isolation or in combination with other injuries. Results: Total number of NTDB patients studied was 731,823, of which 213,357 (29%) had a reported HI. CHI represented 22% of all TP and 74% of HI. OHI was reported in 8% of all TP and was 26% of HI. Craniotomy (crani) was performed in 3.6% of all HI (1% of all TP). This was in 2.8% of OHI and 2.6% of CHI. Mean Glasgow Coma Scale score (GCS) of crani patients was 9, and 13 for the noncrani group. Subdural hematoma occurred in 18% of HI (5% of TP), with 13% undergoing crani. Epidural hematoma occurred in 10% of HI (3% of all TP), with 17% undergoing crani. Median time to OR for all cranis was 195 minutes (195 for CHI; 183 for OHI). Of all cranis, 6.5% were performed within 1 hour of hospital admission. intracranial pressure (ICP) monitoring was reportedly used in 0.7% of TP and 2.2% of HI. Conclusions: Care of TP with HI rarely requires the explicit expertise and immediate presence of a neurosurgeon due to volume and nature of care. HI was diagnosed in <30% of TP reported to the NTDB. Over 95% required nonoperative management alone, with only 1% of all TP and 2%-4% of HI TP requiring crani and/or ICP monitoring. Immediate availability of NS is not essential if a properly trained and credentialed trauma surgeon or other health care provider can appropriately monitor patients for neurologic demise and effect early transfer to a center capable of, and committed to, operative and postoperative neurosurgical care. A subgroup of patients known to have a high propensity for the specific expertise of a neurosurgeon may be able to be identified for direct transport to these committed centers.
Background: The purpose of this study was to prospectively compare patient outcomes based on the presence of in-house versus on-call attending trauma surgeons at comparable Level I trauma centers. Methods: Two designated Level I trauma centers agreed to prospectively review trauma admissions over a 6-month period, one institution with 24-hour in-house trauma attending surgeons (IH), and the other with trauma-attending surgeons taking call from home (OC) available to the hospital within 15 minutes of notification. A 6-month prospective study was conducted reviewing all trauma patients admitted to both trauma centers with an Injury Severity Score greater than or equal to 16. Comparisons were made between institutions utilizing admission demographics, clinical presentation, times to clinical care, and mortality rates, Results: In comparison, OC and IH institutions were distinctly different in geographic environment, size, and number of patients admitted. As a group, IH patients were significantly older, with higher Injury Severity Scores and lower Glasgow Coma Scale scores than the OC group. In all comparisons, OC trauma attending surgeons responded to the trauma room with equal speed or more rapidly when compared with IH trauma attending surgeons. There were no other significant differences in either population in times to provision of clinical care or in clinical outcome, Conclusion: The ability of the OC institution to be similar to the IH institution in its provision of clinical care and mortality rate is accomplished in an environment where trauma attending surgeons live within a Ii-minute response time to the trauma center. Using a voice-paged trauma alert activation with accurate information and sufficient warning, evaluation, provision of care, and clinical outcome of the acutely injured patient can be provided equally by in-house trauma attending surgeons and trauma attending surgeons on-call from home.
Objective: To determine the impact of the presence of an attending trauma surgeon during trauma team activation on system function and patient outcome.
Methods: After a retrospective review of medical records and trauma registry, a comparative study between two American College of Surgeons Committee on Trauma Level I trauma centers was performed. One center (Hennepin County Medical Center) required a chief surgical resident, two junior residents, and a board-certified emergency medicine faculty to be present in the emergency department for all trauma team activations. The attending trauma surgeon was notified at the time of trauma team activation and was neither required to be present in the emergency department at time of patient arrival nor in the hospital 24 h/day. The other center (St. Paul Ramsey Medical Center) required a chief surgical resident, two junior residents, a board-certified emergency medicine faculty member, and an attending trauma surgeon to be present in the emergency department for all trauma activations and in hospital 24 hours/day. Over a 21-month period, all major trauma patients (Injury Severity Score > 15 or emergent operation within 4 hours of admission and any Injury Severity Score) that triggered trauma team activation were examined. Resuscitation time, time to incision, probability of survival, and mortality were analyzed.
Results: Resuscitation time was shorter at St. Paul Ramsey Medical Center when compared with Hennepin County Medical Center. Analysis by mechanism of injury demonstrates that this was true for blunt trauma (39 ± 13 vs. 27 ± 12 minutes, p = 0.001) and for penetrating trauma (28 ± 14 vs. 24 ± 17 minutes, p = 0.01). Subgroup analysis of penetrating trauma victims demonstrated that there was a significant difference in resuscitation times for gunshot wounds but not for stabs. There was no difference in how quickly operations could be initiated for blunt trauma patients. However, in penetrating cases, time to incision was significantly shorter at St. Paul Ramsey Medical Center (50 ± 29 vs. 66 ± 43 minutes, p = 0.01). There was no significant difference in mortality for any category of Trauma and Injury Severity Score probability of survival in blunt or penetrating trauma. Analysis of "in-house" and "out-house" time intervals demonstrated no difference in survival in any mechanism of injury, nor was there a difference in overall mortality.
Conclusion: The presence of a trauma surgeon on the trauma team reduced resuscitation time and reduced time to incision for emergent operations, particularly in penetrating trauma. However, it had no measurable impact on mortality based on Trauma and Injury Severity Score probability of survival. Attending trauma surgeon presence on the trauma team improves in-hospital trauma system function without affecting patient outcome.
There were significant differences in the time taken to resuscitate 257 trauma patients from four internationally recognized trauma centres. The fastest unit completed resuscitation in 15 min while the slowest took 105 min. This variation was not explained by differences in the type of patient dealt with, seniority of the team leader, or the number of personnel in the trauma team. Although there were significant differences between the units with regard to these parameters, they did not account for the resuscitation time variations. The average post-qualification time of the team leader at the fastest unit was 2 years. Although the slowest unit had the smallest trauma team (two people), larger numbers of personnel did not shorten resuscitation times. The time taken to carry out the ABC of the primary survey was significantly correlated with patient's physiological change in the resuscitation room (R = -0.63, P less than 0.0001 with systolic blood pressure; R = -0.68, P less than 0.01 with the revised trauma score). A multiple regression with survival as the dependent variable revealed that this time was also a predictor of the patient's eventual outcome (t = 3.18, P less than 0.005).
Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.
Presently virtually all patients with acute head trauma are computed tomography (CT) scanned and transferred to a neurosurgical operating room before any surgical intervention. The time required for this, especially if the patient is transferred to another institution, may lead to a significant delay in treatment. In a patient with an expanding intracranial hematoma and evidence of brainstem compromise this delay may produce a worse outcome. Cranial burr hole placement can rapidly, safely, and accurately find and partially decompress most extracerebral intracranial hematomas. A burr hole placed rapidly before CT and transfer could prevent further damage to the brain by an expanding hematoma. The case of a child with a preterminal epidural hematoma whose outcome was excellent because of a burr hole placed in the emergency department (ED) is presented. In light of this case and a complete literature review, it is suggested that more frequent attempts to decompress intracranial hematomas in the ED may be warranted.
Sixty-nine severely head-injured patients treated by general surgeons over a 28 month period with admission Glasgow Coma Scale motor scores of 3 to 8 were reviewed retrospectively. Fifty-one patients were comatose on admission with periods from injury to admission exceeding 4 h in 34 patients who were referred from peripheral hospitals. Forty patients with acute intracranial bleeding underwent emergency decompressive surgery with 13 good recoveries and 18 deaths; good recoveries were observed in 11 of 20 patients with extradural haemorrhages, one out of eight patients with subdural haemorrhages, and one of 12 patients with intracerebral and/or combined haemorrhages. Twenty-nine patients with no evidence of acute mass lesions were treated medically with sedation, mechanical ventilation and mannitol infusion for cerebral decompression with seven good recoveries and 16 deaths. There were 15 good outcomes in 40 patients with admission motor scores of 6, 7 or 8 and five good outcomes in 29 patients with scores of 3, 4 or 5. A good outcome of 29% in the study may be improved by (i) better neurosurgical training of surgical and nursing staff; (ii) provision of technologically advanced diagnostic and treatment modalities; (iii) an efficient referral system; and (iv) provision of effective long-term rehabilitation.
The benefit derived from in-house board-certified attending surgeons (IHBCS) staffing trauma centers has recently been questioned. We compared the outcomes and provider-related complications of patients with severe injuries who were treated at two university trauma centers, one with IHBCS, and one with PGY-4 or PGY-5 residents in house (RIH). The RIH center had a significantly longer resuscitation time (160 vs. 58.8 minutes; p < 0.01). Except in cases of vascular injury, the odds ratio of dying at the RIH institution was significantly greater in all groups when the variables of transport time, Revised Trauma Score, and ISS were controlled. Errors in judgment were significantly more likely to have been made at the RIH institution in all groups. It is concluded that the management and ultimate outcome are significantly improved when IHBCS are involved with the resuscitation and early care of specific cohorts of severely injured patients.
The purpose of this study is to evaluate the effect of having attending trauma surgeons with added qualifications in surgical critical care present for the initial resuscitation at a regional trauma center.
This study is a retrospective review of patients admitted between August of 1994 and December of 1995 from our trauma registry. The patients were categorized by the call preference of the admitting physician as in-house (IH) or call-back from home (CB), day of admission (weekend vs. weekday), time of admission (AM VS. PM), and a value of the injury severity scale < or = 15 or > 15. Demographics, admission vital signs, Injury Severity Scale, Glasgow Coma Score, and elapsed time to diagnostic, therapeutic, and/or operative interventions were studied. The effect on intensive care unit length of stay, mortality, and hospital cost for resuscitation were also studied.
The study population consisted of 1,043 patients. The IH and CB groups each included two attending surgeons. IH significantly reduced the average time to completion of diagnostic peritoneal lavage (22 vs. 34 minutes; p < 0.05), therapeutic intervention (21 vs 38 minutes; p < 0.05), and transport to the operating room (206 vs. 312 minutes; p < 0.05) during the AM compared with CB. There was no difference in these times for the PM admissions. There was no significant difference in intensive care unit length of stay. Among patients with severe head and thoracoabdominal injury (Abbreviated Injury Score > 4 and 3, respectively) there was no difference in mortality. Analysis of cost for emergency room resuscitation in severely injured patients (Injury Severity Score > or = 15), seen during weekdays, was significantly less when evaluated by IH (IH = $5,097 vs. CB = $6,779; p < 0.05).
During the initial resuscitation of patients with severely injured during the weekdays, IH significantly reduced the cost, and elapsed time to diagnostic testing, therapeutic intervention, and to the operating room, respectively. IH reduced fatalities compared with CB.
The purpose of this study was to prospectively compare patient outcomes based on the presence of in-house versus on-call attending trauma surgeons at comparable Level I trauma centers.
Two designated Level I trauma centers agreed to prospectively review trauma admissions over a 6-month period, one institution with 24-hour in-house trauma attending surgeons (IH), and the other with trauma-attending surgeons taking call from home (OC) available to the hospital within 15 minutes of notification. A 6-month prospective study was conducted reviewing all trauma patients admitted to both trauma centers with an Injury Severity Score > or =16. Comparisons were made between institutions utilizing admission demographics, clinical presentation, times to clinical care, and mortality rates.
In comparison, OC and IH institutions were distinctly different in geographic environment, size, and number of patients admitted. As a group, IH patients were significantly older, with higher Injury Severity Scores and lower Glasgow Coma Scale scores than the OC group. In all comparisons, OC trauma attending surgeons responded to the trauma room with equal speed or more rapidly when compared with IH trauma attending surgeons. There were no other significant differences in either population in times to provision of clinical care or in clinical outcome.
The ability of the OC institution to be similar to the IH institution in its provision of clinical care and mortality rate is accomplished in an environment where trauma attending surgeons live within a 15-minute response time to the trauma center. Using a voice-paged trauma alert activation with accurate information and sufficient warning, evaluation, provision of care, and clinical outcome of the acutely injured patient can be provided equally by in-house trauma attending surgeons and trauma attending surgeons on-call from home.
To determine the impact of the presence of an attending trauma surgeon during trauma team activation on system function and patient outcome.
After a retrospective review of medical records and trauma registry, a comparative study between two American College of Surgeons Committee on Trauma Level I trauma centers was performed. One center (Hennepin County Medical Center) required a chief surgical resident, two junior residents, and a board-certified emergency medicine faculty to be present in the emergency department for all trauma team activations. The attending trauma surgeon was notified at the time of trauma team activation and was neither required to be present in the emergency department at time of patient arrival nor in the hospital 24 h/day. The other center (St. Paul Ramsey Medical Center) required a chief surgical resident, two junior residents, a board-certified emergency medicine faculty member, and an attending trauma surgeon to be present in the emergency department for all trauma activations and in hospital 24 hours/day. Over a 21-month period, all major trauma patients (Injury Severity Score > 15 or emergent operation within 4 hours of admission and any Injury Severity Score) that triggered trauma team activation were examined. Resuscitation time, time to incision, probability of survival, and mortality were analyzed.
Resuscitation time was shorter at St. Paul Ramsey Medical Center when compared with Hennepin County Medical Center. Analysis by mechanism of injury demonstrates that this was true for blunt trauma (39+/-13 vs. 27+/-12 minutes, p = 0.001) and for penetrating trauma (28+/-14 vs. 24+/-17 minutes, p = 0.01). Subgroup analysis of penetrating trauma victims demonstrated that there was a significant difference in resuscitation times for gunshot wounds but not for stabs. There was no difference in how quickly operations could be initiated for blunt trauma patients. However, in penetrating cases, time to incision was significantly shorter at St. Paul Ramsey Medical Center (50+/-29 vs. 66+/-43 minutes, p = 0.01). There was no significant difference in mortality for any category of Trauma and Injury Severity Score probability of survival in blunt or penetrating trauma. Analysis of "in-house" and "out-house" time intervals demonstrated no difference in survival in any mechanism of injury, nor was there a difference in overall mortality.
The presence of a trauma surgeon on the trauma team reduced resuscitation time and reduced time to incision for emergent operations, particularly in penetrating trauma. However, it had no measurable impact on mortality based on Trauma and Injury Severity Score probability of survival. Attending trauma surgeon presence on the trauma team improves in-hospital trauma system function without affecting patient outcome.
The purpose of this study was to assess the impact on patient outcome and hospital performance of preparing for and achieving American College of Surgeons (ACS) Level I trauma verification.
The center was a previously designated state regional trauma center located adjacent to a major metropolitan area. Preparation for ACS verification began in early 1996 and was completed in early 1998. Final verification took place in April 1999. Data were analyzed before (1994) and after (1998) the process. There was a marked increase in administrative support with trauma named one of the hospital's six centers of excellence. Two full-time board-certified trauma/critical care surgeons were added to the current six trauma surgeons. Their major focus was trauma care. Trauma support staff was also increased with case managers, a trauma nurse practitioner, additional trauma registrars, and administrative support staff. Education and continuous quality improvement were markedly expanded starting in 1996.
There were 1,098 trauma patients admitted in 1994, and 1,658 in 1998. Overall mortality decreased (1994, 7.38%; 1998, 5.37%; p < 0.05). There was a marked decrease in mortality for severely injured (Injury Severity Score > 30) patients (1994, 44% mortality [38 of 86]; 1998, 27% [22 of 80]; p < 0.04). Average length of stay also decreased (1994, 12.22 days; 1998, 9.87 days; p < 0.02). This yielded an estimated cost savings for 1998 of greater than $4,000 per patient (total saving estimate of $7.4 million).
Trauma system improvement as related to achieving ACS Level I verification appeared to have a positive impact on survival and patient care. There were cost savings realized that helped alleviate the added expense of this system improvement. The process of achieving ACS Level I verification is worthwhile and can be cost effective.
The value of an in-house trauma surgeon is debated. Previous studies focus on comparing in-house and on-call surgeons at different institutions or different periods in time. The purpose of this study was to simultaneously evaluate in-house and on-call trauma surgeons in a single Level I trauma center and to determine the impact of in-house trauma surgeons on the mortality of severely injured patients.
All records were reviewed for patients classified as major resuscitations from July 1997 through November 1999. Multiple logistic regression was performed to determine predictors of mortality on the basis of trauma surgeon status (in-house vs. on-call) and response time, while controlling for Injury Severity Score (ISS) and Revised Trauma Score.
Of the 4,278 admissions, 537 were trauma codes. Mean ISS was 20.16 +/- 11.59. There was no difference between groups admitted by in-house surgeons versus on-call surgeons with respect to ISS or Revised Trauma Score. Mortality for the group was 24.8% (133 of 537); no statistical difference existed between observed and expected mortality by TRISS. The average response time was 3.96 minutes for the in-house group and 14.70 minutes for the on-call group (p < 0.001). Neither the call status nor the response time of the trauma surgeon significantly decreased emergency department or hospital mortality. There was a trend for improved outcome in those patients cared for by an in-house surgeon who were upgraded to a code, transferred into the institution, admitted during the night, or neurologically impaired. This trend did not reach statistical significance.
When the trauma surgeon was rapidly available (< 15 minutes), there was no difference in emergency department or hospital mortality between in-house and on-call trauma surgeons. Selected subgroups of severely injured patients may benefit from an in-house trauma surgeon. If trauma surgeons are not readily available in an institution, an in-house call policy may be necessary for the prompt resuscitation of critically ill patients.
Although not directly involved in designation per se, the American College of Surgeons (ACS) Committee on Trauma verification/consultation program in conjunction with has set the national standards for trauma care. This study analyzes the impact of a recent verification process on an academic health center.
Performance improvement data were generated monthly from the hospital trauma registry. Forty-seven clinical indicators were reviewed. Three study periods were defined for comparative purposes: PRE (January, June, October 1997), before verification/consultation; CON (April 1999-October 1999), after reorganization; and VER (November 1999-September 2000), from consultation to verification.
Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (< 120 minutes) improved in each study section (PRE, 21%; CON, 48%; VER, 76%). Enhanced nursing documentation correlated with improved clinical care such as early acquisition of head computed axial tomographic scans in neurologic injured patients (PRE, 66%; CON, 97%; VER, 95%). Intensive care unit length of stay (< 7 days) decreased (PRE, 87%; VER, 97.8%). Other transformations included increase in institutional morale with recognition of trauma excellence within the hospital and resurgence of the trauma research programs (60 institutional review board-approved projects).
The ACS verification/consultation program had a positive influence on this developing academic trauma program. Preparation for ACS verification/consultation resulted in significant improvements in patient care, enhancement of institutional pride, and commitment to care of the injured patient.
The purpose of this study was to compare the impact of trauma patient outcomes before and after Level II American College of Surgeons (ACS) verification was received in a not-for-profit community hospital.
This was a retrospective analysis of hospital discharge data for timeframes before and after Level II ACS verification was conducted. Originally, 8,674 patients were identified using the International Classification of Diseases, 9th Revision codes for trauma. These data were parsed to 7,811 patients by using International Classification of Diseases, 9th Revision codes 800 xx through 959.9 x, which signify an admitting diagnosis of trauma; 3,835 of the patients were admitted after the July 28, 1998, verification date. Blunt injuries constituted the vast majority of the patients (n = 7,488). Outcome measures studied included changes in length of stay (LOS), mortality, and total cost. Internal control was coronary artery bypass graft patients at the same hospital, and external control was trauma patients at a non-ACS hospital over the same time period. Data are presented with p values and SE and the ratio of observed/expected values on the basis of the all-payer severity-adjusted diagnosis-related group severity model.
The two timeframes exhibited statistically different outcomes in several variables. Adjusting for severity postverification, LOS was 10% less (p < 0.000). Similarly, severity-adjusted mortality observed/expected ratios were significantly different: 0.81 before versus 0.59 after (p < 0.000). The severity-adjusted ratio of costs found that the postverification era was 5% lower (p < 0.000). The contribution margin of the trauma patient population to the hospital well exceeded any postverification costs. Both control groups exhibited no significant changes in their severity-adjusted outcomes, which could have invalidated these results.
This study suggests that the efforts and resources consumed achieving ACS Level II trauma center verification appear to result in desired outcomes as evidenced by decreased LOS, reduced in-hospital mortality rates, reduced cost, and improved contribution margins.
The presence of a surgeon at the initial assessment and care of the trauma patient has been the focal point of trauma center designation. However, for Level I verification, the American College of Surgeons Committee on Trauma currently does not require the presence of an attending trauma surgeon in the hospital (IH), provided senior surgical residents are immediately available. Likewise, the state of Missouri does not mandate an IH presence of the attending trauma surgeon but requires senior (postgraduate year 4 or 5) level surgical residents to immediately respond, with a 20-minute response time mandated for the attending surgeon if IH or out of the hospital (OH). Nevertheless, some claim that IH coverage by attending surgeons provides better care for seriously injured patients.
This retrospective study assessed patient care parameters over the past 10 years on critically injured patients to detect any difference in outcome whether the surgeon was IH or OH at the time of the trauma team activation (cardiopulmonary instability, Glasgow Coma Scale [GCS] score < 9, penetrating truncal injury). Patients were subcategorized into blunt/penetrating, shock (systolic blood pressure < 90 mm Hg) on arrival, GCS score < 9, Injury Severity Score (ISS) > 15, or ISS > 25. Response was examined from 8 am to 6 pm weekdays (IH) or 6 pm to 8 am weekdays and all weekends (OH). Patient care parameters examined were mortality, complications, time in the emergency department, time to the operating room, time to computed tomographic scanning, intensive care unit length of stay (LOS), and hospital LOS.
For all patients (n = 766), there was no significant difference in any parameters except intensive care unit LOS (IH, 4.90 +/- 7.96 days; OH, 3.58 +/- 7.69 days; p < 0.05). For blunt trauma (n = 369), emergency department time was shorter (99.71 +/- 88.26 minutes vs. 126.51 +/- 96.68 minutes, p < 0.01) and hospital LOS was shorter (8.04 +/- 1.02 days vs. 11.08 +/- 1.15 days, p < 0.05) for OH response. For penetrating trauma (n = 377), shock (n = 187), GCS score < 9 (n = 248), ISS > 15 (n = 363), and ISS > 25 (n = 230), there were no statistically significant differences in any patient care parameter between IH and OH response. For those in most need of urgent operation-penetrating injuries and shock-there were no differences in time to operating room or mortality for OH or IH response.
As long as initial assessment and care is provided by senior level IH surgical residents and as long as the attending surgeon responds in a defined period of time (if OH) to guide critical decision-making, the IH presence of an attending surgeon has not been shown in this retrospective study to improve care of the critically injured patient.
The relationship between information and communication technology (ICT) and trauma work coordination has long been recognized. The purpose of the study was to investigate the type and frequency of use of various ICTs to activate and organize trauma teams in level I/II trauma centers. In a cross-sectional survey, questionnaires were mailed to trauma directors and clinicians in 457 trauma centers in the United States. Responses were received from 254 directors and 767 clinicians. Communication with pre-hospital care providers was conducted predominantly via shortwave radio (67.3%). The primary communication methods used to reach trauma surgeons were manual (56.7%) and computerized group page (36.6%). Computerized group page (53.7%) and regular telephone (49.8%) were cited as the most advantageous devices; e-mail (52.3%) and dry erase whiteboard (52.1%) were selected as the least advantageous. Attending surgeons preferred less overhead paging and more cellular phone communication than did emergency medicine physicians and nurses. Cellular phones have become an important part of hospital-field communication. In high-volume trauma centers, there is a need for more accurate methods of communicating with field personnel and among hospital care providers.
The trauma center certification requirements of the American College of Surgeons include the expectation that, whenever possible, general surgeons be routinely present at the emergency department arrival of seriously injured patients. The 2 historical factors that originally prompted this requirement, frequent exploratory laparotomies and emergency physicians without trauma training, no longer exist in most modern trauma centers. Research from multiple centers and in multiple varying formats has not identified improvement in patient-oriented outcomes from early surgeon involvement. Surgeons are not routinely present during the resuscitative phase of Canadian and European trauma care, with no demonstrated or perceived decrease in the quality of care. American trauma surgeons themselves do not consistently believe that their use in this capacity is either necessary or an efficient distribution of resources. There is not compelling evidence to support the assumption that trauma outcomes are improved by the routine presence of surgeons on patient arrival. Research is necessary to clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Individual trauma centers should be permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria.