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PubMed2001

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers.

BACKGROUND: Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care. METHODS: Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care. RESULTS: Mean CPS for 506 PRE period patients (0.44 +/- 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 +/- 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 +/- 0.19) was significantly higher than the mean CPS of decedents (0.57 +/- 0.25). CONCLUSIONS: Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care.

Adult↗

PubMed1992

Differences in trauma care among pediatric and nonpediatric trauma centers.

To characterize pediatric trauma care, state trauma registry data from all designated trauma centers in Pennsylvania were divided into three categories, that from: (1) pediatric centers, (2) urban nonpediatric centers, (3) and rural nonpediatric centers. From October 1, 1986 through September 30, 1989 (3 years), 4,615 patients less than 15 years old were admitted to 28 trauma centers in Pennsylvania. Nonpediatric centers cared for the majority of children (2,734, 59.2%), but the average number of children treated per nonpediatric institution (105.1 per year) was far fewer than the average treated in the pediatric centers (940.5). Pediatric trauma centers in the state treated a younger population (6.4 +/- 4.2 years, mean +/- SD) compared with urban and rural nonpediatric centers (8.4 +/- 4.2 and 8.1 +/- 4.3 years, respectively; P less than .05). Pediatric centers received proportionately more children by transfer (56.2%), victims of falls (34.6%), pedestrian injuries (16.8%), and head and neck injuries (41.8%, all P less than .05). Nonpediatric centers received children directly from the scene of injury more frequently than transferred from other hospitals. The male:female sex ratio in urban nonpediatric centers was significantly higher (70.1%, P less than .05) than in the other two groups. Rural nonpediatric centers cared for a higher proportion of motor vehicle passengers (28.5%) and patients classified as "other" in the state registry, a category to which bicycle injuries are assigned (28.2%, P less than .05). Mortality was highest in rural nonpediatric centers (6.2%). The death rate in pediatric centers and urban nonpediatric centers were similar (4.1%) and significantly lower (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1992

Community hospital level II trauma center outcome.

Currently, level II trauma center standards allow trauma surgeons to take call out-of-hospital. To address the concern that this practice may adversely influence outcome, we tested the hypothesis that the survival of injury victims treated at a level II trauma center is significantly different from that predicted by the Major Trauma Outcome Study (MTOS). In addition, we examined the impact of trauma surgeons taking call out-of-hospital on the survival of patients with severe thoracoabdominal injury. Over a 26-month period, a total of 3,689 consecutive injured patients who were treated at a community hospital level II trauma center were entered into this study. There was no significant difference between the MTOS survival and the actual survival in the overall population (96% vs. 97%, respectively; Z statistic = ns). Among the patients with severe thoracoabdominal injury (i.e., Abbreviated Injury Scale score greater than or equal to 3), there was no significant difference in survival between the patients whose arrival time corresponded to the presence of an in-hospital surgeon (0700-1800 hours) versus those who arrived when a surgeon was generally out-of-hospital (1801-0659 hours), (76% vs. 81%, respectively; p = ns). From these data we conclude that there was no significant difference between the survival observed and that predicted by the MTOS at our community hospital, which complies with level II trauma center standards. Furthermore, in the cohort with severe thoracoabdominal injury, the response of trauma surgeons from out-of-hospital did not adversely influence survival.

Emergency Medical Service Communication Systems↗

PubMed2005

Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (injury severity score > 15).

BACKGROUND: We studied the association of the American College of Surgeons (ACS) trauma center designation and mortality in adult patients with severe trauma (Injury Severity Score > 15). ACS designation of trauma centers into different levels requires substantial financial and human resources commitments. There is very little work published on the association of ACS trauma center designation and outcomes in severe trauma. STUDY DESIGN: National Trauma Data Bank study including all adult trauma admissions (older than 14 years of age) with Injury Severity Score (ISS) > 15. The relationship between ACS level of trauma designation and survival outcomes was evaluated after adjusting for age, mechanism of injury, ISS, hypotension on admission, severe liver trauma, aortic, vena cava, iliac vascular, and penetrating cardiac injuries. RESULTS: A total of 130,154 patients from 256 trauma centers met the inclusion criteria. Adjusted mortality in ACS-designated Level II centers and undesignated centers was notably higher than in Level I centers (adjusted odds ratio, 1.14; 95% CI, 1.09-120; p < 0.0001 and adjusted odds ratio, 1.09; CI, 1.05-1.13; p < 0.0001, respectively). CONCLUSIONS: Severely injured patients with ISS > 15 treated in ACS Level I trauma centers have considerably better survival outcomes than those treated in ACS Level II centers.

Adolescent↗

PubMed1995

Efficacy of free flaps for pediatric trauma patients in an adult trauma center.

Although many trauma centers are primarily "adult-oriented," the presentation of unusual life- or limb-threatening wounds in children occasionally have mandated urgent microvascular tissue transfer for salvage. For these rare instances, should a microsurgical team accustomed to dealing with adult trauma patients even attempt to meet such a specialized challenge? A retrospective analysis of all free flaps performed by the author's team in trauma patients from 1984 to 1993, revealed only 10 pediatric patients who had had 11 separate free flaps. Their ultimate success rate was 90.9 percent--statistically the same rate (87.0 percent) as for 93 adult free flaps. The majority of these pediatric flaps were for urgent coverage of the lower extremity and they were all successful, eliminating any need for traditional pedicled flaps during the same time period. Improvement in technical expertise and judgment seemed to be more important factors than actual chronological age in determining free-flap success in general, and in children in particular. Therefore, free flaps in the pediatric population can be appropriately performed in an adult trauma center.

Adolescent↗

PubMed2002

Missed injuries in a level I trauma center.

BACKGROUND: Major trauma presents major diagnostic and therapeutic problems. Any delay in providing the treatment necessary may lead to increased morbidity and mortality, prolonged length of hospital stay, and increased cost. This study was undertaken to determine the extent, contributing factors, and implication of missed injuries and relate them to the three surveys in a Danish Level I trauma center. METHODS: The records of all major traumatized patients admitted to the Odense University Hospital from January 1996 through December 1999 have been studied to determine the extent and type of missed injuries. The initial examination is carried out by the trauma team in the A&E department according to standard protocols. Resuscitation is carried out according to Advanced Trauma Life Support principles and details are documented in the patient journal and in a special trauma journal. RESULTS: Sixty-four of 786 patients (incidence, 8.1%) had 86 missed injuries. The missed injuries averaged 1.3 injuries per patient. There were 45 male and 19 female patients, with a median age of 33 years (range, 12-81 years). The median ISS was 17 (range, 4-50); 14%, 38%, and 48% of the injuries were missed in primary, secondary, and tertiary surveys, respectively. CONCLUSION: Our study demonstrates that missed injuries can occur at any stage of the management of patients with major trauma. Repeated assessments, both clinical and radiologic, are mandatory to diminish the problem. In initial assessment, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain throughout the patient's stay in hospital.

Adolescent↗

PubMed1998

Use of physician assistants as surgery/trauma house staff at an American College of Surgeons-verified Level II trauma center.

BACKGROUND: Historically, surgical physicians staff trauma centers, which provide trauma patients with improved outcomes. Such benefits fuel the expansion of designated trauma centers. Cutbacks in residency programs of surgical specialties, however, necessitate substitutions for traditional trauma providers. METHODS: A literature and record review was conducted to examine the use of physician assistants in a large community hospital's verified trauma center. Current and historical outcomes were analyzed regarding the trauma surgeon/physician assistant model. RESULTS: Injury Severity Scores increased 19%, transfer time to the operating room decreased 43%, transfer time to the intensive care unit decreased 51%, and transfer time to the floor decreased 20%. The length of stay for admissions decreased 13%, and the length of stay for neurotrauma intensive care unit patients decreased 33%. CONCLUSION: The Hurley Medical Center trauma surgeon/physician assistant model is a viable alternative for verified trauma centers unable to maintain a surgical residency program. Consistency and quality of care indicated by shortened length of stay is a hallmark of such a model providing the highest quality of care.

Adolescent↗

PubMed2006

Mountain biking injuries requiring trauma center admission: a 10-year regional trauma system experience.

BACKGROUND: Mountain biking has become an increasingly popular recreational and competitive sport with increasingly recognized risks. The purpose of this study was to review a population based approach to serious injuries requiring trauma center admission related to mountain biking, identify trends and develop directions for related injury prevention programs. METHODS: Three trauma centers in the Greater Vancouver area exclusively serve a major mountain bike park and the North Shore Mountains biking trails. The Trauma Registries and the patient charts were reviewed for mountain bike injuries from 1992 to 2002. The data were analyzed according to demographics, distribution, and severity of injuries, and need for operative intervention. Findings were reviewed with injury prevention experts and regional and national mountain-biking stakeholders to provide direction to injury prevention programs. RESULTS: A total of 1,037 patients were identified as having bicycling-related injuries. Of these, 399 patients sustained 1,092 injuries while mountain biking. There was a threefold increase in the incidence of mountain biking injuries over a 10-year period. Young males were most commonly affected. Orthopedic injuries were most common (46.5%) followed by head (12.2%), spine (12%), chest (10.3%), facial (10.2%), abdominal (5.4%), genitourinary (2.2%), and neck injuries (1%). High operative rate was observed: 38% of injuries and 66% of patients required surgery. One patient died from his injuries. Injury prevention programs were developed and successfully engaged the target population. CONCLUSION: Mountain biking is a growing cause of serious injuries. Young males are principally at risk and serious injuries result from intended activity and despite protective equipment. Injury prevention programs were developed to address these concerns.

Abbreviated Injury Scale↗

PubMed1995

Trauma center designation: initial impact on trauma-related mortality.

The movement towards trauma care regionalization in Québec was initiated in 1990, with formal designation of three level I trauma centers in 1993. The purpose of this study is to evaluate the impact of trauma center designation on mortality. The study design is that of a two-cohort study, one assembled during 1987 when designation was not in effect, and the other during the first 5 months of designation. The study focuses on patients that fulfilled the following criteria: i) arrived alive at the hospital, and ii) were admitted. The outcome measures are adjusted mortality, and excess mortality as measured by the TRISS methodology. A total of 158 patients treated in 1987, and 288 treated in 1993, were identified. The mean age of the patients treated in 1993 was significantly higher (40.0, +/- 18.1), when compared with the 1987 group (30.9 +/- 18.1; p < 0.001). Patients in the 1987 cohort had a significantly higher proportion of injuries caused by stabbing (p = 0.02), and a significantly lower proportion caused by falls (p = 0.003). The 1987 cohort had a higher rate of abdominal injuries (p = 0.0001), and external injuries (p = 0.0001), and a significantly lower rate of head or neck injuries (p = 0.003), and injuries to the extremities (p = 0.0001). The mean Injury Severity Score (ISS) for the 1987 cohort was 14.96 (+/- 12.36), and 15.49 (+/- 11.61) in 1993 (p = 0.65). The crude mortality rate was 20% for 1987, and 10% for 1993. The crude odds ratio for mortality in 1987 was 2.10 with 95% confidence intervals between 1.22 and 3.62 (p = 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMedDate not supplied

Are trauma centers important? You bet your life!

Trauma centers and trauma systems are vital community assets. By aggregating resources and personnel dedicated to the care of the injured patient, they lower trauma morbidity and mortality. The trauma center is a key educational component of all members of the health care team. Complex and advanced medical care is coordinated in a fiscally responsible manner that facilitates and improves patient care and stimulates innovation. The threat of more domestic terrorism and mass casualties in the post 9-11 world has exponentially increased the need for, and responsibilities of, trauma systems. Healthy trauma centers are an indispensable component of a healthy community.

Cost-Benefit Analysis↗

PubMed1989

Trauma registry and trauma center biases in injury research.

Trauma centers and trauma registries have become important sources of data for trauma research. In their present form, both have serious biases in data selection, however, that can affect epidemiologic research results. This prospective study of 601 woodworking-related injuries seen at a trauma center involved a diverse population, a wide range of severities, both inpatients and outpatients, and primary versus referred patients. Eighty-eight per cent were outpatients and thus excluded by traditional trauma registries. Only 6% of primary patients, but 43% of referred patients, were hospitalized. Eighty-nine per cent of outpatients, and 28% of inpatients had AIS of 1. However, among primary patients 79% or more of lost or altered days of work, home, or recreational activity during 6 months postinjury occurred among ambulatory patients. Substantial differences were shown between hospitalized and ambulatory patients, and between primary and referred patients, in type of activity at time of injury, and in anatomic location and injury type. Trauma registry collection and analysis methods for epidemiologic research need substantial restructuring if they are to truly represent the tremendous problem of injury in our society.

Adult↗

PubMed2000

Operative management of injured children at an adult level I trauma center.

BACKGROUND: The geographic distribution of trauma centers results in a significant number of children being treated in adult centers. The emphasis on nonoperative management of pediatric blunt trauma has heightened concern that in adult trauma centers, an aggressive operative approach will continue to be used. We hypothesized that pediatric commitment at a Level I trauma center results in appropriate nonoperative care of injured children as established by regional pediatric trauma centers. METHODS: The records of 1,792 consecutively treated children admitted to the trauma service during a 6-year period (January of 1990 to December of 1995) were reviewed. Patients were stratified into one of three age groups: 0 to 5, 6 to 11, and 12 to 17 years of age. RESULTS: Mean age of the study patients was 10.0 +/- 0.1 years, 1,147 were boys (64%), and their mean Injury Severity Score was 7.3 +/- 0.3. The injury mechanism was blunt in 1,550 (87%) and 132 (7%) required laparotomy. In the 0- to 5-year-old blunt mechanism group, 6% underwent laparotomy or thoracotomy from 1990 to 1992. In comparison, only 1% of this age group had a laparotomy from 1993 to 1995 (p < 0.05, Fisher's exact test). A similar trend was found in the 6- to 11-year-old children after blunt injury (4% laparotomy rate from 1990 to 1992; 2% from 1993-1995). CONCLUSION: There has been a declining trend in the operative management of blunt pediatric trauma, especially in children less than 6 years old, whereas the operative management of penetrating injuries has remained stable. These data confirm that pediatric commitment in a Level I trauma center results in nonoperative treatment of injured children commensurate with that established in regional pediatric trauma centers.

Adolescent↗

PubMed1985

Ineffectiveness of the trauma score and the CRAMS scale for accurately triaging patients to trauma centers.

Both the Trauma Score (TS) and the CRAMS scale have been advocated for field triage of trauma victims to trauma centers. To determine which scale best serves this purpose, both scores were calculated by computer for 5,130 trauma cases in our statewide computer file of ambulance rescue runs from 1981 through 1983. A total of 3,231 patients (63%) were treated in the ED and released; 1,857 (36.2%) were admitted to the hospital (202 of whom were transferred directly from the ED to the operating room [OR] for immediate operation); and 42 (0.8%) were DOA or died in the ED. Major trauma was defined as a TS of 12 or less or a CRAMS scale of 8 or less. Both scales correctly identified as major trauma all patients who were DOA or died in the ED. The TS identified as major trauma more patients admitted to the hospital than did the CRAMS scale (33% vs 21%; P less than .0001). The TS identified as major trauma more patients transferred from the ED to the OR than did the CRAMS scale (37% vs 21%; P less than .002). Both scales failed to identify as major trauma almost two out of three patients brought directly from the ED to the OR. The paramedics', or emergency medical technicians' qualitative judgements about injury severity, reflected in their coding injuries as life- or limb-threatening, was almost as good (more than 90% sensitive and specific) as either score (100% sensitive and specific) in identifying patients who died, and was better in identifying patients sent from the ED to the OR.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis-Related Groups↗

PubMed1981

Factors affecting trauma center utilization in Illinois.

The Illinois Trauma System has served as a prototype for many of the advanced emergency medical services systems developed during the past decade. The Illinois Trauma Study uses a cross-sectional research design to assess the trauma patient utilization patterns at hospitals in Illinois. Data were collected from 33 Trauma Centers and 43 nonsystem hospitals for the time interval July 1973-June 1974. Results indicated that 45.5 per cent of patients admitted with specified trauma conditions were hospitalized at Trauma Centers. When adjustment is made for differences in the size of hospitals, a 50 per cent excess in patient capture is found at Trauma Centers. This excess utilization found in Trauma Centers for this sample of trauma victims was not found among all patients admitted to these hospitals. Factors found to be associated with high Trauma Center use are race (high use among nonwhites), injury severity, evening admission to hospital and vehicular injury. Also, approximately two thirds of trauma patients that were admitted to intensive care units or transferred from other hospitals were hospitalized at Trauma Centers.

Adolescent↗

PubMed2002

Vascular trauma in Colombia: experience of a level I trauma center in Medellín.

Trauma has become a major health problem in Colombia. The large number of trauma patients has made San Vicente de Paul Hospital of Medellín a major national referred trauma center. Under-reporting is a major problem in Colombia, as in other underdeveloped countries, because of the absence of automated information systems. Despite this and limited financial health resources, time to definitive treatment, morbidity, and mortality are similar to those of centers in developed countries. This article has covered the authors' experience with vascular injuries over a period of 5 years, representing 664 patients; the results were shown in this article. In addition, advances made in the development of new tools for the diagnosis of vascular trauma, such as helical CT angiography, were discussed.

Adolescent↗

PubMed2003

Popliteal artery trauma in a rural level I trauma center.

Popliteal vascular trauma has historically been an urban phenomenon. We hypothesized that rural popliteal artery injury would result more often from blunt mechanisms of injury (MOI), have a longer time to operation, and result in a higher amputation rate. We retrospectively reviewed all cases of popliteal artery injury from December 1994 to May 2001 at our rural trauma center. Age, gender, Injury Severity Score (ISS), MOI, scene transport versus transfer from a referring hospital, time to operation, and operative times were studied. Significance was determined by Student's t test with a P value < or = 0.05. Thirty-two popliteal artery injuries were found. Blunt trauma accounted for 50 per cent of the injuries. Eighty-eight per cent of the patients were transferred from a referring hospital. Patients transported directly from the scene had a higher ISS. Longer operative times translated into an increased need for fasciotomy. The amputation rate was 19 per cent. This is the first attempt to delineate the specific nature of rural popliteal artery trauma. The amputation rate was not different between the two different MOI and was independent of the time to operation. Of those patients receiving an amputation 83 per cent were transferred from another hospital and despite a statistically lower ISS still required an amputation.

Adult↗

PubMed1998

Impact of bicycle helmet safety legislation on children admitted to a regional pediatric trauma center.

PURPOSE: The regional pediatric trauma center in Buffalo, NY, has been active in pediatric injury prevention programs, including community education and distribution of bicycle helmets, since 1990. Since June 1, 1994, the use of bicycle safety helmets for children under 14 years of age has been mandated by a state law in New York. The authors undertook this study to assess the impact of this legislation on the frequency of helmet use in children involved in bicycle crashes presenting to the regional pediatric trauma center, and to assess the impact of helmet use on the number and severity of head injuries. METHODS: Bicycle crash victims (n = 208) admitted to a regional pediatric trauma center from 1993 to 1995 were studied retrospectively. Head injuries were classified as concussion alone, skull fractures, intracranial hemorrhages (ie, epidural, subdural, and subarachnoid), cerebral contusions, or diffuse cerebral edema alone (without any other intracranial injury). Helmeted children (HC) were compared with nonhelmeted children (NHC) using chi2 and Fisher's Exact test. P value less than .05 was considered significant. RESULTS: Only 31 children (15%) wore helmets at the time of the crash. Helmet use increased from 2%, during the period of education alone, to 26% after the legislation went into effect (P < .00001). The proportion of children suffering head injuries was similar in both groups (HC, 68%; NHC, 61%; P = NS). However, the type of head injury was different. HC were more likely to sustain concussion alone (HC, 65%; NHC, 44%; P < .03). HC were less likely to have skull fractures (HC, 0%; NHC, 13%; P < .02), and exhibited a trend toward less intracranial hemorrhages (HC, 0%; NHC, 9%; P = NS), cerebral contusions (HC, 3%; NHC, 5%; P = NS), and cerebral edema (HC, 0%; NHC, 0.6%; P = NS). Excluding the isolated concussions, head injuries were noted in only one HC, compared with 30 NHC (P < .04). None of the three children who died wore helmets at the time of the crash, and all died of multiple head injuries. CONCLUSIONS: The bicycle helmet safety law resulted in a 13-fold increase in the use of bicycle helmets among the children admitted to a regional pediatric trauma center after bicycle crashes, but the helmet use remains inadequate. Helmet use reduced the severity of head injuries, and might have prevented deaths caused by head injuries.

Bicycling↗

PubMed2000

An examination of the volume-mortality relationship for New York State trauma centers.

OBJECTIVES: New York State Trauma Registry data were analyzed to determine whether there is a significant relationship between the volume of trauma patients treated by a trauma center and its risk-adjusted inpatient mortality rate. METHODS: Stepwise logistic regression was used to identify significant independent predictors of mortality, their weights, and the probability of in-hospital mortality for each patient. These data were then used to calculate risk-adjusted mortality rates for various ranges of hospital volume. Ranges were identified on the basis of homogeneity of mortality rates, the number of hospitals in each range, and the number of patients in each range. Three volume measures were used: (1) total annual volume of trauma cases > or = 1200 and total annual volume > or = 240 for patients with Injury Severity Score (ISS) > or = 15 (equivalent to American College of Surgeons [ACS] criteria), (2) total annual volume of patients with ISS > or = 15, and (3) total annual volume of cases in the Registry (approximately, inpatients with ISS > or = 9). RESULTS: Results show that the 35 New York State trauma centers not meeting the ACS criteria had lower, but not significantly lower, observed and risk-adjusted mortality rates (7.62% and 8.25%, respectively) than the corresponding rates for the 8 New York State trauma centers that met the ACS criteria (9.36% and 8.83%, respectively). Regarding the other two criteria, hospital ranges representing lower annual volumes tended to have somewhat lower, although not significantly lower, observed and risk-adjusted mortality rates. For example, using a total annual volume for patients with ISS > or = 15, the risk-adjusted mortality rates for the volume ranges 1-150, 151-250, and 251+ were 7.78%, 9.23%, and 8.70%, respectively. CONCLUSIONS: We were unable to document an inverse relationship between hospital volume and inpatient mortality rate for trauma centers in New York State. Volume criteria should not be considered indicators of the quality of trauma care.

Age Distribution↗