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At least 163 records · Page 9Linked to original sources

PubMed2006

The delivery of critical care services in US trauma centers: is the standard being met?

BACKGROUND: Although there is substantial evidence supporting the benefits of an intensivist model of critical care delivery, the extent to which this model has been adopted by trauma centers across the United States is unknown. We set out to evaluate how critical care is delivered in Level I and II trauma centers and the extent to which these centers implement evidence-based patient care practices known to improve outcome. METHODS: All Level I and Level II trauma centers in the United States were surveyed using a previously validated questionnaire pertaining to the organizational characteristics of critical care units. Questions identifying the impediments to the implementation of an intensivist model of critical care delivery were added to the original survey. An intensivist model intensive care unit (ICU) was defined as one meeting all of the following criteria: a) the physician director was board certified in critical care; b) >50% of physicians responsible for care were board certified in critical care; c) an intensivist made daily rounds on the patients; and d) an intensive care team had the authority to write orders on the patients. The survey respondents were also queried regarding the extent to which they complied with evidence-based guidelines for care in the ICU. RESULTS: The overall response rate was 65% (295 centers). Only 61% of Level I centers and 22% of Level II centers provided an intensivist model of critical care delivery. Sixty-nine percent of centers had a form of collaborative care with an intensivist, but few centers had dedicated intensivists without responsibilities outside the ICU. The most common reason cited for not involving an intensivist in the delivery of critical care services was a concern regarding a loss of continuity of care. There was limited implementation of evidence-based practices in the ICU; the model of critical care delivery had no effect on rates of implementation of these practices. CONCLUSION: The process of trauma center verification and designation should assure a high quality of trauma care. In keeping with these expectations of quality, the delivery of critical care services in trauma centers should evolve to a model that both includes the trauma surgeon in the care of the injured and allows for collaboration with a dedicated intensivist, who may or may not be a surgeon. The benefits of an intensivist model might be distinct from the utilization of evidence-based practices, suggesting that there might be incremental benefit in using these practices as markers of quality.

Critical Care↗

PubMed2006

Building a trauma center and system in Tuscany, Italy.

BACKGROUND: Growing evidence supports the premise that adult trauma centers lower the risk of death for severely injured patients. The same principles have been applied to the pediatric population and mounting research suggests that, as in the adult population, gravely injured children have better outcomes at pediatric trauma centers where personnel trained and experienced in the specific needs and unique physiology of injured children provide care. As in the United States, acute traumatic injury represents an important public healthcare concern to the Tuscan regional government whose goal is to maximize clinical outcomes within available resources. In order to address this problem, the Tuscan regional government has created a new and innovative collaboration between the Meyer Pediatric Hospital/University of Florence School of Medicine and the Children's Hospital Boston/Harvard Medical School to build a pediatric trauma center and regional pediatric trauma referral system. GOALS AND OBJECTIVES: This long-term international initiative will seek to develop a demonstration model for pediatric trauma care that may later be replicated elsewhere. The initial goals of the project will focus on expanding the role of the pediatricians working in the emergency department to include the acute care of medical, surgical, orthopedic and multiple trauma patients. This new configuration will closely resemble the single provider model of emergency medical care commonly utilized in the United States. During this transition period to a more broadly trained emergency physician, a multi-disciplinary trauma team will be created and pediatric trauma clinical practice guidelines will be introduced into the emergency department and inpatient care units. Systems measurements will be achieved through a comprehensive quality improvement and risk management program. Ultimately, all Tuscan regional pediatric major trauma will be consolidated at the Meyer Pediatric Hospital in Florence.

Boston↗

PubMed2002

Urban trauma centers: not quite dead yet.

With decreasing violent crime and an increase in the use of nonoperative management techniques the viability of urban trauma centers has come into question. In addition the workload and productivity for surgeons at such centers may be threatened. The current study examines the changing characteristics of patients admitted to an urban Level I trauma center over a 5-year period and examines factors that may affect trauma surgeon utilization. We reviewed all trauma registry admissions from January 1995 through December 1999. Data were collected regarding patient demographics, mechanism of injury, diagnostic workup, injury character and severity, operative procedures, intensive care unit (ICU) length of stay (LOS), hospital LOS, and patient disposition. Admissions declined 23 per cent over the 5-year period. Fewer patients were admitted to general practice units whereas more patients required ICU admission. Over the study period both mean patient age and mean Injury Severity Score increased significantly. Gunshot wound admissions declined by 45 per cent, but the percentage of those admitted who required operation rose 17 per cent. Number of operations for trauma performed by general surgeons was unchanged over time. Hospital LOS declined over time, and ICU LOS was unchanged. Although trauma center admissions--particularly those due to violent crime--are on the decline the operative productivity of trauma surgeons has remained unchanged. Patients admitted to the hospital are older and more severely injured; they undeniably require a higher level of care and service coordination. Urban trauma centers remain viable and are in fact more efficient in caring for sicker patients.

Adult↗

PubMed1989

Mortality of patients with head injury and extracranial injury treated in trauma centers.

The types and severity of injuries of 49,143 patients from 95 trauma centers were coded according to the 1985 version of the Abbreviated Injury Scale (AIS). This paper analyzes the causes, incidence, and mortality in 16,524 patients (33.6% of the trauma center patients) with injury to the brain or skull and compares them to patients without head injury. Relative to its incidence, patients with head injury composed a disproportionately high percentage (60%) of all the deaths. This was due to the high mortality rate for head-injured patients. Overall mortality of patients with head injury (18.2%) was three times higher than if no head injury occurred (6.1%). This mortality was little influenced by extracranial injuries except when minor and moderate head injuries were accompanied by very severe (AIS levels 4 to 6) injuries elsewhere. The cause of death in head-injured patients was approximated and it was found that 67.8% were due to head injury, 6.6% to extracranial injury, and 25.6% to both. Head injury is thus associated with more deaths (3,010 vs. 1,972) than all other injuries and causes almost as many deaths (2,040 vs. 2,170) as extracranial injuries. Because of its high mortality, head injury is the single largest contributor to trauma center deaths.

Brain Injuries↗

PubMed2001

Outcome analysis of Pennsylvania trauma centers: factors predictive of nonsurvival in seriously injured patients.

BACKGROUND: The purpose of this study was to evaluate the impact of five trauma center characteristics on survival outcome in nine serious injury categories. METHODS: A retrospective analysis of prospectively collected data from 1992 to 1996 on patients older than 14 years of age from 24 accredited trauma centers in Pennsylvania was performed. Trauma center characteristics selected for evaluation were level of accreditation, volume of trauma admissions, presence of in-house trauma surgeons, presence of a surgical residency program, and presence of an on-site medical school. Each of these characteristics was evaluated to determine its impact on survival in the selected serious injuries. A logistic regression model was then created to evaluate the most seriously injured patients as defined by A Severity Characterization of Trauma score of < 0.50. On the basis of the logistic regression model, odd ratios were calculated treating low volume as a significant risk factor for mortality. RESULTS: Of the 88,723 patients meeting registry criteria, 13,942 met the serious injury criteria. Independent analysis suggested that accreditation was beneficial regardless of level, volume of patients treated had a direct impact on survival outcome, and the presence of a surgical residency program may confer survival benefit. Of the 13,942 patients with serious injuries, those with A Severity Characterization of Trauma score of < 0.5 were selected for evaluation by logistic regression (n = 3,562). The logistic regression model, however, showed that only volume of patients treated had a consistent association with improved survival. Odds ratio analysis revealed low volume as a significant risk factor for mortality in seven of the nine injuries studied. CONCLUSION: In this analysis, only volume of patients treated had a direct impact on survival outcome. Accreditation, regardless of level, appears to be beneficial.

Accreditation↗

PubMed1992

Analysis of organ procurement failure at an urban trauma center and the impact of HIV on organ procurement at a regional transplantation center.

A 42-month experience with 100 patients with fatal head injuries was analyzed to identify areas of organ procurement failure. Thirty-six patients were ineligible for organ donation. Reasons for exclusion included advanced age (7), sepsis (16), hepatitis (1), systemic illnesses (3), and HIV infection or risk (9). Resuscitation failure (17 patients) and late deaths from failed support (16 patients) left 31 potential donors. Of the 30 families asked to donate, 17 consented (56.7%). Annual consent rates were 25%, 71%, 75%, and 67%. Efforts to improve organ procurement should focus on resuscitation and physiologic support of potential donors. To assess the impact of HIV infection or risk on organ procurement, a 3-year experience of the regional transplantation center (RTP) was reviewed. Of 1,714 referrals to the RTP from 102 hospitals, 1,120 were from trauma centers. The incidence of rejection because of HIV risk or infection was significantly higher in the trauma center group than in the group from non-trauma centers, 17.2% versus 10.2% (p less than 0.004). A similar difference was noted between metropolitan and suburban hospitals (p less than 0.0001). Hepatitis risk was comparable, 3.9% vs. 3.2%. The risk of HIV infection is emerging as a factor limiting organ donation at urban trauma centers.

Adolescent↗

PubMed1989

Patterns of alcohol and drug abuse in an urban trauma center: the increasing role of cocaine abuse.

Alcohol continues to play a major etiologic role in blunt trauma. It is involved in 65-70% of fatal highway crashes. The role of illicit drugs, although accepted as an etiologic factor in trauma, is less well described. This is especially true of blunt and penetrating trauma related to violent crime. During a 9-month period, in a randomly selected group, blood and urine samples were taken from 169 traumatized patients for alcohol and general toxicology screens. There were 81 cases (47.9%) related to violent crime. One hundred twenty-six patients (74.5%) tested positive for illicit or prescription drugs in their blood. These included cocaine (54.4%), cannabinoids (37.2%), barbiturates (7.1%), amphetamines (4.7%), benzodiazepines (10.1%), opiates (9%), and codeine (1%). Sixty-one patients (35.5%) tested positive for alcohol. Alcohol was found in 6.2% of violent crime-related cases. Illicit drugs were found in 80.3% of violent crime-related cases. Alcohol and drugs, especially illicit drugs, are major etiologic factors in both accidental and crime-related trauma in the urban population. All patients admitted to trauma centers, especially urban trauma centers, should be screened for alcohol and drugs.

Accidents, Traffic↗

PubMed1987

A national alcohol and trauma center survey. Missed opportunities, failures of responsibility.

The results of a national survey of trauma centers concerning their assessment and response to the problem of alcohol and trauma are reported. Surveys were returned from 154 trauma centers located in 43 states and the District of Columbia. The profile of the 125,000 patients treated at the centers is a 30-year-old man sustaining blunt trauma, usually in a vehicular crash. Two-thirds of centers estimated that the majority of their patients had abused alcohol. While acknowledging alcohol as a significant cause of trauma, only 55.2% of centers routinely obtain admitting blood alcohol levels. Less than a third of the centers employ alcoholism counselors. Most trauma centers are not providing services that allow them to fulfill their responsibility to detect and initiate treatment of alcohol abuse, a major cause of traumatic injury.

Accidents, Traffic↗

PubMed2002

Outcome of major cardiac injuries at a Canadian trauma center.

BACKGROUND: Canadian trauma units have relatively little experience with major cardiac trauma (disruption of a cardiac chamber) so injury outcome may not be comparable to that reported from other countries. We compared our outcomes to those of other centers. METHODS: Records of patients suffering major cardiac trauma over a nine-year period were reviewed. Factors predictive of outcome were analyzed. RESULTS: Twenty-seven patients (11 blunt and 16 penetrating) with major cardiac trauma were evaluated. Injury severity scores (ISS) were similar for blunt (49.6 +/- 16.6) and penetrating (39.5 +/- 21.6, p = 0.20) injuries. Five of 11 blunt trauma patients, and 9 of 16 penetrating trauma patients, had detectable vital signs on hospital arrival (p = 0.43). Ten patients underwent emergency department thoracotomy and 11 patients had cardiac repair in the operating theatre. Eleven patients survived and 16 died. Survivors had a lower ISS (33.7 +/-15.4) than non-survivors (50.4 +/- 20.4; p = 0.03). Two of 11 blunt trauma patients and 9 of 16 penetrating trauma patients survived (p = 0.06). Eleven of 14 patients with detectable vital signs survived; all 13 without detectable vital signs died (p = 0.00003). Ten of eleven patients treated in the operating theatre survived, while only one of the other 16 patients survived (p = 0.00002). CONCLUSIONS: Patients with major cardiac injuries and detectable vital signs on hospital arrival can be salvaged by prompt surgical intervention in the operating theatre. Major cardiac injuries are infrequently encountered at our center but patient survival is comparable to that reported from trauma units in other countries.

Adolescent↗

PubMedDate not supplied

Judicial outcome for the intoxicated driver admitted to a regional trauma center.

OBJECTIVE: To examine the judicial outcomes for intoxicated drivers who were admitted to regional trauma centers as a result of motor vehicle collisions (MVCs). METHODS: A retrospective review of the trauma registry of a Level I trauma center was conducted for the period from January 1, 1989, through December 31, 1990. Inclusion criteria for entry into the study were 1) identification of the patient as the driver involved in an MVC, 2) a blood alcohol content (BAC) above 0.10 g/dL, and 3) survival until discharge from the hospital. A total 245 patients from the trauma registry met the inclusion criteria. The number of persons from the submitted list who were later convicted of driving under the influence of alcohol (DUI) was obtained from the Department of Motor Vehicles (DMV) of the Common- wealth of Virginia. RESULTS: Of the list submitted to the DMV, only nine individuals (3.7%; 95% confidence interval = 1.3--6.0%) were convicted of DUI during the MVCs that led to hospitalization during the study period. During the same time period, the statewide conviction rate for DUI-cited drivers was 85%. CONCLUSION: Admission to the trauma service at a Level I trauma center may provide a refuge from legal consequences for intoxicated drivers involved in MVCs.

Accidents, Traffic↗

PubMed1993

Pediatric trauma patients in an 'adult' trauma center.

The injury patterns, age distribution, and outcome of pediatric patients (age < 15 years) treated in an "adult" trauma center is incompletely defined. A total of 1115 pediatric trauma patients (9.6% total trauma admissions) treated over a 6-year period in a level I suburban trauma center without a pediatric trauma service or a pediatric surgeon were reviewed for age distribution; injury mechanism, injury pattern, and injury severity; surgical procedures; disposition; and mortality. All charts were subject to internal and external peer review, including five site surveys. Resuscitation, surgery, critical care, and stepdown management were provided by a trauma team led by in-house attending trauma surgeons (mean PGY = 20). Of the patients 22% were preschool (age 0-4 years), and 34% were adolescent (age 12-14 years); the mechanism was blunt (96%), with motor vehicular crash being the most frequent; the mean ISS was 11.1, with 39% of ISSs > 9; significant injuries (AIS score > or = 3) of the head and extremities were dominant; 3.9% of patients underwent laparotomy, primarily for injuries to the bowel, spleen, and liver. There was only one laparotomy in the 0-4 year age group. The mean length of stay of patients was 6.2 days, with 38% requiring time in the ICU. Of the patients, 90% were discharged home; the treated trauma patient mortality rate was 25 of 988, or 2.5%; 92% of these died of nonsurvivable head injuries. No deaths were judged preventable. There was no significant difference of noncompliance for the pediatric patients when compared with the adult population in five trauma audit filters.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1989

Status of trauma center designation.

1) In 1986 20 states are designating trauma centers. 2) ACS guidelines appear to be the accepted standard. 3) Almost all of the states providing designation retain the power of final designation but allow individual hospitals to initiate the process. 4) Designation is usually based on actual capability and frequently requires a site visit team in which surgeons and emergency medicine physicians play a prominent role. 5) Designation appears to be for a finite period of time but half of the states do not provide for de-designation. 6) A national mandate is necessary for timely and uniform implementation of trauma center designation.

General Surgery↗

PubMed2003

Identification and evaluation of patients with mild traumatic brain injury: results of a national survey of level I trauma centers.

BACKGROUND: Mild traumatic brain injury (MTBI), alone or in combination with other injuries, is frequently present in trauma patients requiring hospital admission. A survey was conducted to characterize the current practices of identification and management of patients with MTBI at Level I trauma centers in the United States. METHODS: Surveys were mailed to trauma program managers at 68 verified Level I trauma centers. RESULTS: Thirty-five (51.4%) centers responded, representing 24 states. Multiple terms are used synonymously with MTBI, and less than half (45%) of centers formally evaluate all trauma patients with MTBI. Patients identified with MTBI discharged from the emergency department are referred for further evaluation at only 34% of centers. There is no consistent practice for determining which hospitalized patients with MTBI are formally evaluated, who performs the evaluations, or which evaluation tool(s) are used. Patients with MTBI and cognitive deficits are referred to a variety of specialists after discharge. CONCLUSION: There is currently no standard practice for defining, evaluating, or managing MTBI at Level I trauma centers. A consistent definition of MTBI and its management could promote recognition of MTBI; facilitate data collection, analysis, and comparison; and provide guidelines for activity modification during recovery.

Brain Injuries↗

PubMed1996

The peacetime trauma experience of U.S. Army surgeons: another call for collaborative training in civilian trauma centers.

OBJECTIVE: To document the ongoing trauma experience of U.S. Army surgeons during peacetime clinical practice. METHODS: Surveys were mailed to the trauma directors of military surgical services worldwide. Questions focused on numbers of operative cases and availability of trauma resources. Laparotomy, thoracotomy, and vascular repair for trauma were considered index cases and simple means were computed based on numbers of cases per general surgeon. RESULTS: Seventy percent of worldwide Army surgical services responded to the survey. In 1992, on the average, a general surgeon in the Army performed 1.3 trauma laparotomies, 0.3 thoracotomies, and 0.3 vascular repairs for trauma. Only 6 of 28 surgical services had an organized "trauma team," 3 held regular trauma conferences, and 1 service kept a registry and could calculate an average injury severity score. CONCLUSIONS: Our data support perceptions concerning lack of an ongoing trauma experience for military surgeons and reinforces the need for collaborative education and training in busy civilian trauma centers. A regional approach is suggested as a viable solution.

Clinical Competence↗

PubMed2005

Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines.

BACKGROUND: American Pediatric Surgical Association consensus guidelines for children with blunt spleen injuries have been defined and validated in children's hospitals, but large administrative data sets indicate that only 10% to 15% of children with blunt spleen injuries are treated at children's hospitals. We sought to identify the frequency and compare the treatment of children with spleen injury in hospitals with and without recognized trauma expertise, with the aim of identifying a meaningful target for dissemination of benchmarks and consensus guidelines. STUDY DESIGN: State health departments' administrative data sets from California, Florida, New Jersey, and New York were analyzed for 2000, 2001, and 2002. All children with head injury or other nonspleen abdominal injuries requiring surgery were excluded. Injury Severity Scores were determined by ICDMAP-90. RESULTS: There were 3,232 patients with blunt spleen injury. Trauma centers had a significantly lower rate of operation for both multiply injured patients (15.3% versus 19.3%, p < 0.001) and those with isolated injury (9.2% versus 18.5%, p < 0.0001) when compared with nontrauma centers. The operative rates at both trauma centers and nontrauma centers exceed published American Pediatric Surgical Association benchmarks for all children with spleen injury (5% to 11%) and the subset with isolated spleen injury (0% to 3%). Independent risk factors for splenectomy included ages 15 to 19 years (p < 0.002), spleen injury severity (p < 0.0001), and presence of multiple injuries (p < 0.04). Adjusted odds ratio for risk of splenic operation in all patients with spleen injury was 2.122 (95% CI:1.455- 3.096) when treated at a nontrauma center (p < 0.0001). CONCLUSIONS: These multistate discharge data indicate that treatment of children with blunt spleen injury differs significantly when comparing trauma centers and nontrauma centers. Because nearly two-thirds of these children were treated at trauma centers, dissemination of American Pediatric Surgical Association guidelines and benchmarks through state or regional trauma systems may reduce the number of children having operations for splenic injury.

Adolescent↗

PubMed2001

Patient volume per surgeon does not predict survival in adult level I trauma centers.

BACKGROUND: The 1999 American College of Surgeons resources for optimal care document added the requirement that Level I trauma centers admit over 240 patients with Injury Severity Score (ISS) > 15 per year or that trauma surgeons care for at least 35 patients per year. The purpose of this study was to test the hypothesis that high volume of patients with ISS > 15 per individual trauma surgeon is associated with improved outcome. METHODS: Data were obtained from the trauma registry of the five American College of Surgeons-verified adult Level I trauma centers in our mature trauma system between January 1, 1998, and March 31, 1999. Data abstracted included age, sex, Glasgow Coma Scale (GCS) score, intensive care unit length of stay, hospital length of stay, probability of survival (Ps), mechanism of injury, number of patients per each trauma surgeon and institution, and mortality. Multiple logistic regression was performed to select independent variables for modeling of survival. RESULTS: From the five Level I centers there were 11,932 trauma patients in this time interval; of these, 1,754 patients (14.7%) with ISS > 15 were identified and used for analysis. Patients with ISS > 15 varied from 173 to 625 per institution; trauma surgeons varied from 8 to 25 per institution; per-surgeon patient volume varied from 0.8 to 96 per year. Logistic regression analysis revealed that the best independent predictors of survival were Ps, GCS score, age, mechanism of injury, and institutional volume (p < 0.01). Age and institutional volume correlated negatively with survival. Analysis of per-surgeon patient caseload added no additional predictive value (p = 0.44). CONCLUSION: The significant independent predictors of survival in severely injured trauma patients are Ps, GCS score, age, mechanism of injury, and institutional volume. We found no statistically meaningful contribution to the prediction of survival on the basis of per-surgeon patient volume. Since this volume criterion for surgeon enpanelment and trauma center designation would not be expected to improve outcome, such a requirement should be justified by other measures or abandoned.

Adult↗

PubMed1982

Regional pediatric trauma center: does a system of management improve outcome?

The Pediatric Trauma Center has existed in Maryland since 1973 for the entire state with the exception of burns and isolated eye or hand injuries which are managed in affiliated hospitals. The article reviews the system and the results obtained in 600 children treated between 1975 and 1981. The authors underline the need for a regional trauma center because this system can reduce the morbidity and mortality associated with trauma in the pediatric age group.

Humans↗

PubMed1998

Cofactors of alcohol-related trauma at a rural trauma center.

To analyze the cofactors of alcohol-related trauma at a rural, Level II trauma center, 127 admitted trauma patients were interviewed about psychological problems, social factors, and medical histories. Patients were divided into two groups, blood alcohol content (BAC) positive and BAC negative, for analysis. Seventy-one patients (56%) were BAC negative; 56 (44%) were BAC positive. Forty-three of the 82 males (52%) had positive BAC tests, compared with 13 of the 45 females (29%) (P = .01). Fifty-one of the 56 BAC-positive patients (91%) were aged 21 to 50 years, compared with 29 of the 71 BAC-negative patients (41%) (P = .0001). Ten of the 12 patients (83%) who were recently unemployed were BAC positive, compared with 46 of the 115 patients (40%) who were not recently unemployed (P = .004). Eleven of the 12 patients (92%) with positive drug screens were BAC positive, compared with 45 of the 115 patients (39%) with negative drug screens (P = .0005). These results show that there are important cofactors of alcohol-related trauma in rural areas.

Adolescent↗