ACS-verified Trauma Centers Research Articles

Financial vulnerability of trauma centers: A national analysis.

Trauma centers function as an essential safeguard in the United States health care system. However, there has been minimal study of their financial health or vulnerability. We sought to perform a nationwide analysis of trauma centers using detailed financial data and a recently developed Financial Vulnerability Score (FVS) metric. The RAND Hospital Financial Database was used to evaluate all American College of Surgeons-verified trauma centers nationwide. The composite FVS was calculated for each center using six metrics. Financial Vulnerability Score tertiles were used to classify centers as high, medium, or low vulnerability, and hospital characteristics were analyzed and compared. Hospitals were also compared by US Census region and teaching versus nonteaching hospitals. A total of 311 American College of Surgeons-verified trauma centers were included in the analysis, with 100 (32%) Level I, 140 (45%) Level II, and 71 (23%) Level III. The largest share of the high FVS tier was consisted of Level III centers (62%), with the majority of Level I (40%) and Level II (42%) in the middle and low FVS tier, respectively. The most vulnerable centers had fewer beds, negative operating margins, and significantly less cash on hand. Lower FVS centers had greater asset/liability ratios, lower outpatient shares, and three times less uncompensated care. Nonteaching centers were statistically significantly more likely to have high vulnerability compared with teaching centers (46% vs. 29%). Statewide analysis showed high discrepancy among individual states. With approximately 25% of Levels I and II trauma centers at high risk for financial vulnerability, disparities in characteristics, including payer mix and outpatient status, should be targeted to reduce vulnerabilities and bolster the health care safety net. Prognostic and Epidemiological; Level IV.

Extending Trauma Quality Improvement Beyond Trauma Centers: Hospital Variation in Outcomes Among Nontrauma Hospitals.

The American College of Surgeons (ACS) conducts a robust quality improvement program for ACS-verified trauma centers, yet many injured patients receive care at non-accredited facilities. This study tested for variation in outcomes across non-trauma hospitals and characterized hospitals associated with increased mortality. The study included state trauma registry data of 37,670 patients treated between January 1, 2013, and December 31, 2015. Clinical data were supplemented with data from the American Hospital Association and US Department of Agriculture, allowing comparisons among 100 nontrauma hospitals. Using Bayesian techniques, risk-adjusted and reliability-adjusted rates of mortality and interfacility transfer, as well as Emergency Departments length-of-stay (ED-LOS) among patients transferred from EDs were calculated for each hospital. Subgroup analyses were performed for patients ages >55 years and those with decreased Glasgow coma scores (GCS). Multiple imputation was used to address missing data. Mortality varied 3-fold (0.9%-3.1%); interfacility transfer rates varied 46-fold (2.1%-95.6%); and mean ED-LOS varied 3-fold (81-231 minutes). Hospitals that were high and low statistical outliers were identified for each outcome, and subgroup analyses demonstrated comparable hospital variation. Metropolitan hospitals were associated increased mortality [odds ratio (OR) 1.7, P = 0.004], decreased likelihood of interfacility transfer (OR 0.7, P ≤ 0.001), and increased ED-LOS (coef. 0.1, P ≤ 0.001) when compared with nonmetropolitan hospitals and risk-adjusted. Wide variation in trauma outcomes exists across nontrauma hospitals. Efforts to improve trauma quality should include engagement of nontrauma hospitals to reduce variation in outcomes of injured patients treated at those facilities.

Whole truths but half the blood: Addressing the gap between the evidence and practice of pre-hospital and in-hospital blood product use for trauma resuscitation.

In recent years, several studies have demonstrated the efficacy of using pre-hospital blood product and in-hospital whole blood for trauma resuscitation. While some observations suggest an encouraging uptake of this evidence by emergency medical service (EMS) agencies and trauma centers, a nationwide characterization of blood product utilization for bleeding trauma patients remains unknown. The objective of this study is to determine nationwide estimates of pre-hospital blood product and in-hospital whole blood utilization for trauma resuscitation. All adult trauma patients reported to the National Emergency Medical Services Information System (NEMSIS) dataset 2019 were included. Proportions of patients who received any pre-hospital blood product were calculated. The American College of Surgeons (ACS) Trauma Quality Programs (TQP) databases 2015-2017 and first quarter of 2020 were used to calculate the proportion of ACS-verified trauma centers that transfused whole blood. Among a total of 3,058,804 pre-hospital trauma patients, only 313 (0.01%) received any blood transfusion; 208 (0.21%) patients with systolic blood pressure (SBP) ≤90 mmHg and 121 (0.67%) patients with SBP ≤90 mmHg and heart rate ≥120 beats per minute received any blood product. The proportion of ACS-verified trauma centers transfusing whole blood increased from 16.7% (45/269) in 2015 to 24.5% (123/502) in first quarter of 2020. Despite strong evidence and recommendations, pre-hospital utilization of blood products for trauma resuscitation remains low. Additionally, while the overall in-hospital whole blood use also remains low, its use has increased at ACS-verified trauma centers over the past 5 years.

Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care.

Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.

Building Consensus to Decrease Firearm Injuries and Death in the USA: Engaging Medical and Public Health Organizations to Find Common Ground

Firearm injury deaths are rising and as of 2017 exceed motor vehicle crash deaths in the USA. We as healthcare professionals treat many of the injured, including those cared for in the network of over 560 ACS-verified trauma centers. In order to address this public health crisis that affects us all, we need to develop a multifaceted public health strategy to decrease and prevent firearm injuries and deaths. While personal opinions about firearm ownership vary significantly across the USA, an inclusive, consensus-based, public health approach to reducing firearm deaths is possible. This article reviews recent literature on this approach, first building consensus among surgeons and then extending across the entire healthcare professional community. There is broad support for a public health approach which focuses on the understanding and addressing the underlying causes of violence while also making firearm ownership as safe as possible. This approach requires the expertise and committed support of healthcare and public health providers, along with their professional organizations, healthcare systems, and public health networks which they lead. To achieve the goals of eliminating preventable firearm-related death and disability also requires engaging firearm owners and members from vulnerable communities as key stakeholders in the public health solution. In order to achieve the goals of the public health approach, increased federal and philanthropic research funding is required to identify and evaluate the most effective injury prevention initiatives.

Pediatric Trauma System Evaluation before and after Level II Verification

ACS-verified trauma centers show higher survival and improved mortality rates in states with ACS-verified Level I pediatric trauma centers. However, few significant changes are appreciated in the first two years after verification. Minimal research exists examining verification of ACS Level II pediatric trauma centers. We analyzed ACS Level II pediatric trauma verification at our institution. In 2014, Sanford Medical Center Fargo became the only Level II pediatric trauma center in North Dakota, as well as the only center between Spokane and Minneapolis. A retrospective review of the institution's pre-existing trauma database one year pre- and postverification was performed. Patients aged <18 years were included in the study (P < 0.05). Patient number increased by 23 per cent, from 167 to 205 patients. A statistically significant increase occured in the three to six year old age group (P = 0.0002); motorized recreational vehicle (P = 0.028), violent (P = 0.009), and other (P = 0.0374) mechanism of injury categories; ambulance (P = 0.0124), fixed wing (P = 0.0028), and personal-owned vehicle (P = 0.0112) modes of transportation. Decreased public injuries (P = 0.0071) and advanced life support ambulance transportation (P = 0.0397). The study showed a nonstatistically significant increase in mean Injury Severity Score (from 6.3 to 7) and Native American trauma (from 14 to 20 per cent). Whereas prolonged ACS Level I pediatric trauma center verification was found to benefit patients, minimal data exist on ACS Level II verification. Our findings are consistent with current Level I ACS pediatric trauma center data. Future benefits will require continued analysis because our Level II pediatric trauma center continues to mature and affect our rural and large Native American community.

Non-accidental trauma: A national survey on management

IntroductionNon-accidental trauma (NAT) has significant societal and health care implications. Standardized care has been shown to improve outcomes. The purpose of our study was to survey trauma centers and elucidate the continued variable management of NAT. MethodsAfter institutional review board approval, an email survey was sent to Level 1 and 2 ACS verified trauma centers along with general and pediatric surgery training programs. Trauma hospital characteristics and NAT management were analyzed. ResultsA total of 493 emails were sent and 91 responses (18%) were received. There were 74 (81%) pediatric surgeons who responded and 15(17%) adult general surgeons. The most common location of respondents were children’s hospitals within academic/community hospitals (58%) followed by stand-alone children hospitals (42%), and adult only hospitals (9%).51 (57%) providers reported using a screening tool; most commonly used by the emergency department (52%). 75% of providers reported utilizing management protocols in which 71% were initiated by trauma surgery. The most common consulting and admitting service for NAT was trauma surgery (86% and 84%).When comparing stand-alone and affiliated children hospitals, there was no difference in the use of a screening tool (54% vs. 59%; p = 0.84), and management protocol (70% vs. 85%; p = 0.19). However, those providers from pediatric trauma centers used a management protocol more often than providers from adult trauma centers (78% vs. 38%; p = 0.04). No providers from adult trauma centers had intentions to initiate a management protocol in the future. ConclusionScreening and management of non-accidental trauma continues to vary across the country. Future studies focusing on standardization and outreach/education to adult trauma centers is warranted.

Characteristics of ACS-verified Level I and Level II trauma centers: A study linking trauma center verification review data and the National Trauma Data Bank of the American College of Surgeons Committee on Trauma.

The Trauma Quality Improvement Project of the American College of Surgeons (ACS) has demonstrated variations in trauma center outcomes despite similar verification status. The purpose of this study was to identify structural characteristics of trauma centers that affect patient outcomes. Trauma registry data on 361,187 patients treated at 222 ACS-verified Level I and Level II trauma centers were obtained from the National Trauma Data Bank of ACS. These data were used to estimate each center's observed-to-expected (O-E) mortality ratio with 95% confidence intervals using multivariate logistic regression analysis. De-identified data on structural characteristics of these trauma centers were obtained from the ACS Verification Review Committee. Centers in the lowest quartile of mortality based on O-E ratio (n = 56) were compared to the rest (n = 166) using Classification and Regression Tree (CART) analysis to identify institutional characteristics independently associated with high-performing centers. Of the 72 structural characteristics explored, only 3 were independently associated with high-performing centers: annual patient visits to the emergency department of fewer than 61,000; proportion of patients on Medicare greater than 20%; and continuing medical education for emergency department physician liaison to the trauma program ranging from 55 and 113 hours annually. Each 5% increase in O-E mortality ratio was associated with an increase in total length of stay of one day (r = 0.25; p < 0.001). Very few structural characteristics of ACS-verified trauma centers are associated with risk-adjusted mortality. Thus, variations in patient outcomes across trauma centers are likely related to variations in clinical practices. Therapeutic study, level III.

The misapplication of the term spinal cord injury without radiographic abnormality (SCIWORA) in adults

Spinal cord injury without radiographic abnormality (SCIWORA) is generally considered a disease of children; however, it is commonly used when referring to adults who have spinal cord injury without computed tomography evidence of trauma (SCIWOCTET). The purpose of this study was to describe characteristics of patients with both adult and pediatric cervical SCIWOCTET admitted to hospitals in our region. A retrospective review of all patients admitted to our two ACS-verified trauma centers with cervical spinal cord injury from January 2005 to December 2009 was performed. All patients with vertebral or ligamentous injury identified on computed tomographic (CT) scan of the cervical spine were excluded. Data gathered on the remaining patients included demographics, injury mechanism, Injury Severity Score, neurologic level and severity of spinal cord injury, magnetic resonance imaging results, and mortality rates. During the 5-year period of this study, 11,644 adult patients and 3,458 pediatric trauma patients were admitted. Of these, 313 patients were thought to have cervical spinal cord injury based on International Classification of Diseases, Ninth Revision (ICD-9) codes, 279 (89.1%) were excluded due to injury noted on CT cervical spine, and 9 were excluded as they were found to not truly have cervical spinal cord injury after review of the medical record. The remaining 25 patients were identified as having cervical SCIWOCTET. Twenty-three patients (92%) were male. The patient ages ranged from 10 to 83 years with a median age of 56 years. The mean Injury Severity Score was 22.6. Sixty-eight percent had a mechanism of fall. Degenerative changes were found on the CT scan of the cervical spine in 96% of all patients and in all 24 adult patients. There was only one pediatric patient with SCIWORA, a 10-year-old boy who had a normal CT scan of the cervical spine but had a persistent neurologic deficit. SCIWOCTET is mainly a disease of adults, and its subset SCIWORA, a disease of children, is much less common. Adults with this disease have CT scans showing canal stenosis and significant degenerative changes in the cervical spine; thus, it is not accurate to state that they have SCIWORA. The characteristics of this patient population are important as SCIWOCTET is the concern when clearing the cervical spines of trauma patients with a CT scan of the cervical spine negative for injury. Epidemiologic study, level III.

Trauma Quality Improvement Using Risk-Adjusted Outcomes

The National Surgical Quality Improvement Program has improved the quality of surgical care by tracking risk-adjusted patient outcomes. Unlike the National Surgical Quality Improvement Program, the trauma center verification program of the American College of Surgeons (ACS) focuses on availability of optimal resources, not outcomes. We hypothesized that significant variations in outcomes exist across similar level ACS-verified trauma centers despite availability of similar resources. The National Trauma Data Bank was used to identify adult patients (age 16-99 years) who were treated at ACS-verified Level I trauma centers that submitted at least 1,000 patients during the 5-year study period (264,102 patients from 58 trauma centers, excluding dead upon arrival). Multivariate logistic regression was used to analyze expected survival for each patient, adjusted for age, gender, race, injury mechanism, transfer status, and injury severity. Observed-to-expected survival ratios (O/E ratios with 95% confidence intervals) were used to rank trauma centers as high performers (O/E ratio significantly larger than 1), low performers (O/E ratio significantly less than 1), or average performers (O/E ratio overlapping 1). Almost half the centers performed significantly different from their risk-adjusted expectation. Fourteen were high performers, 11 were low performers, and 33 were average performers. The trauma center verification process in its present form may not ensure optimal outcome across all verified centers. If further validated, these findings suggest significant room for trauma quality improvement by replicating structures and processes of high performing trauma centers.