Level Of Trauma Care Research Articles

Trauma Care at Rural Level III Trauma Centers in a State Trauma System

Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care. During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail. A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5. Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.

National inventory of hospital trauma centers.

Trauma centers benefit thousands of injured individuals every day and play a critical role in responding to disasters. The last full accounting of the number and distribution of trauma centers identified 471 trauma centers in the United States in 1991. To determine the number and configuration of trauma centers and identify gaps in coverage. Interviews with trauma center directors (September 2001 to April 2002), data from the American Hospital Association's Annual Survey of Hospitals (2000), and the US Health Resources Administration's Area Resource File (2001) were used to determine characteristics of trauma center hospitals and the geographic areas they serve in all 50 states and in the District of Columbia. Characteristics of trauma centers were examined by level of care and compared with nontrauma centers. Hospitals are designated or certified as trauma centers by a state or regional authority or verified as trauma centers by the American College of Surgeons Committee on Trauma. Trauma centers that treat only children (n = 31) were excluded. Total number of trauma centers and number of trauma centers per million population. In 2002, there were 1154 trauma centers in the United States, including 190 level I centers and 263 level II centers. Several states have categorized every hospital with an emergency department at some level of trauma care while others have designated a limited number of level I and level II centers only. The number of level I and II centers per million population ranges from 0.19 to 7.8 by state. When compared with nontrauma center hospitals, trauma centers are larger, more likely to be teaching hospitals, and more likely to offer specialized services. Although the availability of trauma centers has improved, challenges remain to ensure the optimal number, distribution, and configuration of trauma centers. These challenges must be addressed, especially in light of the recent emphasis on hospital preparedness and homeland security.

Using Trauma and Injury Severity Score (TRISS)-Based Analysis in the Development of Regional Risk Adjustment Tools to Trend Quality in a Voluntary Trauma System: The Experience of the Trauma Foundation of Northeast Ohio

Presently, no trauma system exists in Ohio. Since 1993, all hospitals in Cuyahoga County (CUY), northeast Ohio (n = 22) provide data to a trauma registry. In return, each received hospital-specific data, comparison data by trauma care level and a county-wide aggregate summary. This report describes the results of this approach in our region. All cases were entered by paper abstract or electronic download. Interrater reliability audits and z score analysis was performed by using the Major Trauma Outcome Study and the CUY 1994 baseline groups. Risk adjustment of mortality data was performed using statistical modeling and logistic regression (Trauma and Injury Severity Score, Major Trauma Outcome Study, CUY). Trauma severity measures were defined. In 1995, 3,375 patients were entered. Two hundred ninety-one died (8.6%). Severity measures differed by level of trauma care, indicating differences in case mix. Probability of survival was lowest in the Level I centers, highest in the acute care hospitals. Outcomes z scores demonstrated survival differences for all levels. In a functioning trauma system, the most severely injured patients should be cared for at the trauma centers. A low volume at acute care hospitals is desirable. By using Trauma and Injury Severity Score with community-specific constants, NE Ohio is accomplishing these goals. The Level I performance data are an interesting finding compared with the data from the Level II centers in the region

Evaluating Performance of Statewide Regionalized Systems of Trauma Care

A new methodology is presented for evaluating the extent to which patients within regionalized systems of trauma care are treated at the appropriate hospitals. Criteria are proposed for retrospectively classifying trauma patients as to whether they should have been treated at a trauma center. The criteria were developed by a panel of nationally recognized trauma experts and are based on the age of the patient and the type and AIS severity of injuries sustained. The criteria were then applied to uniformly collected data available for all trauma discharges in 1988 from acute care hospitals in a state with a well developed system of regionalized trauma care. According to the criteria, 19% of all trauma discharges in 1988 should have been treated at a trauma centers. Of those who should have been treated at a trauma center according to criteria, 66% actually received treatment at a center. Of those who were classified not to have required care at a trauma center, 62% actually were treated at non-trauma center hospitals. The congruence between where patients should have been treated and the actual level of hospital care received varied by the type and severity of the traumatic injuries sustained. The results of the analysis provide insights into the characteristics of trauma patients at higher risk of not getting the appropriate level of trauma care and should assist in improving guidelines for triage and transfer within a regionalized system of care.

Advanced trauma life support training for physicians and nurses: a pilot program.

Abstract ATLS training is making dramatic inroads into the management of multiple-systems trauma patients. This course, sponsored by the ACS, is helping develop a common language between physicians at all levels of trauma care. We strongly believe that ATLS training should be offered to ED nurses as well, in recognition of the fact that they are intimately involved in the initial assessment and resuscitation of trauma victims. Our initial two efforts at piloting ATLS training for nurses together with physicians have met with unqualified success. Physicians and nurses alike have been enthusiastic in their praise, stressing the commonality of purpose that lies at the core of this program. Such a program openly admits the reality of the necessity for interdependence, for open communication, and for mutual respect between physicians and nurses. We hope that our positive experience and evaluation will help encourage the ACS to offer its course nationally to nurses along with physicians and perhaps even to provide nurses with official recognition of successful completion. We believe that such a joint program is the optimal way to improve the care of multiple-systems trauma victims in the crucial first hour.