Nontrauma Centers Research Articles

Insurance Status Biases Trauma-system Utilization and Appropriate Interfacility Transfer: National and Longitudinal Results of Adult, Pediatric, and Older Adult Patients.

To identify the association between insurance status and the probability of emergency department admission versus transfer for patients with major injuries (Injury Severity Score >15) and other complex trauma likely to require higher-level trauma center (TC) care across the spectrum of TC care. Trauma systems were developed to facilitate direct transport and transfer of patients with major/complex traumatic injuries to designated TCs. Emerging literature suggests that uninsured patients are more likely to be transferred. Nationally weighted Nationwide Emergency Department Sample (2010-2014) and longitudinal California State Inpatient Databases/State Emergency Department Databases (2009-2011) data identified adult (18-64 yr), pediatric (≤17 yr), and older adult (≥65 yr) trauma patients. Risk-adjusted multilevel (mixed-effects) logistic regression determined differences in the relative odds of direct admission versus transfer and outcome measures based on initial level of TC presentation. In all 3 age groups, insured patients were more likely to be admitted [eg, nontrauma center (NTC) private vs uninsured odds ratio (95% confidence interval): adult 1.54 (1.40-1.70), pediatric 1.95(1.45-2.61)]. The trend persisted within levels III and II TCs (eg, level II private vs uninsured adult 1.83 (1.30-2.57)] and among other forms of trauma likely to require transfer. At the state level, among transferred NTC patients, 28.5% (adult), 34.1% (pediatric), and 39.5% (older adult) of patients with major injuries were not transferred to level I/II TCs. An additional 44.3% (adult), 50.9% (pediatric), and 57.6% (older adult) of all NTC patients were never transferred. Directly admitted patients experienced higher morbidity [adult: 19.6% vs 8.2%, odds ratio (95% confidence interval):2.74 (2.17-3.46)] and mortality [3.3% vs 1.8%, 1.85 (1.13-3.04)]. Insured patients with significant injuries initially evaluated at NTCs and level III/II TCs were less likely to be transferred. Such a finding appears to result in less optimal trauma care for better-insured patients and questions the success of transfer-guideline implementation.

Design and implementation of the Western Pennsylvania regional Stop the Bleed initiative.

Hemorrhage is the leading cause of preventable death in trauma, and nearly 40% of prehospital deaths can be attributed to blood loss. The Stop the Bleed program provides a structured curriculum for teaching hemorrhage control and the use of bleeding control kits. To overcome implementation barriers and to achieve the goal of making education on bleeding control as common as cardiopulmonary resuscitation, widespread implementation with outreach to the public and law enforcement is necessary. We provide a description and analysis of the implementation of a regional Stop the Bleed program, which includes a step-by-step guide to the design of this program provided as a template to guide attempts at large-scale Stop the Bleed program development. Combining the efforts of regional trauma and nontrauma centers as a hub-and-spoke design, a region covering four states, 72 counties, and 30,000 square miles was targeted. A total of 27,291 individuals were trained in a 21-month period including 3,172 trainers, 19,310 lay public, and 4,809 law enforcement officers. A total of 436 bleeding control kits were distributed to 102 public schools, and tourniquets were provided to 4,809 law enforcement officers. Program development and community outreach resulted in official recognition of the program by the Pennsylvania State Senate. With the use of a multicenter outreach program design with emphasis on law enforcement and public education while developing a train-the-trainer program, widespread and rapid dissemination of Stop the Bleed teaching is feasible. The general steps described in this manuscript may serve as a template for new or developing programs in other areas to increase the national exposure to Stop the Bleed. Economic/Decision study, level IV.

Association of System-Level Factors With Secondary Overtriage in Trauma Patients

ImportanceStudies show that secondary overtriage (SO) contributes significantly to the economic burden of injured patients; thus, the association of SO with use of the trauma system has been examined. However, the association of the underlying trauma system design with such overtriage has yet to be evaluated.ObjectivesTo evaluate whether the distribution of trauma centers in a statewide trauma system is associated with SO and to identify clinical and demographic factors that may lead to SO.Design, Setting, and ParticipantsA retrospective cohort study was performed using 2008-2012 data from the Ohio Trauma and Emergency Medical Services registries. All patients taken to level III or nontrauma centers from the scene of the injury with an Injury Severity Score less than 15 and discharged alive were included. Among these patients, those with SO were identified as those who were subsequently transferred to a level I or II trauma center, had no surgical intervention, and were discharged alive within 48 hours of admission. The SO group was analyzed descriptively. Multiple logistic regression was used to identify system-level factors associated with SO. Statistical analysis was performed from August 1, 2017, to January 31, 2018.Main Outcomes and MeasuresThe primary outcome was the occurrence of SO.ResultsOf 34 494 trauma patients able to be matched in the 2 registries, 7881 (22.9%) met the inclusion criteria, of whom 965 (12.2%) had SO. The median age in the SO group was 40 years (interquartile range, 26-55 years), with 299 women and 666 men. After adjusting for age, sex, comorbidities, injury type, and insurance status, the study found that system-level factors (number of level I or II trauma centers in the region [>1]) were significantly associated with SO (adjusted odds ratio, 1.98; 95% CI, 1.64-2.38; P < .001; area under the curve, 0.89). The reasons for choice of destination by emergency medical services (specifically, choosing the closest facility: adjusted odds ratio, 1.65; 95% CI, 1.37-1.98; P < .001) and use of a field trauma triage protocol (adjusted odds ratio, 2.21; 95% CI, 1.70-2.87; P < .001), significantly increased the likelihood of SO.Conclusions and RelevanceThis study’s findings suggest that the distribution of major trauma centers in the region is significantly associated with SO. Subsequent investigation to identify the optimal number and distribution of trauma centers may therefore be critical. Specific outreach and collaboration of level III trauma centers and nontrauma centers with level I and II trauma centers, along with the use of telemedicine, may provide further guidance to level III trauma centers and nontrauma centers on when to transfer injured patients.

Yield of serious axial injury from pan scans after blunt trauma in haemodynamically stable low-risk trauma patients.

Whole body computed tomography (WBCT) scanning for trauma has gained popularity but its role in low-risk patients is controversial. We aimed to determine the rate of serious axial/truncal injury and emergency intervention in conscious, stable patients undergoing WBCT for blunt trauma in two non-trauma centre EDs in the Victorian trauma system. Retrospective cohort study by medical record and radiology report review. Patients were included if they were conscious, haemodynamically stable adults presenting by ambulance and having WBCT scan. Exclusion criteria were age <16 years, no history of trauma, Glasgow Coma Scale <14, systolic blood pressure <90 mmHg and intoxication with alcohol or drugs. Data collected included demographics, clinical findings, results of CT scans and emergency interventions (emergency truncal surgery, transfer to a trauma centre and/or transfusion within 24 h). The outcomes of interest were the rate of defined serious axial/truncal injury and emergency interventions. One hundred and four patients were studied. Median age was 45 years; 67% were men. Median injury severity score (ISS) was 1.5 (interquartile range 0-5); only one patient had an ISS ≥15. Ninety (87%, 78-92%) patients had no defined serious injury. Five (5%) patients had a defined emergency intervention - four trauma centre transfers and one transfusion. Two of these were not trauma-related. The rate of serious axial/truncal injury was low. The high rate of normal scans makes it likely that the risk:benefit ratio between injury identification and radiation related cancer risk is unacceptably high. This data supports a selective CT strategy in low-risk trauma patients.

Serious games may improve physician heuristics in trauma triage

Trauma triage depends on fallible human judgment. We created two "serious" video game training interventions to improve that judgment. The interventions' central theoretical construct was the representativeness heuristic, which, in trauma triage, would mean judging the severity of an injury by how well it captures (or "represents") the key features of archetypes of cases requiring transfer to a trauma center. Drawing on clinical experience, medical records, and an expert panel, we identified features characteristic of representative and nonrepresentative cases. The two interventions instantiated both kinds of cases. One was an adventure game, seeking narrative engagement; the second was a puzzle-based game, emphasizing analogical reasoning. Both incorporated feedback on diagnostic errors, explaining their sources and consequences. In a four-arm study, they were compared with an intervention using traditional text-based continuing medical education materials (active control) and a no-intervention (passive control) condition. A sample of 320 physicians working at nontrauma centers in the United States was recruited and randomized to a study arm. The primary outcome was performance on a validated virtual simulation, measured as the proportion of undertriaged patients, defined as ones who had severe injuries (according to American College of Surgeons guidelines) but were not transferred. Compared with the control group, physicians exposed to either game undertriaged fewer such patients [difference = -18%, 95% CI: -30 to -6%, P = 0.002 (adventure game); -17%, 95% CI: -28 to -6%, P = 0.003 (puzzle game)]; those exposed to the text-based education undertriaged similar proportions (difference = +8%, 95% CI: -3 to +19%, P = 0.15).

Noncontrast Head CT in Children: National Variation in Radiation Dose Indices in the United States.

Radiologists should manage the radiation dose for pediatric patients to maintain reasonable diagnostic confidence. We assessed the variation in estimated radiation dose indices for pediatric noncontrast head CT in the United States. Radiation dose indices for single-phase noncontrast head CT examinations in patients 18 years of age and younger were retrospectively reviewed between July 2011 and June 2016 using the American College of Radiology CT Dose Index Registry. We used the reported volume CT dose index stratified by patient demographics and imaging facility characteristics. The registry included 295,296 single-phase pediatric noncontrast head CT studies from 1571 facilities (56% in male patients and 53% in children older than 10 years of age). The median volume CT dose index was 33 mGy (interquartile range = 22-47 mGy). The volume CT dose index increased as age increased. The volume CT dose index was lower in children's hospitals (median, 26 mGy) versus academic hospitals (median, 32 mGy) and community hospitals (median, 40 mGy). There was a lower volume CT dose index in level I and II trauma centers (median, 27 and 32 mGy, respectively) versus nontrauma centers (median, 40 mGy) and facilities in metropolitan locations (median, 30 mGy) versus those in suburban and rural locations (median, 41 mGy). Considerable variation in the radiation dose index for pediatric head CT exists. Median dose indices and practice variations at pediatric facilities were both lower compared with other practice settings. Decreasing dose variability through proper management of CT parameters in pediatric populations using benchmarks generated by data from registries can potentially decrease population exposure to ionizing radiation.

Nationwide Assessment of Factors Associated with Nonoperative Management of Pediatric Splenic Injury

To evaluate variation in care nationwide for children with splenic injuries at pediatric trauma, adult trauma, and nontrauma centers. We used the National Inpatient Sample from 2001 to 2010 to identify pediatric patients with splenic injury. We analyzed demographic, clinical, and hospital status characteristics. The primary objective was comparison of splenectomy rates at pediatric, adult, and nontrauma centers. We identified 34,599 patients with splenic injury. Throughout the study, 3,979 (11.5%) patients underwent splenectomy: 8.2 per cent of patients at pediatric trauma, 17.6 per cent at adult trauma, and 14.5 per cent at nontrauma centers. Multivariate regression analysis demonstrated patients had decreased odds of splenectomy at pediatric trauma centers compared with adult and nontrauma centers (OR = 0.42, P < 0.001). In addition, children aged 14 to 17 years (OR = 2.5) with injury severity score > 14 (OR = 5.8) had increased odds of undergoing splenectomy. In this nationwide sample, children with splenic injury treated at adult trauma and nontrauma centers had significantly higher rates of splenectomy compared with children treated at pediatric trauma centers. We highlight the need for interventions that ensure all injured children receive appropriate and high quality trauma care.

Pre-Trauma Center Management of Intracranial Pressure in Severe Pediatric Traumatic Brain Injury.

Pre-trauma center care is a critical component in severe pediatric traumatic brain injury (TBI). For geographically large trauma catchment areas, optimizing increased intracranial pressure (ICP) management may potentially improve outcomes. This retrospective study examined ICP management in nontrauma centers and during interfacility transport to the trauma center. Charts from a pediatric level I trauma center were reviewed for admissions between 2008 and 2013. Patients with a Glasgow Coma Scale score of 8 or less, head Abbreviated Injury Scale score of 3 or higher, and requiring intubation at a nontrauma center were included. Exclusion criteria included head injury secondary to drowning, stroke, obstetrical complications, asphyxia, and afflicted head trauma (younger than 5 years). Trauma center charts contained coalesced data from first responders, nontrauma centers, and transport. Twenty-five patients (74%) had increased ICP upon admission at trauma center, 48% experienced ICPs greater than 20 cm H2O within 12 hours of admission, 12% required an urgent craniotomy, and 16% had herniation syndromes on neuroimaging. Pre-trauma center ICP management included osmotherapy and head-of-bed elevation. Sixty-four percent of patients with increased ICP at trauma center admission received pre-trauma center ICP management. Early increased ICP is a common presentation of severe pediatric TBI during pre-trauma center management. However, what constitutes optimal care remains unknown. Given the difficulties of diagnosing early increased ICP in this setting, prophylactic raising ICP-lowering strategies may be considered.

Comparative Effectiveness of Initial Treatment at Trauma Center vs Neurosurgery-Capable Non-Trauma Center for Severe, Isolated Head Injury

Head injury is an increasing contributor to death and disability, particularly among the elderly. Older patients are less likely to be treated at trauma centers, and head injury is the most common severe injury treated at non-trauma centers. We hypothesized that patients initially triaged to trauma centers would have lower rates of mortality and higher rates of discharge home without services than those treated at non-trauma centers. We used the State Emergency Department and Inpatient Databases (2011 to 2012) for 6 states to conduct a retrospective cohort study of patients with severe, isolated head injury. Combined, these databases capture all visits to non-federal emergency departments. We compared in-hospital mortality and discharge status for all adults and for the subgroup aged 65 years or older who initially presented to either a trauma center or a neurosurgery-capable non-trauma center. To account for selection bias, we used differential distance from patients' homes to a trauma center as an instrumental variable and performed a multivariable matched analysis. Of 62,198 patients who presented with severe, isolated head injury, 44.2% presented to non-trauma centers and 55.8% to trauma centers. In multivariable matched instrumental variable analysis, initial presentation to a trauma center was associated with no significant difference in overall mortality (-1.06%; 95% CI-3.36% to 1.19%), but a 5.8% higher rate of discharge home (95% CI 1.7% to 10.0%). Among patients aged 65 years or older, initial presentation to a trauma center was associated with a 3.4% reduction in mortality (95% CI 0.0% to 7.1%). Patients with isolated, severe head injury have better outcomes if initially treated in designated trauma centers. As 40% of such patients were triaged to non-trauma centers, there are major opportunities for improving outcomes.

Effects of distance and rescue time to medical facilities on traffic mortality utilizing GIS

ABSTRACTAlthough supported by little scientific evidence, the concept of ‘golden hour,’ which claims that mortality for trauma patients rises significantly over rescue time, plays a vital role in the design of our current trauma system. Only the contrary results could be found by using Fatality Analysis Reporting System data from 2010 to 2012. The results of logistic regression showed that longer total time intervals were associated with lower traffic mortality, with an odds ratio (OR) of 0.993 per minute. Utilizing the closest facility solver in the Geographic Information System, the effect of ‘reverse causation’ and the difference between trauma centre and non-trauma centre on the time-mortality relationship were discussed. Furthermore, based on the Kentucky Collision Analysis for the Public data from 2010 to 2012, the results of logistic regression showed that the mortality increased with each additional mile to the trauma centre with an OR of 1.011 per mile.

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial

ObjectiveTo determine whether a behavioral intervention delivered through a video game can improve the appropriateness of trauma triage decisions in the emergency department of non-trauma centers.DesignRandomized clinical trial.SettingOnline intervention in...

Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury

ObjectiveAmong injured patients transferred from one emergency department (ED) to another, we determined factors associated with being discharged from the second ED without procedures, or admission or observation. MethodsWe analyzed all patients with injury diagnosis codes transferred between two EDs in the 2011 Healthcare Utilization Project State Emergency Department and State Inpatient Databases for 6 states. Multivariable hierarchical logistic regression evaluated the association between patient (demographics and clinical characteristics) and hospital factors, and discharge from the second ED without coded procedures. ResultsIn 2011, there were a total of 48,160 ED-to-ED injury transfers, half of which (49%) were transferred to non-trauma centers, including 23% with major trauma. A total of 22,011 transfers went to a higher level of care, of which 36% were discharged from the ED without procedures. Relative to torso injuries, discharge without procedures was more likely for patients with soft tissue (OR 6.8, 95%CI 5.6–8.2), head (OR 3.7, 95%CI 3.1–4.6), facial (OR 3.8, 95%CI 3.1–4.7), or hand (OR 3.1, 95%CI 2.6–3.8) injuries. Other factors included Medicaid (OR 1.3, 95%CI 1.2–1.5) or uninsured (OR 1.3, 95%CI 1.2–1.5) status. Treatment at the receiving ED added an additional $2859 on average (95% CI $2750–$2968) per discharged patient to the total charges for injury care, not including the costs of ambulance transport between facilities. ConclusionOver a third of patients transferred to another ED for traumatic injury are discharged from the second ED without admission, observation, or procedures. Telemedicine consultation with sub-specialists might reduce some of these transfers.

Triage of Injured Patients in New York State Prior to Implementation of the American College of Surgeons Committee on Trauma Verification System

Trauma center (TC) care reduces mortality for injured patients, but non-trauma centers (NTCs) treat more than a third of severely injured patients. In 2012, New York State (NYS) adopted the American College of Surgeons Committee on Trauma (ACS-COT) system of TC verification. We hypothesized that before this change, NYS had a lower undertriage rate than states already using the ACS-COT system. We identified all NYS residents presenting for injury in 2011 using the State Emergency Department and Inpatient Databases. We used injury severity score (ISS) ≥ 15 to indicate those likely to benefit from TC care. Multivariable logistic regression to identified predictors of TC presentation. We used coarsened exact matching (CEM) to compare NYS to New Jersey (NJ) and Massachusetts (MA), which had ACS-COT verified TCs. Of 14,788 patients with ISS > 15, 59.5 presented to a TC (57.3% for ISS 16-24 and 77.0% for ISS ≥25). In multivariable logistic regression, each mile of increased distance to a TC was associated with 3% lower odds of TC presentation. Older age, female sex, and residence in a low-income area were associated with undertriage. Chest injuries had the highest odds of TC presentation (odds ratio [OR] 3.7, 95% CI 3.0-4.5), while falls had the lowest (OR 0.4, 95% CI 0.3-0.4). After CEM, odds of TC presentation in NYS were equivalent to NJ and MA. Prior to adoption of ACS-COT system, 2 in 5 severely injured NYS patients were treated at NTCs, equivalent to comparison states. Ongoing system improvement should balance rigorous TC designation standards, maximizing patient access, and optimizing triage.

Association Between Insurance and Transfer of Injured Children From Emergency Departments.

To determine if injured children presenting to nondesignated trauma centers are more or less likely to be transferred relative to being admitted based on insurance status. We conducted a cross-sectional study by using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Pediatric trauma patients receiving care in emergency departments (EDs) at nontrauma centers who were either admitted locally or transferred to another hospital were included. We performed logistic regression analysis adjusting for injury severity and other confounders and incorporated nationally representative weights to determine the association between insurance and transfer or admission. Nine thousand four hundred and sixty-one ED pediatric trauma events at 386 nontrauma centers met inclusion criteria. EDs that treated a higher proportion of patients with Medicaid had higher odds of transfer relative to admission (odds ratio [OR]: 1.2 per 10% increase in Medicaid; 95% confidence interval [CI]: 1.1-1.4), resulting in overall higher odds of transfer among patients with Medicaid compared with patients with private insurance (OR: 1.3; 95% CI: 1.0-1.5). A patient's insurance status was not associated with different odds of transfer relative to admission within individual EDs after adjusting for the ED's proportion of patients with Medicaid (Medicaid OR: 1.0; 95% CI: 0.8-1.1). Injured pediatric patients presenting to nondesignated trauma centers are slightly more likely to be transferred than admitted when the ED treats a higher proportion of Medicaid patients. In this study, ongoing concerns about inequities in the delivery of care among hospitals treating high proportions of children with Medicaid are reinforced.

343EMF Primary Triage Patterns of Seriously Injured Children in California (2005-2013)

Trauma centers (TC) are demonstrated to save lives. However, TC and especially pediatric trauma centers (pTC) are scarce and concentrated in urban areas. A population-level understanding of where injured children are initially cared for (primary triage) is incomplete. We determine patient and regional factors associated with primary triage location. Retrospective cohort study of California Office of Statewide Health Planning and Development (OSHPD) linked emergency department and inpatient discharge data (2005-2013). California residents 0-17 years admitted with serious trauma diagnoses (injury severity score (ISS) >9) were included. Hospitals were categorized as: pTC, adult level I/II TC (aTC), level III/IV TC, pediatric non-trauma center (pediatric nTC), and adult non-TC (nTC). Using multivariable, multivariate logistic regression, we calculated predicted probabilities of primary triage to pTC, aTC and nTC, evaluating age, sex, race/ethnicity, payer, ISS, injury mechanism, intention, type, zip-code level poverty, urban/rural status, and presence of a TC in county of residence. During the study period, 25,312 children were admitted for serious injury. Primary triage to a pTC, aTC, level III/IV, pediatric nTC, and nTC occurred 37%, 36%, 2% 3%, and 22% of the time respectively. The median age of children triaged to a pTC, aTC, level III/IV, pediatric nTC, and nTC was 9 (IQR 3-14), 15 (11-17), 14 (7-16), 4 (0-12), and 13 (5-16) years. The median ISS of children in all hospital types was 16 (IQR 11-17). Half of children <14 years were triaged to pTC compared to aTC and nTC (52% vs. 22%, 26%). Conversely, half of children 14-17 were triaged to aTC compared to pTC or nTC (54%, vs. 20%, 26%). Children with public insurance were twice as likely to be triaged to pTC and aTC compared to nTC (40%, 38% vs. 22%); those with private non-HMO insurance were approximately 10% more likely to be triaged to pTC and aTC compared to nTC (36% and 37% vs. 27%); those with private HMO insurance were less likely to be triaged to pTC and aTC compared to nTC, (19%, 27% vs. 55%). Children in motor vehicle collisions (MVC) were twice as likely to be triaged to pTC and aTC compared to nTC (39%, 44% vs. 17%). Children with assault were more likely to be triaged to pTC and aTC compared to nTC (33%, 40% vs. 27%). Children living in counties with a TC were more likely to be triaged to pTC than aTC and nTC (61% vs. 19%, 20%). Children from micropolitan areas were more likely to be triaged to pTC compared to aTC and nTC (51% vs. 12%, 37%), and those with zip-code median household income below 200% FPL were 10% more likely to be triaged to a pTC and aTC compared to nTC (36%, 37% vs. 27%). Our population perspective of primary triage location for California children with serious injuries demonstrates that triage location is associated with age, payer, mechanism of injury, and intent. Regional variables demonstrate that children in rural areas are regionalized to pediatric trauma care.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Adequacy and accuracy of nontrauma center computed tomography: What are we missing?

Timely and appropriate use of computed tomography (CT) scans is critical to the evaluation of traumatic injuries. The objective of this study was to assess the adequacy of CT scans performed at nontrauma centers (NTCs) as they pertain to the management of trauma patients. Adult patients transferred to our ACS-verified Level I trauma center from any NTC between May and December 2012 were enrolled prospectively. Available CT images from NTCs were reviewed in a blinded fashion by our facility's trauma radiologist; his interpretations were compared with those from the NTC. Interpretations of the trauma centers (TCs) images were compared with the NTC interpretations. Means and proportions were used to summarize the data. A total of 235 consecutive patients with a complete dataset were included, of which, 203 (86.4%) had a CT scan performed at an NTC. Additional imaging was obtained at the TC in 76% of patients with outside CT (154 of 203), with inadequacy of outside CTs for patient workup based on mechanism of injury (76%) and technical inadequacy of outside images (31%) being the main, nonexclusive reasons to repeat imaging. Image interpretation by the trauma radiologist at the TC using NTC images identified missed injuries in 49% of the patients, and 90% of these missed injuries were deemed clinically significant, meaning the injury would have altered patient care had they been identified. When the same body region was imaged at the TC, 54% had missed injuries, of which 76% were deemed significant. This study demonstrates inaccuracy in the interpretation of NTC images, which can lead to inappropriate management of trauma patients. Parameters other than imaging need to be used to identify patients requiring a higher level of care. Therapeutic and care management study, level V.

A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.

Pediatric trauma undertriage in Ohio.

Appropriate and timely triage is an essential component of a trauma system. In the state of Ohio, there are 6 verified pediatric trauma centers (PTCs) across 8 state regions. The purpose of this study was to better understand the pediatric undertriage rates in the state. We used the Ohio Trauma Registry from 2007 to 2012, consisting of 14,045 records of children younger than 16 years admitted to a hospital for more than 48 hours or who sustained a traumatic death. Pediatric undertriage was defined as not being directly transported to a PTC when one was available within 30 minutes or not being transferred to a PTC within 2 hours of injury. The state pediatric undertriage rate was 52%, only decreasing to 35% when up to a 4-hour transfer time was allowed. Across state trauma regions, undertriage rates varied from 94% to 40%. More than 28% of injured children had access to a PTC within 30 minutes of their home. A trauma center (adult or pediatric) was within 30 minutes for 66% of the children, yet 32% of the children went to a nontrauma center first. Overall, 29% of children never made it to a PTC, and 4% of children remained at a nontrauma center, with regional variation from 5% to 0.5%. Statewide mortality was nearly 3%, with regional variations between 5% and 0.4%. Mortality rate within the appropriately triaged group was 5.3%, while mortality rate in the undertriage group was only 0.7%. Overall, 53% of transferred patients had a more than 2-hour transfer time. Despite the significant number of PTCs in Ohio, there remains a high undertriage rate with significant regional variations and long transfer times. Continued analysis will be useful in furthering trauma system development for the injured child. Therapeutic/care management study, level IV; epidemiological, level IV.

The American College of Surgeons Needs-Based Assessment of Trauma Systems: Estimates for the State of California.

In 2015, the American College of Surgeons Committee on Trauma convened a consensus conference to develop the Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining the number of trauma centers required for a region. We tested the performance of NBATS with respect to the optimal number of trauma centers needed by region in California. Trauma center data were obtained from the California Emergency Services Authority Information Systems (CEMSIS). Numbers of admitted trauma patients (ISS > 15) were obtained using statewide nonpublic admissions data from the California Office of Statewide Health Planning and Development (OSHPD), CEMSIS, and data from local emergency medical service agency (LEMSA) directors who agreed to participate in a telephone survey. Population estimates per county for 2014 were obtained from the U.S. Census. NBATS criteria used included population, transport time, community support, and number of discharges for severely injured patients (ISS > 15) at nontrauma centers and trauma centers. Estimates for the number of trauma centers per region were created for each of the three data sources and compared to the number of existing centers. A total of 62 state-designated trauma centers were identified for California: 13 (21%) Level I, 36 (58%) Level II, and 13 (11%) Level III. NBATS estimates for the total number of trauma centers in California were 27% to 47% lower compared to the number of trauma centers in existence, but this varied based on urban/rural status. NBATS estimates were lower than the current state in 70% of urban areas but were higher in almost 90% of rural areas. All data sources (OSHPD, CEMSIS, local data) produced similar results. Estimates from the NBATS tool are different from what is currently in existence in California, and differences exist based on whether the region is rural or urban. Findings from the current study can help inform future iterations of the NBATS tool. Economic, level V.

Estimate of mortality reduction with implementation of advanced automatic collision notification

ABSTRACTObjective: Advanced Automatic Collision Notification (AACN) is a system on a motor vehicle that notifies a public safety answering point (PSAP), either directly or through a third party, that the vehicle has had a crash. AACN systems enable earlier notification of a motor vehicle crash and provide an injury prediction that can help dispatchers and first responders make better decisions about how and where to transport the patient, thus getting the patient to definitive care sooner. The purposes of the current research are to identify the target population that could benefit from AACN, and to develop a reasonable estimate range of potential lives saved with implementation of AACN within the vehicle fleet.Methods: Data from the Fatality Analysis Reporting System (FARS) years 2009–2015 and National Automotive Sampling System–Crashworthiness Data System (NASS-CDS) years 2000–2015 were obtained. FARS data were used to determine absolute estimates of the target population who may receive benefit from AACN. These estimates accounted for a number of factors, such as whether a fatal occupant had nearby access to a trauma center and also was correctly identified by the injury severity prediction algorithm as having a “high probability of severe injury.” NASS-CDS data were used to provide relative comparisons among subsets of the population. Specifically, relative survival rate ratios between occupants treated at trauma centers versus at non-trauma centers were determined using the nonparametric Kaplan–Meier estimator. Finally, the fatality reduction rate associated with trauma center care was combined with the previously published fatality reduction rate for faster notification time to develop a range for possible lives saved.Results: Two relevant target populations were identified. A larger subset of 6893 fatalities can benefit only from earlier notification associated with AACN. A smaller subgroup of between 1495 and 2330 fatalities can benefit from both earlier notification and change in treatment destination (i.e., non-trauma center to trauma center). A Kaplan–Meier life curve and a multiple proportional hazard model were used to predict the benefits associated with transport to a trauma center. The resulting range for potential lives saved annually was 360 to 721.Conclusions: This analysis provides the estimates of lives that could potentially be saved with full implementation of AACN and universal cell coverage availability. This represents a fatality reduction of approximately 1.6% to 3.3% per year, and more than double the lives saved by earlier notification alone. In conclusion, AACN is a postcrash technology with a promising potential for safety benefit. AACN is therefore a key component of integrated safety systems that aim to protect occupants across the entire crash spectrum.