State-designated Trauma Centers Research Articles

Getting patients to the right level of trauma center after motorcycle crashes in a rural trauma system

PurposeAfter a motorcycle crash (MCC), emergency medical services (EMS) responders must balance trauma center proximity with clinical needs of patients, which is especially challenging in rural states. The study purpose was to determine if MCC patients treated at lower-level trauma centers (LLTC) experienced higher mortality when compared to patients transported directly to the highest level of trauma care available in the state at Level II trauma centers. ProceduresA retrospective study was conducted on MCC patients transported by EMS to Montana hospitals and met registry inclusion criteria in 2020–2021. The first study group included patients initially transported to state-designated trauma centers (equivalent to Level III-V) or non-designated hospitals (LLTC), and the second group included patients transported directly to American College of Surgeon verified Level II trauma centers (L2TC). Secondary transfer was defined as initial transport to a LLTC and subsequent transfer to a L2TC. Primary study outcome was mortality at the L2TC. Chi-square tests and Wilcoxon rank sum tests were used for analysis. FindingsIn the study period, 337 MCC patients were transported by EMS; 186 (55%) patients were transported to a LLTC while 151 patients (45%) were transported to a L2TC. There were no statistically significant differences in mortality (12% vs 8%, p = 0.30) when comparing secondary transfer patients to patients transported directly to a L2TC. ConclusionsNearly half of patients initially evaluated at a LLTC required transfer to a higher-level of care. Secondary transfer was not associated with increased mortality.

Nationwide analysis of proximity of American College of Surgeons–verified and state-designated trauma centers to the nearest highway exit and associated prehospital motor vehicle collision fatalities

BackgroundMotor vehicle collisions remain a leading cause of trauma-related deaths. We aim to investigate the relationship between the proximity of trauma centers to the nearest highway exit and prehospital motor vehicle collision fatalities at the county level nationwide. MethodsThis was a cross-sectional study evaluating the association between the distance of trauma centers to the nearest highway exit and prehospital motor vehicle collision fatalities between the years 2014 and 2019. Prehospital motor vehicle collision fatalities were obtained from National Highway Traffic Safety Administration. Mapping software was used to determine the distance of trauma center to the nearest highway exit and transport time. Linear regression analysis was performed. ResultsA total of 2,019 American College of Surgeons–verified and/or state-designated trauma centers were included (211 Level 1, 356 Level 2, 491 Level 3, and 961 Level 4 trauma centers). Prehospital motor vehicle collision fatalities were positively correlated with the distance of trauma center to the nearest highway exit for counties with trauma centers located ≤5 miles from the nearest highway exit (r = 0.328; P < .001). In the 612 counties with a 10% increase in prehospital motor vehicle collision fatalities from 2014 to 2019, prehospital motor vehicle collision fatalities were also positively correlated with distance to the nearest highway exit (r = 0.302; P < .001). The counties with more dispersed distributions of trauma centers were significantly associated with motor vehicle collision fatalities (Spearman’s rank coefficient = 0.456; 95% confidence interval, 0.163–0.675; P = .003). ConclusionShorter distances between trauma centers and the nearest highway exit are associated with fewer prehospital motor vehicle collision fatalities for counties with trauma centers ≤5 miles of the nearest highway exit. Further enhancement of existing highway infrastructure and standardization of emergency medical services transport protocols are needed to address the burden of prehospital motor vehicle collision fatalities in the United States.

Trauma patient transport times unchanged despite trauma center proliferation: A 10-year review.

In certain regions of the United States, there has been a dramatic proliferation of trauma centers. The goal of our study was to evaluate transport times during this period of trauma center proliferation. Aggregated data summarizing level I trauma center admissions in Arizona between 2009 and 2018 were provided to our institution by the Arizona Department of Health Services. We evaluated patient demographics, transport times, and injury severity for both rural and urban injuries. Data included statistics summarizing 266,605 level I trauma admissions in the state of Arizona. The number of state-designated trauma centers during this time increased from 14 to 47, with level I centers increasing from 8 to 13. Slight decreases in mean Injury Severity Score (rural, 9.4 vs. 8.4; urban, 7.9 vs. 7.0) were observed over this period. Median transport time for cases transported from the injury scene directly to a level I center remained stable in urban areas at 0.9 hours in both 2009 and 2018. In rural areas, transport times for these cases were approximately double but also stable, with median times of 1.8 and 1.9 hours. Transport times for cases requiring interfacility transfer before admission at a level I center increased by 0.3 hours for urban injuries (5.3-5.6 hours) and 0.9 hours for rural injuries (5.6-6.5 hours). Despite the threefold increase in the number of state-designated trauma centers, transport time has not decreased in urban or rural areas. This finding highlights the need for regulatory oversight regarding the number and geographic placement of state-designated trauma centers. Care management, level IV, Epidemiological, level III.

Differences in trauma mortality between ACS-verified and state-designated trauma centers in the US

BackgroundTraumatic injury is a leading cause of deaths worldwide, and designated trauma centers are crucial to preventing these. In the US, trauma centers can be designated as level I-IV by states and/or the American College of Surgeons (ACS), reflecting the resources available for care. We examined whether state- and ACS-verified facilities of the same level (I-IV) had differences in mortality, complications, and disposition, and whether differences varied by center level. Materials and methodsUsing all admissions reported to the National Trauma Data Bank 2010–2015, we estimated risk ratios for the association between current ACS verification (vs. state designation) and patient mortality and complications, adjusting for trauma level and facility, injury, and demographic characteristics. We tested the interaction between trauma level and ACS verification, stratifying by trauma level in the presence of significant statistical interaction. ResultsOverall, patients admitted to ACS-verified vs state-designated facilities had similar adjusted mortality risk [RR 1.00; 95% CI 0.91–1.03] and lower risk of discharge to intermediate care facilities [RR 0.58; 95% CI 0.44 to 0.78]. However, Level III and IV facilities had lower adjusted mortality risk when ACS-verified, with much lower mortality risk in ACS-verified Level IV facilities [RR 0.25; 95% CI 0.12 to 0.54]. DiscussionFindings suggest that while outcomes are similar between ACS-verified and state-designated Level I and II centers, state-designated Level III and particularly Level IV centers show poorer outcomes relative to their ACS-verified counterparts. Further research could explore mechanisms for these differences, or inform potential changes to state designation processes for lower-level centers.

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.

Geriatric outcomes for trauma patients in the state of Florida after the advent of a large trauma network.

Florida State has one of the largest geriatric populations in the United States. However, recent data show that up to the year 2010, geriatric trauma patients were least served by designated trauma centers (TCs). One existing TC and five provisional Level 2 TCs were combined to create a large-scale trauma network (TN). The new TCs were placed in those areas with the lowest ratios of TC to residents based on census data. The aim of this study was to measure the TN impact on the population of geriatric trauma patients. Data from the Florida State Agency for Health Care Administration were used to determine mortality, length of stay, and complication rates for geriatric trauma patients (≥ 65 years). The potential effect of the TN was measured by comparing outcomes before and after the initiation of the TN. A total of 165,640 geriatric patients were evaluated. Multivariate regression methods were used to match and adjust for age, injury status (penetrating vs. nonpenetrating), sex, race, comorbidity, and injury severity (DRG International Classification of Diseases-9th Rev. Injury Severity Score). Since the advent of the TN, an additional 1,711 geriatric patients were treated compared with the previous period. The TN was responsible 86% of these new patients. There was a temporal association with a decrease in both mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) and length of stay (p < 0.0001) for geriatric patients since the advent of the TN. The improved access was associated with a significant decrease in mortality in the regions serviced by the TN. Geriatric patients make up a significant proportion of trauma patients within the TN. The temporal improvement in outcomes may be associated with the increased proportion of patients being treated in state-designated TCs as a result of the addition of the TN. Epidemiologic study, level III.

Unintentional and Sexual Abuse-related Pediatric Female Genital Trauma: A Multiinstitutional Study of Free-standing Pediatric Hospitals in the United States

To evaluate a large national database of free-standing pediatric institutions to define the characteristics of patients who have both unintentional and sexual abuse-related pediatric female genital trauma (PFGT), to describe variation in practice across institutions and between trauma and nontrauma hospitals, and to determine factors associated with diagnostic evaluation and surgical repair of PGFT. We performed a retrospective cohort using the Pediatric Health Information System (PHIS) discharge database with information from 41 freestanding children's hospitals. We identified inpatient and emergency department visits for female patients younger than 18 years of age with International Classification of Diseases, Ninth Revision diagnosis codes for nonobstetric PFGT discharged in the 5-year period between January 1, 2003 and December 31, 2007. We identified 5664 patients with PFGT, with 64% having been evaluated in state-designated trauma centers. Although overall only 4.2% (236/5664) underwent a diagnostic evaluation, independent of age, mechanism of injury, associated injuries, and insurance status, patients evaluated in a trauma center were 2.6 times more likely to have a diagnostic evaluation. Patients who underwent a diagnostic evaluation were 18 times more likely to have a surgical repair. Other factors associated with increased odds of diagnostic evaluation included age group and specific mechanisms of injury. Among institutions in PHIS, diagnostic evaluation and surgical repair is rarely performed and is defined by variability in approach between hospitals--especially between trauma vs nontrauma institutions. This study of PFGT suggests that aggressive diagnostic evaluation in the operating room may be beneficial for this population.

Insurance Status, Not Race, Is a Determinant of Outcomes from Vehicular Injury

Hypothesizing that outcomes from specific injury mechanisms should not vary by race or socioeconomic status, we analyzed the relationship of race and ethnicity to fatality in motor vehicle crash victims treated during 2008 and 2009. Logistic regression analysis of pooled administrative data assessed the contribution of patient demographics and injury severity to outcome, defined as mortality during acute hospitalization. Demographic factors included age, sex, race, ethnicity, and insurance. Severe injury was defined using ICD-9 Injury Severity Score (survival probability) p < 0.85, presence of up to 3 comorbidities, and/or diagnosis of spinal cord injury and/or traumatic brain injury. Mortality was stratified by survival time after trauma center arrival to death within 24 hours or thereafter. Factors contributing to outcomes were tested using chi square analysis of the calculated model estimate. For 8,758 motor vehicle crash victims treated in state-designated trauma centers, age, sex, injury severity, and 2 or more comorbidities consistently predicted survival. Neither race nor ethnicity was associated with increased mortality risk. Being uninsured was related to death within 24 hours (p < 0.001). The majority of the uninsured who died within 24 hours had an ICD-9 Injury Severity Score p ≤ 0.5. Mortality risk after 24 hours was driven by traumatic brain injury and comorbidities. The results of this study indicated that higher immediate mortality of the uninsured is a behavioral and socioeconomic rather than physiologic marker. This higher mortality is driven by increased injury severity that increases cost of care in uninsured survivors. This disparity suggests that risk-taking behavior, especially relating to safety practices and licensing regulations, is an important etiologic factor. Improved outcomes require better public education and enforcement in conjunction with improvements in processes of care.

More Than Bike Helmets and Car Seats

More Than Bike Helmets and Car Seats

Florida's Trauma Surgeons: A Vanishing Breed

The delivery of trauma and emergency surgical care is in a state of crisis. We hypothesized that this looming crisis was already manifested in Florida. The trauma medical directors of the 20 state designated trauma centers were surveyed for information pertaining to number of available surgeons for trauma call, number of night calls/month, age of the current trauma surgeons, and the estimated number of years each surgeon planned to continue taking call. We also queried trauma medical directors about recruitment of additional trauma surgeons. Fourteen directors responded. Each program had at least four surgeons taking trauma call on average 5.3 nights/month. Sixty-three per cent of surgeons taking call were less than 50-years-old. Thirty surgeons (39.5%) planned to discontinue trauma call within 10 years, leaving 46 surgeons (60.5%) presently committed to longer than 10 years of call. Nine programs were actively recruiting. Five programs (50%) were recruiting for < 1 year, three programs (30%) were recruiting for 1 to 2 years, and two programs (20%) were recruiting > 2 years. Florida's trauma surgeons are a vanishing breed. Given the recruiting difficulties, the diminishing numbers of Florida's general surgeons will have to fill the gaps.

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers: A Retrospective Analysis: Chang DC, Bass RR, Cornwell EE, et al. Arch Surg 2008;143:8:776–81

This retrospective 10-year analysis from Maryland evaluated whether age bias was a factor in undertriage that was defined as a trauma patient not being transported to a state-designated trauma center. The authors defined trauma patients as those who met American College of Surgeons physiology, injury, or mechanism criteria and were designated a Level I priority status by Emergency Medical Service (EMS) personnel. A total of 26,565 trauma patients were identified from the Maryland Ambulance Information System database.

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers: The Authors’ Response

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers: The Authors’ Response

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers—Invited Critique

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers—Invited Critique

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers

To determine whether age bias is a factor in triage errors. Retrospective analysis of 10 years (1995-2004) of prospectively collected data in the statewide Maryland Ambulance Information System followed by surveys of emergency medical services (EMS) and trauma center personnel at regional EMS conferences and level I trauma centers, respectively. Trauma patients were defined as those who met American College of Surgeons physiology, injury, and/or mechanism criteria and were subjectively declared priority I status by EMS personnel. Undertriage, defined as when trauma patients were not transported to a state-designated trauma center. The registry analysis identified 26 565 trauma patients. The undertriage rate was significantly higher in patients aged 65 years or older than in younger patients (49.9% vs 17.8%, P < .001). On multivariate analysis, this decrease in trauma center transports was found to start at age 50 years (odds ratio, 0.67; 95% confidence interval, 0.57-0.77), with another decrease at age 70 years (odds ratio, 0.45; 95% confidence interval, 0.39-0.53) compared with patients younger than 50 years. A total of 166 respondents participated in the follow-up surveys and ranked the top 3 causal factors for this undertriage as inadequate training, unfamiliarity with protocol, and possible age bias. Even when trauma is recognized and acknowledged by EMS, providers are consistently less likely to consider transporting elderly patients to a trauma center. Unconscious age bias, in both EMS in the field and receiving trauma center personnel, was identified as a possible cause.

System care improves trauma outcome: Patient care errors dominate reduced preventable death rate

A review of 452 trauma deaths in Hillsborough County, Florida, in 1984 documented that 23% of non-CNS trauma deaths were preventable and occurred because of inadequate resuscitation or delay in proper surgical care. In late 1988 Hillsborough County organized a County Trauma Agency (HCTA) to coordinate trauma care among prehospital providers and state-designated trauma centers. The purpose of this study was to review county trauma deaths after the inception of the HCTA to determine the frequency of preventable deaths. Results: 504 trauma deaths occurring between October 1989 and April 1991 were reviewed. Through committee review, 10 deaths were deemed preventable; 2 occurred outside the trauma system. Of the 10 deaths, 5 preventable deaths occurred late in severely injured patients. Conclusion: The preventable death rate has decreased to 7.0% with system care. The causes of preventable deaths have changed from delayed or inadequate intervention to postoperative care errors.