Trauma Center In California Research Articles

Financial Vulnerability of American College of Surgeons-Verified Trauma Centers: A Statewide Analysis.

Although trauma centers represent an integral part of healthcare in the US, characterization of their financial vulnerability has not been reported. We sought to characterize the financial health and vulnerability among California trauma centers and identify factors associated with high and low vulnerability. The RAND Hospital Data financial dataset was used to evaluate all American College of Surgeons (ACS)-verified trauma centers in California. Financial vulnerability of each center was calculated using 6 metrics to calculate a composite Financial Vulnerability Score (FVS). Tertiles of the FVS were generated to classify trauma centers as high, medium, or low financial vulnerability. Hospital characteristics were also analyzed and compared. Forty-seven ACS trauma centers were identified. Nine were Level I, 27 were Level II, and 8 were Level III. Level I centers encompassed the greatest proportion of the high FVS tier (44%), whereas Level II and III centers were the most likely to be in the middle and lower tiers, respectively (44%; 63%). Lower FVS centers had greater asset:liability ratios, operating margins, and days cash on hand compared with the 2 higher tiers, whereas high FVS centers showed a greater proportion of uncompensated care, outpatient share rates, outpatient surgeries, and longer days in net accounts. Lower FVS centers were more likely to be teaching hospitals and members of a larger corporate entity. Many ACS trauma centers are at moderate/high risk for financial vulnerability and disparate impacts of stressor events, and the FVS may represent a novel metric that could be used at the local or statewide level.

Massive Transfusion Protocol Over-Activation

Abstract Introduction/Objective Massive blood transfusion protocol (MTP) is revealed in many cases, such as massive hemorrhage after surgeries, trauma settings, and labor and delivery. Patients who require blood transfusion of more than ten units of packed red blood cells in 24 hours or transfusion of more than four units of packed red blood cells (PRBCs) in one hour are the massive blood transfusion protocol candidates. Methods/Case Report A retrospective study was performed at a 225-bed level III trauma center in California. The overall massive blood transfusion protocol utilization, blood product emergency release, and blood product waste were recorded twelve months before and after launching an educational and collaboration program between blood banks and clinicians about the difference between massive transfusion protocol and blood emergency release. Results (if a Case Study enter NA) MTP utilization for the 12 months (June 2017 to June 2018) was demonstrated as 59 MTP activations: 32 MTPs from the emergency department, 4 MTPs from inpatient floors, 3 MTPs from labor and delivery, and 4 MTPs from operating rooms while the blood product emergency releases were 7 emergency releases. MTP utilization from (June 2018 to June 2019) was demonstrated as 15 MTP activations: 11 MTPs from the emergency department, 2 MTPs from inpatient floors, 1 MTPs from labor and delivery, and 1 MTPs from operating rooms, while the blood product emergency releases were 43 emergency releases. The blood product waste was reduced by 44.6% in 2018. Conclusion There was a significant reduction in MTP activation and blood product waste after implementing the educational program for the clinicians. The collaboration between the blood bank and the clinicians and coordinating educational sessions for clinicians about the difference between MTP and emergency release and the negative impact of the MTP over-activation on the blood product waste and the clinical laboratory scientists in the blood bank is vital in MTP utilization.

COVID-19 in trauma: a propensity-matched analysis of COVID and non-COVID trauma patients

PurposeThere is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients.MethodsA retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019–6/30/2019 and 1/1/2020–6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups.ResultsA total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients.ConclusionThis multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients.

Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients.

Geriatric hip fracture patients are susceptible to the adverse effects of opioid-induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). This is a prospective observational study. A level 1 trauma center in California. From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. All prospectively enrolled patients were given FIBs. For a single-shot FIB, a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0-44.5) versus 29.5 (interquartile range = 6.0-56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0-24.0) versus 29.0 (interquartile range = 12.0-59.0) (P < .001). FIBs reduce preoperative opioid intake and have low rates of opioid-related adverse events in geriatric hip fracture patients. The level of evidence was II.

Catastrophic expenditures in California trauma patients after the Affordable Care Act: reduced financial risk and racial disparities

BackgroundHospital charges due to major injury can result in high out-of-pocket expenses for patients. We analyzed the effect of the Affordable Care Act (ACA) on catastrophic health expenditures (CHE) among trauma patients. MethodsWe identified trauma patients aged 19-64 admitted to a safety-net Level 1 trauma center in California from 2007 to 2017. Out-of-pocket expenditures and income were calculated using hospital charges, insurance status, and ZIP code. CHE was defined using the World Health Organization definition of out-of-pocket spending exceeding 40% of inflation-adjusted income minus food and housing expenditures. Multivariable logistic regression was performed to assess odds of CHE post-ACA (2014–2017) vs. pre-ACA (2007–2013). ResultsOf 7519 trauma patients, 20.6% experienced CHE, including 89.0% of uninsured patients. There was a 74% decrease in odds of CHE post-ACA (aOR: 0.26, 95% CI: 0.22–0.30), with greater decreases among Black (aOR: 0.09, 95% CI: 0.04–0.18) and Hispanic (aOR: 0.23, 95% CI: 0.19–0.29) patients. ConclusionsACA implementation was associated with markedly decreased odds of catastrophic expenditures and decreased racial disparities in financial protection among trauma patients in our study.

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.

Cervical spine clearance protocols in Level I, II, and III trauma centers in California

Background contextCervical spine clearance protocols were developed to standardize the clearance of the cervical spine after blunt trauma and prevent secondary neurologic injuries. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in California is unknown. PurposeTo evaluate the cervical spine clearance protocols in all trauma centers of California. Study designAn observational cross-sectional study. Patient sampleIncluded from Level I, II, III trauma centers in California. Outcome measuresThe self-reported outcomes of each trauma center's cervical spine clearance protocols were assessed. MethodsLevel I (n=15), II (n=30), and III (n=11) trauma centers in California were contacted. Each available protocol was reviewed for four scenarios: clearing the asymptomatic patient, the initial imaging modality used in patients not amenable to clinical clearance, and the management strategies for patients with persistent neck pain with a negative computed tomography (CT) scan and those who are obtunded. Results were compared with the 2009 Eastern Association for the Surgery of Trauma (EAST) cervical spine clearance guidelines. ResultsThe response rate was 96%. Sixty-three percent of California's trauma centers (Level I, 93%; Level II, 60%; Level III, 27%) had written cervical spine clearance protocols. For asymptomatic patients, 83% of Level I and 61% of Level II centers used National Emergency X-Radiography Utilization Study criteria with/without painless range of motion. For those requiring imaging, 67% of Level I and 56% of Level II centers stated a CT scan should be the first line of imaging. For obtunded patients and patients with persistent neck pain and a negative CT scan, more than 90% of Level I and more than 70% of Level II trauma centers incorporated the 2009 EAST recommendations. No institution recommended passive flexion-extension radiographs for the obtunded patient. ConclusionsWritten cervical spine clearance protocols exist in 63% of California's trauma centers and only 51% of the centers have protocols that follow current evidence-based guidelines. Standardization and utilization of these protocols should be encouraged to prevent missed injuries and secondary neurologic injuries.

Cervical Spine Clearance Protocols in Level I, II and III Trauma Centers in California

Cervical spine clearance protocols were developed to standardize the clearance of the cervical spine following blunt trauma and prevent secondary neurological injuries. The degree of incorporation of evidence-based guidelines into protocols at trauma centers in the California is unknown.

Isolated Free Fluid on Abdominal CT Imaging in Blunt Trauma: Operative Exploration or Observation?

To determine if operative exploration or observation is the preferred management for hemodynamically stable blunt trauma patients with isolated free fluid on abdominal computed tomography (CT) imaging, researchers reviewed the management and outcomes for 156 such patients admitted to a level 1 trauma center in California from 2009 to 2012. All patients were 16 …

The association of trauma center closures with increased inpatient mortality for injured patients.

Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed. We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure. The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51). Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure. Prognostic and epidemiologic, level III.

Plasma-Lyte Versus Normal Saline for Resuscitation of Trauma Patients

Use of Plasma-Lyte, a calcium-free crystalloid with an electrolyte profile similar to blood, for the resuscitation of trauma patients has not previously been studied. At a level I trauma center in California, researchers randomized 46 severely injured trauma patients to resuscitation with normal saline or Plasma-Lyte for the initial 24 hours. Patients with life- or limb-threatening …

Readiness to Change and Reasons for Intended Reduction of Alcohol Consumption in Emergency Department versus Trauma Population

IntroductionThe primary objective was to identify the most common reasons for intending to cut back on alcohol use, in emergency department (ED) and trauma patient populations. The secondary objective was to determine the association between reason to cut back on alcohol and education level.MethodsWe conducted the study at a level one trauma center in California between 2008 and 2012. This was a retrospective analysis of data collected from computerized alcohol screening and intervention (CASI). We excluded patients who drank too little, and those whose scores were consistent with dependency (Alcohol Use Disorders Identification Test [AUDIT]>19). The CASI database includes the patient’s age, gender, language, education level, an AUDIT score (1–40 scale), a readiness to change score (1–10), and the option to choose any of 10 “reasons to cut back” on their alcohol consumption.ResultsFrom 10,537 patients, 1,202 met criteria for the study (848 ED, 354 trauma). Overall, the most common reasons cited for cutting back on alcohol were “To avoid health problems” (68.5%), “To avoid getting a DUI” (43.6%), “It could save me money” (42.0%), and “To avoid situations where I could get hurt” (41.0%). Trauma patients cited the following reasons significantly more than ED patients: “To avoid situations where I could get hurt” (46.3% versus 38.8%, respectively), “So I can be in control of my behavior” (40.7% versus 32.2%), and “My partner or spouse wants me to stop” (20.1% versus 15.0%). Additionally, those patients who cited “To avoid health problems” reported 1.2 points higher than average (p<0.001) on the 10-point readiness to change scale. Those who have completed some college or an associate degree cited “To avoid health problems” less often than high school graduates (odds ratio [OR] 0.45), while they cited “To avoid situations where I could get hurt” (OR 2.5) and “To avoid being in a car crash caused by alcohol use” (OR 3.8) more often than high school graduates.ConclusionHealth, injury, finances, and legal issues remain top concerns for patients, while trauma patients specifically had proportionately more concerns with situations where they could get hurt.

The impact of combined use of fall-risk medications and antithrombotics on injury severity and intracranial hemorrhage among older trauma patients

PurposeUse of fall-risk medications (medications that increase risk of falling in the elderly as defined by Beers criteria, STOPP/START criteria, and other literature) or antithrombotics is common in the elderly, and the impact of their concomitant use should be assessed in regards to fall injuries. The primary objective of this study is to assess the simultaneous outpatient use of fall-risk medications and antithrombotics in elderly fall-patients, and secondarily to analyze the injury severity score and occurrence of intracranial hemorrhage. MethodsConsecutive chart review at a level 2 trauma center in California, USA from August 01, 2009 to October 31, 2010. Records included 112 patients at least 65 years of age admitted with an outpatient fall. Fisher's exact and Student's t-tests were used (alpha 0.05, two-tailed) to examine prescribing patterns, intracranial hemorrhage occurrence, and injury severity score. Regression adjusted for antithrombotic and fall-risk medication type and number, opiate use, co-morbidities, age, and gender. ResultsThirty-nine percent (44/112) of outpatients were prescribed antithrombotics plus fall-risk medications. The mean injury severity score (ISS) was 13.3 (range 1–26, standard deviation 7.2) for patients taking both medication classes versus 9.7 (range 1–25, standard deviation 7.5) for patients taking antithrombotics alone (p = 0.027). Additionally, in patients over 80 years of age, intracranial hemorrhage occurred more frequently with the use of antithrombotics plus fall-risk medications versus antithrombotics alone (18/29 = 62.1% versus 7/24 = 29.2%, p = 0.027, odds ratio = 3.974, 95% confidence interval = 1.094–15.010). Multivariate analyses showed an independent relationship between intracranial hemorrhage occurrence and type of therapy, as well as injury severity score and simultaneous therapy with fall-risk medications and antithrombotics. ConclusionSimultaneous prescribing of antithrombotics and fall-risk medications is common. For outpatients over 80 years of age, the odds of experiencing a post-fall intracranial hemorrhage are 4 times higher when prescribed antithrombotics plus fall-risk medications compared to antithrombotics alone, and injury severity is higher with combined use of these medication classes.

A Population-Wide Study of Pediatric Access to Trauma Centers in California, 2005-2011

A Population-Wide Study of Pediatric Access to Trauma Centers in California, 2005-2011

Cost of Treating Uninsured Jeopardizing Trauma Centers

Cost of Treating Uninsured Jeopardizing Trauma Centers