Tag Archives: trauma center

Solid organ

Does Trauma Center Level Make A Difference In Treating Solid Organ Injury?

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In the last two posts, I reviewed contrast anomalies in solid organs, specifically the spleen. Today, I’ll be more general and examine a recent paper that compared management and outcomes after the other major solid organ injury, liver, at Level I vs Level II trauma centers.

There are several papers that have detailed overall differences in outcomes, and specifically mortality, at Level I and II centers. Some of these show outcomes that are not quite as good at Level II centers when compared to Level I. On paper, it looks like these two levels should be very similar. Take away research and residents, and maybe a few of the more esoteric capabilities like reimplantation, and aren’t they about the same?

Well, not really. They can be, though. Level I criteria are fairly strict, and the variability between difference Level I centers is not very great. Level II criteria are a bit looser, and this allows more variability. Many Level II centers function very much like a Level I, but a few are only a bit higher functioning than a Level III with a few extra surgical specialists added in.

A paper currently in press used the Michigan Trauma Quality Improvement Program (MTQIP) data from all 29 ACS verified Level I and II centers in the state (wow!). Six years of information was collected, including the usual demographics, outcome data, and management. A total of 538 patients met inclusion criteria, and this was narrowed down to 454 so statistical comparisons of similar patients could be made for Level I vs Level II centers.

Here are the factoids:

  • Mortality was significantly higher in Level II centers compared to Level I (15% vs 9%) and patients were more likely to die in the first two days, suggesting hemorrhage as the cause
  • Patients were more likely to die in the ED at Level II centers, despite a significantly lower Injury Severity Score (ISS)
  • Pneumonia and ARDS were significantly more likely to develop in Level II center patients
  • Level II centers used angiography less often and took patients to the OR more frequently
  • Level II centers admitted fewer patients to the ICU, but ICU admission was associated with significantly decreased mortality
  • Complications were fewer at Level II centers, but they were less likely to rescue patients when they occurred

Bottom line: Level I and II centers are supposed to be roughly the same, at least on paper. But a number of studies have suggested that there are more disparities than we think. Although this paper is a retrospective review, the sheer number of significant differences and its focus on one particular injury makes it more compelling.

So what to do? Tighten up the ACS Orange Book criteria? That’s a slow and deliberate process that won’t help our patients now. The quickest and most effective solution is for all centers to adopt uniform practice guidelines so they all perform like the highly successful Level I programs in the study. There are plenty of them around. If you are not yet using one, I urge you to have a look at the example below. Tweak it to fit your center. And use your PI program to trend the outcomes!

Related post:

Reference: Variability in Management of Blunt Liver Trauma and Contribution of Level of ACS-COT Verification Status on Mortality. J Trauma, in press, Dec 1, 2017.

Prehospital

EMS: Scoop and Run or Stay and Play for Trauma Care? Part 1

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Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures and begin resuscitation, or do I perform the minimum I can and get to the nearest hospital ASAP?

Some newer papers have addressed this debate very recently with some intriguing results, but I wanted to start out with one that I’ve discussed before.

For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?

Here are the factoids:

  • Admissions to a group of 8 trauma centers were analyzed over a 3 year period, and included a total of 1112 patients
  • A total of 76% were taken directly to a Level I trauma center (scoop and run, 76%); 24% were transferred to the trauma center from another hospital (stay and play?).
  • Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!

Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.

Bottom line: This is an interesting paper, but it’s kind of a mutant. When I think about the stay and play concent, I’m really thinking about delays going to a trauma center, not a non-trauma hospital fierst! And the authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?

Obviously, a lot of work needs to be done to add detail to this particular paper. Tomorrow, I’ll look at this concept as it applies to patients with penetrating injury.

Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.

General

What Happens When A New Trauma Center Opens In Your Back Yard?

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For trauma centers, it’s a zero sum game. The number of trauma patients in a given geographic location is fixed. (Actually, it goes up slowly over time as the population increases). So if a new center opens, those patients are redistributed. The new center gets more patients because they are now “designated.” And the existing centers get fewer because there are not as many patients left.

This is a phenomenon that is growing more widespread as more lower level trauma centers come online. Areas like Phoenix, Denver, and parts of Florida are particularly hard hit. Established Level I and II centers are complaining because their volumes are down, which can cause a hit to the financial bottom line.

Seems to make sense. But is it true? A time series analysis was carried out using Pennsylvania trauma system data to gauge the impact of opening new Level II and III centers on an existing Level I center. Ten years of data were gathered, looking at volume and mortality changes during the following sequence of designations:

  • A new Level II opens 70 months into the study period
  • A new Level III opens at 95 months, then closed 11 months later
  • A new Level II and Level III open at 107 months

Here are the factoids, from the perspective of the Level I center:

  • Volume at the Level I center grew slowly over the 70 months that no new trauma centers were operating
  • Volume dropped 10% when the first Level II opened, and 13% when the Level II and III opened simultaneously
  • There was no change when the temporarily accredited Level III opened
  • Overall, the Level I center treated 1,903 fewer patients than expected after the other centers opened, an overall decrease of 10% 
  • Average injury severity and revised trauma score remained the same at the Level I, but mortality decreased (!)

Bottom line: More trauma centers generally equals fewer patients for existing ones. Unfortunately, the decision to become a trauma center these days, especially levels II and III, tends to be based on business factors. The American College of Surgeons Committee on Trauma (ACSCOT) released a position statement early this year regarding the designation of multiple trauma centers in a geographic location. They basically have left it up to the individual states or trauma systems to optimize placement or limit numbers. They also emphasize that the numbers need to support best patient care, not necessarily best business strategy. Unfortunately, politics will not let this happen. I believe that the tightening of verification requirements for centers that are verified by the ACSCOT (as in the new Orange book criteria) will serve to shake out the centers that barely meet them. But only time will tell.

Reference: 

General

Do We Need All Those Trauma Centers In The US?

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There are a lot of trauma centers in the US. Unfortunately, they are not very evenly distributed. An example of this disparity can be found in Washington state. Harborview Medical Center is the only Level I trauma center serving all of Washington, Alaska, Montana, and Idaho. Yet in other metropolitan areas, there can be multiple Level I’s, II’s, and III’s. And in some other areas, new centers seem to be popping up right and left.

Unfortunately, there is such a thing as too many trauma centers. Opening a new center is a zero sum game, however. No more trauma patients will miraculously appear. They will only get redistributed from other centers, decreasing the number of their trauma admissions. Until the next one opens and begins to take patients away from the last new one, as well. Frequently, the “need” for the new center is strictly an economic one for its parent organization, not an actual population need.

The American College of Surgeons Committee on Trauma (ACSCOT) released a position statement on this phenomenon early this year. They promote the following guidelines:

  • Designation responsibility falls to the governmental agency that oversees the regional trauma system. This body needs leadership and statutory authority to enforce reasonable guidelines on how many centers may exist.
  • Trauma professionals must advocate for their patients in educating the lead agency about what the needs really are. The interests of the patients must supersede the interests of the providers and their health care organizations.
  • The designation process should be guided by a concrete regional trauma plan.
  • Needs should be assessed using concrete measures like the number of centers per 100,000 people, population location with respect to these centers, EMS transport times, trauma mortality, and frequency of diversion status.
  • Trauma center allocation should be reassessed on a regular basis.
  • Regional variability must be taken into account.

Bottom line: A super-abundance of trauma centers already exists in several cities around the US (and you know who you are). Unfortunately, the cat is out of the bag, and few if any designating agencies have stepped up to the plate to deal with this. The sad truth is that little will happen until hastily and poorly resourced centers start to close unexpectedly, straining established trauma centers and jeopardizing patient safety. When this crisis finally hits, our state and regional trauma systems will finally seek and wield the authority to designate more intelligently.

Reference: Statement on trauma center designation based upon system need. ACSCOT January 2015.

General

Scoop and Run or Stay and Play for Trauma Care?

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Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures, or do I perform the minimum I can and get to the nearest hospital?

For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?

Admissions to a group of 8 trauma centers were analyzed over a 3 year period. A total of 1112 patients were studied. Patients were divided into two groups: those who were taken directly to a Level I trauma center (76%), and those who were transferred from another hospital (24%). 

Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!

Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.

Bottom line: this is an interesting paper, but there are a number of flaws that prevent us from mandating that all trauma patients should go directly to the trauma center. The authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?

A lot of work needs to be done to add detail to this work. In the meantime, we have to trust our experienced prehospital providers to determine who really needs to go to the closest appropriate center, and what that really is.

Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.