All posts by TheTraumaPro

Best of AAST #3: Level I vs Level II Trauma Centers

There is an ongoing debate over the differences between Level I vs Level II trauma centers in the US. On paper, the major differences include resident rotations in trauma, research, and the available of certain specialty surgeons and services. There have been several papers that look at survival differences between the two levels.

One podium paper at AAST 2018 re-examines this debate. It is a medium-sized pooled series that looks at a particular type of injury, pelvic ring fractures. These injuries can be complex, and many times require specialized orthopedic expertise. ACS Level I centers are required to have at least one Orthopedic Trauma Association fellowship-trained surgeon among their orthopedists. This is not required for Level II centers, but many do have them.

The group at the University of Michigan examined patients with partially stable or unstable pelvic ring injuries in a trauma collaborative database including 29 Level I and Level II centers over a 7-year period. They used propensity matching to compare 610 patients admitted to Level I and 610 patients admitted to Level II centers with these injuries:

Here are the factoids:

  • Mortality was significantly increased at Level II centers ( 12%) vs Level I centers (8%)
  • Angiography was used significantly less at Level II centers (6% vs 11%)
  • Complex repairs were used significantly less frequently at Level II centers (32% vs 42%)
  • Patients were significantly less likely to be admitted to an ICU at Level II centers, and were more often admitted to stepdown units (45% vs 52%)
  • Failure to rescue rate was lower (better) in ICU patients

Bottom line: Obviously, there are some limitations to using this pooled data, but it does provide larger numbers than many similar papers have. It cannot distinguish Level II centers that have OTA-trained orthopedic surgeons from those that do not. But the results are rather striking. It’s not clear exactly which of the institutional differences might be responsible for the improved mortality, and they all probably contribute to some degree. But the abstract appears to show that Level II centers are not just non-academic Level Is. This work suggests that certain injury patterns really should be transferred to a center with the specialized resources to treat it well.

Best of AAST #2: Cervical Spine Clearance And Distracting Injuries

Debate has forever swirled around how to clear the cervical spine. Clear clinically? CT scan plus exam? CT only? Flexion/extension views? Distracting injury?

This last one has been problematic for a long time. What is a distracting injury? Is there a difference between lower extremity wounds vs upper chest/shoulder wounds from a distraction standpoint? Is it possible to clinically clear the cervical spine if one of these injuries exist?

Finally, a multi-institutional trial was performed that strives to answer this question. Seven Level I US trauma centers participated in this 3.5 year long study. All patients with GCS > 14 underwent a standard clinical exam regardless of whether a possible distracting injury was present. Then all underwent CT evaluation of the entire cervical spine.

Here are the factoids:

  • Distracting injuries were classified into three regions: head, torso, and extremities, but no further analysis was presented in the abstract
  • Nearly 3,000 patients were enrolled and 70% had a potential distracting injury
  • A total of 233 patients (8%) had a cervical spine injury identified by CT
  • 136 patients had a cervical injury AND distracting injury, and 14 were missed by clinical exam (10%)
  • 87 patients had a cervical injury BUT NO distracting injury, and 10 were missed by clinical exam (13%)
  • Only one injury missed by clinical exam required operation

Bottom line: This study shows the usual prevalence of cervical spine injury after blunt trauma, but adds some interesting information regarding distracting injury. Basically, clinical examination will miss about 1% of patients with a negative exam, regardless of distracting injury status. Therefore, the study suggests that clinical clearance should be attempted on all patients first, regardless of “distracting injury.”

Reference: Clearing the cervical spine for patients with distracting injuries: an AAST multi-institutional trial. Session I Paper 3, AAST 2018.

Best of AAST #1: The Price of Being a Trauma Center

The annual meeting of the American Association for the Surgery of Trauma (AAST) begins in two weeks. Today, I will kick off a series of commentaries on many of the abstracts being presented at the meeting. All readers should be aware that I have only the abstracts to work with. As I always caution, final judgement cannot be passed until the full paper has been reviewed. And many of these will not make the jump to light speed and ever get published. So take them with a grain of salt. They may point to some promising developments, but then, maybe not.

First up is a nice analysis on the price of being a trauma center. One of my mentors, Bill Schwab, always used to say that trauma centers are always in a state of “high-tech waiting.” It costs money to keep surgeons in house, other medical and surgical specialists at the ready, and an array of services and equipment available at all hours. Any hospital administrator can tell you that trauma is expensive. But how expensive, exactly?

The trauma group at the Medical Center of Central Georgia in Macon did a detailed analysis of the cost of readiness for trauma centers in the year 2016. The Georgia State Trauma Commission, trauma medical directors, trauma program managers, and financial officers from the Level I and II centers in Georgia determined the various categories and reported their actual costs for each. An independent auditor reviewed the data to ensure reporting consistency. Significant variances were analyzed to ensure accurate information.

Here are the factoids:

  • Costs were lumped into four major categories:  administrative, clinical medical staff, in-house OR, and education/outreach
  • Clinical medical staff was the most expensive component, representing 55% of costs at Level I centers and 65% at Level II
  • Only about $110,000 was spent annually on outreach and education at both Level I and II centers, representing a relative lack of resources for this component.
  • Total cost of being a Level I center is about $10 million per year, and $5 million per year for Level II

Here is a copy of the table with the detailed breakdown of each component:

Bottom line: Yes, it’s expensive to be a trauma center. It’s a good idea for any trauma center wannabe to perform a detailed  analysis to make sure that it makes sense financially. This is most important in areas where there are plenty of trauma centers already.  Tools have been developed to determine how many trauma centers will fit within a given geographic area (see below). Unfortunately, very few if any states use this tool to determine how many centers are reasonable. In come cities, it’s almost like the wild west, with centers popping up at random all over the place. This abstract suggests that an additional analysis is mandatory before taking the plunge into this expensive business.

Related post:

Reference: How much green does it take to be orange? Determining cost associated with trauma center readiness. Podium abstract #18, session VIII, AAST 2018.

The August 2018 Trauma MedEd Newsletter Is Here!

Welcome to the current newsletter. This is part 1 of 2 issues where I discuss the massive transfusion protocol (MTP). Here are some of the things I cover:

  • Introduction to MTP
  • Building your own MTP
  • Key factors in the MTP
  • When to activate it
  • How to analyze it

The September issue will be released to subscribers late this month and will cover the product ratio question, using TEG in the MTP, TXA, and that old yet new thing, whole blood. I’ll release it to everyone in October, so subscribe now if you want it sooner!

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME201808a.

Benefits Of A Dedicated Ortho Operating Room For Trauma

Level I and II trauma centers that are verified by the American College of Surgeons are required to have a method for ensuring that urgent orthopedic cases have good access to an operating room (OR). Some hospitals (that have room availability) have achieved this by dedicating an OR for this purpose. In a few hospitals, the room is available 24/7, but most provide daily block time that has a reasonable release time (typically about 6am). This allows procedures to reliably get done the next morning.

Previous papers have documented many of the benefits of this practice: decreased length of stay, fewer surgical revisions, decreased cost, and of course, fewer after-hours operations. But by definition, this adds a delay of several hours to the case. If the patient comes in at 7pm, the case may not start for 12 hours or more.

Could this increase the risk of infection or other complications? The orthopedic group at Stormont Vail in Topeka KS (Level I) looked at their retrospective experience over a 6 year period. They specifically examined cases in which a time delay could increase the infection rate: open tib/fib fractures. They recorded the usual demographics, time to procedure, and broke the data down by Gustilo grade of the fracture.

Here are the factoids:

  • The authors treated 297 patients with a total of 347 open fractures
  • About half were treated before a dedicated ortho OR was implemented, and half after
  • Average time to debridement in the dedicated OR was 13 hours, vs 5 hours in the on-call system
  • Overall, the number debrided within 24 hours was the same in both groups
  • Primary fracture union was significantly higher in the dedicated room group (73% vs 57%)
  • Patients treated initially in the dedicated room were significantly less likely to need an unplanned procedure later (for malunion or infection)
  • There was no difference in infection, non-union, or amputation rates

Bottom line: Let your orthopedic surgeon sleep if you have a dedicated OR so the work can get done first thing the next day! It saves wear and tear on the hospital infrastructure that occurs when cases are done in the middle of the night, as well as the surgeon. Besides saving time and money, final outcomes are better, too!

Reference: Use of the Dedicated Orthopaedic Trauma Room for Open Tibia and Femur Fractures: Does It Make a Difference? J Ortho Trauma 32(8):377-380, 2018.