Category Archives: Trauma Center

Best of AAST 2022 #8: Financial Vulnerability Of Trauma Centers

September 15, 2022 The Trauma Pro Leave a comment

Here’s another abstract on trauma center / system finance. Trauma centers are part of the safety net in the healthcare systems of many countries. The way they are funded varies tremendously. In the US, health insurance pays most of the bill for patient care. Unfortunately, not all patients are covered, so there is financial risk to the center based on how many underpaying patients present for care.

The group at Scripps Mercy in San Diego performed a financial health analysis of all ACS-verified trauma centers in the US. They applied a Financial Vulnerability Score metric (FVS), although I could not locate anything on this via an internet search. They analyzed the RAND Hospital Financial Database, which is based on information obtained from the CMS Healthcare Cost Report Information System. Using this data they calculated the FVS for each center. They sub-grouped the hospitals into high, medium, and low vulnerability and compared them.

Here are the factoids:

A total of 617 trauma centers were identified and analyzed: 194 Level I, 278 Level II, and 145 Level III
Level III trauma centers made up 59% of the high financial risk centers
The majority of Level I and II centers were in the middle or low risk categories
Characteristics of high risk centers were lower number of beds, negative operating margin, and less cash on hand
Low risk centers had greater asset to liability ratios, lower outpatient shares, and 3x less uncompensated care
The largest proportion of HFR hospitals were in New England and East North Central regions
Non-teaching centers had significantly higher financial risk than teaching hospitals (46% vs 29%)

The authors concluded that about 25% of Level I and II trauma centers are at high financial risk and that factors such as payor mix and outpatient status should be targeted to reduce this risk.

Bottom line: This is a fascinating abstract but leaves a lot to the imagination. The databases used have not been used in previous papers, and the information contained in them is proprietary. The FVS is also new and I have not been able to obtain any details.

Nevertheless, if the data and analysis are sound it may provide some new information to trauma centers and perhaps some insight on what factors to address to lessen their financial vulnerability. This is a lot of ifs. Hopefully the authors will enlighten us during the presentation so we can appreciate the real world value of the analysis.

Here are my questions and comments for the authors/presenter:

Please explain both the dataset used and the new FVS metric. Most readers and listeners are unfamiliar. We need to see how the data and analysis apply to trauma center financials and how the FVS has been validated.
How can the vulnerability factors be addressed? Payor mix is based on patient coverage and their socioeconomic status. It would seem to be difficult to manipulate by the trauma center. Outpatient vs inpatient status is also difficult to change and not fall afoul of CMS rules. What were other factors that were identified that could help centers reduce their financial vulnerability?

This could be an interesting abstract, but there was not enough room in the abstract to reveal all the details. Hopefully all will become obvious during the presentation.

Reference: FINANCIAL VULNERABILITY OF TRAUMA CENTERS: A NATIONAL ANALYSIS, Plenary paper #41, AAST 2022.

Abstracts, Trauma Center

Best of AAST 2022 #2: How Much Does It Cost To Be A Trauma Center?

September 7, 2022 The Trauma Pro Leave a comment

Becoming and remaining a trauma center is an expensive proposition. Some components can pay for themselves (surgical specialists and operating rooms) but others are required yet generate no revenue. These costs must somehow be offset for a trauma center to remain viable.

How much does it actually cost? There have been two papers that deal with this topic (see references). One was published way back in 2004 and examined readiness costs averaged across 10 Florida trauma centers. They comingled data for these hospitals, which were a mix of adult, pediatric, Level I and Level II centers. They arrived at a median annual cost of readiness of $2.1 million.

A similar study was published in 2017 for Level I and Level II centers in Georgia. They were ultimately able to estimate that the annual average readiness cost for Level I centers was $6.8 million, and for Level II centers was $2.3 million.

That’s a lot of money! These hospitals tend to be larger and have specialty centers that allow them to generate enough revenue to support the non-revenue parts of the trauma program.

But what about Level III and Level IV centers? They are generally much smaller hospitals. In many more rural states they are critical access hospitals with 25 or fewer beds. They don’t have a wealth of other programs that can generate significant excess revenue.

So how much does it cost them? A group at Mercer University in Atlanta attempted to quantify this issue. They developed a survey tool along the lines of the previous work. They sent this to all 14 Level III and Level IV trauma centers in the state, who based their numbers on 2019 data.

Here are the factoids:

For Level III centers, the average annual readiness cost was $1.7 million
The most expensive components for Level III centers were for clinical medical staff. This was most likely related to stipends for service / call coverage.
For Level IV centers, the cost was only $82 thousand and primarily involved administrative costs (most likely trauma program personnel)
Education and outreach programs are mandated for these centers but the centers actually spent only $8,000 annually. The authors believe this represented significant under-resourcing by the hospitals.

The authors concluded that there is a need for additional trauma center funding to enable Level III and IV centers to meet the requirements set forth by the American College of Surgeons.

My comments: This is a very enlightening paper on the cost of being a trauma center. Only two papers have previously explored this, and only for higher level centers. However, the devil is in the details. The nuts and bolts numbers and the assumptions made on how they fit together are key. But it does provide some enlightening information on what it costs to be a trauma center. And the disparity between the two levels is fascinating / frightening.

Here are my questions for the authors / presenters:

What assumptions did you have to make to arrive at these numbers? Please explain the details of your model and where you think the weaknesses in it may lie.
Why is it so much more expensive to be a Level III center? The abstract places the blame on “clinical medical staff.” Are these on-call stipends or something else?
What would you tell wannabe Level III or IV centers looking to become a trauma center? Unfortunately, these numbers might scare some of the off.

Thanks for an intriguing and challenging paper! The discussion will be very interesting!

References:

ASSESSING TRAUMA READINESS COSTS IN LEVEL III AND LEVEL IV TRAUMA CENTERS. Plenary session paper #10, AAST 2022.
The cost of trauma center readiness. Am J Surg 187(1):7-13, 2004.
What Are the Costs of Trauma Center Readiness? Defining and Standardizing Readiness Costs for Trauma Centers Statewide. Am Surg 83(9):979-990, 2017.

Trauma Center

What GCS Should Trigger Trauma Activation?

May 24, 2022 The Trauma Pro Leave a comment

For the most part, trauma centers are free to pick and choose their own trauma team activation trigger criteria. Typically, these are a mix of physiologic, anatomic, and mechanistic items. However, the American College of Surgeons Committee on Trauma mandates that either seven (Orange Book) or eight (Gray Book) specific criteria must present in every center’s highest-level activation list.

One of these mandatory criteria is a Glasgow Coma Scale (GCS) score of eight or less. The reason is that this level denotes a severe brain injury and as patients approach it they are less and less able to protect their own airway. Although this specific GCS is a minimum, centers are free to choose their own specific threshold as long as it is not any lower.

How does a center choose the “right” GCS? It seems straightforward, right? A mild TBI is defined as GCS from 13-15. These patients have only lost one or two points in their eye-opening, verbal, and motor scores and are relatively unlikely to have a significant lesion in their head or an airway issue.

At the other end of the spectrum is the severe TBI, with a GCS of 3-8. These are a chip shot, with the potential for severe injury and a frequently threatened airway. They demand rapid assessment and intervention, hence the required trauma activation.

But what about those patients with moderate TBI with a GCS from 9-12? They obviously have a higher risk for serious intracranial injury. And as the GCS declines, the patient’s ability to protect their airway decreases. At some point between those GCS scores, most clinicians hit their own internal trigger to provide a definitive airway.

So what do actual trauma centers choose as their threshold? I conducted an informal survey of my readers, asking them to provide their specific GCS threshold.

Here are the factoids:

A total of 147 trauma centers of all levels responded
They were located in the United States, Germany, Saudi Arabia, and Singapore
This chart shows the number of centers that selected a threshold less than or equal to the GCS on the horizontal axis:

Nearly a third of centers (30%) adhere strictly to the ACS criterion of 8
Another 22% use a threshold of 9, possibly to avoid any confusion from having a “less than or equal to” criterion
There is another bump on the curve at 13, with 20% using this threshold

Bottom line: A little more than half of centers use a GCS threshold of 8 or 9 as their TTA trigger. This meets the ACS criteria, but could potentially leave a few airways unprotected from time to time. Only about 5% of centers use the higher GCS levels with the exception of GCS 13. That seems to be another popular one.

Which one is right for you? GCS 8 will always work because it is the minimum requirement. My own personal threshold trends higher. I would rather be called to an activation and apply my own judgement rather than come running only when the patient needs to be intubated followed by a trip to the OR for craniotomy.

You will need to work with your emergency physicians, trauma surgeons, and neurosurgeons to determine their collective comfort levels. It comes down to a balance between safety and unnecessary intubation. Look at your own center’s experience and pick a threshold that achieves a proper balance of overall patient safety.

Trauma Center

Optimizing Feedback To Referring Hospitals

February 24, 2022 The Trauma Pro Leave a comment

The American College of Surgeons requires that referring hospitals provide feedback to prehospital providers and referring hospitals regarding the transfer process.

Failure to do so can actually result in a weakness or deficiency during a site visit. (Psst! Pay attention, referring hospitals if you want to start getting feedback. Read that first sentence again.) Sometimes the feedback is verbal, either in person or by phone. Many receiving centers send written letters outlining care and care issues. But unfortunately, some don’t do it at all, or only very inconsistently.

Harborview Hospital in Seattle is a very busy Level I center, with nearly 6,000 trauma admissions per year. More than half of their patients come from a huge catchment area including Washington state, Wyoming, Alaska, Idaho, and Montana. The amount of work to provide proper feedback on over 3,000 patients annually can be overwhelming.

They implemented a “U-link” program that provided access to patient chart info for the hospital sending each patient. It was HIPAA compliant, and login information was sent within 72 hours of patient arrival.

Here are the factoids:

90 referring hospitals set up the U-link system
Care transcripts, radiology reports, and discharge summaries were the most frequently viewed items
The most desired feedback was on over- or under-resuscitation (89%), injuries (84%), appropriateness of transfer (78%), and deviation from ATLS protocols (76%)
Information was used for education (100%), systems analysis (99%), and performance improvement (PI, 92%)

Bottom line: Your referral partners crave feedback on the patients they send! Develop a system that guarantees it on each patient at a reasonable time after admission. You may or may not be able to link them into your specific electronic medical record, but you can certainly send out informational letters and email!

Reference: Optimizing feedback from a designated Level I trauma/burn center to referring hospitals. JACS 220(1):99-104, 2015.

Trauma Center

The Value Of In-House Call – Part 2

February 8, 2022 The Trauma Pro Leave a comment

In my last post, I detailed an older study that did not show much of an impact from having the trauma surgeon in-house at all times. However, like many of the papers published on this over the years, it suffered from small numbers and questionable endpoints.

A group in the Netherlands sought to analyze everything they could find on the topic and perform a meta-analysis and systematic review. They scanned the literature beginning in 1976, the year that the ACS Committee on Trauma published the first resource criteria for trauma center verification. A total of 16 studies (RCTs and observational) that included information on over 64,000 patients were carefully selected for study. The endpoints of interest were in-hospital mortality and several process measures including lengths of stay and time to OR and CT.

Here are the factoids:

In-house mortality significantly decreased with in-house surgeons, with a relative risk reduction of 14% (from good quality papers, primarily published after 2000)
ICU length of stay was shorter with an in-house surgeon in four studies, longer in one
Hospital length of stay was shorter with the in-house surgeon in four studies, longer in two
Time to OR was significantly faster in seven studies with an in-house surgeon, but no difference was seen in five
Time to CT was shorter in one study and no different in four with the in-house surgeon

Bottom line: What does it all mean? We have been led to believe that doing a meta-analysis / systematic review can help us make sense of a group of papers with flaws such as low numbers, questionable design, or bias. This work shows that this is not necessarily the case.

Think of a good meta-analysis as a set of eyeglasses focused on a selected body of literature. The blurry individual papers are grouped together and brought into better focus by the meta-analysis process. However, the final visual acuity is still determined by the overall quality of the individual research works.

If the overall quality is low, things will remain somewhat blurry even after meta-analysis. As individual paper quality improves, or the papers at least include some higher quality data mixed in with chaff, the overall clarity of the meta-analysis gets better and better.

In this meta-analysis, all papers included mortality information. There is enough there to show the association of an in-house trauma surgeon and lower mortality. But as with all association studies, it is impossible to say that the improved survival is due to the surgeon alone. There are many other factors that were not or could not be evaluated in the studies that might parallel the presence of the surgeon. And similarly with the process measures (LOS, time to resource use), we are generally seeing a preponderance of that show a positive effect. But it’s still not open and shut.

I interpret this meta-analysis / systematic review as overall positive and supportive of having an in-house surgeon. It definitely dovetails with my own experience with in-house call over the past 38 years. I recognize the crudeness of the outcome measures selected, and our inability to quantify more subtle benefits. And we still haven’t fully figured it out the value, even after over 20 years of decent studies. This means we probably won’t ever fully know the answer since the system we work in continues to shift, potentially rendering the older information obsolete.

We will most likely continue with in-house call at highest-level trauma centers for the foreseeable future. In my opinion, and as is suggested by most of the literature, that is a good thing for our patients.

Reference: In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis, Journal of Trauma and Acute Care Surgery: August 2021 – Volume 91 – Issue 2 – p 435-444,

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