Category Archives: Trauma Systems

Best Of AAST 2022 #7: Funding State Trauma Systems

September 14, 2022 The Trauma Pro Leave a comment

As of about 10 years ago, every state in the US has implemented a state trauma system. The way these systems are funded and their sources vary widely. Most receive their funds via some combination of a line item in the budget, grants, or fees levied on state residents. The total per capita funding amount can be calculated based on the total dollars received divided by the state population.

The per capita funding across the US varies widely. Some provide very little assistance while others are much more generous. I have visited trauma centers in nearly every state and have witnessed the difficulties many state trauma systems face due to funding shortfalls.

Does financial support have an impact on trauma care? A better question is, do state systems have an impact on trauma care? The literature on that last question tells us the answer is a resounding yes. We assume that having some money improves what the system can do. But that’s just an assumption. Until now.

The group at Northwestern University did a deep dive into the financial support of state trauma systems to address this question. Their goal was to measure the impact of it on something easily measurable: mortality. They selected five states to study based upon their broad geographic and demographic variability and the availability of comprehensive data for analysis.

Two states (MA, NY) allocated $0.00 per capita trauma funding, and three provided between $0.09 and $1.80 per capita. The authors analyzed data from comprehensive patient encounter databases from these states. Their primary goal was to compare mortality differences between the two levels of support. They were also able to link ED and inpatient encounters and analyze triage decisions for appropriateness.

Here are the factoids:

Nearly a quarter of a million patients with ISS > 15 were analyzed over a study period of two years
Median age was 72 and ISS was 17 (older with significant injuries)
Trauma mortality was significantly decreased in the states that provided financial support compared with those that did not (odds ratio 0.75)
All triage levels were associated with a similar decrease in mortality (appropriate triage to a Level I or II center, undertriage admitted to a Level III or IV center, and re-triage (emergent transfer from an ED to a Level I or II center))
The best improvement in mortality was seen in re-triaged patients in funded states (odds ratio of 0.63)

The authors concluded that state system funding was associated with lower mortality in severely injured patients and that increasing funding may facilitate it.

Bottom line: Several papers have been written showing the benefit of having a trauma system, and all of the US has bought into this concept. However, funding of these systems varies widely by state. The assumption (up to now) has been that just having a system is enough. This abstract goes a step further and suggests that actually paying for it is important, too.

The authors performed quite of bit of data manipulation and used some sophisticated statistical tools that I am not familiar with. However, the authors are certainly qualified, and I am going to assume that the analysis was sound.

The one important point to keep in mind is that this paper is one of the first of its kind but can only show association, not causation. Nevertheless, it is an important contribution to the trauma system literature. It will definitely prompt additional research which will hopefully corroborate the results. This line of work should give state systems the ammunition to approach their legislatures to open the pocketbook and improve the outcomes of their residents. Mortality reductions of 25-37% cannot be ignored!

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

Please explain the data sources you used and the analysis (briefly). These are very comprehensive databases and appear to contain a wealth of data. Tell us why you chose them, how you linked them, and explain your analyses.
Why limit your analyses to these five states? Could you have found some with even higher levels of support that would drive your point home even better?
Be sure to provide more detail on your analysis of triage status. There are some important lessons to be learned here regarding state triage criteria vs mortality.
Are you planning any additional similar studies? This is important work that will help state systems obtain a more appropriate level of support.

This is an intriguing abstract that should prompt additional research regarding state trauma system funding.

Reference: THE IMPACT OF STATE TRAUMA FUNDING ON TRIAGE AND MORTALITY OF TRAUMA PATIENTS. Plenary paper #38, AAST 2022.

Trauma Systems

Best of EAST #4: Futile Trauma Transfers

January 5, 2021 The Trauma Pro Leave a comment

Level I and II trauma centers are regularly on the receiving end of what may be termed as “futile transfers.” These are patients who have sustained unsalvageable injuries and are initially seen at a lower level center. They are then transferred upstream where they succumb shortly (0-48 hours) after arrival.

As you might imagine, these patients can place a significant burden on resources at the Level I or II center. This is an even more acute situation given the large numbers of COVID patients who also require hospitalization and palliative care services these days.

The group at the University of Kansas sought to put some numbers on this phenomenon. They examined their own experience as one of two Level I trauma centers in the Kansas City metro area. They defined futile care as patients who died or were discharged to hospice care within 48 hours of arrival and who did not undergo operative, endoscopic, or interventional radiology procedures.

Here are the factoids:

A total of 1,241 patients were transferred in during the two year study period
Of these, 407 had stays of 48 hours or less, and 18 (1.5%) were deemed futile care according to their definition
The futile care patients tended to be much older (75 vs 61 years) and were much more severely injured (ISS 21 vs 8)
When transport and hospital charges were combined, the average total cost was $56,000
Total cost to this hospital was $1.7 million, and this was extrapolated to an annual cost of 27 million for the entire US

The authors concluded that these futile transfers are a small yet costly patient population. They suggested that accurately identifying these patients and providing resources to help referral hospitals figure out how to care for them would be helpful.

My comments: This is a very straightforward descriptive paper that details a problem that every high level trauma center sees on a regular basis. Older patients, typically those with critical head injuries that are beyond treatment, are transferred to the “big house.” The families are frequently told that there are no local resources to provide the care needed, and that the higher level center is their only chance.

The families then have unrealistic expectations, and are inconvenienced by the travel involved. Wouldn’t it be better to just tell the family that the injury is a really bad one, and provide palliative / hospice care in the local community? Unfortunately, it’s not that simple. Many small hospitals do not have providers who are well-versed in this type of care. Thus, the suggestion to provide resources (people? training?) is a sound one.

This abstract highlights a problem we all face but seldom publicize. Hopefully this one will get us talking. And acting.

Here are my questions for the authors and presenter:

What kind of resources do you think are needed to allow referral hospitals to care for these patients?
How will these hospitals know when care is futile? Will there be an expectation to work with the receiving center to help determine this?

I enjoyed this paper and can’t wait to hear the details!

Reference: Futile trauma transfers: an infrequent but costly component of regionalized trauma care. EAST 2021, paper 9.

Trauma Systems

Trauma Center Density In Urban Areas

October 21, 2020 The Trauma Pro Leave a comment

The focus of this post is going to be a little different. I’ll be coming up out of the trenches of clinical care, and focusing on trauma systems for a bit. Specifically, I’m going to look at the density of high-level trauma centers in bigger cities. For my non-US readers, this paper is based on data from the States, but is most likely applicable in your countries as well.

Why look at trauma center distribution? More than 80% of the population lives in an urban area of the US. And over the next thirty years, that number will approach 90%. As more people move to the big cities, there are concentrations of homelessness, poverty, mental illness, and violence. This last factor is one of the reasons for trauma center existence, and their distribution is ostensibly one of the reasons to have a trauma system in the first place.

In theory, there should be an optimal number of trauma centers for a given population base. The American College of Surgeons (ACS) created a needs-based assessment tool to predict the optimal number of centers given the population size, trauma volume, EMS transport times, and more. If you are interested, you can download it here.

But has it been followed? Trauma leaders from some of the most established Level I centers in the country performed an analysis of the density of Level I and II centers in 15 of the largest cities in the US. They tried to test what social and economic conditions in an area determined the number of centers available in it, if any.

The cities were determined using information from 2015 census information. The trauma centers in each were identified from ACS or state system information.

Here are the factoids:

14 of 15 cities had multiple Level I or II centers
There was a large variation of centers per geographic area covered, ranging from 1 per 150 km sq (Philadelphia) to 1 per 596 km sq (San Antonio)
Population density (the population divided by the number of trauma centers) varied from 1:285,000 people in Columbus to 1:870,000 in San Francisco
The median minimum distance between centers was 8 km, and varied from 1 km in Houston to 43 km in San Antonio
Poverty and unemployment rates were highly correlated to violence rates
There was no correlation with trauma center density and social determinants of health or violence rates

Bottom line: What does all this mean? It appears that the number and geographic distribution of trauma centers in larger cities has nothing to do with need as measured by the social and economic conditions of the area. More likely, it is related to financial considerations. Trauma center closures in urban areas have disproportionately occurred in the lowest income areas. And it is less likely that new centers will open in these areas.

Obviously, hospitals need to make money to survive. Insurance coverage has become more available to people with lower incomes over the past 10 years. Unfortunately, the reimbursement rates for hospital stays continue to decline slowly. This combination makes it more difficult for a hospital to eke out an existence in one of these areas.

What can be done? Unfortunately, this is one of those many-headed hydra type issues. There are so many competing interests, and the people affected have little representation in the process. Our trauma systems should play a larger part in this, as they are supposed to have some say over the structure and distribution of their centers. Unfortunately, many of them do not have the financial support or the political wherewithal to do this.

Ultimately, I believe that we are working for something that should be considered a common good. Which means that it is up to state and ultimately the federal government to work with all the stakeholders to better control the distribution of this valuable resource. Which means that it is up to the trauma center administrators and trauma leaders to make sure the call is heard by their government leaders who can make things happen.

This is likely to remain a sticky problem during the age of COVID. Resources are needed for more pressing matters right now. But when the time comes, all trauma professionals need to speak up and help work this problem. Get involved with your regional trauma advisory committee. Make sure your state trauma advisory council makes it a priority. And don’t shy away from letting your legislators know about the problem. Otherwise, they will remain blithely unaware and our patients may continue to suffer.

Reference: Describing the density of high-level trauma centers in
the 15 largest US cities. Trauma Surgery & Acute Care Open 2020;5:e000562.

Trauma Center, Trauma Systems

Secondary Overtriage: What Is It, And Why Is It Bad?

July 31, 2018 The Trauma Pro Leave a comment

Simply put, secondary overtriage (SO) is the unnecessary transfer of a patient to another hospital. How can you, as the referring trauma professional, know that it is unnecessary? Almost by definition, you can’t, unless you have some kind of precognition. If you knew it wasn’t necessary, you wouldn’t do it in the first place, right?

But using the retrospectoscope, it’s much easier. The classic definition describes a patient who is discharged from the hospital shortly after arrival there. What is “shortly?” Typically, it occurs within 48 hours in a patient with low injury severity (ISS < 16) and without operative intervention. Definitions may vary slightly.

And why is it bad?

Several states with rural trauma systems have scrutinized this issue. The first study is from West Virginia, where six years of state registry data were analyzed. Over 19,000 adults were discharged home from a non-Level I center within 48 hours after an injury. Of those, about 1,900 (10%) had been transferred to a “higher level of care” and discharged from that center (secondary overtriage, could be any higher-level trauma center).

The factoids:

Patients with ISS > 15 and requiring blood transfusion were more likely to be SO. (I would argue that this is appropriate triage in most cases!)
Neurosurgical, spine and facial injuries were also associated with SO. (This one is a little more interesting, see below).
SO was more likely for transfers during the night shift, when resources are often more scarce

The problem is that this study is descriptive only. It doesn’t really help us figure out which patients could/should be kept based on any of the variables they collected.

The next study is from Dartmouth in New Hampshire and examines transfers into that single Level I center from 72 other hospitals. Registry data were examined over 5 years, identifying transfer patients with ISS < 15 who were discharged within 48 hours without an operation.

Yet more factoids:

62% of the nearly 8,000 patients received by this center were transfers
Overall SO rate was 26%
A quarter of adult patients and one half of pediatric patients were considered SO, and about 15% of them were actually discharged from the ED (!)
Head and neck, and soft tissue injuries were most common among SO patients

The real bottom line: Here are my thoughts on what you can do to try to decrease the number of your patients with SO and optimize the transfer process:

Work with your upstream trauma center to determine how much imaging you really need to perform
Develop a reliable method of getting those images to them
Ask them to help you develop practice guidelines and educate your hospital/ED staff to help manage common diagnoses that often result in SO from your center
If you are located in a rural area, inquire about RTTD courses you might attend

References:

Secondary overtriage in a statewide rural trauma system. J Surg Research 198:462-467, 2015.
Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg 48(8):763-768, 2013.

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