Category Archives: Trauma Systems

EAST 2017 #9: Geographic Location and Fatal Car Crashes

Trauma resources (centers and helicopter services) are not geographically evenly distributed across the US. The East and West coasts are saturated with resources, maybe overly so. At the other extreme, some northern states (Alaska and the north central US) have very few trauma resources, and injured patients may have to travel several hundreds of miles to get definitive trauma care.

The group at the University of Pittsburgh looked at trauma resource distribution across the state of Pennsylvania, and matched that with geographical data from fatal car crashes over a two  year period. They used some special statistical tools to analyze this type of data, and reported their findings in a format that will be unfamiliar to many: fatalities per 100 million vehicle miles traveled (VMT).

Here are the factoids:

  • 863 fatal crashes occurred during the study period, killing 884 people
  • The median fatality rate for the state was .187 per 100 million VMT
  • Fatality hotspots became very apparent in areas farther from trauma system resources (TSR) (see map below, dark areas are bad)
  • The fatality rate increased significantly by 0.01 per 100 million VMT for each mile farther away from any TSR.
  • If just 2 helicopters had been relocated from trauma centers to high fatality regions, the overall fatality rate could have been reduced by 12%, in theory

Bottom line: This novel way of looking at injury data confirms what we all knew or suspected: injuries occurring farther away from trauma resources may lead to higher mortality and disability. And knowledge is power. If we can see it, we can do something about it. This type of analysis should be done on regional, state, and national levels to help us better serve our patients.

Questions and comments for the authors/presenters:

  1. Be able to describe your statistics simply
  2. How did you deal with data from the border areas of the state? Did you include trauma resources from adjacent states in your analysis?
  3. You mention “county-level” factors in adjusting mortality rates for distance. What were these?
  4. This is a novel way of approaching system planning. Nice job!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related post:

Reference: Distance matters: effect of geographic trauma system resource organization on fatal motor vehicle collisions. Paper #3, EAST 2017.

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How Many Trauma Centers Should There Be?

Trauma centers seem to be popping up all over the US. Many metropolitan area have literally scores of centers at various levels. And yet there are swaths across this country where you won’t find a single Level I, and only a few Level IIs. In most states, there is little guidance from the designating authority regarding whether a new trauma center is feasible or even needed. The American College of Surgeons (ACS) has given little guidance over the years, except for a white paper in 2015 that essentially said that it is up to the designating authorities to determine this.

Last August, the ACS organized a consensus conference to try to develop an objective method for figuring out when enough is enough. There was unanimous support for developing a tool that would encourage designation to meet the needs of the trauma patient, not the financial needs of a hospital or hospital system. This Needs-Based Assessment of Trauma Systems (NBATS) tool looks at 6 factors, some of which take a little calculation to complete. A point score is arrived at that predicts the additional number of trauma centers that may be needed. Currently, this tool is in draft form and is in the process of being optimized.

Click here to download the draft document.

So far, this has been a theoretical exercise. But a group at Stanford decided to test the tool on the entire state of California. They used a variety of data sources to compile the needed numbers, and did some complicated spatial analyses of transport times to accurately calculate NBATS scores.

Here are the factoids:

  • 74 trauma centers were identified in the state – 15 Level I, 37 Level II, 14 Level III, and 8 Level IV
  • The state was broken down into 30 Local Emergency Medical Service Agency trauma service regions
  • Only 4 of the 30 regions had scores suggestion that they had enough trauma centers
  • The tool suggested that 9 regions needed 1 more trauma center, 13 would require 2 more, and 4 would require 3 more
  • The model also suggested that 3 regions already had more than needed

Bottom line: There is already literature showing that adding additional (too many?) trauma centers to a region can have a negative impact on patient volumes and resource availability at Level I and II centers. This tool may allow state trauma systems to more objectively determine exactly where more centers are justified, enabling them to rise above the usual political battles (maybe). Unfortunately, the tool does not take available surgical resources in the region (trauma surgeons, neurosurgeons,  orthopedic surgeons) into account, or provide guidance on which levels of new centers should be developed. But it’s a good start to help solve a sticky problem.

Reference: ACS needs based assessment of trauma systems (NBATS) tool: California example. AAST 2016, Paper #24.

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