Tag 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 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.

Trauma Systems

Are State Trauma Systems Cost-Effective?

March 8, 2017 The Trauma Pro Leave a comment

Every state in the US now has a formal trauma system. Several studies are available that document the advantages of these systems in terms of outcomes and survival. Trauma professionals get this. But the governmental agencies and legislators who help create, fund, and maintain them tend to focus on cost as well.

Arkansas was the last state in the union to implement a trauma system. A study in press from the University of Arkansas details their experience. They examined the impact of the new system on mortality, patient care, and attempted to calculate a return on investment from the taxpayers in an effort to show the added value.

The study was commissioned by the Arkansas Department of Health and carried out by the state Trauma Advisory Council. It was led by out of state investigators in an effort to maintain impartiality. A comprehensive review of records was performed by a panel of 5 surgeons, 1 emergency physician, 2 trauma program managers, 1 ground and 1 flight paramedic. Preventable and potentially preventable deaths were identified and analyzed in depth. Value of life lost was calculated by using a conservative $100,000 per year lost. A total of 290 charts were reviewed pre-system, and 382 post-trauma system implementation using proportional sampling of about 2500 trauma deaths in one year.

Here are the factoids:

A significantly higher percentage of patients were triaged to Level I trauma centers after the system was implemented
Preventable mortality was decreased from 30% to 14% (!!)
This means that 79 extra lives were saved due to implementation of the trauma system
Non-preventable deaths with opportunity for improvement remained constant at about 55%
Non-preventable deaths without opportunity for improvement increased from 16% to 38% (!)
Using the most conservative VLL calculation, this equates to $2.4M in savings per life saved
This adds up to $186M in savings to the taxpayers of Arkansas, a 9-fold return on their investment of $20M in the trauma system.

Bottom line: Wow! This nicely done studies gives us excellent insight into the hows and whys of the value of an organized state trauma system. It is likely that the triage system directed more patients to the most appropriate level of care, leading to fewer preventable deaths. And it enticed hospitals to up their game and make the move toward formal trauma center designation. This improved education and training at those centers, leading to better patient care.

There is a wealth of information in this study, and I recommend that everyone with an interest in or are already participating in their state trauma system read it in its entirety. Hospitals that are reluctant to join or are lagging in meeting criteria need to recognize that they are not serving their communities as well as they think. And legislators must realize that the financial impact of even a small investment has real and significant consequences to their constituents.

Related posts:

Reference: Does the Institution of a Statewide Trauma
System Reduce Preventable Mortality and Yield
a Positive Return on Investment for Taxpayers? JACS in press, 2017.

Trauma Systems

How Many Trauma Centers Should There Be?

August 31, 2016 The Trauma Pro Leave a comment

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.

Home of the Trauma Professional's Blog