Transfer of Trauma Patients to Level 1 and 2 Trauma Centers: Mortality Outcomes and Race – Insurance Disparities

Abstract Background Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. Methods We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. Results We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92–0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%). Conclusions Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.

Download Full-text

Comparison of Outcomes for Pediatric Trauma at Different Types of Trauma Centers: The Unresolved Mystery

The American Surgeon ◽

10.1177/000313481808400665 ◽

2018 ◽

Vol 84 (6) ◽

pp. 1054-1057

Author(s):

Adel Elkbuli ◽

Jennifer R. Lopez ◽

Paul Perales Villarroel ◽

Darwin Ang ◽

Huazhi Liu ◽

...

Keyword(s):

Pediatric Trauma ◽

Health Care Administration ◽

Trauma Patients ◽

Trauma Centers ◽

Pediatric Hospital ◽

Pediatric Hospitals ◽

Crude Mortality Rate ◽

Level 1 ◽

Expected Mortality ◽

Level 2

In Florida, injured children can receive emergent care at one of three types of state-approved trauma centers (TCs). A Level 1 combined adult/pediatric TC (L1, A + P), a Level 2 TC with an associated pediatric hospital (L2 + PH) or a pediatric TC at a pediatric hospital (PTH). This study aims to compare the mortality outcomes between Florida L1, A + Ps, to L2 + PHs, and PTHs. A retrospective review of dataset from the Agency for Health Care Administration compared outcomes from 2013 to 2016 at all three types of TCs. Outcomes were stratified by using the observed over expected mortality (O/E). Significance defined as P < 0.05. A total of 13,428 pediatric trauma patients were treated at all three TCs (L1, A + P, L 2 + PHs, or PTH). L1, A + Ps treated 6975 pediatric patients with 104 deaths [crude mortality rate (CMR) 1.49%, O/E = 0.96], L2 + PHs treated 4066 patients with 69 deaths (CMR 1.70%, O/E = 1.21), PTHs treated 2387 patients with 34 deaths (CMR 1.42%, O/E = 1.25). When O/E's at L1, A + Ps and L2 + PHs were compared, results were statistically significant (P = <0.03),but not at L1, A + P versus PTHs. This is the first study to reveal that Level 1 adult/pediatric TCs have lower mortality rates compared with Level 2 TCs with an associated pediatric hospital. Level 1,A + P TCs had similar outcomes to pediatric TCs at standalone pediatric hospitals.

Download Full-text

Minor change in initial PEEP setting decreases rates of ventilator-associated events in mechanically ventilated trauma patients

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000455 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000455

Author(s):

Ethan Ferrel ◽

Kristina M Chapple ◽

Liviu Gabriel Calugaru ◽

Jennifer Maxwell ◽

Jessica A Johnson ◽

...

Keyword(s):

Logistic Regression ◽

Injury Severity ◽

Trauma Patients ◽

Trauma Centers ◽

Level Of Evidence ◽

Mechanically Ventilated ◽

Change In Practice ◽

Level 1 ◽

The Impact ◽

Level 1 Trauma Center

BackgroundSurveillance of ventilator-associated events (VAEs) as defined by the National Healthcare Safety Network (NHSN) is performed at many US trauma centers and considered a measure of healthcare quality. The surveillance algorithm relies in part on increases in positive end-expiratory pressure (PEEP) to identify VAEs. The purpose of this cohort study was to evaluate the effect of initiating mechanically ventilated trauma patients at marginally higher PEEP on incidence of VAEs.MethodsAnalysis of level-1 trauma center patients mechanically ventilated 2+ days from 2017 to 2018 was performed after an institutional ventilation protocol increased initial PEEP setting from 5 (2017) to 6 (2018)cm H2O. Incidence of VAEs per 1000 vent days was compared between PEEP groups. Logistic regression modelling was performed to evaluate the impact of the PEEP setting change adjusted to account for age, ventilator days, injury mechanism and injury severity.Results519 patients met study criteria (274 PEEP 5 and 245 PEEP 6). Rates of VAEs were significantly reduced among patients with initial PEEP 5 versus 6 (14.61 per 1000 vent days vs. 7.13 per 1000 vent days; p=0.039). Logistic regression demonstrated that initial PEEP 6 was associated with 62% reduction in VAEs.ConclusionsOur data suggest that an incrementally increased baseline PEEP setting was associated with a significantly decreased incidence of VAEs among trauma patients. This minor change in practice may have a major impact on a trauma center’s quality metrics.Level of evidenceIV.

Download Full-text

Early Chemoprophylaxis in Severely Injured Trauma Patients Reduces Risk of Venous Thromboembolism

The American Surgeon ◽

10.1177/0003134820939914 ◽

2020 ◽

Vol 86 (9) ◽

pp. 1185-1193

Author(s):

Jason P. Hecht ◽

Emily J. Han ◽

Mary-Margaret Brandt ◽

Wendy L. Wahl

Keyword(s):

Venous Thromboembolism ◽

Injury Severity ◽

Unit Length ◽

Trauma Patients ◽

Severely Injured ◽

Trauma Centers ◽

Vte Prophylaxis ◽

American College Of Surgeons ◽

Level 1 ◽

Injured Patients

Background Venous thromboembolism (VTE) remains a serious complication for trauma patients. While early VTE prophylaxis has gained traction, the timing of prophylaxis remains uncertain. We hypothesized that VTE prophylaxis within 24 hours of admission would have lower VTE rates and similar rates of adverse events in seriously injured patients. Methods Trauma patients were included from 32 American College of Surgeons verified Level 1 and 2 trauma centers over a 10-year period. Patients with injury severity score (ISS) <15, death or discharge within 48 hours of arrival, or who received no prophylaxis were excluded. Results 14 096 patients received VTE prophylaxis with an ISS of ≥15. Patients given prophylaxis at <24 hours had fewer VTE events and trended toward fewer serious in-hospital complications. Mortality and return to the operating room were similar across groups. Hospital and intensive care unit length of stay in the <24 hours prophylaxis group was significantly shorter when VTE prophylaxis was initiated earlier. Conclusions In severely injured trauma patients with ISS >15, early VTE prophylaxis within 24 hours significantly reduced the risk of VTE as compared with delayed prophylaxis. Early chemoprophylaxis was found to be efficacious in reducing the incidence of VTE; however, the safety of this practice should be evaluated by future prospective studies.

Download Full-text

Level 1 Trauma Centers and OEF/OIF Emergency Departments: Comparison of Trauma Patient Populations

Military Medicine ◽

10.1093/milmed/usaa133 ◽

2020 ◽

Vol 185 (9-10) ◽

pp. e1569-e1575

Author(s):

Shelia C Savell ◽

Alexis Blessing ◽

Nicole M Shults ◽

Alejandra G Mora ◽

Kimberly L Medellin ◽

...

Keyword(s):

Emergency Department ◽

Trauma Patient ◽

Emergency Departments ◽

Trauma Center ◽

San Antonio ◽

Trauma Patients ◽

Trauma Centers ◽

Level 1 ◽

Hospital Days ◽

Level 1 Trauma Center

Abstract Introduction Brooke Army Medical Center (BAMC), the largest military hospital and the only level 1 trauma center in the DoD, cares for active duty, retired uniformed services personnel, and beneficiaries. In addition, BAMC works in collaboration with the Southwest Texas Regional Advisory Council (STRAC) and University Hospital (UH), San Antonio’s other level 1 trauma center, to provide trauma care to residents of the city and 22 counties in southwest Texas from San Antonio to Mexico (26,000 square mile area). Civilian-military partnerships are shown to benefit the training of military medical personnel; however, to date, there are no published reports specific to military personnel experiences within emergency care. The purpose of the current study was to describe and compare the emergency department trauma patient populations of two level 1 trauma centers in one metropolitan city (BAMC and UH) as well as determine if DoD level 1 trauma cases were representative of patients treated in OEF/OIF emergency department settings. Materials and Methods We obtained a nonhuman subjects research determination for de-identified data from the US Air Force 59th Medical Wing and the University of Texas Health Science Center at San Antonio Institutional Review Boards. Data on emergency department patients treated between the years 2015 and 2017 were obtained from the two level 1 trauma centers (BAMC and UH, located in San Antonio, Texas); data included injury descriptors, ICU and hospital days, and department procedures. Results Two-proportion Z-tests indicated that trauma patients were similar across trauma centers on injury type, injury severity, and discharge status; yet trauma patients differed significantly in terms of mechanism of injury and regions of injury. BAMC received significantly greater proportions of patients injured from falls, firearms and with facial and head injuries than UH, which received significantly greater proportion of patients with thorax and abdominal injuries. In addition, a significantly greater proportion of patients spent more than 2 days in the ICU and greater than two total hospital days at BAMC than in UH. In comparison to military emergency departments in combat zones, BAMC had significantly lower rates of blood product administration and endotracheal intubations. Conclusions The trauma patients treated at a military level 1 trauma center were similar to those treated in the civilian level 1 trauma center in the same city, indicating the effectiveness of the only DoD Level 1 trauma center to provide experience comparable to that provided in civilian trauma centers. However, further research is needed to determine if the exposure rates to specific procedures are adequate to meet predeployment readiness requirements.

Download Full-text

Large-Scale Airmedical Transport from a Peripheral Hospital to Level-1 Trauma Centers after Remote Mass-Casualty Incidents in Israel

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00007500 ◽

2009 ◽

Vol 24 (6) ◽

pp. 549-555 ◽

Cited By ~ 5

Author(s):

Ophir Lavon ◽

Dan Hershko ◽

Erez Barenboim

Keyword(s):

Large Scale ◽

Medical Personnel ◽

Mass Casualty ◽

Mass Casualty Incidents ◽

Trauma Patients ◽

Trauma Centers ◽

Preparedness Plan ◽

Peripheral Hospital ◽

Number Of Patients ◽

Level 1

AbstractIntroduction:Mass-casualty incidents (MCIs) result in the evacuation of many patients to the nearest medical facility. However, an overwhelming number of patients and the type and severity of injuries may demand rapid, mass airmedical transport to more advanced medical centers. This task may be challenging, particularly after a MCI in a neighboring country. The Israeli Air Force Rescue and Airmedical Evacuation Unit (RAEU) is the main executor of airmedical transport in Israel, including MCIs.Problem:The available data on airmedical transport from remote MCIs are limited. The objective of this study was to evaluate the airmedical transport from a rural hospital after two remote MCIs.Methods:The study was retrospective and reviewed descriptive records of airmedical transports.Results:The RAEU was involved in airmedical transports from a peripheral hospital shortly after two remote MCIs that occurred in the Sinai desert near the Egyptian-Israeli border. Nineteen (22.4%) and 25 (100%) of the treated trauma patients from each event were airmedically transported to Level-1 Trauma Centers in Israel within hours of the dispatch. The rapid dispatch and accumulation of medical personnel and equipment was remarkable. The airmedical surge capacity was broad and sufficient. Cooperation with local authorities and a tailored boarding procedure facilitated a quality outcome.Conclusions:The incorporation of a large-scale airmedical transport program with designated multidisciplinary protocols is an essential component to a remote disaster preparedness plan.

Download Full-text

P104: Literature review of telemedicine for trauma patients in rural areas

CJEM ◽

10.1017/cem.2016.280 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S113-S113

Author(s):

A. Pichard-Jolicoeur ◽

M. Mbakop-Nguebou ◽

Joyce Dogba ◽

J. Labrie ◽

F.K. Tounkara ◽

...

Keyword(s):

Literature Review ◽

Trauma Care ◽

Rural Areas ◽

Trauma Patients ◽

Trauma Centers ◽

Independent Review ◽

Hospital Stays ◽

Potential Impact ◽

Level 1 ◽

Transfer Times

Introduction: Trauma is the leading cause of death among people under 40. With more than 7 million Canadians living over one hour’s travel from a level 1 or 2 trauma center, access to quality trauma care in Canada is a major concern. We recently reported that more than 40% of rural EDs across Canada were more than 300 km from levels 1 and 2 trauma centers. Direct transportation to trauma centers is therefore unusual and most trauma cases are initially managed in rural EDs. Assistance from trauma centers via telemedicine could thus be valuable in optimizing initial stabilization and inter-facility transfers. Objective: Is telemedicine a potentially effective intervention for improving rural trauma care? Methods: We conducted a literature review to examine the potential impact (number of transfers, transfer times, length of hospital stays and mortality) of telemedicine on rural trauma care. Two reviewers independently searched PubMed, Embase and Cochrane databases with key words / concept combinations: telemedicine, trauma and rural. Articles included in the final review had to address the question with specific methodologies. After duplicate removal, 312 articles were found relevant. After independent review of titles and abstracts, only 25 articles pertained to the specific question. Only three studies met inclusion criteria. Results: These studies reported 187 successful teleconsultations in the context of rural trauma care, 29 of which involved significant interventions (8 interventions potentially lifesaving). Some unnecessary inter-facility transfers were avoided. However, transfer times to trauma centers and length of hospital stays appeared slightly longer with telemedicine. Conclusion: The literature on the efficacy of telemedicine in trauma care is scarce, with only three studies addressing the question. Conclusions generally favor telemedicine, but additional research must should determine its impact and better understand the barriers/facilitators to the implementation of telemedicine for rural trauma care.

Download Full-text

Increases in Violence and Changes in Trauma Admissions During the COVID Quarantine

The American Surgeon ◽

10.1177/00031348211050824 ◽

2021 ◽

pp. 000313482110508

Author(s):

Garrett N. Klutts ◽

Joe Deloach ◽

Sacha A. McBain ◽

Hanna Jensen ◽

Kevin W. Sexton ◽

...

Keyword(s):

Penetrating Trauma ◽

Mean Value ◽

Trauma Patients ◽

Trauma Centers ◽

Societal Norms ◽

Time Period ◽

Transfusion Requirements ◽

Hospital Resources ◽

The Mean ◽

Level 1

Background The COVID-19 pandemic caused an abrupt change to societal norms. We anecdotally noticed an increase in penetrating and violent trauma during the period of stay-at-home orders. Studying these changes will allow trauma centers to better prepare for future waves of COVID-19 or other global catastrophes. Methods We queried our institutional database for all level 1 and 2 trauma activations presenting from the scene within our local county from March 18 to May 21, 2020 and matched time periods from 2016 to 2019. Primary outcomes were overall trauma volume, rates of penetrating trauma, rates of violent trauma, and transfusion requirements. Results The number of penetrating and violent traumas at our trauma center during the period of societal quarantine for the COVID-19 pandemic was more than any historical total. During the COVID-19 time period, we saw 39 penetrating traumas, while the mean value for the same time period from 2016 to 2019 was 26 ( P = .03). We saw 45 violent traumas during COVID; the mean value from 2016 to 2019 was 32 ( P = .05). There was also a higher rate of trauma patients requiring transfusion in the COVID cohort (6.7% vs 12.2%). Discussion Societal quarantine increased the number of penetrating and violent traumas, with a concurrent increased percentage of patients transfused. Despite this, there was no change in outcomes. Given the continuation of the COVID-19 pandemic, quarantine measures could be re-implemented. Data from this study can help guide expectations and utilization of hospital resources in the future.

Download Full-text

Pathologic Fibrinolysis is More Common in a Rural Trauma Setting

The American Surgeon ◽

10.1177/0003134820973726 ◽

2020 ◽

pp. 000313482097372

Author(s):

James M. Bardes ◽

Daniel J. Grabo ◽

Sijin Wen ◽

Alison Wilson

Keyword(s):

Trauma Team ◽

Rural Environment ◽

Trauma Patients ◽

Future Studies ◽

Factors Influencing ◽

American College Of Surgeons ◽

Level 1 ◽

Transferred Patients ◽

Prehospital Time ◽

Level 1 Trauma Center

Introduction Fibrinolysis (lysis) has been extensively studied in trauma patients. Many studies on the distribution of lysis phenotype have been conducted in setting with short prehospital time. This study aimed to evaluate the distribution of lysis phenotypes in a population with prolonged prehospital times in a rural environment. Methods A retrospective study was performed at an American College of Surgeons-verified level 1 trauma center, serving a large rural population. Full trauma team activations from January 1, 2017 to August 31, 2018 were evaluated, and all patients with an ISS>15 analyzed. Thromboelastography was routinely performed on all participants on arrival. Lysis phenotypes were classified based on LY30 results: shutdown (≤.8%), physiologic (.9-2.9%), and hyper (>2.9%). Results 259 patients were evaluated, 134 (52%) presented direct from the scene. For scene patients, lysis distribution was 24% physiologic, 49% shutdown, and 27% hyper. Transferred patients demonstrated a reduction in physiologic lysis to 14% ( P = .03), shutdown present in 66%, and hyper in 20%. Empiric prehospital tranexamic acid was given to 18 patients, physiologic lysis was present in 6%, shutdown 72%, and hyper 22%; this increase was not statistically significant ( P = .5). Conclusion Fibrinolysis phenotypes are not consistent across all trauma populations. This study showed rural trauma patients had a significantly increased rate of pathologic lysis. This was consistent for scene and transfer patients who received care at another facility prior to arrival for definitive care. Future studies to evaluate the factors influencing these differences are warranted.

Download Full-text

Does Gender Matter: A Multi-Institutional Analysis of Viscoelastic Profiles for 1565 Trauma Patients With Severe Hemorrhage

The American Surgeon ◽

10.1177/00031348211033542 ◽

2021 ◽

pp. 000313482110335

Author(s):

Alison Smith ◽

Juan Duchesne ◽

Matthew Marturano ◽

Shaun Lawicki ◽

Kevin Sexton ◽

...

Keyword(s):

Alpha Angle ◽

Reaction Times ◽

Maximum Amplitude ◽

Trauma Patients ◽

Trauma Centers ◽

Survival Difference ◽

Severe Hemorrhage ◽

Male Patients ◽

Level I ◽

Clot Formation Time

Background Viscoelastic tests including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are being used in patients with severe hemorrhage at trauma centers to guide resuscitation. Several recent studies demonstrated hypercoagulability in female trauma patients that was associated with a survival advantage. The objective of our study was to elucidate the effects of gender differences in TEG/ROTEM values on survival in trauma patients with severe hemorrhage. Methods A retrospective review of consecutive adult patients receiving massive transfusion protocol (MTP) at 7 Level I trauma centers was performed from 2013 to 2018. Data were stratified by gender and then further examined by TEG or ROTEM parameters. Results were analyzed using univariate and multi-variate analyses. Results A total of 1565 patients were included with 70.9% male gender (n = 1110/1565). Female trauma patients were older than male patients (43.5 ± .9 vs 41.1 ± .6 years, P = .01). On TEG, females had longer reaction times (6.1 ± .9 min vs 4.8 ± .2 min, P = .03), increased alpha angle (68.6 ± .8 vs 65.7 ± .4, P < .001), and higher maximum amplitude (59.8 ± .8 vs 56.3 ± .4, P < .001). On ROTEM, females had significantly longer clot time (99.2 ± 13.7 vs 75.1 ± 2.6 sec, P = .09) and clot formation time (153.6 ± 10.6 sec vs 106.9 ± 3.8 sec, P < .001). When comparing by gender, no difference for in-hospital mortality was found for patients in the TEG or ROTEM group ( P > .05). Multivariate analysis showed no survival difference for female patients (OR 1.11, 95% CI .83-1.50, P = .48). Conclusions Although a difference between male and females was found on TEG/ROTEM for certain clotting parameters, no difference in mortality was observed. Prospective multi-institutional studies are needed.

Download Full-text