Effect of American College of Surgeons Level 1 Trauma Center Designation on Management of Adult Severe TBI Patients

Abstract INTRODUCTION Severe traumatic brain injury (TBI) remains a leading cause of morbidity and mortality. There is a wide variability in treatment paradigm for patients with severe TBI. American College of Surgeons (ACS) level 1 trauma centers have access to 24 h neurosurgical coverage. In this study, we use the National Trauma Database (NTDB) to evaluate if ACS trauma center designation correlates with the management and outcomes of severe TBI in adults. METHODS Adult patients (<65 yr) with a severe isolated nonpenetrating TBI were identified in the NTDB from years 2007 to 2014. ICD-9 procedure codes were used to identify primary treatment approaches: intracranial pressure monitoring and cranial surgery. Multivariate logistic regression was used to determine the impact of ACS designation on procedures and patient outcomes. Patient and injury characteristics were included in the analysis. RESULTS A total of 54 769 TBI patients were identified. Among those, 22 316 (42%) were treated at an ACS level 1 trauma center and 31 835 (58%) were treated elsewhere. Level 1 designated patients had significantly more intracranial pressure (ICP) monitors placed (12.3% vs10.8%; P < .0001) and more cranial surgeries performed (17.7% vs 15.7%; P < .0001). A greater percentage of patients were admitted to the intensive care unit (ICU; 89.9% vs 83.9%; P < .0001) and had a longer hospital stay (16.1 vs 15.2; P < .0001) at ACS level 1 trauma centers. In a regression analysis, patients at level 1 centers were associated with a 14% and 17% increased odds of obtaining a cranial surgery or ICP monitor, respectively. Patients treated at a level 1 center were associated with a 6% decrease in odds of mortality (P = .01). CONCLUSION ACS level 1 designation did correlate with increased rates of neurosurgical intervention and ICU admissions. This translated into patient outcomes as those treated at level 1 facilities were associated with lower rates of mortality.

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Early Prognostication after Traumatic Brain Injury: Specific Validation of the IMPACT Prognostic Calculator in a Level 1 Trauma Center

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1685137 ◽

2019 ◽

Vol 80 (06) ◽

pp. 423-429

Author(s):

Anna Jung ◽

Felix Arlt ◽

Maciej Rosolowski ◽

Jürgen Meixensberger

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Trauma Center ◽

Roc Analysis ◽

Time Frame ◽

Extended Model ◽

Severe Tbi ◽

Level 1 ◽

The Impact ◽

Level 1 Trauma Center

AbstractThe present study evaluated the usefulness of the IMPACT prognostic calculator (IPC) for patients receiving acute neurointensive care at a level 1 trauma center in Germany. A total of 139 patients with traumatic brain injury (TBI) were assessed. One day after trauma, the extended model of the IPC was found to provide the most valid prediction of 6-month mortality/unfavorable outcome. Different time frames within the first day could be determined by analyzing mild, moderate, and severe TBI cohorts. The CORE + CT model at time frame Z2 (<6 h from the point of first documentation) for mild TBI exhibited the highest values in the receiver operating characteristic (ROC) analysis (area under the curve [AUC], 0.9; sensitivity, 1; specificity, 0.7). For patients with moderate head injury at time frame Z2/3 (<6–12 h from point of first documentation), the extended model fit best. For patients with severe TBI, the extended model at time frame Z6 (48–72 h from point of first documentation) best predicted 6-month mortality and unfavorable outcome (ROC analysis: AUC, 0.542/0.445; sensitivity, 0.167/0.364; specificity, 0.575/0.444). Center-specific validation demonstrated the validity of the IPC in the early phase after TBI. These findings support the usefulness of the IPC for predicting the prognosis of patients with TBI. However, further prospective validation using a larger TBI cohort is needed.

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Identifying trauma patients with benefit from direct transportation to Level-1 trauma centers

BMC Emergency Medicine ◽

10.1186/s12873-021-00487-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Charlie A. Sewalt ◽

Benjamin Y. Gravesteijn ◽

Daan Nieboer ◽

Ewout W. Steyerberg ◽

Dennis Den Hartog ◽

...

Keyword(s):

Logistic Regression ◽

Trauma Center ◽

Trauma Patients ◽

Trauma Centers ◽

Absolute Benefit ◽

Predicted Probability ◽

Prehospital Triage ◽

Level 1 ◽

Level 1 Trauma Center ◽

Level 2

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.

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Efforts to Improve Appropriate Trauma Activation for Patients Transferred to a Level 1 Trauma Center From Outside Hospitals

The American Surgeon ◽

10.1177/0003134820919732 ◽

2020 ◽

Vol 86 (5) ◽

pp. 467-475

Author(s):

Sara Seegert ◽

Roberta E. Redfern ◽

Bethany Chapman ◽

Daniel Benson

Keyword(s):

Injury Severity ◽

Trauma Centers ◽

Activation Level ◽

American College Of Surgeons ◽

Before And After ◽

Trauma Response ◽

Level 1 ◽

Transferred Patients ◽

Trauma Activation ◽

Level 1 Trauma Center

Trauma centers monitor under- and overtriage rates to comply with American College of Surgeons Committee on Trauma verification requirements. Efforts to maintain acceptable rates are often undertaken as part of quality assurance. The purpose of this project was to improve the institutional undertriage rate by focusing on appropriately triaging patients transferred from outside hospitals (OSHs). Trauma physicians received education and pocket cards outlining injury severity score (ISS) calculation to aid in prospectively estimating ISS for patients transferred from OSHs, and activate the trauma response expected for that score. Under- and overtriage rates before and after the intervention were compared. The postintervention period saw a significant decrease in overall overtriage rate, with simultaneous trend toward lower overall undertriage rate, attributable to the significant reduction in undertriage rate of patients transferred from OSHs. Prospectively estimating ISS to assist in determining trauma activation level shows promise in managing appropriate patient triage. However, questions arose regarding the necessity for full trauma activation for transferred patients, regardless of ISS. It may be necessary to reconsider how patients transferred from OSHs are evaluated. Full trauma activation can be a financial and resource burden, and should not be taken lightly.

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Does the ‘halo effect’ of trauma center verification extend to severe postpartum hemorrhage? A four-year retrospective review of level 1 trauma centers in the United States

Trauma ◽

10.1177/1460408620943485 ◽

2020 ◽

pp. 146040862094348

Author(s):

Phoenix Vuong ◽

Arturo Torices Dardon ◽

Chun-Cheng Chen ◽

Sarah Stankiewicz ◽

Daniel Skupski ◽

...

Keyword(s):

Respiratory Failure ◽

Organ Failure ◽

Postpartum Hemorrhage ◽

Odds Ratio ◽

Trauma Center ◽

Halo Effect ◽

Trauma Centers ◽

Comorbidity Index ◽

Level 1 ◽

Level 1 Trauma Center

Introduction Designated high-quality trauma services have been shown to improve outcomes of trauma patients by virtue of access to specialized personnel and resources. It remains unclear if a ‘halo effect’ extends these benefits more generally to non-trauma populations. Obstetric patients who develop severe postpartum hemorrhage often require close attention in intensive care units and utilize more resources. Given the overlapping needs between trauma and obstetric patients, we hypothesize that the ‘halo effect’ might extend to patients with severe postpartum hemorrhage. Methods The Nationwide Inpatient Sample for years 2008 to 2011 was queried. Patients with severe postpartum hemorrhage were identified as those requiring transfusion, hysterectomy, or uterine repair. After stratifying by level 1 trauma center versus non-level 1 trauma center status, unadjusted univariate comparisons were made. Adjusted odds ratio of end-organ failure and death were analyzed using multivariable logistic regression. Results A total of 11,135 patients were identified with severe postpartum hemorrhage. The majority were hospitalized at non-level 1 trauma centers rather than level 1 trauma centers (71.4% vs. 28.6%). Patients at non-level 1 trauma centers were younger, more likely to be white, admitted electively, insured, and healthier with a lower comorbidity index. There was no significant difference in rates of mortality or organ failure. However, after adjustment for differences in comorbidity index, race, and emergency admission, patients at non-level 1 trauma centers had a significantly higher risk of respiratory failure (odds ratio, 1.27; 95% confidence interval, 1.01–1.59). Conclusions These findings suggest that the outcomes of obstetric patients with severe postpartum hemorrhage admitted in level 1 trauma centers are not overall significantly different when compared to those in non-level 1 trauma centers. However, after adjusting for baseline characteristics, there was a reduced risk of respiratory failure in patients admitted to level 1 trauma centers.

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(P2-74) Does Implementation of Protocols Improve the Red Area Disposition Time of Emergency Department at a Level-1 Trauma Center?

Prehospital and Disaster Medicine ◽

10.1017/s1049023x11005188 ◽

2011 ◽

Vol 26 (S1) ◽

pp. s160-s160

Author(s):

R. Kumar ◽

K. Shyamla ◽

S. Bhoi ◽

T.P. Sinha ◽

S. Chauhan ◽

...

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Trauma Center ◽

Safety Issues ◽

Ed Visits ◽

Level 1 ◽

The Impact ◽

Level 1 Trauma Center ◽

Final Disposition ◽

Disposition Time

BackgroundAcute care addresses immediate resuscitation and early disposition to definitive care. Delay in final disposition from the emergency department (ED) affects outcomes in terms of morbidity and mortality. An audit was performed to assess the impact of protocols on red area disposition time.MethodsAn audit of red (resuscitation) area disposition time was performed among patients with compromised airway, breathing, and circulation. The red area disposition time was defined as the time from ED arrival to red area disposition. Pre-protocol data from nursing report books were reviewed for ED to operating room (OR), ED to intensive care unit (ICU), and overall disposition time between September 2007 and January 2008. Similar outcomes were documented after implementation of protocols during February to December 2008.ResultsIn the pre-protocol period, 992 red area patients were enrolled out of 10,000 ED visits. Out of which 527 (53.1%) were shifted to the OR and 222 (22.3%) to ICU. The average ED disposition time was 3.5 hours (range 2–5). Similarly, 1797 red area patients were enrolled in the post-protocol period out of 25,928. Of these, 453 (25.2%) patients were shifted to the OR, and 423 (23.7%) were shifted to the ICU. The average ED disposition time was 1.5 hours (range 10 minutes–3 hours).ConclusionsImplementation of protocols improves the red area disposition time of the ED. Auditing is an important tool to address patient safety issues.

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Good Neighbors? The Effect of a Level 1 Trauma Center on the Performance of Nearby Level 2 Trauma Centers

Annals of Surgery ◽

10.1097/sla.0b013e3182122346 ◽

2011 ◽

Vol 253 (5) ◽

pp. 992-995 ◽

Cited By ~ 6

Author(s):

Barbara Haas ◽

David Gomez ◽

Melanie Neal ◽

Christopher Hoeft ◽

Najma Ahmed ◽

...

Keyword(s):

Trauma Center ◽

Trauma Centers ◽

Level 1 ◽

Level 1 Trauma Center ◽

Level 2

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B-17 The impact of a hospital-based air ambulance program on a level 1 trauma center

AeroMedical Journal ◽

10.1016/s0894-8321(87)80148-1 ◽

1987 ◽

Vol 2 (5) ◽

pp. 36

Author(s):

Kevin Fitzpatrick ◽

Joseph A. Moylan ◽

Gregory Georgiade ◽

Rita Weber

Keyword(s):

Trauma Center ◽

Air Ambulance ◽

Level 1 ◽

The Impact ◽

Level 1 Trauma Center

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The Relationship between Hospital Volume and In-Hospital Mortality of Severely Injured Patients in Dutch Level-1 Trauma Centers

Journal of Clinical Medicine ◽

10.3390/jcm10081700 ◽

2021 ◽

Vol 10 (8) ◽

pp. 1700

Author(s):

Charlie Sewalt ◽

Esmee Venema ◽

Erik van Zwet ◽

Jan van Ditshuizen ◽

Stephanie Schuit ◽

...

Keyword(s):

Hospital Mortality ◽

Trauma Center ◽

Hospital Volume ◽

Injury Severity ◽

Severely Injured ◽

Trauma Centers ◽

Severely Injured Patients ◽

Level 1 ◽

Injured Patients ◽

Level 1 Trauma Center

Centralization of trauma centers leads to a higher hospital volume of severely injured patients (Injury Severity Score (ISS) > 15), but the effect of volume on outcome remains unclear. The aim of this study was to determine the association between hospital volume of severely injured patients and in-hospital mortality in Dutch Level-1 trauma centers. A retrospective observational cohort study was performed using the Dutch trauma registry. All severely injured adults (ISS > 15) admitted to a Level-1 trauma center between 2015 and 2018 were included. The effect of hospital volume on in-hospital mortality was analyzed with random effects logistic regression models with a random intercept for Level-1 trauma center, adjusted for important demographic and injury characteristics. A total of 11,917 severely injured patients from 13 Dutch Level-1 trauma centers was included in this study. Hospital volume varied from 120 to 410 severely injured patients per year. Observed mortality rates varied between 12% and 24% per center. After case-mix correction, no statistically significant differences between low- and high-volume centers were demonstrated (adjusted odds ratio 0.97 per 50 extra patients per year, 95% Confidence Interval 0.90–1.04, p = 0.44). The variation in hospital volume of the included Level-1 trauma centers was not associated with the outcome of severely injured patients. Our results suggest that well-organized trauma centers with a similar organization of care could potentially achieve comparable outcomes.

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Impact of Crystalloid to PRBC Ratio in Patients with Exsanguinating Penetrating Abdominal Injuries: The Conundrum of Resuscitation

Panamerican Journal of Trauma, Critical Care & Emergency Surgery ◽

10.5005/jp-journals-10030-1058 ◽

2013 ◽

Vol 2 (1) ◽

pp. 52-57

Author(s):

Marie Unruh ◽

Marquinn Duke ◽

Peter Meade ◽

Norman E McSwain ◽

Juan C Duchesne

Keyword(s):

Logistic Regression ◽

Trauma Center ◽

Survival Benefit ◽

High Ratio ◽

Abdominal Injuries ◽

Hemostatic Resuscitation ◽

Level 1 ◽

Overall Survival Benefit ◽

The Impact ◽

Level 1 Trauma Center

ABSTRACT Background When intraoperative hemostatic resuscitation (IHR) implements high transfusion ratios of FFP:PRBC (>1:2), there is an associated increased survival in patients with exsanguinating penetrating abdominal injuries (EPAI). The impact of crystalloids: PRBC during IHR has not been analyzed. We hypothesize that minimizing the amount of intraoperative crystalloids:PRBC in combination with high ratio FFP: PRBC will correlate with a survival benefit in patients with EPAI. Methods This was a 9-year retrospective analysis of patients with EPAI at a Level 1 Trauma Center. EPAI was defined as any patient who received >20 units of PRBC during IHR. Intraoperative ratio for FFP:PRBC was recorded, and patients were placed in three separate categories accordingly: high (>1:2), mid (1:4 - 1:2), and low ratio (<1:4) groups. Quantity of crystalloids used during each category was recorded and a ratio of crystalloids:PRBC calculated. Logistic regression model was applied to analyze impact of crystalloid:PRBC on mortality, comparing the high FFP:PRBC ratio group to the low FFP: PRBC ratio group. Results Intraoperative high ratio FFP:PRBC conveyed a 32% overall survival benefit when compared with low ratio groups. Patients that received a high ratio FFP:PRBC when compared to low ratio group, received less intraoperative crystalloids (calculated crystalloids:PRBC ratios 1:3.4 vs 1:1.1; p = 0.001). Our logistic regression demonstrated a survival benefit with a high FFP:PRBC [OR 95%;0.19 , CI (0.05-0.33), p = 0.003] and the calculated low crystalloid:PRBC [OR 95%; 0.11 CI (0.01- 0.59), p = 0.001]. Conclusion We were able to demonstrate a survival advantage in patients with EPAI that received IHR of a high ratio of FFP:PRBC and a low ratio of crystalloids:PRBC. These findings suggest that in patients with EAPI requiring massive volumes of PRBC, the ratio of intraoperative FFP:PRBC should be high and crystalloids:PRBC should be low. How to cite this article Guidry C, Unruh M, Duke M, Meade P, McSwain NE Jr, Duchesne JC. Impact of Crystalloid to PRBC Ratio in Patients with Exsanguinating Penetrating Abdominal Injuries: The Conundrum of Resuscitation. Panam J Trauma Critical Care Emerg Surg 2013;2(1):52-57.

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