scholarly journals Is higher-level trauma center care associated with better outcomes in patients injured by low-energy trauma?

2021 ◽  
Author(s):  
Michael Tonkins ◽  
Daniel Bradbury ◽  
Paul Bramley ◽  
Lisa Sabir ◽  
Anna Wilkinson ◽  
...  
Keyword(s):  
Trauma Center ◽  
Ground Level ◽  
Risk Of Bias ◽  
Low Energy ◽  
Trauma Centers ◽  
Improved Outcomes ◽  
Center Care ◽  
The Usa ◽  
Level 3 ◽  
Level 1

Background In high-income countries trauma patients are becoming older, more likely to have comorbidities, and are being injured by low-energy mechanisms, chiefly ground-level falls. It is currently unknown whether existing trauma systems improve the outcomes of these patients. This systematic review investigates the association between higher-level trauma center care and outcomes of adult patients who were admitted to hospital due to injuries sustained following low-energy trauma. Methods A pre-registered systematic review (CRD42020211652) of subject databases and grey literature, supplemented by targeted manual searching, was conducted in January 2021. Studies were eligible if they reported outcomes in adults admitted to hospital due to low-energy trauma. Studies were excluded if participants were not adults or were not admitted to hospital. Studies in lower- and middle-income settings were excluded due to differences in demographics and healthcare systems. Risk of bias was assessed by independent reviewers using the Robins-I tool. In the presence of study heterogeneity a narrative synthesis was pre-specified. Results Three observational studies were included from 2,898 unique records. The studies' risk of bias was moderate-to-serious due to potential residual confounding and selection bias. All studies compared outcomes among adults injured by ground-level falls treated in trauma centers verified by the American College of Surgeons in the USA. The studies reported divergent results. One demonstrated improved outcomes in level 3 or 4 trauma centers (Observed: Expected Mortality 0.973, 95%CI 0.971-0.975), one demonstrated improved outcomes in level 1 trauma centers (Adjusted Odds Ratio 0.71, 95%CI 0.56-0.91), and one demonstrated no difference between level 1 or 2 and level 3 or 4 trauma center care (Adjusted Odds Ratio 0.91 (0.80-1.04). Conclusions There is currently no strong evidence for the efficacy of major trauma centers in caring for adult patients injured by a ground-level fall. Further studies at lower risk of bias and studies conducted outwith the USA are required.

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

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.

scholarly journals Effect of the COVID-19 pandemic on the ability of level 1 trauma centers to meet American College of Surgeons research requirements

2021 ◽  
Vol 6 (1) ◽  
pp. e000692
Author(s):  
Robert M Madayag ◽  
Erica Sercy ◽  
Gina M Berg ◽  
Kaysie L Banton ◽  
Matthew Carrick ◽  
...  
Keyword(s):  
Cross Sectional Study ◽  
Trauma Centers ◽  
Level Of Evidence ◽  
Cross Sectional ◽  
American College Of Surgeons ◽  
The Usa ◽  
Virus Exposure ◽  
Level 1 ◽  
Verification Process ◽  
Question Survey

IntroductionThe COVID-19 pandemic has had major effects on hospitals’ ability to perform scientific research while providing patient care and minimizing virus exposure and spread. Many non-COVID-19 research has been halted, and funding has been diverted to COVID-19 research and away from other areas.MethodsA 28-question survey was administered to all level 1 trauma centers in the USA that included questions about how the pandemic affected the trauma centers’ ability to fulfill the volume and research requirements of level 1 verification by the American College of Surgeons (ACS).ResultsThe survey had a 29% response rate (40/137 successful invitations). Over half of respondents (52%) reported reduced trauma admissions during the pandemic, and 7% reported that their admissions dropped below the volume required for level 1 verification. Many centers diverted resources from research during the pandemic (44%), halted ongoing consenting studies (33%), and had difficulty fulfilling research requirements because of competing clinical priorities (40%).DiscussionResults of this study show a need for flexibility in the ACS verification process during the COVID-19 pandemic, potentially including reduction of the required admissions and/or research publication volumes.Level of evidenceLevel IV, cross-sectional study.

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

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Matthew Helton ◽  
Austin Porter ◽  
Kevin Thomas ◽  
Jeffrey C Henson ◽  
Mason Sifford ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Patient Outcomes ◽  
Trauma Center ◽  
Trauma Centers ◽  
Cranial Surgery ◽  
American College Of Surgeons ◽  
Severe Tbi ◽  
Level 1 ◽  
The Impact ◽  
Level 1 Trauma Center

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.

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 ◽  
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.

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

2011 ◽  
Vol 253 (5) ◽  
pp. 992-995 ◽  
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

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

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.

Maintaining trauma center operational readiness during a pandemic

2021 ◽  
Vol 16 (1) ◽  
pp. 25-34
Author(s):  
Alexander C. Cavalea, MD ◽  
Robin McGoey, MSGC, MD ◽  
Rebecca W. Schroll, MD, FACS ◽  
Patrick R. McGrew, MD ◽  
Jonathan E. Schoen, MD, MPH ◽  
...  
Keyword(s):  
New Orleans ◽  
Trauma Center ◽  
Medical Center ◽  
Lessons Learned ◽  
Trauma Centers ◽  
Surge Capacity ◽  
High Resource ◽  
Slow Moving ◽  
Level 1 ◽  
Level 1 Trauma Center

The coronavirus disease 2019 (COVID-19) pandemic is a slow-moving global disaster with unique challenges for maintaining trauma center operations. University Medical Center New Orleans is the only level 1 trauma center in New Orleans, LA, which became an early hotspot for COVID-19. Intensive care unit surge capacity, addressing components including space, staff, stuff, and structure, is important in maintaining trauma center operability during a high resource-strain event like a pandemic. We report management of the trauma center’s surge capacity to maintain trauma center operations while assisting in the care of critically ill COVID-19 patients. Lessons learned and recommendations are provided to assist trauma centers in planning for the influx of COVID-19 patients at their centers.

Population Coverage of Trauma Systems: What Do Helicopters Add?

2019 ◽  
Vol 85 (9) ◽  
pp. 1073-1078
Author(s):  
W. Andrew Smedley ◽  
K. Lorraine Stone ◽  
John Killian ◽  
Allison Brown ◽  
Paige Farley ◽  
...  
Keyword(s):  
Trauma Center ◽  
Trauma Patients ◽  
Trauma Centers ◽  
Trauma Systems ◽  
Timely Response ◽  
Center Care ◽  
Added Benefit ◽  
Level I ◽  
Time Critical ◽  
Drive Time

Trauma is a time-critical condition. Helicopters are thought to enhance the accessibility to trauma centers, but this benefit is poorly quantified. The aim of this study was to conduct a geographical analysis of the added benefit provided by helicopters, over ground transport. This study uses geospatial analysis. Helicopter bases and Level I and II designated trauma centers were geocoded. 60-minute drive-time and elliptical flight-time isochrones were mapped with ArcGIS™ (Esri, Redlands, CA). Calculations included allowance for mission ground time (MGT). We compared the proportion of the population that could be taken to Level I and II trauma centers, within 60 minutes, by road and by air. Using a 30-minute MGT model, helicopters permit 279,317 additional residents (5.8%) access to a Level I trauma center within 60 minutes. Using the 20-minute MGT model, 1,089,177 more residents (22.8%) would have access to Level I trauma center care. The benefits were marginally greater for access to Level I and II trauma center care. Helicopters enhance access to specialist trauma center care, but the benefit is small and dependent on MGT. Consideration should be given to the siting of helicopters, particularly in relation to trauma patients, MGT, and the timely response of EMS when determining the triage for helicopter transport.

scholarly journals Chronic hyponatremia in patients with proximal femoral fractures after low energy trauma: A retrospective study in a level-1 trauma center

Bone Reports ◽  
2020 ◽  
Vol 12 ◽  
pp. 100234
Author(s):  
Daniel Bernd Hoffmann ◽  
Christian Popescu ◽  
Marina Komrakova ◽  
Lena Welte ◽  
Dominik Saul ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Trauma Center ◽  
Femoral Fractures ◽  
Low Energy ◽  
Proximal Femoral Fractures ◽  
Chronic Hyponatremia ◽  
Level 1 ◽  
Level 1 Trauma Center

scholarly journals Higher Volume Predicts Improved Outcomes for Severe Pediatric Traumatic Brain Injury Patients at Level 1 and 2 Trauma Centers

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Anna Kimata ◽  
Oliver Young Tang ◽  
Wael Asaad
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Odds Ratio ◽  
Pediatric Trauma ◽  
Complication Rates ◽  
Trauma Centers ◽  
Pediatric Traumatic Brain Injury ◽  
Improved Outcomes ◽  
Level 1 ◽  
Pediatric Tbi

Abstract INTRODUCTION Recent research has demonstrated improved outcomes for trauma patients at higher volume institutions. However, the volume-outcome relationship for severe pediatric traumatic brain injury (TBI) patients, specifically, has yet to be demonstrated. METHODS We isolated all severe pediatric TBI admissions (GCS admission score 3-8) to pediatric American College of Surgeons (ACS) level 1 and 2 trauma centers in the 2012 National Trauma Data Bank. Pediatric TBI volume was analyzed on a continuous scale as the primary independent variable. Our outcome variables were mortality, hospital discharge disposition (home, rehab/other care facility, died/hospice), presence of complications (deep vein thrombosis [DVT], cardiac arrest, cerebrovascular accident, acute respiratory distress syndrome [ARDS], urinary tract infection [UTI], pneumonia), length of stay (LOS), and intensive care unit (ICU) days. We utilized multivariate analyses to adjust for the following confounding variables: injury type, age, gender, race, hospital teaching status, region of hospital, ISS, comorbidities (hypertension, bleeding disorder, congenital anomalies, respiratory disease), and GCS at admission. Statistical significance was assessed at P < .05. RESULTS There were 1441 severe pediatric TBI admissions in 69 unique pediatric ACS level 1 or 2 trauma centers in 2012. Following multivariate adjustment, the treatment at hospitals with a higher pediatric TBI volume was associated with a shorter LOS (0.5 d per +10 patients, P = .02) and higher odds of discharge home (odds ratio = 1.08 per +10 patients, P = .01). Moreover, patients at higher volume centers had a lower risk of complications (odds ratio = 0.91 per +10 patients, P = .01), particularly ARDS (odds ratio = 0.64 per +10 patients, P < .001) and pneumonia (odds ratio = 0.89 per +10 patients, P = .047). CONCLUSION Among level 1 and 2 pediatric trauma care facilities, patients treated at higher volume centers had lower complication rates, a more favorable discharge, and a shorter LOS. This suggests a need to investigate differences in approach to care between higher and lower volume hospitals and consider the role of transfer and referral networks in optimizing care.

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