How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study

ObjectiveTo evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system.SettingICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million.Participants5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only.ResultsA higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit.ConclusionThe Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.

Download Full-text

Factors associated with interhospital transfer of children with respiratory failure from level II to level I pediatric intensive care units

Journal of Critical Care ◽

10.1016/j.jcrc.2015.06.008 ◽

2015 ◽

Vol 30 (5) ◽

pp. 1080-1084 ◽

Cited By ~ 4

Author(s):

Folafoluwa O. Odetola ◽

Sarah J. Clark ◽

James G. Gurney ◽

Janet E. Donohue ◽

Achamyeleh Gebremariam ◽

...

Keyword(s):

Intensive Care ◽

Respiratory Failure ◽

Intensive Care Units ◽

Pediatric Intensive Care ◽

Pediatric Intensive Care Units ◽

Factors Associated ◽

Interhospital Transfer ◽

Level Ii ◽

Level I

Download Full-text

Characteristics and outcomes of inter-hospital transfers from Level II to Level I pediatric intensive care units

Pediatric Critical Care Medicine ◽

10.1097/00130478-200611000-00047 ◽

2006 ◽

Vol 7 (6) ◽

pp. 617

Author(s):

Folafoluwa O. Odetola ◽

Thomas P. Shanley ◽

James G. Gurney ◽

Sarah J. Clark ◽

Ronald E. Dechert ◽

...

Keyword(s):

Intensive Care ◽

Intensive Care Units ◽

Pediatric Intensive Care ◽

Pediatric Intensive Care Units ◽

Level Ii ◽

Level I

Download Full-text

Laparoscopy in the Evaluation of Blunt Abdominal Injury in Level-I and II Pediatric Trauma Centers

The American Surgeon ◽

10.1177/00031348211033535 ◽

2022 ◽

pp. 000313482110335

Author(s):

Aryan Haratian ◽

Areg Grigorian ◽

Karan Rajalingam ◽

Matthew Dolich ◽

Sebastian Schubl ◽

...

Keyword(s):

Abdominal Surgery ◽

Trauma Center ◽

Injury Severity ◽

Pediatric Trauma ◽

Trauma Patients ◽

Improvement Program ◽

Blunt Abdominal Injury ◽

Level Ii ◽

American College Of Surgeons ◽

Level I

Introduction An American College of Surgeons (ACS) Level-I (L-I) pediatric trauma center demonstrated successful laparoscopy without conversion to laparotomy in ∼65% of trauma cases. Prior reports have demonstrated differences in outcomes based on ACS level of trauma center. We sought to compare laparoscopy use for blunt abdominal trauma at L-I compared to Level-II (L-II) centers. Methods The Pediatric Trauma Quality Improvement Program was queried (2014-2016) for patients ≤16 years old who underwent any abdominal surgery. Bivariate analyses comparing patients undergoing abdominal surgery at ACS L-I and L-II centers were performed. Results 970 patients underwent abdominal surgery with 14% using laparoscopy. Level-I centers had an increased rate of laparoscopy (15.6% vs 9.7%, P = .019 ); however they had a lower mean Injury Severity Score (16.2 vs 18.5, P = .002) compared to L-II centers. Level-I and L-II centers had similar length of stay ventilator days, and SSIs (all P > .05). Conclusion While use of laparoscopy for pediatric trauma remains low, there was increased use at L-I compared to L-II centers with no difference in LOS or SSIs. Future studies are needed to elucidate which pediatric trauma patients benefit from laparoscopic surgery.

Download Full-text

Characteristics and Outcomes of Inter-hospital Transfers from Level II to Level I Pediatric Intensive Care Units

Pediatric Critical Care Medicine ◽

10.1097/00130478-200611000-00043 ◽

2006 ◽

Vol 7 (6) ◽

pp. 616

Author(s):

&NA;

Keyword(s):

Intensive Care ◽

Intensive Care Units ◽

Pediatric Intensive Care ◽

Pediatric Intensive Care Units ◽

Level Ii ◽

Level I

Download Full-text

Pediatric Trauma System Evaluation before and after Level II Verification

The American Surgeon ◽

10.1177/000313481908501137 ◽

2019 ◽

Vol 85 (11) ◽

pp. 1281-1287

Author(s):

Michael D. Dixon ◽

Scott Engum

Keyword(s):

Native American ◽

Trauma Center ◽

Injury Severity ◽

Life Support ◽

Pediatric Trauma ◽

Trauma System ◽

Trauma Centers ◽

Level Ii ◽

Level I ◽

Pediatric Trauma Center

ACS-verified trauma centers show higher survival and improved mortality rates in states with ACS-verified Level I pediatric trauma centers. However, few significant changes are appreciated in the first two years after verification. Minimal research exists examining verification of ACS Level II pediatric trauma centers. We analyzed ACS Level II pediatric trauma verification at our institution. In 2014, Sanford Medical Center Fargo became the only Level II pediatric trauma center in North Dakota, as well as the only center between Spokane and Minneapolis. A retrospective review of the institution's pre-existing trauma database one year pre- and postverification was performed. Patients aged <18 years were included in the study ( P < 0.05). Patient number increased by 23 per cent, from 167 to 205 patients. A statistically significant increase occured in the three to six year old age group ( P = 0.0002); motorized recreational vehicle ( P = 0.028), violent ( P = 0.009), and other ( P = 0.0374) mechanism of injury categories; ambulance ( P = 0.0124), fixed wing ( P = 0.0028), and personal-owned vehicle ( P = 0.0112) modes of transportation. Decreased public injuries ( P = 0.0071) and advanced life support ambulance transportation ( P = 0.0397). The study showed a nonstatistically significant increase in mean Injury Severity Score (from 6.3 to 7) and Native American trauma (from 14 to 20 per cent). Whereas prolonged ACS Level I pediatric trauma center verification was found to benefit patients, minimal data exist on ACS Level II verification. Our findings are consistent with current Level I ACS pediatric trauma center data. Future benefits will require continued analysis because our Level II pediatric trauma center continues to mature and affect our rural and large Native American community.

Download Full-text

The Impact of American College of Surgeons Trauma Center Designation and Outcomes after Early Thoracotomy: A National Trauma Databank Analysis

The American Surgeon ◽

10.1177/000313481207800123 ◽

2012 ◽

Vol 78 (1) ◽

pp. 36-41 ◽

Cited By ~ 5

Author(s):

Marko Bukur ◽

Bernardino Castelo Branco ◽

Kenji Inaba ◽

Ramon Cestero ◽

Leslie Kobayashi ◽

...

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Trauma Patients ◽

National Trauma ◽

Level Ii ◽

Pressure Time ◽

Significant Difference ◽

American College Of Surgeons ◽

Level I ◽

The Impact

Trauma centers are designated by the American College of Surgeons (ACS) into four different levels based on resources, volume, and scientific and educational commitment. The purpose of this study was to evaluate the relationship between ACS center designation and outcomes after early thoracotomy for trauma. The National Trauma Databank (v. 7.0) was used to identify all patients who required early thoracotomy. Demographics, clinical data, and outcomes were extracted. Patients were categorized according to ACS trauma center designation. Multivariate logistic regression was used to evaluate the impact of ACS trauma center designation on mortality. From 2002 to 2006, 1834 (77.4%) patients were admitted to a Level I ACS verified trauma center, 474 (20.0%) to a Level II, and 59 (3.6%) to a Level III/IV facility. After adjusting for differences between the groups, there were no significant differences in mortality (overall: 53.3% for Level I, 63.1% for Level II, and 52.5% for Level III/IV, adjusted P = 0.417; or for patients arriving in cardiac arrest: 74.9% vs 87.1% vs 85.0%, P = 0.261). Subgroup analysis did not show any significant difference in survival irrespective of mechanism of injury. Glasgow Coma Scale score # 8, Injury Severity Score >16, no admission systolic blood pressure, time from admission to thoracotomy, and nonteaching hospitals were found to be independent predictors of death. For trauma patients who have sustained injuries requiring early thoracotomy, ACS trauma center designation did not significantly impact mortality. Nonteaching institutions however, were independently associated with poorer outcomes after early thoracotomy. These findings may have important implications in educational commitment of institutions. Further prospective evaluation of these findings is warranted.

Download Full-text

Geriatric Trauma Mortality: Does Trauma Center Level Matter?

The American Surgeon ◽

10.1177/0003134820983190 ◽

2020 ◽

pp. 000313482098319

Author(s):

Frederick B. Rogers ◽

Madison E. Morgan ◽

Catherine Ting Brown ◽

Tawnya M. Vernon ◽

Kellie E. Bresz ◽

...

Keyword(s):

Geriatric Patients ◽

Injury Severity ◽

Data Bank ◽

Absolute Number ◽

Geriatric Trauma ◽

Multivariate Logistic Regression Model ◽

Trauma Patients ◽

Adjusted Analysis ◽

Level Ii ◽

Level I

Background Given their mostly rural/suburban locations, level II trauma centers (TCs) may offer greater exposure to and experience in managing geriatric trauma patients. We hypothesized that geriatric patients would have improved outcomes at level II TCs compared to level I TCs. Methods The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for geriatric (age ≥65 years) trauma patients admitted to level I and II TCs in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in care between level I and II TCs. A multivariate logistic regression model assessed the adjusted impact of care at level I vs II TCs on mortality, complications, and functional status at discharge (FSD). The National Trauma Data Bank (NTDB) was retrospectively queried for geriatric (age ≥65 years) trauma admissions to state-accredited level I or level II TCs in 2013. Results 112 648 patients met inclusion criteria. The proportion of geriatric trauma patients across level I and level II TCs were determined to be 29.1% and 36.2% ( P <.001), respectively. In adjusted analysis, there was no difference in mortality (adjusted odds ratio [AOR]: 1.13; P = .375), complications (AOR: 1.25; P = .080) or FSD (AOR: 1.09; P = .493) when comparing level I to level II TCs. Adjusted analysis from the NTDB (n = 144 622) also found that mortality was not associated with TC level (AOR: 1.04; P = .182). Discussion Level I and level II TCs had similar rates of mortality, complications, and functional outcomes despite a higher proportion (but lower absolute number) of geriatric patients being admitted to level II TCs. Future consideration for location of centers of excellence in geriatric trauma should include both level I and II TCs.

Download Full-text