The Price of Always Saying Yes: A Cost Analysis of Secondary Overtriage to an Urban Level I Trauma Center

2018 ◽  
Vol 84 (8) ◽  
pp. 1368-1375 ◽  
Author(s):  
Marko Bukur ◽  
Candace Teurel ◽  
Joseph Catino ◽  
Stanley Kurek
Keyword(s):  
Trauma Center ◽  
Injury Severity ◽  
Tissue Injury ◽  
Spinal Injury ◽  
Financial Burden ◽  
Trauma System ◽  
Soft Tissue Injury ◽  
Cost Savings ◽  
Urban Level ◽  
Level I

Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the “Orange Book” transfer criteria and who had a length of stay of <48 hours. Average ED and transport charges were calculated for total transfer charges. A total of 2397 TT were treated. The number of TT increased over the study interval. The mean age of TT was 59.7 years (SD ± 26.4 years); patients were predominantly male (59.2%), white (83.2%), with at least one comorbidity (71.5%). Blunt trauma accounted for 96.8 per cent of admissions with a median Injury Severity Score of nine (IQR: 5–16). Predominant injuries were isolated closed head trauma (61.4%), skin/soft tissue injury (18.9%), and spinal injury (17.6%). SOT was 48.2 per cent and increased yearly (P < 0.001). The median trauma center charge for SOT was ($27,072; IQR: $20,089–34,087), whereas ED charges were ($40,440; IQR: $26,150–65,125), resulting in a total cost of $67,512/patient. A liberal TT policy results in a high SOT rate adding significant unnecessary costs to the health-care system. Efforts to establish transfer guidelines may allow for significant cost savings without compromising care.

Right Patient, Right Place, Right Time

2020 ◽  
pp. 000313482094738
Author(s):  
Benjamin L. Gough ◽  
Matthew D. Painter ◽  
Autumn L. Hoffman ◽  
Richard J. Caplan ◽  
Cynthia A. Peters ◽  
...  
Keyword(s):  
Propensity Score ◽  
Trauma Center ◽  
Injury Severity ◽  
Linear Regression Analysis ◽  
Trauma System ◽  
Hospital Length Of Stay ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
Level I ◽  
Transferred Patients

Introduction This study sought to compare outcomes of trauma patients taken directly from the field to a Level I trauma center (direct) versus patients that were first brought to a Level III trauma center prior to being transferred to a Level I (transfer) within our inclusive Delaware trauma system. Methods A retrospective review of the Level I center’s trauma registry was performed using data from 2013 to 2017 for patients brought to a single Level I trauma center from 2 surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. Results When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared with direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (odds ratio [OR] 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality ( P < .001). ISS was predictive of increased risk of mortality ( P < .001), increased LOS ( P < .001), and craniotomy ( P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred ( P < .001). Discussion Delays in the presentation to our Level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

Pediatric Trauma System Evaluation before and after Level II Verification

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.

Defining Early Trauma-induced Coagulopathy Using Thromboelastography

2014 ◽  
Vol 80 (10) ◽  
pp. 994-998 ◽  
Author(s):  
Douglas Z. Liou ◽  
Hedyeh Shafi ◽  
Matthew B. Bloom ◽  
Rex Chung ◽  
Eric J. Ley ◽  
...  
Keyword(s):  
Trauma Center ◽  
Injury Severity ◽  
Abbreviated Injury Scale ◽  
Trauma Induced Coagulopathy ◽  
High Acuity ◽  
Urban Level ◽  
Level I ◽  
Early Trauma ◽  
Mean Time ◽  
Clear Description

Early trauma-induced coagulopathy (ETIC) is abnormal coagulation detected on presentation, but a clear description is lacking. We used thromboelastography (TEG) to characterize ETIC. Data were prospectively collected on high-acuity trauma activations at an urban Level I trauma center between July 2012 and May 2013. Patients with admission TEG before any blood transfusion were stratified by Injury Severity Score (ISS): mild (less than 16), moderate (16 to 24), severe (25 or greater). TEG parameters were compared between groups. ETIC was defined as any abnormality detected on TEG. Fifty-two patients were included; mean age was 49 years and mean time to the emergency department was 26 minutes. Mean ISS for the cohort was 17 with 28 patients in mild, eight in moderate, and 16 in severe. Glasgow Coma Score was lower and head Abbreviated Injury Scale was higher in severe ( P < 0.001). Forty-three (83%) patients had an abnormal TEG. Shortened reaction (R) time was noted in 42 patients. There were no differences in any TEG parameters between the injury severity groups. Hyperfibrinolysis was detected in four (8%) patients. ETIC was present in over 80 per cent of high-acuity trauma activations irrespective of injury severity and characterized primarily by shortened R time, indicating ETIC is initially described by a hypercoagulable state as a result of thrombin generation.

Trauma System Overtriage: Are We on Track?

2014 ◽  
Vol 80 (10) ◽  
pp. 960-965 ◽  
Author(s):  
Zoe Fullerton ◽  
Graham W. Donald ◽  
Henry G. Cryer ◽  
Catherine E. Lewis ◽  
Ali Cheaito ◽  
...  
Keyword(s):  
Emergency Department ◽  
Retrospective Study ◽  
Trauma Center ◽  
Injury Severity ◽  
Trauma System ◽  
Length Of Hospital Stay ◽  
Optimal Care ◽  
American College Of Surgeons ◽  
Level I ◽  
Trauma Activation

The American College of Surgeons (ACS) recommends trauma overtriage rate (OT) below 50 per cent to maximize efficiency while ensuring optimal care. This retrospective study was undertaken to evaluate OT rates in our Level I trauma center using the most recent criteria and guidelines. OT rates during a 12-month period were measured using six definitions based on combinations of Injury Severity Score (ISS), length of hospital stay (LOS, in days), procedures, and disposition after the emergency department. Reason for trauma activation was 55 per cent criteria, 16 per cent guidelines, 11 per cent paramedic judgment, five per cent no reason, and 13 per cent no documentation. OT rates ranged from 22.6 per cent (ISS less than 9, LOS 1 day or less, no consults) to 48.2 per cent (ISS less than 9, LOS 3 days or less, with procedures/consults) and were in compliance with ACS recommendations. Physiologic assessment criteria and anatomic injury had the lowest OT rates and contained all mortalities. Passenger space intrusion (PSI), pedestrian versus automobile (criterion and guideline), and extrication (guideline) all had consistently high rates of OT. We conclude that PSI should be reduced to a guideline, the pedestrian versus automobile criterion and guideline should be combined, and extrication could be removed from the triage scheme.

Analysis of Profit and Loss by Injury Severity over 20 Years at a University Level I Trauma Center

2016 ◽  
Vol 82 (7) ◽  
pp. 644-648
Author(s):  
Zachary Dietch ◽  
Jeffrey S. Young ◽  
Steven D. Young
Keyword(s):  
Trauma Center ◽  
Injury Severity ◽  
Positive Margin ◽  
Cost Data ◽  
Hospital Charges ◽  
Data Set ◽  
Average Loss ◽  
University Level ◽  
Level I ◽  
Injured Patients

We examined financial data from a University Level I Trauma Center from 1994 to 2014. We sought to investigate the hypothesis that lower injury severity correlates with increased profitability. We examined data from July 1994 to December 2014. This included hospital charges, Medicare cost data, final reimbursement, and payor source. Patients were separated into Injury Severity Score (ISS) groupings: 0 to 9, 10 to 14, 15 to 24, >24, and >14. Mean and standard deviation of mean are reported. We had complete data on 27,582 patients. Overall profit per case when subtracting costs from reimbursements was $1,932/case (total profit in unadjusted dollars = $53,475,828 or $2,673,791/year). When examined by ISS, profitability was significantly different between ISS 0 to 14 and 15 to 24, and > 24. When charge data were examined, the average loss per case was -$31,313 for the 27,582 patient data set. When using cost, and not charge data, overall trauma care had a positive margin. Severely injured patients (ISS > 14) were the most profitable, with a significantly higher profit per case than all other groupings. Only through examination of cost data can realistic determinations of trauma center profitability be made. If only charge data had been examined in this study, the overall loss from the 20-year period would have been $863,675,166 and not a profit of $53,475,828.

scholarly journals Usefulness of Pelvic Radiographs in the Initial Trauma Evaluation with Concurrent CT: Is Additional Radiation Exposure Necessary?

2018 ◽  
Vol 2018 ◽  
pp. 1-4 ◽  
Author(s):  
Anne K. Misiura ◽  
Autumn D. Nanassy ◽  
Jacqueline Urbine
Keyword(s):  
Trauma Center ◽  
Pediatric Trauma ◽  
Trauma Patients ◽  
Additional Information ◽  
Pelvic Radiographs ◽  
Pelvic Radiograph ◽  
Digital Radiograph ◽  
Urban Level ◽  
Level I ◽  
Pediatric Trauma Center

Trauma patients in a Level I Pediatric Trauma Center may undergo CT of the abdomen and pelvis with concurrent radiograph during initial evaluation in an attempt to diagnose injury. To determine if plain digital radiograph of the pelvis adds additional information in the initial trauma evaluation when CT of the abdomen and pelvis is also performed, trauma patients who presented to an urban Level I Pediatric Trauma Center between 1 January 2010 and 7 February 2017 in whom pelvic radiograph and CT of the abdomen and pelvis were performed within 24 hours of each other were analyzed. A total of 172 trauma patients had pelvic radiograph and CT exams performed within 24 hours of each other. There were 12 cases in which the radiograph missed pelvic fractures seen on CT and 2 cases in which the radiograph suspected a fracture that was not present on subsequent CT. Furthermore, fractures in the pelvis were missed on pelvic radiographs in 12 of 35 cases identified on CT. Sensitivity of pelvic radiograph in detecting fractures seen on CT was 65.7% with a 95% confidence interval of 47.79-80.87%. Results suggest that there is no added diagnostic information gained from a pelvic radiograph when concurrent CT is also obtained, a practice which exposes the pediatric trauma patient to unnecessary radiation.

Initial Approach to the Management of Multisystem Trauma

2019 ◽  
pp. 397-401
Author(s):  
David S. Morris
Keyword(s):  
Trauma Center ◽  
Injury Severity ◽  
Hospital Admissions ◽  
The United States ◽  
Emergency Department Visits ◽  
Severely Injured ◽  
Level Ii ◽  
Level I ◽  
Nonfatal Injuries ◽  
Injured Patients

Nearly 200,000 people die of injury-related causes in the United States each year, and injury is the leading cause of death for all patients aged 1 to 44 years. Approximately 30 million people sustain nonfatal injuries each year, which results in about 29 million emergency department visits and 3 million hospital admissions. Management of severely injured patients, typically defined as having an Injury Severity Score greater than 15 is best managed in a level I or level II trauma center. Any physician who provides care for critically ill patients should have a basic familiarity with the fundamentals of trauma care.

scholarly journals Evaluation of Protective Equipment Used Among Motorbike Riders

2019 ◽  
Vol 11 (2) ◽  
pp. 44-47 ◽  
Author(s):  
Roxanne Stiles ◽  
Clint Benge ◽  
P.J. Stiles ◽  
Fanglong Dong ◽  
Jeanette Ward ◽  
...  
Keyword(s):  
Retrospective Review ◽  
Trauma Center ◽  
Injury Severity ◽  
Protective Equipment ◽  
Safety Equipment ◽  
Hospital Outcomes ◽  
Equipment Usage ◽  
Level I

Introduction. This study compared outcomes between patientsinjured at a motorbike track, which requires riders to follow safetyequipment guidelines, and those involved in recreational riding wheresafety equipment usage is voluntary. Methods. A retrospective review was conducted of all patients presentingwith motorbike-related injuries at an American College ofSurgeons verified level-I trauma center between January 1, 2009 andDecember 31, 2013. Data collected included demographics, injurydetails, safety equipment use, hospitalization details, and dischargedisposition. Comparisons were made regarding protective equipmentusage. Results. Among the 115 patients admitted, more than half (54.8%, n =63) were injured on a motorbike track, and 45.2% (n = 52) were injuredin a recreational setting. The majority of patients were male (93.9%),Caucasian (97.4%), and between the ages of 18 to 54 (64.4%). Helmetusage was higher among track riders (95.2%, n = 60) than recreationalriders (46.2%, n = 24, p < 0.0001). Comparisons of injury severity andoutcomes between those who wore protective equipment and thosewho did not were not significant. Conclusions. Even though track riders wore protective equipmentmore than recreational riders, there was no difference between thegroups regarding injury severity or hospital outcomes. These resultssuggested that motocross riders should not rely on protective equipmentas the only measure of injury prevention.Kans J Med 2018;11(2):44-47.

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