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

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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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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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.

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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.

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Does emergency medicine length of stay predict trauma outcomes at a Level 1 Trauma Center?

Journal of Hospital Administration ◽

10.5430/jha.v4n5p1 ◽

2015 ◽

Vol 4 (5) ◽

pp. 1 ◽

Cited By ~ 2

Author(s):

Erin Powers Kinney ◽

Kamal Gursahani ◽

Eric Armbrecht ◽

Preeti Dalawari

Keyword(s):

Length Of Stay ◽

Trauma Center ◽

Injury Severity ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Hospital Capacity ◽

Significant Difference ◽

Level 1 ◽

Level 1 Trauma Center

Objective: Previous studies looking at emergency department (ED) crowding and delays of care on outcome measures for certain medical and surgical patients excluded trauma patients. The objectives of this study were to assess the relationship of trauma patients’ ED length of stay (EDLOS) on hospital length of stay (HLOS) and on mortality; and to examine the association of ED and hospital capacity on EDLOS.Methods: This was a retrospective database review of Level 1 and 2 trauma patients at a single site Level 1 Trauma Center in the Midwest over a one year period. Out of a sample of 1,492, there were 1,207 patients in the analysis after exclusions. The main outcome was the difference in hospital mortality by EDLOS group (short was less than 4 hours vs. long, greater than 4 hours). HLOS was compared by EDLOS group, stratified by Trauma Injury Severity Score (TRISS) category (< 0.5, 0.51-0.89, > 0.9) to describe the association between ED and hospital capacity on EDLOS.Results: There was no significant difference in mortality by EDLOS (4.8% short and 4% long, p = .5). There was no significant difference in HLOS between EDLOS, when adjusted for TRISS. ED census did not affect EDLOS (p = .59), however; EDLOS was longer when the percentage of staffed hospital beds available was lower (p < .001).Conclusions: While hospital overcrowding did increase EDLOS, there was no association between EDLOS and mortality or HLOS in leveled trauma patients at this institution.

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Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences

The American Surgeon ◽

10.1177/000313481408001130 ◽

2014 ◽

Vol 80 (11) ◽

pp. 1132-1135 ◽

Cited By ~ 4

Author(s):

Peter E. Fischer ◽

Paul D. Colavita ◽

Gregory P. Fleming ◽

Toan T. Huynh ◽

A. Britton Christmas ◽

...

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Local Trauma ◽

Level 1 ◽

Poor Outcomes ◽

Injured Patients ◽

Level 1 Trauma Center

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

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

Neurosurgery ◽

10.1093/neuros/nyz310_682 ◽

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.

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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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