American College of Surgeons trauma center verification versus state designation

Abstract

Objectives Single center experience has shown that American College of Surgeons (ACS) trauma verification can improve outcomes. The current objective was to compare mortality between ACS verified and State designated centers in a national sample. Methods Subjects ≥16yr from ACS verified or State designated level I and II centers were identified in the NTDB 2007–08. A predictive mortality model was constructed using TQIP methodology. Imputation was used for missing data. Probability of mortality in the model determined expected deaths. Observed to expected (O/E) mortality ratios with 90%CI and outliers (90%CI above or below 1.0) were compared across ACS and State level I and II centers. The mortality model was repeated with ACS vs. State included. Results There were 900,274 subjects. The model had an AUC of 0.92 to predict death. Level I ACS centers had a lower median O/E ratio than State (0.95 [IQR 0.82–1.05] vs 1.02 [0.87–1.15], p<0.01), with no difference in level II centers. Level II State centers had more high O/E outliers (Table). ACS verification was an independent predictor of survival in level II centers (OR 1.26; 95%CI 1.20–1.32, p<0.01), but not in level I centers (p=0.84). Conclusions Level II centers have a disproportionate number of high mortality outliers and ACS verification is a predictor of survival. Level I ACS centers have lower O/E ratios overall but no difference in outliers. ACS verification appears beneficial. This data suggests that level II centers benefit most, and promoting level II ACS verification may be an opportunity for improved outcomes. Level of Evidence: III

Association between volume of severely injured patients and mortality in German trauma hospitals

“…1⋅20 to 1⋅32; P < 0⋅010), but not in level I centres (P = 0⋅84). The study concluded that level II centres especially benefited from ACS verification 9 .…”

“…Several recently published studies have addressed the issue of a clearly defined patient volume for American trauma centres. In a systematic review, a large number of studies between 1976 and 2013 were investigated for any correlation between patient volume and mortality. In this summary of the North American literature, the correlation between patient volume and mortality was not proven.…”

“…There already exist requirements for a clearly defined number of operations and interventions, for example with regard to transplantations or endoprostheses. The effect of patient volume on mortality among patients with major trauma is not yet clear and it is not possible to make general recommendations. With a view to improving the quality of care, the present study aimed to analyse the effect of patient volume on mortality in German trauma centres.…”

Management of traumatic haemorrhage – the US perspective

“…In the US, this model can be found in some states but not others. Approximately, two-thirds of the fifty states designate trauma centres in accordance with the published guidelines of the American College of Surgeons [1]. A small handful of states (e.g.…”

Implementation of Massive Transfusion Protocols in the United States: The Relationship Between Evidence and Practice

“…For perspective, there were 189 level I trauma centers (123 American College of Surgeons [ACS]-verified, 157 state-designated, 91 both) and 185 level II trauma centers (124 ACS-verified, 161 state-designated, 100 both) in the United States during 2007-2008. 1 The authors rightfully cite the overall 52% response rate and the over-representation of level I centers as limitations of their study. To maintain consistency with the majority of the published literature, we present ratios as plasma:RBCs, platelet:RBCs, or plasma:platelets:RBCs; “high” ratios equate to relatively more plasma and platelets.…”