Enhanced trauma program commitment at a level i trauma center

Abstract

Hypothesis: With advances in surgical care, the occurrences of major adverse outcomes have become a rare event. The effect of a surgical service can be more comprehensively evaluated by following the Donabedian model, looking at the triad of structure, process, and outcome. It is hypothesized that the implementation of a focused program commitment at a trauma center is associated with improvements in process of care and patient outcomes.Design: Evaluation of prospectively collected information in a trauma registry for the 3-year periods immediately before (1995-1997) and after (1999-2001) the implementation (in 1998) of the full-time trauma service.Setting: Level I university-affiliated trauma center.Patients: Patients meeting criteria for major trauma. Intervention:The implementation of a full-time trauma service, featuring 24-hour in-house attending coverage, dedicated trauma admitting unit, regular trauma core curriculum, regular multidisciplinary quality assurance meetings, and state designation for level I status.Main Outcome Measures: Process of care measures, including time in the emergency department (ED) and trauma "bypass" hours (ie, time spent in the trauma resuscitation area). Outcome measures, including lengths of stay, overall mortality and mortality, excluding ED deaths.Results: The total number of patients with major trauma increased from 2240 (1995)(1996)(1997) to 2513 (1999-2001). The average time in the ED for patients going to the operating room, intensive care unit, and observation wards all decreased significantly (84 vs 52 minutes, 197 vs 118 minutes, and 300 vs 140 minutes, respectively; all with PϽ.01). The number of hours that the trauma center was closed owing to ED overcrowding also decreased significantly, from 56 to 2.7 hours per month (PϽ.01). After excluding ED deaths, there was a trend on bivariate analyses toward lower overall mortality rates (4.5% vs 3.4%, P=.07) and mortality rates among patients with severe head injury (23.8% vs 17.2%, P =.07). On further analyses with multiple logistic regression, controlling for age, Injury Severity Score, Abbreviated Injury Score (for a head injury), and admission blood pressure, the later period is associated with a 31% decrease in overall odds of death (P=.047) and a 42% decrease in odds of death among patients with severe head injury (an Abbreviated Injury Score, Ն3; P=.03). Conclusion:The implementation of a full-time trauma service is associated with improved timeliness of triage and therapeutic interventions and improved patient outcomes.

Improved Prophylaxis and Decreased Rates of Preventable Harm With the Use of a Mandatory Computerized Clinical Decision Support Tool for Prophylaxis for Venous Thromboembolism in Trauma

“…24 These data and our baseline compliance rate suggest that trauma patients may be getting VTE prophylaxis at higher rates than other medical and surgi- cal patients. 5,6 Perhaps a well-defined protocol for trauma care, which has been shown to improve outcomes in trauma, 25,26 also helps to increase compliance with VTE prophylaxis. In our study, we observed nearly a 2-fold improvement in prophylaxis orders among patients with no contraindications to enoxaparin.…”

Effect of Trauma Center Designation on Outcome in Patients With Severe Traumatic Brain Injury

“…4 In their study of the influence of a statewide trauma system on outcomes of these types of patients, Mullins et al 10 noted that patients with head injuries appeared to benefit from trauma system development more than patients with other index injuries, with a clearly demonstrated reduction in the risk of death in patients with head injuries (adjusted OR,0.70; 95% CI,0.59-0.82). 16 In patients with severe head injuries (head AIS Ն 3), Cornwell et al 14 also found that changes in care associated with achieving state designation of level 1 status resulted in decreased mortality (23.8% vs 17.2%; P = .07) and a resulting 42% decrease in the odds of death for these patients (P = .03).…”

Alarming Surge in Nonsurvivable Urban Trauma and the Case for Violence Prevention

“…3 Additional analysis has found that a majority of patients who present to our institution as the victims of lethal GSWs are declared dead shortly after arrival to the ED, suggesting that violence prevention via community outreach is key. 4 The findings of our present study have amplified this message with alarming clarity.…”