EFFECTIVE COMPARISON OF TRAUMA CENTER PERFORMANCE IS STILL AN
ILLUSIVE GOAL
Brian Celso, PhD; J.J. Tepas III, MD*; Lewis M. Flint, MD*; Lawrence
Lottenberg, MD*; Rodney M. Durham, MD*; Emran R. Imami, MD; Michael
Fabian, MD; Andrew J. Kerwin, MD
University of Florida, Jacksonville, Florida, and University of South
Florida, Tampa, Florida
Purpose: Assessment of trauma system performance mandates comparison
of outcomes among component facilities. We hypothesized that
physiologic and anatomic data can predict individual patient outcome,
and thereby be aggregated to compare performance among centers.
Methods: 2000-2002 registry data from five trauma centers (3LI, 2III)
in the same state designated system was analyzed. A five-group MANOVA
was conducted to determine if differences exist among the trauma
centers based on the variables of AGE, HR, BP, GCS, and ISS. A
logistical regression model was then constructed to assess the
contribution of each of these measures as predictor variables, and to
determine odds ratios of trauma center performance based on patient
survival.
For the purpose of this study, Center 5, a Level I with the highest
volume, was selected as the control standard. . Alpha level was set
at p<.05.
Results: A total of 22,306 cases were obtained for analysis. Overall
multivariate MANOVA indicated that the five trauma centers differed
significantly on the entire set of both anatomic and physiologic
variables. All contributed to the overall multivariate result,
however the variance within each precluded valid comparison of trauma
centers to each other.
Logistical regression confirmed that all physiological and anatomical
measurements were significant predictors of individual patient
mortality. When the model was controlled for the effect of these
variables, the odds ratios of survival for two Level I and one Level
II centers were statistically better than the control.
Conclusion: Trauma center physiologic and anatomic data were
significantly different among the five trauma centers. Therefore,
comparisons between these trauma centers using just this data would
be inaccurate as there is not equivalence. When controlling for these
severity measures for purposes of prediction, patient outcome did
vary among trauma centers. Thus, differences in trauma patients
cannot fully explain predictive factors that contribute to survival
or mortality. Controlling for these patient variables, however,
isolates trauma center performance for focused analysis of the actual
process of patient care.
J.J. Tepas TTI, MD
University of Florida
HSC/Surgery
655 West 8th Street
Jacksonville, FL 32209
Phone: (904) 244-3915
Fax: (904) 244-3870
Email: [EMAIL PROTECTED]
TRAUMA SYSTEM REPORT CARD: FLORIDA VS. INDIANA
Lawrence Lottenberg, MD*, Joseph J. Tepas, MD*, Patrick D. Kilgo, MS,
Steve Dearwater, MS and George H. Rodman Jr MD*
Memorial Regional Hospital, Hollywood, Florida; University of Florida
Jacksonville; Florida Department of Health; Wake Forest University
School of Medicine; Clarian-Methodist Hospital, Indianapolis, Indiana
Introduction: While exact quantitative norms are not defined, trauma
systems at varying levels of maturity should have differences in
high-risk patients' patterns of care and outcomes.
Method: Two years (1999-2000) of hospital trauma patient discharge
data from Florida (FL, mature system) and Indiana (IN, immature
system) were analyzed to describe trauma center distribution for
high-risk patients (ISS>25) in four age groups (age< 16; 16-44;
45-64; 65+), treatment differences, survival rates, length of
hospital stay (HLOS), and need for post-hospital institutional care
in the two states.
Results: High-risk (ISS>25) adults but not children (Table 1),
receive trauma center care more frequently in FL vs. IN (73% vs. 56%;
p<.001)
Table I FL ADULT IN ADULTS FL PEDS IN PED
All pts. 123,049 40,092 11,348 3,566
Trauma Centers 46,011 11,192 6,165 1,431
% Trauma Center 37% 28% 54% 40%
ISS ³ 25 5,017 1,470 445 160
Trauma Centers 3,667 828 349 120
% Trauma Center 73% 56% 78% 75%
Table II Florida Indiana
Avg Age 44 y/o 39 y/o
Avg ISS 31.2 32.1
Avg ICISS SRR 0.4810 0.4692
% Died 31% 26%
% Home 35% 44%
Avg HLOS days 15.1 13.5
FL patients are older (Table 11; 44 vs 39 y/o; p<.001), have higher
mortality rate (31% vs. 26%; p<.001), longer HLOS (15.1 vs. 13.5;
p=.005), and are discharged home less frequently than in IN (35% vs.
44%; p<.001). Tracheostomy (ages 16-44; 19% vs. 15%; p<.001), caval
filter (4% vs. 1%; p<.001), and splenectomy rates (ages 16-44; 72%
vs. 58%; p<.001) are different in FL vs. IN. Conclusions: Hospital
discharge data can demonstrate the expected patient distribution
difference when comparing a mature trauma system vs. a voluntary
evolving system. Unexpected treatment and outcome differences in
these two systems warrant more analysis using exact patient matching
techniques.
Lawrence Lottenberg MD
Director Trauma and Critical Care
Memorial Regional Hospital
3501 Johnson St
Hollywood, Florida 33021
A POPULATION BASED STUDY OF TRAUMA DEATHS ACROSS A RURAL STATE
WITHOUT A FORMAL TRAUMA SYSTEM
F. Rogers, P. Morrow, L. Madsen, K. Pellicore, S.R. Shackford, T.M.
Osler, R. Jawa, J. Rebuck
Background: The literature of trauma typically involves the study of
hospitalized patients, most of whom are very unlikely to die. This
approach ignores the vast preponderance of trauma deaths that occur
prior to hospital admission, and therefore provides a biased
impression of how trauma deaths might be prevented.
Methods: We examined all 219 trauma related fatalities in a single
New England state in the year 2001 using the records of the medical
examiner and inpatient hospital records. All deaths that had medical
intervention were analyzed by 3 trauma surgeons looking for errors in
care.
Results: Most deaths were due to MVC's (41%), suicide (32%), or falls
(11%). Most (63%) victims expired prior to any medical intervention
(dead at scene). These injuries were usually anatomically
overwhelming, and no medical intervention would have been effective.
Few patients died in transport. Patients who survived to
hospitalization either died early of head injury (35%), multisystem
trauma (26%), or sepsis (13%). Few errors in medical care were
identified.
Conclusions: Most patients die at the scene with overwhelming
injuries. There are few opportunities to improve the outcome of those
patients who die following trauma in our rural state. Suicide is a
significant problem in this rural state and trauma system efforts may
be better focused on prevention programs.
Frederick B. Rogers, MD
University of Vermont
111 Colchester Ave,
Fletcher 466
Burlington, VT 05401
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