Compliance with recommended care at trauma centers: association with patient outcomes.

BACKGROUND: State health departments and the American College of Surgeons focus on the availability of optimal resources to designate hospitals as trauma centers, with little emphasis on actual delivery of care. There is no systematic information on clinical practices at designated trauma centers. The objective of this study was to measure compliance with 22 commonly recommended clinical practices at trauma centers and its association with in-hospital mortality. STUDY DESIGN: This retrospective observational study was conducted at 5 Level I trauma centers across the country. Participants were adult patients with moderate to severe injuries (n = 3,867). The association between compliance with 22 commonly recommended clinical practices and in-hospital mortality was measured after adjusting for patient demographics and injuries and their severity. RESULTS: Compliance with individual clinical practices ranged from as low as 12% to as high as 94%. After adjusting for patient demographics and injury severity, each 10% increase in compliance with recommended care was associated with a 14% reduction in the risk of death. Patients who received all recommended care were 58% less likely to die (odds ratio = 0.42; 95% CI, 0.28-0.62) compared with those who did not. CONCLUSIONS: Compliance with commonly recommended clinical practices remains suboptimal at designated trauma centers. Improved adoption of these practices can reduce mortality.

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries.

OBJECT: Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS: This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS: The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS: Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

Insuring the uninsured: potential impact of Health Care Reform Act of 2010 on trauma centers.

BACKGROUND: Viability of trauma centers is threatened by cost of care provided to patients without health insurance. The health care reform of 2010 is likely to benefit trauma centers by mandating universal health insurance by 2014. However, the financial benefit of this mandate will depend on the reimbursement provided. The study hypothesis was that compensation for the care of uninsured trauma patients at Medicare or Medicaid rates will lead to continuing losses for trauma centers. METHODS: Financial data for first hospitalization were obtained from an urban Level I trauma center for 3 years (n = 6,630; 2006-2008) and linked with clinical information. Patients were grouped into five payments categories: commercial (29%), Medicaid (8%), Medicare (20%), workers' compensation (6%), and uninsured (37%). Prediction models for costs and payments were developed for each category using multiple regression models, adjusting for patient demographics, injury characteristics, complications, and survival. These models were used to predict payments that could be expected if uninsured patients were covered by different insurance types. Results are reported as net margin per patient (payments minus total costs) for each insurance type, with 95% confidence intervals, discounted to 2008 dollar values. RESULTS: Patients were typical for an urban trauma center (median age of 43 years, 66% men, 82% blunt, 5% mortality, and median length of stay 4 days). Overall, the trauma center lost $5,655 per patient, totaling $37.5 million over 3 years. These losses were encountered for patients without insurance ($14,343), Medicare ($4,838), and Medicaid ($15,740). Patients with commercial insurance were profitable ($5,295) as were those with workers' compensation ($6,860). Payments for the care of the uninsured at Medicare/Medicaid levels would lead to continued losses at $2,267 to $4,143 per patient. CONCLUSION: The health care reforms of 2010 would lead to continued losses for trauma centers if uninsured are covered with Medicare/Medicaid-type programs. LEVEL OF EVIDENCE: Economic analysis, level II.

Chronic consequences of acute injuries: worse survival after discharge.

BACKGROUND: The Trauma Quality Improvement Program uses inhospital mortality to measure quality of care, which assumes patients who survive injury are not likely to suffer higher mortality after discharge. We hypothesized that survival rates in trauma patients who survive to discharge remain stable afterward. METHODS: Patients treated at an urban Level I trauma center (2006-2008) were linked with the Social Security Administration Death Master File. Survival rates were measured at 30, 90, and 180 days and 1 and 2 years from injury among two groups of trauma patients who survived to discharge: major trauma (Abbreviated Injury Scale score ≥ 3 injuries, n = 2,238) and minor trauma (Abbreviated Injury Scale score ≤ 2 injuries, n = 1,171). Control groups matched to each trauma group by age and sex were simulated from the US general population using annual survival probabilities from census data. Kaplan-Meier and log-rank analyses conditional upon survival to each time point were used to determine changes in risk of mortality after discharge. Cox proportional hazards models with left truncation at the time of discharge were used to determine independent predictors of mortality after discharge. RESULTS: The survival rate in trauma patients with major injuries was 92% at 30 days posttrauma and declined to 84% by 3 years (p > 0.05 compared with general population). Minor trauma patients experienced a survival rate similar to the general population. Age and injury severity were the only independent predictors of long-term mortality given survival to discharge. Log-rank tests conditional on survival to each time point showed that mortality risk in patients with major injuries remained significantly higher than the general population for up to 6 months after injury. CONCLUSION: The survival rate of trauma patients with major injuries remains significantly lower than survival for minor trauma patients and the general population for several months postdischarge. Surveillance for early identification and treatment of complications may be needed for trauma patients with major injuries. LEVEL OF EVIDENCE: Prognostic study, level III.

Barriers to compliance with evidence-based care in trauma.

BACKGROUND: We have preciously demonstrated that trauma patients receive less than two-thirds of the care recommended by evidence-based medicine. The purpose of this study was to identify patients least likely to receive optimal care. METHODS: Records of a random sample of 774 patients admitted to a Level I trauma center (2006-2008) with moderate to severe injuries (Abbreviated Injury Scale score ≥3) were reviewed for compliance with 25 trauma-specific processes of care (T-POC) endorsed by Advanced Trauma Life Support, Eastern Association for the Surgery of Trauma, the Brain Trauma Foundation, Surgical Care Improvement Project, and the Glue Grant Consortium based on evidence or consensus. These encompassed all aspects of trauma care, including initial evaluation, resuscitation, operative care, critical care, rehabilitation, and injury prevention. Multivariate logistic regression was used to identify patients likely to receive recommended care. RESULTS: Study patients were eligible for a total of 2,603 T-POC, of which only 1,515 (58%) were provided to the patient. Compliance was highest for T-POC involving resuscitation (83%) and was lowest for neurosurgical interventions (17%). Increasing severity of head injuries was associated with lower compliance, while intensive care unit stay was associated with higher compliance. There was no relationship between compliance and patient demographics, socioeconomic status, overall injury severity, or daily volume of trauma admissions. CONCLUSION: Little over half of recommended care was delivered to trauma patients with moderate to severe injuries. Patients with increasing severity of traumatic brain injuries were least likely to receive optimal care. However, differences among patient subgroups are small in relation to the overall gap between observed and recommended care. LEVEL OF EVIDENCE: II.

Moving from "optimal resources" to "optimal care" at trauma centers.

BACKGROUND: The Trauma Quality Improvement Program has shown that risk-adjusted mortality rates at some centers are nearly 50% higher than at others. This "quality gap" may be due to different clinical practices or processes of care. We have previously shown that adoption of processes called core measures by the Joint Commission and Centers for Medicare and Medicaid Services does not improve outcomes of trauma patients. We hypothesized that improved compliance with trauma-specific clinical processes of care (POC) is associated with reduced in-hospital mortality. METHODS: Records of a random sample of 1,000 patients admitted to a Level I trauma center who met Trauma Quality Improvement Program criteria (age ≥ 16 years and Abbreviated Injury Scale score 3) were retrospectively reviewed for compliance with 25 trauma-specific POC (T-POC) that were evidence-based or expert consensus panel recommendations. Multivariate regression was used to determine the relationship between T-POC compliance and in-hospital mortality, adjusted for age, gender, injury type, and severity. RESULTS: Median age was 41 years, 65% were men, 88% sustained a blunt injury, and mortality was 12%. Of these, 77% were eligible for at least one T-POC and 58% were eligible for two or more. There was wide variation in T-POC compliance. Every 10% increase in compliance was associated with a 14% reduction in risk-adjusted in-hospital mortality. CONCLUSION: Unlike adoption of core measures, compliance with T-POC is associated with reduced mortality in trauma patients. Trauma centers with excess in-hospital mortality may improve patient outcomes by consistently applying T-POC. These processes should be explored for potential use as Core Trauma Center Performance Measures.

Rapid response team interventions for severe hyperkalemia: evaluation of a patient safety initiative.

RATIONALE: This study evaluates outcomes and process measures associated with a rapid response team (RRT) intervention for patients with severe hyperkalemia. STUDY POPULATION: Inpatients on medical-surgical floors (excluding dialysis or comfort care patients) at a 1000-bed tertiary hospital from 2005 to 2009 with severe hyperkalemia (defined as potassium [K(+)] ≥ 6.3 mEq/L). METHODS: Retrospective administrative data and medical record review. Hyperkalemia incidence (based both on coding data and laboratory test results) was assessed, as was the association between hyperkalemia and mortality. Independent physician reviewers adjudicated selected cases for death directly attributable to hyperkalemia and potential for preventability with the RRT intervention. All 115 Baylor University Medical Center (Dallas, TX) cases receiving the RRT hyperkalemia intervention over a 12-month period (December 2006-December 2007) underwent in-depth process assessment. RESULTS: Hyperkalemia occurred as a codable diagnosis in approximately 3.2% of all hospital discharges annually (5-year average of 42 000 discharges), and K(+) values ≥ 6.3 mEq/L were observed in 0.8% to 0.9% of all K(+) assays run by the laboratory in the months sampled. Deaths determined to be directly related to hyperkalemia and potentially preventable were rare, with a total of only 4 events during the study period (3 of these were in the pre-implementation phase), precluding statistical analysis on mortality related to the intervention. The RRT averaged 6 to 10 interventions for hyperkalemia monthly (representing 10% of all inpatient K(+) values ≥ 6.3 mEq/L). Mean initial K(+) level triggering the RRT cascade was 6.7 ± 0.3 mEq/L; average time from floor notification of critical K(+) level to bedside RRT arrival was 14.6 ± 12.1 minutes. Over 24 to 36 hours, K(+) declined 1.7 ± 1.1 mEq/L between patients' initial and final K(+) values (P < 0.001). CONCLUSIONS: Hyperkalemia occurs frequently in inpatient settings. Rapid response team intervention for this condition facilitates timely correction of critical laboratory test results and consistent treatment through use of a standardized protocol. Benefit of the intervention on mortality could not be reliably demonstrated in this study due to event rarity and challenges with case ascertainment. Further research with a prospective, multi-site cluster design using electronic medical records and larger sample sizes could demonstrate which RRT hyperkalemia intervention components warrant widespread adoption.

The use of cadaver tissue in advanced microsurgical training.

Ex-vivo microsurgical instruction with fresh cadaver tissue offers an ideal educational design for intermediate and advanced training for orthopedic and plastic surgery residents and hand fellows. It can be also utilized to maintain and sharpen the skills of the experienced micro-surgeon. The following article describes the harvesting technique for nerves and vessels, lists the expected cross sectional diameters for each of the peripheral vessels and nerves used. The method of implementation in a workshop educational model is described as well.