Is state trauma funding associated with mortality among injured hospitalized patients?

BACKGROUND: We sought to quantify the association between state trauma funding and (1) in-hospital mortality and (2) transfers of injured patients. METHODS: We conducted an observational cross-sectional study of states with publicly available trauma funding data. We analyzed in-hospital mortality using linked data from the Nationwide Inpatient Sample (NIS), American Hospital Association (AHA) Annual Survey, and these State Department of Public Health trauma funding data. RESULTS: A total of 594,797 injured adult patients were admitted to acute care hospitals in 17 states. Patients in states with >$1.00 per capita state trauma funding had 0.82 (95 â€‹% CI: 0.78-0.85, p â€‹< â€‹0.001) decreased adjusted odds of in-hospital mortality compared to patients in states with less than $1.00 per capita state trauma funding. CONCLUSIONS: Increased state trauma funding is associated with decreased adjusted in-hospital mortality.

Geographic Disparities in Re-triage Destinations Among Seriously Injured Californians.

Objective: To quantify geographic disparities in sub-optimal re-triage of seriously injured patients in California. Summary of Background Data: Re-triage is the emergent transfer of seriously injured patients from the emergency departments of non-trauma and low-level trauma centers to, ideally, high-level trauma centers. Some patients are re-triaged to a second non-trauma or low-level trauma center (sub-optimal) instead of a high-level trauma center (optimal). Methods: This was a retrospective observational cohort study of seriously injured patients, defined by an Injury Severity Score > 15, re-triaged in California (2009-2018). Re-triages within one day of presentation to the sending center were considered. The sub-optimal re-triage rate was quantified at the state, regional trauma coordinating committees (RTCC), local emergency medical service agencies, and sending center level. A generalized linear mixed-effects regression quantified the association of sub-optimality with the RTCC of the sending center. Geospatial analyses demonstrated geographic variations in sub-optimal re-triage rates and calculated alternative re-triage destinations. Results: There were 8,882 re-triages of seriously injured patients and 2,680 (30.2 %) were sub-optimal. Sub-optimally re-triaged patients had 1.5 higher odds of transfer to a third short-term acute care hospital and 1.25 increased odds of re-admission within 60 days from discharge. The sub-optimal re-triage rates increased from 29.3 % in 2009 to 38.6 % in 2018. 56.0 % of non-trauma and low-level trauma centers had at least one sub-optimal re-triage. The Southwest RTCC accounted for the largest proportion (39.8 %) of all sub-optimal re-triages in California. Conclusion: High population density geographic areas experienced higher sub-optimal re-triage rates.

Re-triage moderates association between state trauma funding and lower mortality of trauma patients.

BACKGROUND: Severely injured patients who are re-triaged (emergently transferred from an emergency department to a high-level trauma center) experience lower in-hospital mortality. Patients in states with trauma funding also experience lower in-hospital mortality. This study examines the interaction of re-triage, state trauma funding, and in-hospital mortality. STUDY DESIGN: Severely injured patients (Injury Severity Score (ISS) >15) were identified from 2016 to 2017 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases in five states (FL, MA, MD, NY, WI). Data were merged with the American Hospital Association Annual Survey and state trauma funding data. Patients were linked across hospital encounters to determine if they were appropriately field triaged, field under-triaged, optimally re-triaged, or sub-optimally re-triaged. A hierarchical logistic regression modeling in-hospital mortality was used to quantify the effect of re-triage on the association between state trauma funding and in-hospital mortality, while adjusting for patient and hospital characteristics. RESULTS: A total of 241,756 severely injured patients were identified. Median age was 52 years (IQR: 28, 73) and median ISS was 17 (IQR: 16, 25). Two states (MA, NY) allocated no funding, while three states (WI, FL, MD) allocated $0.09-$1.80 per capita. Patients in states with trauma funding were more broadly distributed across trauma center levels, with a higher proportion of patients brought to Level III, IV, or non-trauma centers, compared to patients in states without trauma funding (54.0% vs. 41.1%, p < 0.001). Patients in states with trauma funding were more often re-triaged, compared to patients in states without trauma funding (3.7% vs. 1.8%, p < 0.001). Patients who were optimally re-triaged in states with trauma funding experienced 0.67 lower adjusted odds of in-hospital mortality (95% CI: 0.50-0.89), compared to patients in states without trauma funding. We found that re-triage significantly moderated the association between state trauma funding and lower in-hospital mortality (p = 0.018). CONCLUSION: Severely injured patients in states with trauma funding are more often re-triaged and experience lower odds of mortality. Re-triage of severely injured patients may potentiate the mortality benefit of increased state trauma funding.

Defining obstacles to emergency transfer of trauma patients: An evaluation of retriage processes from nontrauma and lower-level Illinois trauma centers.

BACKGROUND: Retriage is the emergency transfer of severely injured patients from nontrauma and lower-level trauma centers to higher-level trauma centers. We identified the barriers to retriage at sending centers in a single health system. METHODS: We conducted a failure modes effects and criticality analysis at 4 nontrauma centers and 5 lower-level trauma centers in a single health system. Clinicians from each center described the steps in the trauma assessment and retriage process to create a process map. We used standardized scoring to characterize each failure based on frequency, impact on retriage, and prevention safeguards. We ranked each failure using the scores to calculate a risk priority number. RESULTS: We identified 26 steps and 93 failures. The highest-risk failure was refusal by higher-level trauma centers (receiving hospitals) to accept a patient. The most critical failures in the retriage process based on total risk, frequency, and safeguard scores were (1) refusal from a receiving higher-level trauma center to accept a patient (risk priority number = 191), (2) delay in a sending center's consultant examination of a patient in the emergency department (risk priority number = 177), and (3) delay in receiving hospital's consultant calling back (risk priority number = 177). CONCLUSION: We identified (1) addressing obstacles to determining clinical indications for retriage and (2) identifying receiving level I trauma centers who would accept the patient as opportunities to increase timely retriage. Establishing clear clinical indications for retriage that sending and receiving hospitals agree on represents an opportunity for intervention that could improve the retriage of injured patients.

Recognizing and Breaking the Cycle of Trauma and Violence Among Resettled Refugees.

Purpose of Review: The number of refugees across the globe continues to grow, leaving a large proportion of the global population in a vulnerable state of health. However, the number of robust clinical interventions has not kept apace. This paper provides a general review of literature on the trauma and violence that refugees face, the impact on health outcomes, and some of the promising models for clinical intervention. Recent Findings: Refugees experience a cycle of trauma, violence, and distress that begins before migration and continues during migration and after resettlement. It has been challenging to develop robust clinical interventions due to the cumulative and cyclic effects of trauma, as well as the unique experiences of trauma that each refugee community and each refugee individual faces. Summary: Trauma-informed care is a critical component of health care. Developing stronger guidelines for trauma-informed care will help clinicians better provide inclusive and equitable care for refugee patients.