The impact of a new trauma center on an existing nearby trauma center.

BACKGROUND: New York State's Trauma System has been in place since 1990. At it's inception, 36 trauma centers were designated by the state. As of 2002 there were 50, with more centers applying for designation. The state designation process looks at various criteria that include volume and manpower standards. There is no review of the impact of a new center on neighboring centers. This impact can include issues of residency training, research, and the maintenance of provider skills. If provider skills deteriorate, there is a risk for increased mortality. This study examines how a new trauma center, in the Bronx, impacted a near-by trauma center. METHODS: Data were collected from the trauma and operating room registries during the 12-month period before and after the designation of a near-by trauma center. Data included number of trauma admissions, Injury Severity Score (ISS), mechanism of injury, mortality, number of laparotomies and thoracotomies, and the type of ambulance used for transport (private vs. municipal). RESULTS: There was a 30% reduction in "major" trauma admissions (ISS >8) and a 14% reduction in admissions with an ISS >15. This reduction included a 22% to 29% reduction in the numbers of severe head injury patients, laparotomies, and thoracotomies. Mortality rates for patients with ISS 16 to 24 and >24 increased after the designation. CONCLUSION: The addition of a new trauma center in the Bronx had a negative impact on a near-by trauma center. Significant reductions in the volume of severely injured patients had a negative impact on factors not routinely measured like resident education, staff competency, and research. It is possible that these factors are at least partially responsible for the increased mortality rates seen after designation. These considerations are not routinely considered during the designation of new trauma centers and may actually adversely affect the very population it is trying to serve. As trauma systems mature, consideration of the impact the new center will have on the existing centers must be included in the designation process.

Elderly hip fracture patients admitted to the trauma service: does it impact patient outcome?

BACKGROUND: Hip fractures are primarily a disease of the elderly. Advanced age and associated comorbidities in this patient population can lead to adverse outcomes. We routinely admit our hip fracture patients to the Trauma Service (TS). The goal of this study is to see if this policy has had a positive impact on patient outcome. METHODS: The Jacobi Medical Center Trauma and Operating Room registries were used to identify all patients aged 65 and over who presented with a hip fracture during the 5-year period from January 1, 2000 to December 31, 2004. Patient charts were used for data retrieval. Outcome variables were length of hospital stay (LOS), time from admission to surgery, in-hospital complication, and in-hospital mortality rates. RESULTS: Complete data were available in 255 patients out of a total of 274 admitted in the study period. The mean age was 81.0 years. The median Injury Severity Score was 10 (range, 9-34). Two hundred forty (94.1%) patients were admitted to the TS. The mean time from admission to surgery was 1.9 days and the mean LOS was 10.5 days. In-hospital complication rate and mortality were 35.8% and 2.1%, respectively. CONCLUSION: Our policy of admitting elderly hip fracture patients to the TS has resulted in a mortality and LOS among the lowest reported in the literature. This data suggest that there is a clear benefit to admitting elderly hip fractures to the TS.

Factors associated with trauma clinic follow-up compliance after discharge: experience at an urban Level I trauma center.

BACKGROUND: Disparities in access to postdischarge services for trauma patients exist, and clinic follow-up remains an important avenue to ensure initial and continued access to postdischarge services. In addition, follow-up is vital to rigorous long-term trauma outcomes research. However, there is a relative paucity of literature specifically addressing clinic follow-up. The purposes of this study were to elucidate factors associated with clinic follow-up compliance and noncompliance after discharge from an urban Level I trauma center and to confirm the prevailing notion that follow-up in trauma clinic is poor. METHODS: Our trauma registry was queried for all trauma service discharges of patients 18 years and older for a 2-year period. Patients with incomplete information were excluded. Demographic data such as race/ethnicity and insurance status were collected on all patients. Primary outcome was defined as trauma clinic follow-up within 4 weeks after discharge. Patients compliant with follow-up were compared with noncompliant patients. RESULTS: After exclusion criteria were applied, there were 1,818 discharges included in the analysis, with 564 (31%) complying with follow-up (p < 0.001). Factors significantly associated with follow-up noncompliance included patients older than 35 years, white race, Medicaid/Medicare payers, blunt mechanism, extended hospital length of stay, and discharge to rehabilitation facilities. No insurance, penetrating mechanism, short hospital stay, discharge to home, and weekend discharge were all significantly associated with follow-up compliance. Discharge on weekends and to home were independent predictors of compliance, whereas, Medicaid/Medicare insurance status and operative intervention were independent predictors of noncompliance. CONCLUSION: This study indentifies factors associated with trauma clinic follow-up compliance and confirms the notion that trauma clinic follow-up compliance at an urban Level I trauma center is alarmingly low. These findings may serve as targets to improve follow-up, thereby improving trauma outcomes research and long-term outcomes. Consequently, clinic follow-up compliance warrants further study and consideration as an essential trauma registry datum. LEVEL OF EVIDENCE: Prognostic study, level III.

Daily multidisciplinary rounds to implement the ventilator bundle decreases ventilator-associated pneumonia in trauma patients: but does it affect outcome?

BACKGROUND: The incidence of ventilator-associated pneumonia (VAP) in trauma patients can be decreased with use of the ventilator bundle (VAPB). Our VAP rate remained high despite the adoption of the VAPB. To better implement the VAPB, a multidisciplinary team composed of the surgical intensive care unit (SICU) nursing staff, physician, and respiratory therapist reviewed briefly a checklist of VAPB goals for each patient before morning attending rounds. We hypothesized that such daily goal rounds (GR) focused on the VAPB would decrease the VAP rate. METHODS: A pre-GR ten-month period (November 2006 to August 2007) was compared with the ten-month period (September 2007 to June 2008) with daily GRs. The occurrence of VAPs was tallied prospectively in all intubated trauma patients using the National Nosocomial Infection Surveillance criteria. Patient characteristics and outcome data were obtained from our trauma registry and medical records. Patient characteristics were similar in the 85 pre-GR patients and the 89 GR patients. RESULTS: The number of VAPs decreased 67% in the GR patients (15 pre-GR vs. 5 GR; p=0.02); however, the all-cause mortality rate remained similar (16.5% vs. 21.3%; p=0.41). When patients were divided into those with and without VAP, there was a significant increase in mean ventilator, SICU, and hospital days in patients with VAP (p=0.01 for all). There were only two deaths among trauma patients with VAP. CONCLUSION: Daily multidisciplinary GRs focused on the VAPB can decrease the incidence of VAP significantly in trauma patients. Ventilator-associated pneumonia correlated with extended mean ventilator, SICU, and hospital days. Interestingly, despite a significant decrease in VAP, a decrease in the mortality rate was not observed. Given the small number of deaths in the VAP cohort, this study has insufficient statistical power to elucidate the true impact of GR intervention or VAP on the mortality rate in trauma patients.