Risk of Injury-Related Readmission Varies by Initial Presenting-Hospital Type Among Children at High Risk for Physical Abuse.

OBJECTIVES: Children experiencing physical abuse may initially present to hospitals with underappreciated minor injuries, only to experience more severe injuries in the future. The objectives of this study were to 1) describe young children presenting with high-risk diagnoses for physical abuse, 2) characterize the hospitals to which they initially presented, and 3) evaluate associations of initial presenting-hospital type with subsequent admission for injury. METHODS: Patients aged younger than 6 years from the 2009-2014 Florida Agency for Healthcare Administration database with high-risk diagnoses (codes previously associated with >70% risk of child physical abuse) were included. Patients were categorized by the hospital type to which they initially presented: community hospital, adult/combined trauma center, or pediatric trauma center. Primary outcome was subsequent injury-related hospital admission within 1 year. Association of initial presenting-hospital type with outcome was evaluated with multivariable logistic regression, adjusting for demographics, socioeconomic status, preexisting comorbidities, and injury severity. RESULTS: A total of 8626 high-risk children met inclusion criteria. Sixty-eight percent of high-risk children initially presented to community hospitals. At 1 year, 3% of high-risk children had experienced subsequent injury-related admission. On multivariable analysis, initial presentation to a community hospital was associated with higher risk of subsequent injury-related admission (odds ratio, 4.03 vs level 1/pediatric trauma center; 95% confidence interval, 1.83-8.86). Initial presentation to a level 2 adult or combined adult/pediatric trauma center was also associated with higher risk for subsequent injury-related admission (odds ratio, 3.19; 95% confidence interval, 1.40-7.27). CONCLUSIONS: Most children at high risk for physical abuse initially present to community hospitals, not dedicated trauma centers. Children initially evaluated in high-level pediatric trauma centers had lower risk of subsequent injury-related admission. This unexplained variability suggests stronger collaboration is needed between community hospitals and regional pediatric trauma centers at the time of initial presentation to recognize and protect vulnerable children.

The International Classification of Disease Critical Care Severity Score demonstrates that pediatric burden of injury is similar to that of adults: Validation using the National Trauma Databank☆.

BACKGROUND/PURPOSE: Resource-based severity of injury (SOI) measures, such as the International Classification of Disease (ICD) Critical Care Severity Score (ICASS), may characterize traumatic burden better than standard mortality-based measures. The purpose of this study was to validate the ICASS in a representative national-level trauma cohort and compare SOI measures between children and adults. METHODS: The National Trauma Databank was used to derive (2008-12) and validate (2013-15) ICASS and ICD Injury Severity Scores (ICISS, standard mortality-based SOI measure). SOI metrics and outcomes were compared between pediatric, adult, and elderly age groups. Logistic regression modeling evaluated predictors of critical care resource utilization. RESULTS: Derivation and validation cohorts consisted of 3.90 and 1.97 million patients, respectively. ICASS strongly predicted actual critical care utilization (OR 1.04, 95% CI 1.04-1.04, p<0.0001). Mean ICASS was 24.4 for children and 33.0 for adults (ratio 0.74), indicating predicted critical care utilization in children was three-quarters that of adults. In contrast, predicted pediatric mortality was less than half that of adults. CONCLUSIONS: Mortality-based SOI measures underestimate pediatric burden of injury. This study validates ICASS and demonstrates that pediatric resource-based SOI is more similar to that of adults. ICASS is easily calculated without a trauma registry and complements mortality-based measures. Level of evidence III, retrospective comparative study.

Needs Based Assessment of Trauma Systems 2, is it ready for primetime? A natural experiment testing its reliability.

INTRODUCTION: Needs Based Assessment of Trauma Systems 2 (NBATS-2) attempts to predict the impact on patient volume and travel time for patients when a new trauma center (TC) is added to the system. The purpose of this study was to examine NBATS-2 predictive accuracy regarding expected volume and travel times of trauma patients at a newly designated TC and nearby legacy TCs when compared with actual data. METHODS: Needs Based Assessment of Trauma Systems predictive model for volume of trauma patients at the new TC was run based on 25th, 50th, and 75th percentiles of both state and National Trauma Data Bank (NTDB) patients per 100 TC beds. This was compared with the actual number of trauma patients from the State Discharge Data set before (2011-2012) and after (2016-2017) designation of the TC. Analysis was then augmented using the geographic information system (ArcGIS) spatial modeling to characterize median travel times for actual trauma patients, before and after designation of the TC. RESULTS: Both state and NTDB 25th, 50th, and 75th percentiles resulted in significant overestimation of volume at the new TC in 2016. After another year of TC maturation (2017), overestimation decreased but was still present. The 25th percentile from state and NTDB data sets provided the most accurate predictions. For the legacy TCs, the model switched from under to overestimation as the state and NTDB percentiles increased. The geographic information system accurately showed patients traveling <40 minutes to a TC nearly doubled. CONCLUSION: Needs Based Assessment of Trauma Systems 2 provides an excellent template for state strategic planning; however, it overestimates new TC volume and under/overestimates volumes for legacy TCs depending on the state and NTDB percentiles used. This study shows that population density of the county in which the new or legacy TC is located should be considered when choosing the appropriate state or NTDB percentile. The geographic information system appropriately showed a decrease in trauma patient travel times after TC designation. LEVEL OF EVIDENCE: Care Management, level V.

Added Cost and Time Spent by Patients With History of Abuse in Florida Emergency Departments.

Interpersonal violence is known to lead to both short- and long-term health effects. Victims of sexual abuse tend to have higher healthcare costs and higher rates of physical and mental health issues than nonvictims. In this study, we investigate whether the comorbidity of mental illness and a personal history of adult physical and sexual abuse (HAPSA) results in higher healthcare costs and length of emergency department (ED) stay among Florida residents. A Negative Binomial and Log-Linear Regression Analysis suggest increased ED visit duration for those with a history of abuse, Hispanics, the uninsured, and those with multiple comorbidities. In addition, increased costs were found to be associated with White race, the uninsured, those with multiple comorbidities, and the facility type (for-profit hospitals).

Two novel resource-based metrics to quantify pediatric trauma severity based on probability of requiring critical care and anesthesia services.

BACKGROUND: Mortality-based metrics like the International Classification of Diseases (ICD) Injury Severity Score (ICISS) may underestimate burden of pediatric traumatic disease due to lower mortality rates in children. The purpose of this study was to develop and validate two resource-based severity of injury (SOI) measures, then compare these measures and the ICISS across a broad age spectrum of injured patients. METHODS: The ICISS and two novel SOI measures, termed ICD Critical Care Severity Score (ICASS) and ICD General Anesthesia Severity Score (IGASS), were derived from Florida state administrative 2012 to 2016 data and validated with 2017 data. The ICASS and IGASS predicted the need for critical care services and anesthesia services, respectively. Logistic regression was used to validate each SOI measure. Distributions of ICISS, ICASS, and IGASS were compared across pediatric (0-15 years), adult (16-64 years), and elderly (65-84 years) age groups. RESULTS: The derivation and validation cohorts consisted of 668,346 and 24,070 emergency admissions, respectively. On logistic regression, ICISS, ICASS, and IGASS were strongly predictive of observed mortality, critical care utilization, and anesthesia utilization, respectively (p < 0.001). The mean ICISS was 10.6 for pediatric and 19.0 for adult patients (ratio, 0.56), indicating that the predicted mortality risk in pediatric patients was slightly over half that of adults. In contrast, the mean ICASS for pediatric and adult patients was 50.2 and 53.2, respectively (ratio, 0.94); indicating predicted critical care utilization in pediatric patients was nearly the same as that of adults. The IGASS comparisons followed comparable patterns. CONCLUSION: When a mortality-based SOI measure is used, the severity of pediatric injury appears much lower than that of adults, but when resource-based measures are used, pediatric and adult burden of injury appear very similar. The ICASS and IGASS are novel and valid resource-based SOI measures that are easily calculated with administrative data. They may complement mortality-based measures in pediatric trauma. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological study.

Inpatient and emergency department costs from sports injuries among youth aged 5-18 years.

OBJECTIVE: To analyse the financial costs from sports injuries among inpatients and emergency department (ED) patients aged 5-18 with a focus on Medicaid patients. METHODS: Fixed-effects linear regression was used to assess the association of patient factors with cost of injury from sports. Florida Agency for Health Care Administration data from 2010 to 2014 were used, which included all inpatient and ED patients aged 5-18 years who had a sports injury. RESULTS: Over 5 years, sports injuries in Florida youth cost $24 million for inpatient care and $87 million for ED care. Youth averaged $6039 for an inpatient visit and $439 for an ED visit in costs from sports injuries. Sports injuries for Medicaid-insured youth cost $10.8 million for inpatient visits and $44.2 million for ED visits. CONCLUSION: Older athletes and males consistently have higher healthcare costs from sports. Baseball, basketball, bike riding, American football, roller-skating/skateboarding and soccer are sports with high costs for both ED patients and inpatients and would benefit from prevention programmes. Injuries from non-contact sport participants are few but can have high costs. These athletes could benefit from prevention programmes as well.

Risk factors for avoidable transfer to a pediatric trauma center among patients 2 years and older.

BACKGROUND: Effective and sustainable pediatric trauma care requires systems of regionalization and interfacility transfer. Avoidable transfer, also known as secondary overtriage, occurs when a patient is transferred to a regional trauma center after initial evaluation at another facility that is capable of providing definitive care. The purpose of this study was to identify risk factors for avoidable transfer among pediatric trauma patients in southwest Florida. METHODS: All pediatric trauma patients 2 years and older transferred from outlying hospitals to the emergency department of a single state-designated pediatric trauma center between 2009 and 2017 were obtained from the institutional registry. Transfers were classified as avoidable if the patient suffered only minor injuries (International Classification of Diseases-9th Rev. Injury Severity Score > 0.9), did not require invasive procedures or intensive care unit monitoring, and was discharged within 48 hours. Demographics and injury characteristics were compared for avoidable and nonavoidable transfers. Logistic regression was used to estimate the independent effects of age, sex, insurance type, mechanism of injury, diagnosis, within region versus out-of-region residence, suspected nonaccidental trauma, and abnormal Glasgow Coma Scale score on the risk of avoidable transfer. RESULTS: A total of 3,876 transfer patients met inclusion criteria, of whom 1,628 (42%) were classified as avoidable. Among avoidable transfers, 29% had minor head injuries (isolated skull fractures, concussions, and mild traumatic brain injury not otherwise specified), and 58% received neurosurgery consultation. On multivariable analysis, the strongest risk factors for avoidable transfer were diagnoses of isolated skull fracture or concussion. Suspected nonaccidental trauma was predictive of nonavoidable transfer. CONCLUSION: Among injured children 2 years and older, those with minor head injuries were at greatest risk for avoidable transfer. Many were transferred because of a perceived need for evaluation by a pediatric neurosurgeon. Future projects seeking to reduce avoidable transfers should focus on children with isolated skull fractures and concussions, in whom there is no suspicion of nonaccidental trauma. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Evaluation of the Georgia trauma system using the American College of Surgeons Needs Based Assessment of Trauma Systems tool.

BACKGROUND: The American College of Surgeons Needs Based Assessment of Trauma Systems (NBATS) tool was developed to help determine the optimal regional distribution of designated trauma centers (DTC). The objectives of our current study were to compare the current distribution of DTCs in Georgia with the recommended allocation as calculated by the NBATS tool and to see if the NBATS tool identified similar areas of need as defined by our previous analysis using the International Classification of Diseases, Ninth Revision, Clinical Modification Injury Severity Score (ICISS). METHODS: Population counts were acquired from US Census publications. Transportation times were estimated using digitized roadmaps and patient zip codes. The number of severely injured patients was obtained from the Georgia Discharge Data System for 2010 to 2014. Severely injured patients were identified using two measures: ICISS<0.85 and Injury Severity Score >15. RESULTS: The Georgia trauma system includes 19 level I, II, or III adult DTCs. The NBATS guidelines recommend 21; however, the distribution differs from what exists in the state. The existing DTCs exactly matched the NBATS recommended number of level I, II, or III DTCs in 2 of 10 trauma service areas (TSAs), exceeded the number recommended in 3 of 10 TSAs, and was below the number recommended in 5 of 10 TSAs. Densely populated, or urban, areas tend to be associated with a higher number of existing centers compared with the NBATS recommendation. Other less densely populated TSAs are characterized by large rural expanses with a single urban core where a DTC is located. The identified areas of need were similar to the ones identified in the previous gap analysis of the state using the ICISS methodology. DISCUSSION: The tool appears to underestimate the number of centers needed in extensive and densely populated areas, but recommends additional centers in geographically expansive rural areas. The tool signifies a preliminary step in assessing the need for state-wide inpatient trauma center services. LEVEL OF EVIDENCE: Economic, level IV.

Association of Trauma Alert Response Charges With Volume and Hospital Ownership Type in Florida.

OBJECTIVE: The purpose was to analyze the association of trauma volume and hospital trauma center (TC) ownership type with trauma alert (TA) response charges, which are billed for activation of the trauma team to the emergency department (ED). METHODS: All Florida ED and inpatients who were billed a TA charge from 2012 to 2014 were included (62 974 observations). Multiple linear regression, controlling for patient and hospital factors, was used to identify associations between TA charges and trauma volume and hospital ownership type. Severity elasticity of trauma response charges was calculated by ownership type. RESULTS: Trauma volume had a significant, inverse relationship with TA charges. For-profit (FP) hospitals had significantly higher TA charges and government-owned hospitals had significantly lower TA charges relative to private not-for-profits. For-profit trauma response charges were inelastic to severity, that is, charges did not change with changes in severity. CONCLUSION: Higher TA charges were associated with lower patient volumes, as well as at FP TCs. Further, only FP TCs used alert charges that were not associated with injury severity. Adding new TCs that reduce volume at existing TCs is expected to increase TA charges, especially if they are FP TCs.

The Probability of Hospitalizations for Mild-to-Moderate Injuries by Trauma Center Ownership Type.

OBJECTIVE: To corroborate anecdotal evidence with systematic evidence of a lower threshold for admission among for-profit hospitals. DATA SOURCES: The study used Florida emergency department and hospital discharge datasets for 2012 to 2014. The treatment variable of interest was for-profit-designated trauma center status. The dependent variable indicated whether a patient with mild-to-moderate injuries was admitted after presenting as a trauma alert and then discharged to home. A separate analysis was conducted of discharges that had a 1-day length of stay. STUDY DESIGN: Generalized estimation equations with logistic distribution models were used to control for the confounding influences and developed for four groups of patients: ICISS = 1 (no probability of mortality), ICISS ≥ 0.99, ICISS ≥ 0.95, and ICISS ≥ 0.85 (zero to 15 percent probability of mortality, which includes all mild and moderate injury patients). PRINCIPAL FINDINGS: For the ICISS = 1 and ICISS ≥ 0.99 models, the centers' for-profit status was the most important predictor. In the ICISS ≥ 0.95 and ICISS ≥ 0.85 models, injury type played a more important role, but for-profit status remained important. For patients with a 1-day stay, for-profit status was associated with an even higher probability of hospitalization. CONCLUSIONS: Considerable differences exist between for-profit and not-for-profit trauma centers concerning hospitalization among the study population, which may be explained by supplier-induced demand.

A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.

Immature patients in a mature system: Regional analysis of Florida's pediatric trauma system.

BACKGROUND: The state of Florida's trauma system is organized into seven regions, two of which lack designated pediatric trauma centers. Injured children residing in these regions often require transfer out of their home region for definitive care. The purpose of this study was to evaluate the effectiveness and efficiency of the current regionalization approach, focusing on variations between regions. METHODS: Using the Florida Agency for Health Care Administration database, we identified all trauma patients 15 years old or younger admitted between 2009 and 2014. Patients with high-risk injury (ICD-9 Injury Severity Score < 0.85) who did not receive definitive treatment at a pediatric trauma center (PTC) were considered undertriaged. Outcomes of interest included mortality and long-term disability. Patients who were definitively treated at a facility outside their home region, but who had low risk injuries (ICD-9 Injury Severity Score > 0.9), required no procedures or ICU monitoring, and were discharged within 48 hours, were considered to have received potentially avoidable out-of-region treatment. Regions were compared, and patients treated in-region were compared to those treated out-of-region. Regression models were used to adjust for covariates. RESULTS: Of 34,816 patients, 8% had high-risk injuries and the overall mortality rate was 1%. Risk-adjusted outcomes were generally similar across all regions. Regional rates of undertriage varied from 0.4% to 4.7% and were highest in regions lacking a PTC. Eleven percent of patients required definitive treatment outside their home region; these patients had higher hospital charges and stayed in the hospital 0.96 days longer (least-squares mean). Rates of potentially avoidable out-of-region treatment ranged from 7% to 12% in the two regions lacking a PTC. After adjustment for confounders, significant unexplained differences in potentially avoidable out-of-region treatment remained between these two regions (OR 2.0, 95% CI 1.6-2.6). CONCLUSIONS: Florida's regionalized pediatric trauma system performs effectively, with low undertriage and acceptable outcomes. Out-of-region treatment, an inevitable byproduct of the current regionalization approach, imposes a measurable burden on the treating facility and patient/family. Unexplained variations in potentially avoidable out-of-region treatment suggest improvements can be made in system efficiency. LEVEL OF EVIDENCE: Economic/decision study, level III.

The trauma ecosystem: The impact and economics of new trauma centers on a mature statewide trauma system.

INTRODUCTION: Florida serves as a model for the study of trauma system performance. Between 2010 and 2104, 5 new trauma centers were opened alongside 20 existing centers. The purpose of this study was to explore the impact of trauma system expansion on system triage performance and trauma center patients' profiles. METHODS: A statewide data set was queried for all injury-related discharges from adult acute care hospitals using International Classification of Diseases, Ninth Revision (ICD-9) codes for 2010 and 2014. The data set, inclusion criteria, and definitions of high-risk injury were chosen to match those used by the Florida Department of Health in its trauma registry. Hospitals were classified as existing Level I (E1) or Level II (E2) trauma centers and new E2 (N2) centers. RESULTS: Five N2 centers were established 11.6 to 85.3 miles from existing centers. Field and overall trauma system triage of high-risk patients was less accurate with increased overtriage and no change in undertriage. Annual volume at N2 centers increased but did not change at E1 and E2 centers. In 2014, Patients at E1 and E2 centers were slightly older and less severely injured, while those at N2 centers were substantially younger and more severely injured than in 2010. The injured patient-payer mix changed with a decrease in self-pay and commercial patients and an increase in government-sponsored patients at E1 and E2 centers and an increase in self-pay and commercial patients with a decrease in government-sponsored patients at N2 centers. CONCLUSION: Designation of new trauma centers in a mature system was associated with a change in established trauma center demographics and economics without an improvement in trauma system triage performance. These findings suggest that the health of an entire trauma system network must be considered in the design and implementation of a regional trauma system. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV; epidemiological, level IV.

Acute appendicitis: variation in outcomes by insurance status.

BACKGROUND: Acute appendicitis (AA) is often studied as a surrogate for acute care surgery. Previous studies have shown differences in outcomes based on insurance status, but associated costs to health care systems are in need of further study. The purpose of the present study was to investigate how treatment, outcomes, and health care resource utilization differ between the uninsured and commercially insured in the setting of AA. METHODS: Patients with AA were identified by International Classification of Diseases, ninth edition, codes using the Agency for Health Care Administration Florida Hospital inpatient discharge data sets for 2002-2011. The outcomes studied were admission with complicated versus uncomplicated appendicitis, receiving laparoscopic versus open appendectomy and experiencing a perioperative complication, length of stay, and overall hospital cost. Data were analyzed using logistic, negative binomial, and least squares multivariate regression. A P value <0.05 was considered significant. All equations controlled for patient demographics, comorbidities, and year and hospital-fixed effects. RESULTS: The uninsured were more likely to present with complicated appendicitis (odds ratio = 1.31, P < 0.01), less likely to receive laparoscopic appendectomy (odds ratio = 0.70, P < 0.01), had longer length of stay, greater costs but had similar rates of perioperative complications in comparison to the commercially insured. CONCLUSIONS: Insurance status is known to affect health care utilization. The uninsured may delay seeking medical assistance, causing greater incidence of complicated disease and increased costs of treatment. Increasing the number of insured via the Affordable Care Act may improve patient outcomes and decrease costs related to AA. These findings may also apply to other acute care surgery conditions.

Explaining Differences in Crash and Injury Crash Outcomes in Red Light Camera Studies.

Evaluations of red light camera (RLC) traffic safety programs have produced mixed results. Some conclude RLCs were associated with significant increases in motor vehicle crashes and injury crashes, whereas other research reports safety benefits. To understand the difference in findings, the present analysis assessed whether standards required for internal validity in quasi-experimental public health program evaluations were adhered to in frequently cited RLC analyses. Four evaluation standards were identified and used to assess the RLC analyses: lack of bias in the selection of both (a) treated sites and (b) comparison sites, (c) integration of relevant control variables in the analysis, and (d) full disclosure of results of the statistical analysis. Six leading RLC studies were then critiqued. Only two of the six studies adhered to the four standards and both concluded RLCs were associated with significant increases in crashes and injury or possible injury crashes. A third study reported an increase in fatal/injury crashes but did not test for statistical significance. Three studies reported equivocal findings; however, each failed to adhere to most standards. Differences in findings were attributed to the evaluation methods used. If implementing an RLC program, communities should use sound public health evaluation methods to assess effectiveness.

The VA Medical Foster Home Program, Ambulatory Care Sensitive Conditions, and Avoidable Hospitalizations.

This quality control study analyzes whether the Veterans Administration Medical Foster Home (VA MFH) program has been successful in improving access and effectiveness of ambulatory care. Individuals hospitalized for one or more of 22 adult ambulatory care sensitive conditions were identified. Pre and post comparisons of a specified population of participants in the program were conducted to determine rates of avoidable hospitalizations for 6 months prior to and following MFH enrollment. The overall rate of avoidable hospitalizations declined from 18.5 to 14.9 per 100 enrollees following enrollment. The number of bed days used declined by 39%, as did the cost associated with avoidable hospitalizations. Enrollment in the VA MFH program resulted in an overall reduction in the rate of avoidable hospitalizations, resource utilization, and costs. Studies are needed comparing these results with other matched cohorts of nursing home eligible veterans.

Measuring trauma system performance: Right patient, right place-Mission accomplished?

BACKGROUND: A regional trauma system must establish and monitor acceptable overtriage and undertriage rates. Although diagnoses from discharge data sets can be used with mortality prediction models to define high-risk injury, retrospective analyses introduce methodological errors when evaluating real-time triage processes. The purpose of this study was to determine if major trauma patients identified using field criteria correlated with those retrospectively labeled high risk and to assess system performance by measuring triage accuracy and trauma center utilization. METHODS: A statewide database was queried for all injury-related International Classification of Diseases, 9th Revision, code discharges from designated trauma centers and nontrauma centers for 2012. Children and burn patients were excluded. Patients assigned a trauma alert fee were considered field-triage(+). The International Classification Injury Severity Score methodology was used to estimate injury-related survival probabilities, with an International Classification Injury Severity Score less than 0.85 considered high risk. Triage rates were expressed relative to the total population; the proportion of low- and high-risk patients discharged from trauma centers defined trauma center utilization. RESULTS: There were 116,990 patients who met study criteria, including 11,368 (10%) high-risk, 70,741 field-triage(-) patients treated in nontrauma centers and 28,548 field-triage(-) and 17,791 field-triage(+) patients treated in trauma centers. Field triage was 86% accurate, with 10% overtriage and 4% undertriage. System triage was 66% accurate, with 32% overtriage and 2% undertriage. Overtriage patients more often, and undertriage patients less often, had severe injury characteristics than appropriately triaged patients. CONCLUSION: Trauma system performance assessed using retrospective administrative data provides a convenient measure of performance but must be used with caution. Residual mistriage can partly be attributed to error introduced by retrospective high-risk definitions, whereas differences between field and system triage accuracy can be attributed to the trauma center's role as a large community hospital. Given the limitations of the data and methods, these results may represent optimal patient distribution within this mature system.

An analysis of the effectiveness of a state trauma system: treatment at designated trauma centers is associated with an increased probability of survival.

BACKGROUND: States struggle to continue support for recruitment, funding and development of designated trauma centers (DTCs). The purpose of this study was to evaluate the probability of survival for injured patients treated at DTCs versus nontrauma centers. METHODS: We reviewed 188,348 patients from the state's hospital discharge database and identified 13,953 severely injured patients admitted to either a DTC or a nontrauma center between 2008 and 2012. DRG International Classification of Diseases-9th Rev. Injury Severity Scores (ICISS), an accepted indicator of injury severity, was assigned to each patient. Severe injury was defined as an ICISS less than 0.85 (indicating ≥15% probability of mortality). Three subgroups of the severely injured patients were defined as most critical, intermediate critical, and least critical. A full information maximum likelihood bivariate probit model was used to determine the differences in the probability of survival for matched cohorts. RESULTS: After controlling for injury severity, injury type, patient demographics, the presence of comorbidities, as well as insurance type and status, severely injured patients treated at a DTC have a 10% increased probability of survival. The largest improvement was seen in the intermediate subgroup. CONCLUSION: Treatment of severely injured patients at a DTC is associated with an improved probability of survival. This argues for continued resources in support of DTCs within a defined statewide network. LEVEL OF EVIDENCE: Epidemiologic study, level III.

The injured elderly: a rising tide.

BACKGROUND: Injury remains a public health challenge despite advances in trauma care. Periodic survey of injury epidemiology is essential to the trauma system's continuous performance improvement. We undertook this study to characterize the changes in Florida injury rates during the past 15 years. METHODS: Injured patients were identified with the use of a statewide database over 15 years ending in 2010. Population data were obtained from the U.S. Census. Severe injury was defined by International Classification Injury Severity Scores less than 0.85. Injury rates were expressed in discharges per 100,000 residents. Trends were analyzed by linear regression. RESULTS: The 1.5 million patient discharges consisted of 5.2% children, 39.7% adults, and 55.1% elderly. The overall injury rate decreased in children by 18% but increased in adults by 2% and in the elderly by 17% during the study period. The proportion of severe injuries decreased in children and the elderly but did not change in adults. Injury patterns changed in all age groups. CONCLUSION: Injury in the elderly is increasing at a rate seven times that of adults. In 2010, the elderly accounted for only 17% of the population but 55% of injury-related discharges. These trends have dramatic implications for the design of future trauma systems and health care resource use.

Fifteen-year trauma system performance analysis demonstrates optimal coverage for most severely injured patients and identifies a vulnerable population.

BACKGROUND: Trauma systems are designed to deliver timely and appropriate care. Prehospital triage regulations and interfacility transfer guidelines are the primary determinants of system efficacy. We analyzed the effectiveness of the Florida trauma system in delivering trauma patients to trauma centers over time. STUDY DESIGN: Injured patients were identified by ICD-9 codes from a statewide discharge dataset, and they were categorized as children (less than 16 years old), adult (16 to 65 years old), or elderly (over 65 years old). Severe injury was defined by International Classification Injury Severity Scores (ICISS) < 0.85. Residence ZIP codes were used as a surrogate for injury location. RESULTS: Severe injury discharges increased at designated trauma centers (DTCs) and decreased at nontrauma centers (NTCs). The proportion of patients with severe injuries discharged from DTCs increased for all age groups, capturing nearly all severely injured children and adults. Access to DTCs was dependent on proximity for severely injured elderly but not for severely injured children and adults. CONCLUSIONS: Triage improved over time, enabling near complete capture of at-risk children and adults independent of DTC proximity. Because distance from a DTC does not limit access for children and adults, existing trauma system resources are sufficient to meet the current demands. Efforts are needed to determine the trauma resource and triage needs of the severely injured elderly.