A Leg to Stand on: Trauma Center Designation and Association with Rate of Limb Salvage in Patients Suffering Severe Lower Extremity Injury.

BACKGROUND: Mangled extremities are one of the most difficult injuries for trauma surgeons to manage. We compare limb salvage rates for a limb-threatening lower extremity injuries managed at Level I vs Level II trauma centers (TCs). STUDY DESIGN: We identified all adult patients with a limb-threatening injury who underwent primary amputation or limb salvage (LS) using the American College of Surgeons (ACS) Trauma Quality Improvement Program database at ACS Level I vs II TCs between 2007 and 2017. A limb-threatening injury was defined as an open tibial fracture with concurrent arterial injury (Gustilo type IIIc). Multivariable analysis and propensity score matching were performed to minimize confounding by indication. RESULTS: There were 712 records for analysis; 391 (54.9%) LS performed and 321 (45.1%) underwent amputation. The rate of LS was statistically higher among patients treated at Level I TCs vs those treated at Level II TCs (47.4% vs 34.8%; p = 0.01). Patients with penetrating injuries (13% vs 9.5%; p = 0.046) and tibial/peroneal artery injury (72.9% vs 50.4%; p < 0.001), as opposed to popliteal artery injury (30.8% vs 58.8%; p < 0.001), were more likely to have LS. The risk-adjusted odds of LS was 3.13 times higher at Level I TCs vs Level II TCs (95% CI, 1.59 to 6.34; p = 0.001). Limb salvage rates were significantly higher at Level I TCs compared with Level II TCs (53.0% vs 34.8%; p = 0.004), even after propensity matching. CONCLUSIONS: In patients with a mangled extremity, limb salvage rates are 50% higher at Level I TCs compared with Level II TCs, independent of case mix and injury severity.

Road Traffic Accidents and Disparities in Child Mortality.

BACKGROUND AND OBJECTIVES: Road traffic accidents are a leading cause of child deaths in the United States. Although this has been examined at the national and state levels, there is more value in acquiring information at the county level to guide local policies. We aimed to estimate county-specific child mortality from road traffic accidents in the United States. METHODS: We queried the Fatality Analysis Reporting System database, 2010-2017, for road traffic accidents that resulted in a death within 30 days of the auto crash. We included all children <15 years old who were fatally injured. We estimated county-specific age- and sex-standardized mortality. We evaluated the impact of the availability of trauma centers and urban-rural classification of counties on mortality. RESULTS: We included 9271 child deaths. Among those, 45% died at the scene. The median age was 7 years. The overall mortality was 1.87 deaths per 100 000 children. County-specific mortality ranged between 0.25 and 21.91 deaths per 100 000 children. The availability of a trauma center in a county was associated with decreased mortality (adult trauma center [odds ratio (OR): 0.59; 95% credibility interval (CI), 0.52-0.66]; pediatric trauma center [OR: 0.56; 95% CI, 0.46-0.67]). Less urbanized counties were associated with higher mortality, compared with large central metropolitan counties (noncore counties [OR: 2.33; 95% CI, 1.85-2.91]). CONCLUSIONS: There are marked differences in child mortality from road traffic accidents among US counties. Our findings can guide targeted public health interventions in high-risk counties with excessive child mortality and limited access to trauma care.

Right Patient, Right Place, Right Time: Field Triage and Transfer to Level I Trauma Centers.

INTRODUCTION: This study sought to compare the outcomes of trauma patients taken directly from the field to a level I trauma center (direct) versus patients that were first brought to a level III trauma center prior to being transferred to a level I (transfer) within our inclusive Delaware trauma system. METHODS: A retrospective review of the level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single level I trauma center from two surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. RESULTS: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared to direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (OR 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001). DISCUSSION: Delays in presentation to our level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

Efforts to Improve Appropriate Trauma Activation for Patients Transferred to a Level 1 Trauma Center From Outside Hospitals.

Trauma centers monitor under- and overtriage rates to comply with American College of Surgeons Committee on Trauma verification requirements. Efforts to maintain acceptable rates are often undertaken as part of quality assurance. The purpose of this project was to improve the institutional undertriage rate by focusing on appropriately triaging patients transferred from outside hospitals (OSHs). Trauma physicians received education and pocket cards outlining injury severity score (ISS) calculation to aid in prospectively estimating ISS for patients transferred from OSHs, and activate the trauma response expected for that score. Under- and overtriage rates before and after the intervention were compared. The postintervention period saw a significant decrease in overall overtriage rate, with simultaneous trend toward lower overall undertriage rate, attributable to the significant reduction in undertriage rate of patients transferred from OSHs. Prospectively estimating ISS to assist in determining trauma activation level shows promise in managing appropriate patient triage. However, questions arose regarding the necessity for full trauma activation for transferred patients, regardless of ISS. It may be necessary to reconsider how patients transferred from OSHs are evaluated. Full trauma activation can be a financial and resource burden, and should not be taken lightly.

Chemoprophylaxis and Venous Thromboembolism in Traumatic Brain Injury at Different Trauma Centers.

Patients with severe traumatic brain injury (TBI) are at an increased risk of venous thromboembolism (VTE). Because of concerns of worsening intracranial hemorrhage, clinicians are hesitant to start VTE chemoprophylaxis in this population. We hypothesized that ACS Level I trauma centers would be more aggressive with VTE chemoprophylaxis in adults with severe TBI than Level II centers. We also predicted that Level I centers would have a lower risk of VTE. We queried the Trauma Quality Improvement Program (2010-2016) database for patients with Abbreviated Injury Scale scores of 4 and 5 of the head and compared them based on treating the hospital trauma level. Of 204,895 patients with severe TBI, 143,818 (70.2%) were treated at Level I centers and 61,077 (29.8%) at Level II centers. The Level I cohort had a higher rate of VTE chemoprophylaxis use (43.2% vs 23.3%, P < 0.001) and a shorter median time to chemoprophylaxis (61.9 vs 85.9 hours, P < 0.001). Although Level I trauma centers started VTE chemoprophylaxis more often and earlier than Level II centers, there was no difference in the risk of VTE (P = 0.414) after controlling for covariates. Future prospective studies are warranted to evaluate the timing, safety, and efficacy of early VTE chemoprophylaxis in severe TBI patients.

Association Between Trauma Center Designation Levels and Survival of Patients With Motor Vehicular Transport Injuries in the United States.

BACKGROUND: Motor vehicular transport (MVT) is a leading cause of injuries globally. Health care regionalization aims at improving patients' outcomes. OBJECTIVES: This study examines the association between trauma center designation levels in the United States and survival of patients with MVT-related injuries. METHODS: We used the National Trauma Data Bank 2015 dataset for this retrospective study. We conducted descriptive and bivariate analyses. This was followed by a multivariate analysis to assess the association between trauma center level and survival to hospital discharge. RESULTS: One hundred sixty-eight thousand five hundred twenty-four patients were included in this study. The mean age was 39.9 years (±19.5 years) with a male predominance (63.8%). Most patients were taken to level I (55.7%) and level II (35.9%) centers. The overall survival of patients with MVT injuries was 95.3%. Involved patients were occupant (64.8%), motorcyclist (17.3%), and pedestrian (12.7%). After adjusting for confounders, patients sustaining MVT injuries who were taken to level II and III trauma centers were less likely survive compared with those taken to level I centers (odds ratio = 0.89 [95% confidence interval 0.81-0.97] and odds ratio = 0.70 [95% confidence interval 0.59-0.82], respectively). CONCLUSIONS: In this study, we identified a survival benefit for patients with MVT injuries when treated at level I compared with level II and III centers. These findings provide additional evidence for the benefit of health care regionalization in the form of trauma center level designation.

The impact of teaching status on trauma center clinical outcomes in the United States.

Teaching status/academic ranking may play a role in the variations in trauma center (TC) outcomes. Our study aimed to determine the relationship between TC teaching status and injury-adjusted, all-cause mortality in a national sampling.Retrospective review of the National Sample Program (NSP) from the National Trauma Data bank (NTDB). TCs were categorized based on teaching status. Adjusted mortality was determined by observed/expected (O/E) mortality ratios, derived using TRauma Injury Severity Score methodology from the Injury Severity Score and Revised Trauma Score. Chi-square and t test analyses were utilized with a statistical significance defined as P <.05.Of the 94 TCs in the NSP, 46 were university, 38 were community teaching, and 10 were community nonteaching. For the University TCs, 62.8% were American College of Surgeons (ACS) level 1 and 81.2% state level 1. Of the community teaching TCs, 39.0% was ACS level 1 and 35.1% was state level 1. Of the community nonteaching TCs, 0% was ACS level 1 and 11.1% was state level 1. University TCs had a significantly higher O/E mortality rate than community teaching (0.75 vs 0.71; P = .04). There were no differences in O/E between community teaching and nonteaching TCs (0.71 vs 0.70; P = .70).Community teaching and nonteaching TCs have lower injury-adjusted, all-cause mortality rates than University Centers. Future studies should further investigate key differences between University TCs and community teaching TC to evaluate possible quality and performance improvement measures.

Identifying Predictors of Undertriage in Injured Older Adults After Implementation of Statewide Geriatric Trauma Triage Criteria.

OBJECTIVES: The objective was to identify factors associated with transport of injured older adults meeting statewide geriatric trauma triage criteria to a trauma center. METHODS: An observational retrospective cohort study using the 2009 to 2011 Ohio Trauma Registry. Subjects were adults ≥ 70 years old who met Ohio's geriatric triage criteria for trauma center transport by emergency medical services. We created multivariable logistic regression models to identify predictors of initial and ultimate (e.g., interfacility transfer) transport to a Level I or II trauma center and to a Level I, II, or III center. RESULTS: Of 10,411 subjects, 47% were initially and 59% were ultimately transported to a Level I or II trauma center with rates of 66 and 74%, respectively, for transport to a Level I, II, or III center. For initial transport to a Level I or II center, age 80 to 89 (odds ratio [OR] = 0.89), age ≥ 90 (OR = 0.76), and either only a Level 3 (OR = 0.3) or no trauma center (OR = 0.11) in county of residence had decreased odds of transport, while male sex (OR = 1.38), black race (OR = 2.07), Injury Severity Score (ISS) 10-15 (OR = 1.99), ISS > 15 (OR = 2.85), and Glasgow Coma Scale score < 9 (OR = 2.11) had increased odds. Results were similar for ultimate transport to a Level I or II center. Analyzing transport to a Level I, II, or III center demonstrated similar results except a Level III trauma center in county of residence was associated with increased odds (OR = 2.00 for initial and 2.21 for ultimate) of transport to a Level I, II, or III center. CONCLUSIONS: We identified factors independently associated with failure to transport injured older adults to trauma centers in statewide data collected after adoption of geriatric triage criteria. Lack of a trauma center in the county of residence remained a factor even in analyses that included ultimate transport.

Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism.

BACKGROUND: Tranexamic acid (TXA) is used as a hemostatic adjunct for hemorrhage control in the injured patient and reduces early preventable death. However, the risk of venous thromboembolism (VTE) has been incompletely explored. Previous studies investigating the effect of TXA on VTE vary in their findings. We performed a propensity matched analysis to investigate the association between TXA and VTE following trauma, hypothesizing that TXA is an independent risk factor for VTE. METHODS: This retrospective study queried trauma patients presenting to a single Level I trauma center from 2012 to 2016. Our primary outcome was composite pulmonary embolism or deep vein thrombosis. Mortality, transfusion, intensive care unit and hospital lengths of stay were secondary outcomes. Propensity matched mixed effects multivariate logistic regression was used to determine adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) of TXA on outcomes of interest, adjusting for prespecified confounders. Competing risks regression assessed subdistribution hazard ratio of VTE after accounting for mortality. RESULTS: Of 21,931 patients, 189 pairs were well matched across propensity score variables (standardized differences <0.2). Median Injury Severity Score was 19 (interquartile range, 12-27) and 14 (interquartile range, 8-22) in TXA and non-TXA groups, respectively (p = 0.19). Tranexamic acid was associated with more than threefold increase in the odds of VTE (aOR, 3.3; 95% CI, 1.3-9.1; p = 0.02). Tranexamic acid was not significantly associated with survival (aOR, 0.86; 95% CI, 0.23-3.25; p = 0.83). Risk of VTE remained elevated in the TXA cohort despite accounting for mortality (subdistribution hazard ratio, 2.42; 95% CI, 1.11-5.29; p = 0.03). CONCLUSION: Tranexamic acid may be an independent risk factor for VTE. Future investigation is needed to identify which patients benefit most from TXA, especially given the risks of this intervention to allow a more individualized treatment approach that maximizes benefits and mitigates potential harms. LEVEL OF EVIDENCE: Therapeutic, level III.

American College of Surgeons Committee on Trauma verification level affects trauma center management of pelvic ring injuries and patient mortality.

BACKGROUND: Pelvic ring fractures represent a complex injury that requires specific resources and clinical expertise for optimal trauma patient management. We examined the impact of treatment variability for this type of injury at Level I and II trauma centers on patient outcomes. METHODS: Trauma quality collaborative data (2011-2017) were analyzed. This includes data from 29 American College of Surgeons Committee on Trauma verified Level I and Level II trauma centers. Inclusion criteria were adult patients (≥16 years), Injury Severity Score of 5 or higher, blunt injury, and evidence of a partially stable or unstable pelvic ring fracture injury coding as classified using Abbreviated Injury Scale version 2005, with 2008 updates. Patients directly admitted, transferred out for definitive care, with penetrating trauma, or with no signs of life were excluded. Propensity score matching was used to create 1:1 matched cohorts of patients treated at Levels I or II trauma centers. Trauma center verification level was the exposure variable used to compare management strategies, resource utilization, and in-hospital mortality in univariate analysis. RESULTS: We selected 1,220 well-matched patients, from 1,768 total patients, using propensity score methods (610 Level I and 610 Level II cohort). There were no significant baseline characteristic differences noted between the groups. Patients with pelvic ring fractures treated at Level I trauma centers had significantly decreased mortality (7.7% vs. 11.6%, p = 0.02). Patients treated at Level II trauma centers were less likely to receive interventional angiography, undergo complicated definitive orthopedic operative treatment, and to be admitted to an intensive care unit. CONCLUSION: Admission with a partially stable or unstable pelvic ring injury to a Level I trauma center is associated with decreased mortality. Level II trauma centers had significantly less utilization of advanced treatment modalities. This variation in clinical practice highlights potential processes to emphasize in the appropriate treatment of these critically ill patients. LEVEL OF EVIDENCE: Economic/Decision, Level II.

Rural Level III centers in an inclusive trauma system reduce the need for interfacility transfer.

BACKGROUND: Development of Level III trauma centers in a regionalized system facilitates early stabilization and prompt transfer to a higher level center. The resources to care for patients at Level III centers could also reduce the burden of interfacility transfers. We hypothesized that the development and designation of Level III centers in an inclusive trauma system resulted in lower rates of transfer, with no increase in morbidity or mortality among the non-transferred patients. METHODS: State trauma registry data from January 2009 through September 2015 were examined from five rural hospitals that transfer patients to our highest (Level II) trauma center and resource hospital. These five rural hospitals began receiving state support in 2010 to develop their trauma programs and were subsequently verified and designated Level III centers (three in 2011, two in 2013). Multivariate logistic regression was used to examine the adjusted odds of patient transfers and adverse outcomes, while controlling for age, gender, penetrating mechanism, presence of a traumatic brain injury, arrival by ambulance, and category of Injury Severity Score. The study period was divided into "Before" Level III center designation (2009-2010) and "After" (2011-2015). RESULTS: 7,481 patient records were reviewed. There was a decrease in the proportion of patients who were transferred After (1,281/5,737) compared to Before (516/1,744) periods (22% vs. 30%, respectively). After controlling for the various covariates, the odds of patient transfer were reduced by 32% (p < 0.0001) during the After period. Among non-transferred patients, there were no significant increases in adjusted odds of mortality, or hospitalizations of seven days or more, Before versus After. CONCLUSIONS: Development of rural Level III trauma centers in a regionalized system can significantly reduce the need for transfer to a remote, higher level trauma center. This may benefit the patient, family, and trauma system, with no adverse effect upon patient outcome. LEVEL OF EVIDENCE: Epidemiological, level III.

Positive Impact of an Aortic Center Designation.

BACKGROUND: In January 2015, we created a multidisciplinary Aortic Center with the collaboration of Vascular Surgery, Cardiac Surgery, Interventional Radiology, Anesthesia and Hospital Administration. We report the initial success of creating a Comprehensive Aortic Center. METHODS: All aortic procedures performed from January 1, 2015 until December 31, 2016 were entered into a prospectively collected database and compared with available data for 2014. Primary outcomes included the number of all aortic related procedures, transfer acceptance rate, transfer time, and proportion of elective/emergent referrals. RESULTS: The Aortic Center included 5 vascular surgeons, 2 cardiac surgeons, and 2 interventional radiologists. Workflow processes were implemented to streamline patient transfers as well as physician and operating room notification. Total aortic volume increased significantly from 162 to 261 patients. This reflected an overall 59% (P = 0.0167) increase in all aorta-related procedures. We had a 65% overall increase in transfer requests with 156% increase in acceptance of referrals and 136% drop in transfer denials (P < 0.0001). Emergent abdominal aortic cases accounted for 17% (n = 45) of our total aortic volume in 2015. The average transfer time from request to arrival decreased from 515 to 352 min, although this change was not statistically significant. We did see a significant increase in the use of air-transfers for aortic patients (P = 0.0041). Factorial analysis showed that time for transfer was affected only by air-transfer use, regardless of the year the patient was transferred. Transfer volume and volume of aortic related procedures remained stable in 2016. CONCLUSIONS: Designation as a comprehensive Aortic Center with implementation of strategic workflow systems and a culture of "no refusal of transfers" resulted in a significant increase in aortic volume for both emergent and elective aortic cases. Case volumes increased for all specialties involved in the center. Improvements in transfer center and emergency medical services communication demonstrated a trend toward more efficient transfer times. These increases and improvements were sustainable for 2 years after this designation.

Ocular injury in orbital fractures at a level I trauma center.

OBJECTIVE: To determine the acuity of ophthalmology referral for orbital fractures. METHODS: This is a retrospective chart review of 73 cases of orbital fractures over a 1-year period at a level I trauma centre. All consultations including those for orbital fractures were included in the study. The age and sex of the patient, date and time of initial emergency room (ER) arrival, date and time of input of the ophthalmology consultation, date and time the patient actually saw ophthalmology, reasons for consultation, location of examination, mechanism, and ocular findings at initial and follow-up examination, and any orbital surgery performed were recorded. RESULTS: Of the 73 patients referred, 10 had an ocular abnormality on examination. Of the 65 routine referrals for orbital fracture received, 5 had an ocular abnormality on examination, whereas 5 of the 8 patients referred for an ocular abnormality in addition to the orbital fracture had an ocular abnormality, for an overall rate of 13.7%. Of the routine referrals, none had severe ocular injuries, such as globe rupture or retrobulbar hemorrhage, requiring immediate ocular intervention. CONCLUSIONS: Orbital fractures may be associated with severe ocular abnormalities, although routine cases of orbital fractures in the absence of suspicion of serious ocular injury may be less likely to have abnormalities requiring emergent evaluation by an ophthalmologist. A prospective study evaluating orbital fractures would help clarify this.

How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study.

OBJECTIVE: To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system. SETTING: ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million. PARTICIPANTS: 5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only. RESULTS: A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit. CONCLUSION: The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.

Patient Outcomes at Urban and Suburban Level I Versus Level II Trauma Centers.

STUDY OBJECTIVE: Regionalized systems of trauma care and level verification are promulgated by the American College of Surgeons. Whether patient outcomes differ between the 2 highest verifications, Levels I and II, is unknown. In contrast to Level II centers, Level I centers are required to care for a minimum number of severely injured patients, have immediate availability of subspecialty services and equipment, and demonstrate research, substance abuse screening, and injury prevention. We compare risk-adjusted mortality outcomes at Levels I and II centers. METHODS: This was an analysis of data from the 2012 to 2014 Los Angeles County Trauma and Emergency Medical Information System. The system includes 14 trauma centers: 5 Level I and 9 Level II centers. Patients meeting criteria for transport to a trauma center are routed to the closest center, regardless of verification level. All adult patients (≥15 years) treated at any of the trauma centers were included. Outcomes of patients treated at Level I versus Level II centers were compared with 2 validated risk-adjusted models: Trauma Score-Injury Severity Score (TRISS) and the Haider model. RESULTS: Adult subjects (33,890) were treated at a Level I center; 29,724, at a Level II center. We found lower overall mortality at Level II centers compared with Level I, using TRISS (odds ratio 0.68; 95% confidence interval 0.59 to 0.78) and Haider (odds ratio 0.84; 95% confidence interval 0.73 to 0.97). CONCLUSION: In this cohort of patients treated at urban and suburban trauma centers, treatment at a Level II trauma center was associated with overall risk-adjusted reduced mortality relative to that at a Level I center. In the subset of penetrating trauma, no differences in mortality were found. Further study is warranted to determine optimal trauma system configuration and allocation of resources.

Advanced Trauma Life Support Time Standards.

INTRODUCTION: Trauma readiness is critical to military medicine. Without medical centers that include persistent volumes of trauma, simulation has become the means to maintain and practice those skills. To create those simulations, standards for both design and metrics to evaluate practitioners are required. MATERIALS AND METHODS: Forty-four traumas were monitored and times to completion of the various steps of Advanced Trauma Life Support were recorded and tabulated. The times recorded for level 1 and level 2 traumas were compared without statistical differences identified. RESULTS: Normative times for various portions of the Advanced Trauma Life Support protocol were provided. These include time to airway assessment, breathing assessment, circulation assessment, establishment of intravenous, completion of primary survey, chest X-ray, first set of vitals, and focused assessment with sonography for trauma scan. CONCLUSIONS: Using these mean times, simulations can be created to best replicate traumas and evaluate the capabilities of practitioners.

Outcome after polytrauma in a certified trauma network: comparing standard vs. maximum care facilities concept of the study and study protocol (POLYQUALY).

BACKGROUND: The aim of this study is to evaluate the performance of the first certified regional trauma network in Germany, the Trauma Network Eastern Bavaria (TNO) addressing the following specific research questions: Do standard and maximum care facilities produce comparable (risk-adjusted) levels of patient outcome? Does TNO outperform reference data provided by the German Trauma Register 2008? Does TNO comply with selected benchmarks derived from the S3 practice guideline? Which barriers and facilitators can be identified in the health care delivery processes for polytrauma patients? METHOD/DESIGN: The design is based on a prospective multicenter cohort study comparing two cohorts of polytrauma patients: those treated in maximum care facilities and those treated in standard care facilities. Patient recruitment will take place in the 25 TNO clinics. It is estimated that n = 1.100 patients will be assessed for eligibility within a two-year period and n = 800 will be included into the study and analysed. Main outcome measures include the TraumaRegisterQM form, which has been implemented in the clinical routine since 2009 and is filled in via a web-based data management system in participating hospitals on a mandatory basis. Furthermore, patient-reported outcome is assessed using the EQ-5D at 6, 12 and 24 months after trauma. Comparisons will be drawn between the two cohorts. Further standards of comparisons are secondary data derived from German Trauma Registry as well as benchmarks from German S3 guideline on polytrauma. The qualitative part of the study will be based on semi-standardized interviews and focus group discussions with health care providers within TNO. The goal of the qualitative analysis is to elucidate which facilitating and inhibiting forces influence cooperation and performance within the network. DISCUSSION: This is the first study to evaluate a certified trauma network within the German health care system using a unique combination of a quantitative (prospective cohort study) and a qualitative (in-depth facilitator/barrier analysis) approach. The information generated by this project will be used in two ways. Firstly, within the region the results of the study will help to optimize the pre-hospital and clinical management of polytrauma patients. Secondly, on a nationwide scale, influential decision-making bodies, such as the Ministries of Health, the Hospital Associations, sickness funds, insurance companies and professional societies, will be addressed. The results will not only be applicable to the region of Eastern Bavaria, but also in most other parts of Germany with a comparable infrastructure. TRIAL REGISTRATION: VfD_Polyqualy_12_001978 , 10.Jan.2013; German Clinical Trials Register DRKS00010039 , 18.02.2016.

Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database.

BACKGROUND: Optimal management of adolescent trauma patients with blunt abdominal solid organ injury (SOI) remains controversial. The purpose of this study was to identify management differences in adolescents with SOI treated at adult trauma centers (ATC) versus pediatric trauma centers (PTC). We hypothesized that adolescents with SOI would undergo different treatment at ATC and PTC. MATERIALS AND METHODS: Retrospective review of the Pennsylvania Trauma Systems Foundation database from 2005-2010 was performed. Adolescent patients (13-18 y old) with SOI (spleen, liver, and kidney injury) were included. Patient baseline characteristics and care processes for each injury were compared between ATC and PTC. RESULTS: A total of 1532 patients with at least one SOI were identified: 946 patients had a splenic injury, 505 had a liver injury, and 424 had a kidney injury. Spleen and liver procedures were performed more often at ATC than at PTC irrespective of injury grade (respectively, 16.1% versus 3.2%, 5.9% versus 0%; P < 0.01). Transarterial embolization for splenic injury was more frequently performed at ATC (2.8% versus 0.6%; P = 0.02). After adjusting for potential confounding factors, care at PTC was significantly associated with lower odds of splenic procedure for patients with splenic injury (OR: 0.16, 95% CI: 0.08-0.36, P < 0.001). In a subgroup analysis of nontransfer patients, care at PTC remained significantly associated with lower odds of splenic procedure (OR: 0.24, 95% CI: 0.10-0.59, P = 0.002) despite higher median injury severity score than ATC. CONCLUSIONS: Significant differences in the management of adolescents with SOI were identified in Pennsylvania. Operative intervention for SOI was more often performed at ATC than at PTC. Further study will be needed to address the impact of these disparities on patient outcomes.

Splenic conservation: variation between pediatric and adult trauma centers.

OBJECTIVES: Nonoperative management of hemodynamically stable children and adolescents with splenic injury regardless of grade has become standard; however, numerous studies have shown a wide variation in management. We compared the treatment and outcomes of adolescent splenic injuries in our region, which includes a pediatric level I trauma center (PTC) and an adult level I trauma center (ATC). METHODS: A retrospective review of the trauma registry was performed on patients 14 to 17 y old with blunt splenic injury admitted to either the local PTC or ATC from January 1999 through December 2010. Demographics, interventions, and hospital course were recorded and compared using Fisher exact, Student t-test, and multivariate analysis. RESULTS: Eighty-six adolescent patients presenting to the PTC and 65 patients presenting to the ATC met the criteria over the 12-y period. Although the ATC received more significantly injured and slightly older patients, logistic multivariate analysis demonstrated that the location of presentation was the only independent factor associated with splenectomy (P = 0.0015). A higher injury severity score was associated with a longer length of stay (LOS), but the nonoperative approach was not associated with a longer LOS (P = 0.96). CONCLUSIONS: Our study demonstrates that the location of presentation was independently associated with splenectomy while controlling for a higher injury severity score at the ATC. With the higher percentage of nonoperative management, treatment at the PTC was not associated with an increased LOS (total or intensive care unit).