Assessing trauma readiness costs in level III and level IV trauma centers.

BACKGROUND: Readiness costs are expenses incurred by trauma centers to maintain essential infrastructure. Although the components for readiness are described in the American College of Surgeons' Resources for Optimal Care of the Injured Patient , the cost associated with each component is not well defined. Previous studies describe readiness costs for levels I and II trauma centers based on these criteria. The purpose of this study was to quantify the cost of levels III and IV trauma center readiness. METHODS: The state trauma commission, along with trauma medical directors, program managers, and trauma center financial staff, standardized definitions for each component of trauma center readiness costs and developed a survey tool for reporting. Readiness costs were grouped into four categories: Administrative/Program Support Staff, Clinical Medical Staff, and Education/Outreach. A financial auditor analyzed all data to verify consistent cost reporting. Trauma center outliers were evaluated to validate variances. All levels III and IV trauma centers (n = 14) completed the survey on 2019 data. RESULTS: Average annual readiness cost is $1,715,025 for a level III trauma center and $81,620 for level IV centers. Among the costliest components were clinical medical staff for level IIIs and administrative costs for level IVs, representing 54% and 97% of costs, respectively. Although education/outreach is mandated, levels III and IV trauma centers only spend approximately $8,000 annually on this category (0.8-3%). CONCLUSION: This study defines the cost associated with each readiness component outlined in the Resources for Optimal Care of the Injured Patient manual. The average readiness cost for a level III trauma center is $1,715,025 and $81,620 for a level IV, underscoring the need for additional trauma center funding to meet the requirements set forth by the American College of Surgeons. LEVEL OF EVIDENCE: Economic and Value-Based Evaluations; Level III.

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.

Accelerated Biologic Aging, Chronic Stress, and Risk for Sepsis and Organ Failure Following Trauma.

Chronic stress and accelerated aging have been shown to impact the inflammatory response and related outcomes like sepsis and organ failure, but data are lacking in the trauma literature. The purpose of this study was to investigate potential relationships between pretrauma stress and posttrauma outcomes. The hypothesis was that pretrauma chronic stress accelerates aging, which increases susceptibility to posttrauma sepsis and organ failure. In this prospective, correlational study, chronic stress and accelerated biologic aging were compared to the occurrence of systemic inflammatory response syndrome, sepsis, and organ failure in trauma patients aged 18-44 years. Results supported the hypothesis with significant overall associations between susceptibility to sepsis and accelerated biologic aging (n = 142). There were also significant negative associations between mean cytokine levels and chronic stress. The strongest association was found between mean interleukin-1ß (IL-1ß) and human telomerase reverse transcriptase (hTERT), r(101) = -0.28), p = .004. Significant negative associations were found between mean cytokine levels, IL-12p70, r(108) = -0.20, p = .034; and tumor necrosis factor-α (TNF-α), r(108) = -0.20, p = .033, and positive life events via the behavioral measure of chronic stress. Results may help identify individuals at increased risk for poor outcomes of trauma and inform interventions that may reduce the risk for sepsis and organ failure.

How much green does it take to be orange? Determining the cost associated with trauma center readiness.

BACKGROUND: Readiness costs are real expenses incurred by trauma centers to maintain essential infrastructure to provide emergent services on a 24/7 basis. Although the components for readiness are well described in the American College of Surgeons' Resources for Optimal Care of the Injured Patient, the cost associated with each component is not well defined. We hypothesized that meeting the requirements of the 2014 Resources for Optimal Care of the Injured Patient would result in significant costs for trauma centers. METHODS: The state trauma commission in conjunction with trauma medical directors, program managers, and financial officers of each trauma center standardized definitions for each component of trauma center readiness cost and developed a survey tool for reporting. Readiness costs were grouped into four categories: administrative/program support staff, clinical medical staff, in-house operating room, and education/outreach. To verify consistent cost reporting, a financial auditor analyzed all data. Trauma center outliers were further evaluated to validate variances. All level I/level II trauma centers (n = 16) completed the survey on 2016 data. RESULTS: Average annual readiness cost is US $10,078,506 for a level I trauma center and US $4,925,103 for level IIs. Clinical medical staff was the costliest component representing 55% of costs for level Is and 64% for level IIs. Although education/outreach is mandated, levels I and II trauma centers only spend approximately US $100,000 annually on this category (1%-2%), demonstrating a lack of resources. CONCLUSION: This study defines the cost associated with each component of readiness as defined in the Resources for Optimal Care of the Injured Patient manual. Average readiness cost for a level I trauma center is US $10,078,506 and US $4,925,103 for a level II. The significant cost of trauma center readiness highlights the need for additional trauma center funding to meet the requirements set forth by the American College of Surgeons. LEVEL OF EVIDENCE: Economic and value-based evaluations, level III.

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.

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.

Verification of resident bedside-procedure competency by intensive care nursing staff.

BACKGROUND: Recent efforts by the Accreditation Council for Graduate Medical Education to standardize resident education and demonstrate objective clinical proficiency have led toward more accurate documentation of resident competencies. Particularly with regard to bedside procedures, hospitals are now requiring certification of competency before allowing a provider to perform them independently. The current system at our institution uses a time-consuming, online verification system. This study provided an alternative method through an identification card with a list of bedside procedures. Our aim was an easier verification method for nurses, allowing fewer delays of bedside procedures and more time for nursing to patient care. METHODS: We performed a prospective, controlled study, using general surgical residents and surgical intensive care nurses. Subjects performed an initial survey of their experience with the current online system in place to identify resident bedside procedure competency. Phase I involved educating the subjects about this current system followed by another survey. Phase II involved introducing our proficiency card. After 3 months, we conducted a final survey to evaluate opinions on the proficiency card, comparing it with the online verification method. RESULTS: Nursing postintervention responses indicated that significantly less time was required to validate a resident's proficiency (P = .04). Prior to the introduction of the proficiency card, only 15% of nurses reported a verification time of 5 minutes or less, compared with 64% postintervention. In addition, nurses rated the card validation as an easier, more efficient method of verification (P = .02). CONCLUSIONS: We believe that its continued use will not only improve the adherence to a mandatory hospital policy but also result in a less-cumbersome verification process, allowing more time for physician and nurse-to-patient care.

"It takes a village" to raise research productivity: Impact of a Trauma Interdisciplinary Group for Research (TIGR) at an urban, Level 1 trauma center.

BACKGROUND: Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, lab technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies like the National Institutes of Health (NIH). This paper describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an on-going NIH-funded study. METHODS: We utilized a pre-test/post-test design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, threats) analysis was used to develop the intervention which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected N=150). Pre/Post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS: Research products increased from N =12 to N=42; (~ 400%). Research proposals for federal funding increased from N=0 to N=3, with success rate of 66%. Participant screenings for the NIH-funded study increased from N=40 to N=313. Consents increased from N=14 to N=70. Lab service fees were reduced from $300/participant to $5/participant. CONCLUSIONS: Adding diversity to our scientific team via TIGR was exponentially successful in 1) improving research productivity, 2) reducing research costs, and 3) increasing research products and mentoring activities that the team prior to TIGR had not entertained. The team is now well-positioned to apply for more federally funded projects and more trauma clinicians are considering research careers than before.

"It takes a village" to raise research productivity: impact of a Trauma Interdisciplinary Group for Research at an urban, Level 1 trauma center.

BACKGROUND: Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, laboratory technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies such as the National Institutes of Health (NIH). This article describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an ongoing NIH-funded study. METHODS: We used a pretest/posttest design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, and threats) analysis was used to develop the intervention, which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected n = 150). Pre-TIGR/post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS: Research products increased from 12 to 42 (approximately 400%). Research proposals for federal funding increased from 0 to 3, with success rate of 66%. Participant screenings for the NIH-funded study increased from 40 to 313. Consents increased from 14 to 70. Laboratory service fees were reduced from $300 per participant to $5 per participant. CONCLUSION: Adding diversity to our scientific team via TIGR was exponentially successful in (1) improving research productivity, (2) reducing research costs, and (3) increasing research products and mentoring activities that the team before TIGR had not entertained. The team is now well positioned to apply for more federally funded projects, and more trauma clinicians are considering research careers than before.

Nonoperative management of solid organ injury diminishes surgical resident operative experience: is it time for simulation training?

BACKGROUND: Nonoperative management (NOM) of solid abdominal organ injury (SAOI) is increasing. Consequently, training programs are challenged to ensure essential operative trauma experience. We hypothesize that the increasing use and success of NOM for SAOI negatively impacts resident operative experience with these injuries and that curriculum-based simulation might be necessary to augment clinical experience. MATERIALS AND METHODS: A retrospective cohort analysis of 1198 consecutive adults admitted to a Level I trauma center over 12 y diagnosed with spleen and/or liver injury was performed. Resident case logs were reviewed to determine operative experience (Cohort A: 1996-2001 versus Cohort B: 2002-2007). RESULTS: Overall, 24% of patients underwent operation for SAOI. Fewer blunt than penetrating injuries required operation (20% versus 50%, P < 0.001). Of those managed operatively, 70% underwent a spleen procedure and 43% had a liver procedure. More patients in Cohort A received an operation compared with Cohort B (34% versus 16%, P < 0.001). Patient outcomes did not vary between cohorts. Over the study period, 55 residency graduates logged on average 27 ± 1 operative trauma cases, 3.4 ± 0.3 spleen procedures, and 2.4 ± 0.2 liver operations for trauma. Cohort A graduates recorded more operations for SAOI than Cohort B graduates (spleen 4.1 ± 0.4 versus 3.0 ± 0.2 cases, P = 0.020 and liver 3.2 ± 0.3 versus 1.8 ± 0.3 cases, P = 0.004). CONCLUSIONS: Successful NOM, especially for blunt mechanisms, diminishes traditional opportunities for residents to garner adequate operative experience with SAOI. Fewer operative occasions may necessitate an increased role for standardized, curriculum-based simulation training.

Systemic inflammatory response syndrome score and race as predictors of length of stay in the intensive care unit.

BACKGROUND: Identifying predictors of length of stay in the intensive care unit can help critical care clinicians prioritize care in patients with acute, life-threatening injuries. OBJECTIVE: To determine if systemic inflammatory response syndrome scores are predictive of length of stay in the intensive care unit in patients with acute, life-threatening injuries. METHODS: Retrospective chart reviews were completed on patients with acute, life-threatening injuries admitted to the intensive care unit at a level I trauma center in the southeastern United States. All 246 eligible charts from the trauma registry database from 1998 to 2007 were included. Systemic inflammatory response syndrome scores measured on admission were correlated with length of stay in the intensive care unit. Data on race, sex, age, smoking status, and injury severity score also were collected. Univariate and multivariate regression modeling was used to analyze data. RESULTS: Severe systemic inflammatory response syndrome scores on admission to the intensive care unit were predictive of length of stay in the unit (F=15.83; P<.001), as was white race (F=9.7; P=.002), and injury severity score (F=20.23; P<.001). CONCLUSIONS: Systemic inflammatory response syndrome scores can be measured quickly and easily at the bedside. Data support use of the score to predict length of stay in the intensive care unit.

Superior mesenteric artery syndrome in the modern trauma patient.

In 1861, von Rokitansky described obstruction of the third part of the duodenum by external compression of the duodenum by the superior mesenteric artery (SMA). In 1926, this entity was furthermore described by Wilke in his presentation of 75 patients with "chronic duodenal compression". In 1968, Mansberger used angiography to define anatomical measurements as the diagnostic criteria for this condition. Current modalities of diagnosis of SMA syndrome include esophagogastroduodenoscopy, computerized tomography angiogram, fluoroscopy, transabdominal ultrasound, and endoscopic ultrasound. The SMA syndrome has been associated with prolonged confinement in the supine position, loss of weight, loss of abdominal wall muscle tone, application of a body cast, and severe burns. With current surgical techniques allowing early ambulation, patients are able to avoid prolonged bed rest. The use of parenteral and enteral nutritional support has limited the loss of weight associated with trauma and burn patients, making this syndrome uncommon in this patient population. Recent reports of SMA syndrome focus on the association with corrective surgical procedures for scoliosis and obesity.