Pediatric trauma mortality: an ecological analysis evaluating correlation between injury-related mortality and geographic access to trauma care in the United States in 2010.

BACKGROUND: Trauma is the leading cause of mortality in the pediatric population >1 year. Analyzing relationships between pediatric trauma-related mortality and geographic access to trauma centers (among other social covariates) elucidates the importance of cost and care effective regionalization of designated trauma facilities. METHODS: Pediatric crude injury mortality in 49 United States served as a dependent variable and state population within 45 minutes of trauma centers acted as the independent variable in four linear regression models. Multivariate analyses were performed using previously identified demographics as covariates. RESULTS: There is a favorable inverse relation between pediatric access to trauma centers and pediatric trauma-related mortality. Though research shows care is best at pediatric trauma centers, access to Adult Level 1 or 2 trauma centers held the most predictive power over mortality. A 4-year college degree attainment proved to be the most influential covariate, with predictive powers greater than the proximity variable. CONCLUSIONS: Increased access to adult or pediatric trauma facilities yields improved outcomes in pediatric trauma mortality. Implementation of qualified, designated trauma centers, with respect to regionalization, has the potential to further lower pediatric mortality. Additionally, the percentage of state populations holding 4-year degrees is a stronger predictor of mortality than proximity and warrants further investigation.

Mindfulness for healthcare providers fosters professional quality of life and mindful attention among emergency medical technicians.

OBJECTIVE: Emergency medical service (EMS) providers are systematically subjected to intense stimuli in their work that may result in distress and emotional suffering. While it is known that mindfulness-based stress reduction (MBSR) helps to foster well-being in healthcare workers, the effectiveness of MBSR among EMS providers is less understood. We explored the impact of a modified version of MBSR for healthcare workers called Mindfulness for Healthcare Providers (MHP) on reducing distress and promoting wellbeing in EMS providers. METHODS: A one-arm pilot study was conducted. We implemented eight two-and-a-half hour sessions of Mindfulness for Healthcare Providers with an additional day-long retreat at the end. Feasibility, perceived stress, professional quality of life, and trait mindfulness were assessed prior to and after the intervention. The professional quality of life scale includes measures of compassion satisfaction, burnout, and secondary trauma. RESULTS: Fifteen veteran EMS providers enrolled in the course; four participants dropped out. Prior to initiation of the study, no significant differences were revealed between those who did not participate (n = 48) and those who did (n = 11). After the intervention EMS providers endorsed statistically significant increases in compassion satisfaction, trait mindfulness, and decreases in burnout compared to the beginning of the program. These changes were sustained at six months post-completion. No significant changes over time were found for secondary trauma or perceived stress. CONCLUSIONS: To our knowledge, this study is the first to employ Mindfulness for Healthcare Providers in an EMS population and to demonstrate a positive impact on self-reported compassion, trait mindfulness, and burnout in this population. Additional research regarding mindfulness training within EMS populations should be conducted to further understand the relationship between mindfulness and perceived stress over time.

Impact of predictive analytics based on continuous cardiorespiratory monitoring in a surgical and trauma intensive care unit.

Predictive analytics monitoring, the use of patient data to provide continuous risk estimation of deterioration, is a promising new application of big data analytical techniques to the care of individual patients. We tested the hypothesis that continuous display of novel electronic risk visualization of respiratory and cardiovascular events would impact intensive care unit (ICU) patient outcomes. In an adult tertiary care surgical trauma ICU, we displayed risk estimation visualizations on a large monitor, but in the medical ICU in the same institution we did not. The risk estimates were based solely on analysis of continuous cardiorespiratory monitoring. We examined 4275 individual patient records within a 7 month time period preceding and following data display. We determined cases of septic shock, emergency intubation, hemorrhage, and death to compare rates per patient care pre-and post-implementation. Following implementation, the incidence of septic shock fell by half (p < 0.01 in a multivariate model that included age and APACHE) in the surgical trauma ICU, where the data were continuously on display, but by only 10% (p = NS) in the control Medical ICU. There were no significant changes in the other outcomes. Display of a predictive analytics monitor based on continuous cardiorespiratory monitoring was followed by a reduction in the rate of septic shock, even when controlling for age and APACHE score.

Dynamic data monitoring improves predictive analytics for failed extubation in the ICU.

OBJECTIVE: Predictive analytics monitoring that informs clinicians of the risk for failed extubation would help minimize both the duration of mechanical ventilation and the risk of emergency re-intubation in ICU patients. We hypothesized that dynamic monitoring of cardiorespiratory data, vital signs, and lab test results would add information to standard clinical risk factors. METHODS: We report model development in a retrospective observational cohort admitted to either the medical or surgical/trauma ICU that were intubated during their ICU stay and had available physiologic monitoring data (n = 1202). The primary outcome was removal of endotracheal intubation (i.e. extubation) followed within 48 h by reintubation or death (i.e. failed extubation). We developed a standard risk marker model based on demographic and clinical data. We also developed a novel risk marker model using dynamic data elements-continuous cardiorespiratory monitoring, vital signs, and lab values. RESULTS: Risk estimates from multivariate predictive models in the 24 h preceding extubation were significantly higher for patients that failed. Combined standard and novel risk markers demonstrated good predictive performance in leave-one-out validation: AUC of 0.64 (95% CI: 0.57-0.69) and 1.6 alerts per week to identify 32% of extubations that will fail. Novel risk factors added significantly to the standard model. CONCLUSION: Predictive analytics monitoring models can detect changes in vital signs, continuous cardiorespiratory monitoring, and laboratory measurements in both the hours preceding and following extubation for those patients destined for extubation failure.

Identifying the low risk patient in surgical intensive and intermediate care units using continuous monitoring.

BACKGROUND: Continuous predictive monitoring has been employed successfully to predict subclinical adverse events. Should low values on these models, however, reassure us that a patient will not have an adverse outcome? Negative predictive values of such models could help predict safe patient discharge. The goal of this study was to validate the negative predictive value of an ensemble model for critical illness (using previously developed models for respiratory instability, hemorrhage, and sepsis) based on bedside monitoring data in the intensive care units and intermediate care unit. METHODS: We calculated the relative risk of 3 critical illnesses for all patients every 15 minutes (n= 124,588) for 2,924 patients downgraded from the surgical intensive care units and intermediate care unit between May 2014 to May 2016. We constructed an ensemble model to estimate at the time of intensive care units or intermediate care unit discharge the probability of favorable outcome after downgrade. RESULTS: Outputs form the ensemble model stratified patients by risk of favorable and bad outcomes in both intensive care units/intermediate care unit; area under the receiver operating characteristic curve = .639/.629 respectively for favorable outcomes and .645/.641 for adverse events. These performance characteristics are commensurate with published models for predicting readmission. The ensemble model remained a statistically significant predictor after adjusting for hospital duration of stay and admitting service. The rate of favorable outcome in the highest and lowest deciles in the intensive care units were 76.2% and 27.3% (2.8-fold decrease) and 88.3% and 33.2% in the intermediate care unit (2.7-fold decrease), respectively. CONCLUSION: An ensemble model for critical illness predicts favorable outcome after downgrade and safe patient discharge (hospital stay <7 days, no readmission, upgrade, or death).

External validation in an intermediate unit of a respiratory decompensation model trained in an intensive care unit.

BACKGROUND: Preventing urgent intubation and upgrade in level of care in patients with subclinical deterioration could be of great utility in hospitalized patients. Early detection should result in decreased mortality, duration of stay, and/or resource use. The goal of this study was to externally validate a previously developed, vital sign-based, intensive care unit, respiratory instability model on a separate population, intermediate care patients. METHODS: From May 2014 to May 2016, the model calculated relative risk of adverse events every 15 minutes (n = 373,271 observations) for 2,050 patients in a surgical intermediate care unit. RESULTS: We identified 167 upgrades and 57 intubations. The performance of the model for predicting upgrades within 12 hours was highly significant with an area under the curve of 0.693 (95% confidence interval, 0.658-0.724). The model was well calibrated with relative risks in the highest and lowest deciles of 2.99 and 0.45, respectively (a 6.6-fold increase). The model was effective at predicting intubation, with a demonstrated area under the curve within 12 hours of the event of 0.748 (95% confidence interval, 0.685-0.800). The highest and lowest deciles of observed relative risk were 3.91 and 0.39, respectively (a 10.1-fold increase). Univariate analysis of vital signs showed that transfer upgrades were associated, in order of importance, with rising respiration rate, rising heart rate, and falling pulse-oxygen saturation level. CONCLUSION: The respiratory instability model developed previously is valid in intermediate care patients to predict both urgent intubations and requirements for upgrade in level of care to an intensive care unit.

Signatures of Subacute Potentially Catastrophic Illness in the ICU: Model Development and Validation.

OBJECTIVES: Patients in ICUs are susceptible to subacute potentially catastrophic illnesses such as respiratory failure, sepsis, and hemorrhage that present as severe derangements of vital signs. More subtle physiologic signatures may be present before clinical deterioration, when treatment might be more effective. We performed multivariate statistical analyses of bedside physiologic monitoring data to identify such early subclinical signatures of incipient life-threatening illness. DESIGN: We report a study of model development and validation of a retrospective observational cohort using resampling (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis type 1b internal validation) and a study of model validation using separate data (type 2b internal/external validation). SETTING: University of Virginia Health System (Charlottesville), a tertiary-care, academic medical center. PATIENTS: Critically ill patients consecutively admitted between January 2009 and June 2015 to either the neonatal, surgical/trauma/burn, or medical ICUs with available physiologic monitoring data. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed 146 patient-years of vital sign and electrocardiography waveform time series from the bedside monitors of 9,232 ICU admissions. Calculations from 30-minute windows of the physiologic monitoring data were made every 15 minutes. Clinicians identified 1,206 episodes of respiratory failure leading to urgent unplanned intubation, sepsis, or hemorrhage leading to multi-unit transfusions from systematic individual chart reviews. Multivariate models to predict events up to 24 hours prior had internally validated C-statistics of 0.61-0.88. In adults, physiologic signatures of respiratory failure and hemorrhage were distinct from each other but externally consistent across ICUs. Sepsis, on the other hand, demonstrated less distinct and inconsistent signatures. Physiologic signatures of all neonatal illnesses were similar. CONCLUSIONS: Subacute potentially catastrophic illnesses in three diverse ICU populations have physiologic signatures that are detectable in the hours preceding clinical detection and intervention. Detection of such signatures can draw attention to patients at highest risk, potentially enabling earlier intervention and better outcomes.

Trauma centre patient volume and inpatient mortality risk reconsidered.

BACKGROUND: Several studies have examined the relationship between injury volumes and trauma centre outcomes, with varying results attributable to differences in the measurement of volume's effect on mortality and differences in how characteristics are addressed as potential confounders. METHODS: This analysis includes all trauma cases reported to the NTDB 2012. The effect of trauma centre volume on patient mortality risk was measured in three different contexts: as a linear function of trauma centre volume, as a dichotomous function comparing patients in trauma centres with and without 1200 or more cases, and as a non-linear function of trauma centre volume. Multivariable weighted Hierarchical Generalized Linear Models were used to account for the combined effects of facility level and patient level covariates. Patient level mortality risk was assessed using the ACS Trauma Quality Improvement Programme methodology. RESULTS: Trauma centre volume was not a statistically significant predictor (at the α=0.01 level) of patient mortality risk, in any of the three models. Comprehensive adjustments for patient level risk were obtained, with excellent discrimination between survivor and decedent cases. The addition of trauma volume to baseline patient mortality risk yielded no improvement in the accuracy of any model. These results were not sensitive to the inclusion of Level II trauma centres. Equivalent results were obtained by repeating the analysis for the Level I subpopulation only. CONCLUSIONS: Case volume may be a reasonable standard for determining whether adequate numbers of injured patients are available to support training needs and experience requirements of a Level I trauma centre. However, case volume is not a useful predictor of patient mortality in individual facilities. Trauma centre volume has no independent effect, after accounting for the patient level characteristics that predominantly influence mortality.

Heart rate dynamics preceding hemorrhage in the intensive care unit.

Occult hemorrhage in surgical/trauma intensive care unit (STICU) patients is common and may lead to circulatory collapse. Continuous electrocardiography (ECG) monitoring may allow for early identification and treatment, and could improve outcomes. We studied 4,259 consecutive admissions to the STICU at the University of Virginia Health System. We collected ECG waveform data captured by bedside monitors and calculated linear and non-linear measures of the RR interbeat intervals. We tested the hypothesis that a transfusion requirement of 3 or more PRBC transfusions in a 24 hour period is preceded by dynamical changes in these heart rate measures and performed logistic regression modeling. We identified 308 hemorrhage events. A multivariate model including heart rate, standard deviation of the RR intervals, detrended fluctuation analysis, and local dynamics density had a C-statistic of 0.62. Earlier detection of hemorrhage might improve outcomes by allowing earlier resuscitation in STICU patients.

Injury, disability and access to care in Rwanda: results of a nationwide cross-sectional population study.

BACKGROUND: Disparities in access to quality injury care are a growing concern worldwide, with over 90 % of global injury-related morbidity and mortality occurring in low-income countries. We describe the use of a survey tool that evaluates the prevalence of surgical conditions at the population level, with a focus on the burden of traumatic injuries, subsequent disabilities, and barriers to injury care in Rwanda. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool is a cross-sectional, cluster-based population survey designed to measure conditions that may necessitate surgical consultation or intervention. Questions are structured anatomically and designed around a representative spectrum of surgical conditions. Households in Rwanda were sampled using two-stage cluster sampling, and interviews were conducted over a one-month period in 52 villages nationwide, with representation of all 30 administrative districts. Injury-related results were descriptively analyzed and population-weighted by age and gender. RESULTS: A total of 1,627 households (3,175 individuals) were sampled; 1,185 lifetime injury-related surgical conditions were reported, with 38 % resulting in some form of perceived disability. Of the population, 27.4 % had ever had a serious injury-related condition, with 2.8 % having an injury-related condition at the time of interview. Over 30 % of household deaths in the previous year may have been surgically treatable, but only 4 % were injury-related. CONCLUSIONS: Determining accurate injury and disability burden is crucial to health system planning in low-income countries. SOSAS is a useful survey for determining injury epidemiology at the community level, which can in turn help to plan prevention efforts and optimize provision of care.

Can focused trauma education initiatives reduce mortality or improve resource utilization in a low-resource setting?

BACKGROUND: Over 90% of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization. METHODS: Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using χ(2) and Fisher's exact test. RESULTS: A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3%, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3-8 had the highest injury-related mortality, which significantly decreased from 58.5% (n = 55) to 37.1% (n = 23), (p = 0.009, OR 0.42, 95% CI 0.22-0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3-5 in the post-intervention period had higher utilization of head CT scans and chest X-rays. CONCLUSIONS: The mortality of severely injured patients decreased after initiation of focused trauma education courses, but no significant increase in resource utilization was observed. The explanation may be complex and multi-factorial. Long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system.

Prevalence of breast masses and barriers to care: results from a population-based survey in Rwanda and Sierra Leone.

BACKGROUND AND OBJECTIVES: Breast cancer incidence may be increasing in low- and middle-income countries (LMIC). This study estimates the prevalence of breast masses in Rwanda (RW) and Sierra Leone (SL) and identifies barriers to care for women with breast masses. only. METHODS: Data were collected from households in RW and SL using Surgeons Overseas Assessment of Surgical Need (SOSAS), a cross-sectional, randomized, cluster-based population survey designed to identify surgical conditions. Data regarding breast masses and barriers to care in women with breast masses were analyzed. RESULTS: 3,469 households (1,626 RW; 1,843 SL) were surveyed and 6,820 persons (3,175 RW; 3,645 SL) interviewed. Breast mass prevalence was 3.3% (SL) and 4.6% (RW). Overall, 93.8% of masses were in women, with 49.1% (SL) and 86.1% (RW) in women >30 years. 73.7% (SL) and 92.4% (RW) of women reported no disability; this was their primary reason for not seeking medical attention. Overall, 36.8% of women who reported masses consulted traditional healers only. CONCLUSIONS: For women in RW and SL, minimal education, poverty, and reliance on traditional healers are barriers to medical care for breast masses. Public health programs to increase awareness and decrease barriers are necessary to lower breast cancer mortality rates in low- and middle-income countries (LMIC).

Estimating pediatric surgical need in developing countries: a household survey in Rwanda.

PURPOSE: Surgical services for children are often absent in resource-limited settings. Identifying the prevalence of surgical disease at the community level is important for developing evidence-based pediatric surgical services and training. We hypothesize that the untreated surgical conditions in the pediatric population are largely uncharacterized and that such burden is significant and poorly understood. Furthermore, no such data exist at the population level to describe this population. METHODS: We conducted a nationwide cross-sectional cluster-based population survey to estimate the magnitude of surgical disease in Rwanda. Conducted as a verbal questionnaire, questions included representative congenital, acquired, malignant and injury-related conditions. Pediatric responses were analyzed using descriptive statistics and univariate analysis. RESULTS: A total of 1626 households (3175 individuals) were sampled with a 99% response rate; 51.1% of all individuals surveyed were younger than age 18. An estimated 50.5% of the total current surgical need occurs in children. Of all Rwandan children, 6.3% (95% CI 5.4%-7.4%), an estimated 341,164 individuals, were identified to have a potentially treatable surgical condition at the time of the interview. The geographic distribution of surgical conditions significantly differed between adults and children (p<0.001). CONCLUSIONS: The results emphasize the magnitude of the pediatric surgery need as well as the need for improved education and resources. This may be useful in developing a collaborative local training program.

Infectious outcomes assessment for health system strengthening in low-resource settings: the novel use of a trauma registry in Rwanda.

BACKGROUND: More than 90% of injury deaths occur in low-income countries where a shortage of personnel, infrastructure, and materials challenge health system strengthening efforts. Trauma registries developed regionally have been used previously for injury surveillance in resource-limited settings, but scant outcomes data exist. METHODS: A 31-item, two-page registry form was developed for use in Rwanda, East Africa. Data were collected over a one-year period from April 2011 to April 2012 at two university referral hospitals. Inpatient 30-d follow up data were abstracted from patient charts, ward reports, and operating room logs. Complications tracked included surgical site infection (SSI), pneumonia, urinary tract infection (UTI), decubitus ulcers, transfusion, cardiac arrest, respiratory failure, and blood thromboses. Univariate analysis with chi-square and the Fisher exact test was performed to determine the association between complications and hospital stay and complications and mortality. Multivariable logistic regression was used to control for age, gender, hospital, mechanism of injury (penetrating versus blunt), and Glasgow Coma scale score (GCS). RESULTS: A total of 2,227 patients were recorded prospectively. One thousand five hundred nineteen patients were admitted for inpatient care (69%) with a 4% (n=67) 30-d mortality. One hundred thirteen patients developed a hospital-acquired infection (88 SSI, 15 UTI, 12 pneumonia). For admitted patients, 25% (n=387) were still in-hospital at 30-d. Whereas the development of any complication was associated with an increased mortality (p<0.0001, unadjusted OR 3.2, 95% CI 1.8-5.7), there was no association between the development of an infection and mortality (p=0.6). Hospital-acquired infection was associated with an increased length of stay (p<0.0001, adjusted odds ratio (OR) 7.3, 95% confidence interval (CI) 4.7-11.2). Surgical site infection and UTI were individually associated with an increased length of stay. CONCLUSIONS: The development of hospital-acquired infections is associated with an increased hospital stay in the trauma population in Rwanda. This has important implications in improving a health system already strained by limited infrastructure, personnel, and finances.

Collaboration in surgical capacity development: a report of the inaugural meeting of the Strengthening Rwanda Surgery initiative.

BACKGROUND: Increasing access to surgical care is among the prioritized healthcare initiatives in Rwanda and other low income countries, where only 3.5 % of surgical procedures worldwide are being performed. Partnerships among surgeons at academic medical centers, non-governmental organizations, and representatives of industry for building sustainable local surgical capacity in developing settings should be explored. METHODS: With the goal of improving collaboration and coordination among the many stakeholders in Rwandan surgery, the Rwanda Surgical Society (RSS) convened a participatory workshop of these groups in Kigali in March 2011. The meeting consisted of presentations from Rwandan surgical leaders and focused brainstorming sessions on collaborative methods for surgical capacity building. RESULTS: The outcome of the meeting was a set of recommendations to the Rwandan Ministry of Health (MOH) and the formation of an ad hoc team, the Strengthening Rwanda Surgery (SRS) Advising Group. The inaugural meeting of the advising group served to establish common goals, a framework for ongoing communication and collaboration, and commitment to a fully Rwandan agenda for surgical and anesthesia capacity development. The SRS Advising Group continues to meet and collaborate on training initiatives and has been integrated into the MOH plan to scale up human resources across disciplines. CONCLUSIONS: The SRS Initiative serves as an example of the concept of early communication and international collaboration in global surgical and anesthesia capacity building partnerships.

Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda.

BACKGROUND: Operative disease is estimated to contribute to 11% of the global burden of disease, but no studies have correlated this figure to operative burden at the community level. We describe a survey tool that evaluates population-based prevalence of operative conditions and its first full-country implementation in Rwanda. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool is a cross-sectional, cluster-based population survey designed to measure conditions that may necessitate an operative consultation or intervention. Household surveys in Rwanda were conducted in October 2011 in 52 clusters nationwide. Data were population-weighted and analyzed with the use of descriptive statistics. RESULTS: A total of 1626 households (3175 individuals) were sampled with a 99% response rate. 41.2% (95% confidence interval [95 CI%] 38.8-43.6%) of the population has had at least one operative condition during their lifetime, 14.8% (95% CI 13.3-16.5%) had an operative condition during the previous 12 months, and 6.4% (95% CI 5.6-7.3%) of the population were determined to have a current operative condition. A total of 55.3% of the current operative need was found in female respondents and 40.3% in children younger than 15 years of age. A total of 32.9% of household deaths in the previous year may have been related to operative conditions, and 55.0% of responding households lacked funds for transport to the nearest hospital providing general practitioner operative services. CONCLUSION: The SOSAS survey tool provides important insight into the burden of operative disease in the community. Our results show a high need for operative care, which has important implications for the global operative community as well as for local health system strengthening in Rwanda.

Healthcare worker safety: a vital component of surgical capacity development in low-resource settings.

INTRODUCTION: A disparate number of occupational exposures to bloodborne pathogens occur in low-income countries where disease prevalence is high and healthcare provider-per-population ratios are low. METHODS: In an effort to highlight the important role of healthcare worker safety in surgical capacity building in Rwanda, we measured self-reported presence of safety materials and compliance with personal protective equipment in the operating theatre as part of a nationwide survey to characterize emergency and essential surgical capacity in all government hospitals. RESULTS: We surveyed 44 hospitals. While staff report general availability of safe disposal of sharps and hazardous waste, presence of and compliance with eye protection was lacking. Staff were cognizant of prevention measures such as double-gloving and 'safe receptacles', as well as hospital policies for post-exposure prophylaxis for HIV following needlesticks, but there was little awareness of hepatitis exposure. CONCLUSIONS: Healthcare worker safety should be a key component of hospital-level surgical capacity.

The Trauma Quality Improvement Program: pilot study and initial demonstration of feasibility.

OBJECTIVE: The American College of Surgeons Committee on Trauma has created a "Trauma Quality Improvement Program" (TQIP) that uses the existing infrastructure of Committee on Trauma programs. As the first step toward full implementation of TQIP, a pilot study was conducted in 23 American College of Surgeons verified or state designated Level I and II trauma centers. This study details the feasibility and acceptance of TQIP among the participating centers. METHODS: Data from the National Trauma Data Bank for patients admitted to pilot study hospitals during 2007 were used (15,801 patients). A multivariable logistic regression model was developed to estimate risk-adjusted mortality in aggregate and on three prespecified subgroups (1: blunt multisystem, 2: penetrating truncal, and 3: blunt single-system injury). Benchmark reports were developed with each center's risk adjusted mortality (expressed as an observed-to-expected [O/E] mortality ratio and 90% confidence interval [CI]) and crude complication rates available for comparison. Reports were deidentified with only the recipient having access to their performance relative to their peers. Feedback from individual centers regarding the utility of the reports was collected by survey. RESULTS: Overall crude mortality was 7.7% and in cohorts 1 to 3 was 16.4%, 12.4%, and 5.1%, respectively. In the aggregate risk-adjusted analysis, three trauma centers were low outliers (O/E and 90% CI <1) and two centers were high outliers (O/E and 90% CI >1) with the remaining 18 centers demonstrating average mortality. Challenges identified were in benchmarking mortality after penetrating injury due to small sample size and in the limited capture of complications. Ninety-two percent of survey respondents found the report clear and understandable, and 90% thought that the report was useful. Sixty-three percent of respondents will be taking action based on the report. CONCLUSIONS: Using the National Trauma Data Bank infrastructure to provide risk-adjusted benchmarking of trauma center mortality is feasible and perceived as useful. There are differences in O/E ratios across similarly verified or designated centers. Substantial work is required to allow for morbidity benchmarking.