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Trauma Systems: Do They Improve Outcomes?

Trauma Systems: Do They Improve Outcomes?. Ronald V. Maier, MD, FACS Jane and Donald D. Trunkey Professor And Vice-Chair, Surgery University of Washington Surgeon-in-Chief Harborview Medical Center. Trauma. Unrecognized Epidemic.

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Trauma Systems: Do They Improve Outcomes?

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  1. Trauma Systems: Do They Improve Outcomes? Ronald V. Maier, MD, FACS Jane and Donald D. Trunkey Professor And Vice-Chair, Surgery University of Washington Surgeon-in-Chief Harborview Medical Center RVM-

  2. Trauma • Unrecognized Epidemic

  3. Leading Causes of Death in Low- and Middle-Income Countries: Number of Deaths Rank Age 5-14 yr Age 15-44 yr Acute lower respiratory infections 212,606 Malaria 209,109 Road traffic injuries 156,643 Drowning 156,414 Diarrhea 133,682 War Injuries 56,984 HIV/AIDS 1,606,263 Road traffic injuries 524,063 Interpersonal violence 483,647 Self inflicted injuries 454,103 TB 426,104 War Injuries 370,497 • 1 • 2 • 3 • 4 • 5 • 6 Source: Krug et al. Am J Pub Health 2000 RVM-

  4. Trauma Center Patients Cause of Injury RVM-

  5. 143,000 Injury DeathsUnited States Accident Facts

  6. For Every 1 Death there are 16 Hospitalizations and 381 Nonhospitalizations As a Result of Injury Rice, MacKenzie and Associates. Cost of Injury in the United States

  7. Estimated Years of Potential Life Lost Before Age 65 per 100,000 Persons, U.S. Source: CDC

  8. 2003-Medical Expenditures RVM- In billions Source: AHRQ

  9. Direct Cost + Indirect Cost Morbidity Cost Mortality Cost Lifetime Cost of InjuryExceeds $325 Billion Productivity losses due to death Medical and related costs 29% 30% 41% Productivity losses due to disability

  10. Trimodal Death Distribution Deaths “Immediate Deaths” “Early Deaths” “Late Deaths” 1 hr 4 hr 1 wk 6 wk

  11. Trauma Systems • “The Right Place at the Right Time”

  12. Response Time and Survival Status E.D. Arrival • Alive n=244 • Dead n=13 Response Time < 30 Min 237 (96%) 10 (4%) > 30 Min 7 (70%) 3 (30%)

  13. Surgeon Response Time and Survival • Probability of survival > 50% and • Surgeon response • Mortality < 30 Min 2.95% > 30 Min 6.19%

  14. Orange County - Non CNS After System 1981 TC NTC 2/23 4/6 Clearly Preventable (9%) (67%) 1/14 1/2 No Operation West & Cales, 1979, 1983

  15. Trauma Preventable Deaths (35%) Trauma Systems Preventable Deaths (3%)

  16. Trauma Center • “Make a plan” = Systemization • Commitment = Focus • Volume = Experience

  17. “ No longer should the patient be transferred to the closest hospital, but rather, to the closest appropriatehospital, (preferably) a trauma center.”

  18. American College of SurgeonsCommittee on Trauma(ACS/COT)Trauma Center Criteria

  19. RVM-

  20. Washington State Trauma System • General Hospitals – 94 • Trauma Centers – 73 • Level I - 1 • Level II - 6 • Level III - 19 • Level IV - 32 • Level V - 15

  21. Designated Trauma Centers in King County Washington

  22. HMC Trauma Admissions 8.4% of transfers are from out of state (941 of 11,211 over 5 years) RVM-

  23. Trauma Center Experience and Outcome (1986-1995) • ISS > 15: 7,681 patients • 86% Blunt; 14% Penetrating • Mortality • Blunt: 17.4 to 14.7% • Penetrating: 39 to 24% • Overall: 4%/yr (risk adjusted) RVM- O’Keefe and Maier. Ann Surg 1999

  24. TRAUMA CENTER CARE: UK DATA • Voluntary hospital participation • Data from 99 hospitals • All years: 20 • Odds of dying  • 5%/year • Higher level care earlier? Lecky et al. Lancet. May 2000 RVM-

  25. Unexpected Deaths(TRISS>=.5)(Excludes transfers & age 85+ years) RVM-

  26. Unexpected Survivors(TRISS<.5)(Excludes transfers & age 85+ years) RVM-

  27. Trauma Audit Death Peer Review Thailand * Statistical significant RVM-

  28. Trauma Centers • Volume increases as system matures • Fatality rates decrease • Primarily severely injured (ISS > 15) RVM-

  29. Trauma Center Experience & Outcome Risk of death ~650 per annum Number of major trauma admissions RVM-

  30. Traffic Fatality Rates Mullins RJ et al. JAMA 1994; 271:1919-24 RVM-

  31. Mortality Based on Level of Trauma Center RVM-

  32. Crash Mortality RatePre/post Trauma System Implementation California Connecticut D.C. Florida Georgia Illinois Massachusetts Missouri Nevada NewJersey NewMexico NewYork NorthCarolina Oregon Pennsylvania SouthCarolina Tennessee Utah Virginia Washington WestVirginia 0.87 (0.86-0.88) All .5 .6 .7 .8 .9 1 1.1 1.2 1.3 1.4 1.5 1.6 Mortality rate ratio

  33. Volume 354:366-378 January 26, 2006 A National Evaluation of the Effect of Trauma-Center Care on Mortality Ellen J. MacKenzie, Ph.D., Frederick P. Rivara, M.D., M.P.H., Gregory J. Jurkovich, M.D., Avery B. Nathens, M.D., Ph.D., Katherine P. Frey, M.P.H., Brian L. Egleston, M.P.P., David S. Salkever, Ph.D., and Daniel O. Scharfstein, Sc.D. RVM-

  34. NSOCT data: Unadjusted but weighted case fatality rates RVM-

  35. Adjusted case fatality rates and relative risk of dying in a TC vs. NTC RVM-

  36. 15 10 5 0 TCs In 30 days 90 days 365 days NTCs Hospital Case Fatality RatiosAdjusted for Differences in Casemix Adjusted Relative Risk: .60.75.95 RVM-

  37. Relative Risks by Age and Severity RVM-

  38. Trauma system Evidence of Benefit of Better Organization 1. All deaths in treated trauma patients: Decreased by 15 – 20% 2. Medically preventable deaths: Decreased by 50% Source: Mann et al. A systematic review of published evidence regarding trauma system effectiveness. J Trauma, 47: S25 – 33, 1999. RVM-

  39. 450 Level I and II Trauma Centers Plotted by Hospital ZIP Code RVM- MacKenzie, Hoyt , Sacra et al, JAMA, 2003

  40. 69% Live w/in 45 Minutes of a TC % Within 45 Min of a Level I/II TC <50% 51% - 75% > 75% RVM- Branas, MacKenzie, Williams et al, JAMA June 6, 2005

  41. ACCESS TO TRAUMA CENTERS IN THE UNITED STATES Level I/II Trauma Center Coverage: Population – 81.1% Land – 22.3% (within 1 hour) Legend Helicoptor or Ambulance Transport Interstate RVM-

  42. Motor Vehicle Crash Mortality and Trauma System Development Crash mortality 9 years Time since trauma center designation RVM-

  43. Planning and Organization of Services: Most of recommendations from high income countries Trauma Center Verification: What should be in place in range of hospitals for: • - Clinical services • - Equipment and supplies • - In-service training • - Administrative functions: • - Quality improvement • Most frequent reason for failing a verification inspection. • Also emphasis of British Trauma Society RVM-

  44. Characteristics of Trauma Presentation and Deaths RVM-

  45. 44,401 Trauma presentations 2594 Deaths 53 M&M conference review documented probable error 601 <50% probability of mortality on admission Critical review & peer review 64 Errors contributing to death Assessment of Errors Contributing to Death RVM-

  46. Major Patterns of Errors Contributing to Trauma Mortality RVM-

  47. Major Patterns of Errors Contributing to Trauma Mortality RVM-

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