BACKGROUND: Between 1999 and 2001, 368 polytrauma patients were treated at the Departments of Traumatology and Surgery of the Karl Franzens University Hospital in Graz, Austria. In 1993, primary interdisciplinary polytrauma management was introduced in the emergency room. Subsequently, responsibilities were reevaluated regularly and cooperation was found to improve steadily. METHODS: All polytrauma patients were classified using the polytrauma registry of the German Society for Traumatology (Deutsche Gesellschaft für Unfallchirurgie, DGU) for evaluation and statistical analysis. Additionally, polytrauma cases have been analyzed at weekly interdisciplinary meetings since April 2000 to ensure an objectively high quality in polytrauma diagnosis and treatment. RESULTS: For trauma patients with an average Injury Severity Score (ISS) of 26.6, the average lengths of stay in the ICU (8.3 days) and in the hospital (21.8 days), were very short. In the year 2000, actual mortality was lower (18.8%) than that precalculated using Trauma Injury Severity Scale (TRISS). In 2001, this was the 4th best standardized mortality score of all participating trauma facilities. CONCLUSIONS: Primary interdisciplinary teamwork in the emergency room of trauma departments is recommended. Selecting the trauma leader depending on the nature of the patient's injuries is the most logical ongoing step towards a specialized medical system in which patients receive optimal treatment under the direction of the most appropriate specialist. In 83% of all polytrauma cases, the trauma leader was an orthopedic trauma surgeon. As this high standard of polytrauma care can only be guaranteed by a quality-management system, there has to be, in addition to the DGU evaluation, a retrospective weekly analysis of the treatment of polytrauma patients in which all of the involved specialists are invited to participate.
OBJECTIVE: To examine whether failure-to-rescue is an important mechanism driving outcome differences across low- and high-mortality hospitals caring for trauma patients.
BACKGROUND: Reducing medical errors and complications has become the focus of quality improvement efforts. Patients undergoing general and vascular surgery in high-mortality hospitals have similar rates of complications but higher failure-to-rescue rates compared to patients in low-mortality hospitals.
METHODS: Retrospective cohort study based on 54,713 patient records in the National Trauma Databank in 2007. Hospitals were classified as low-mortality, average, and high-mortality hospitals using the Trauma Mortality Probability Model. Regression modeling was used to explore the impact of hospital quality ranking on the incidence of major complications and on the incidence of failure-to-rescue (death after a major complication), adjusting for injury severity, mechanism of trauma, and patient physiology.
RESULTS: Trauma patients in low-mortality hospitals had similar unadjusted rates of major complications compared to patients in high-mortality hospitals (5.9% vs. 5.5%). However, patients in low-mortality hospital had a lower failure-to-rescue rate compared to patients in high-mortality hospitals (adj OR 0.26: 95% CI 0.20, 0.39)
CONCLUSION: Our findings suggest that the primary driver of differences in hospital quality for trauma patients is failure-to-rescue as opposed to differences in complication rates. Achieving lower mortality rates in trauma patients may require reducing both the incidence of major complications and the incidence of death after major complications.
OBJECTIVE: The elderly injured have been identified as a population with unique needs compared with nonelderly trauma patients. We sought to determine whether trauma center (TC) performance is consistent across age groups and to assess whether aggregate evaluations of TC performance capture quality of care among the elderly.
BACKGROUND: The recently launched Trauma Quality Improvement Program utilizes external benchmarking of TC outcomes to identify centers with above-average performance, with the goal of disseminating best practices. If variation exists in TC performance across age groups, such variation might significantly impact on the success of external benchmarking programs in improving quality of care.
METHODS: Study data were derived from the National Trauma Databank (2007), limited to level I and II centers and adults with moderate to severe injuries (injury severity score > 9). Separate logistic regression models were constructed to produce TC risk-adjusted mortality for both the young and the elderly (age > 65 years). Observed-to-expected mortality ratios were used to identify centers with above or below average performance overall, among the young and among the elderly.
RESULTS: We identified 87,754 patients across 132 facilities; 25% were elderly. After adjustment for case mix, 9 centers were identified as above-average performers in the elderly population. Only 2 of these centers were also above-average performers among young patients. Overall, concordance for center performance across age strata evidenced poor agreement (κ, 0.23). In addition, aggregate assessment of center performance did not reliably identify high-performing centers for elderly patients.
CONCLUSIONS: The use of outcome-based benchmarking harbors significant potential for trauma quality improvement. Evaluations of aggregate TC performance may not adequately reflect the care provided to the elderly injured. Elderly trauma patients may warrant special attention in the context of ongoing quality improvement programs.
OBJECTIVE: The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications.
METHODS: The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity.
RESULTS: Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS.
CONCLUSION: Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.
BACKGROUND: The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement. We hypothesized that an outreach program would stimulate peer review and identify systematic deficiencies in the care of patients with injuries. METHODS: We developed a quality improvement program aimed at providing educational feedback to hospitals that referred patients to our American College of Surgeons-verified level I trauma center. We traveled to each referral center to provide feedback on the initial treatment and ultimate outcome of patients that were transferred to us. These feedback sessions were presented in the format of case presentations and case discussions. RESULTS: The outreach program was presented at each hospital every 3 months to 6 months. Nine hospitals were included in our program. We received 334 patients in transfer from these hospitals during the study period. Formal peer review that focused on trauma patients increased from 14% of hospitals to 100% of hospitals after institution of the program. Eighty-five percent of hospitals thought that the care of patients with injuries was improved as a result of the program. Eighty-five percent of hospitals developed process improvement initiatives as a result of the program. CONCLUSIONS: A formal outreach program can stimulate peer review at rural hospitals, provide continuing education in the care of patients with injuries, and foster process improvements at referring hospitals.
BACKGROUND: The University Medical Center Groningen is a level I trauma center in the northern part of the Netherlands. Sixty-three percent of all the patients admitted at the Trauma Nursing Department (TND) are acute patients who are admitted directly after trauma. In 2006 and 2007, the University Medical Center Groningen was not always capable of admitting all trauma patients to the TND due to the relatively high-bed occupation. Therefore, the reduction of the average length of stay (LOS) formed the objective of the project described in this study.
METHODS: We used the process-focused method of Lean Six Sigma to reduce hospital stay by improving the discharge procedure of patients in the care processes and eliminating waste and waiting time. We used the "Dutch Appropriateness Evaluation Protocol" to identify the possible causes of inappropriate hospital stay. The average LOS of trauma patients at the TND at the beginning of the project was 10.4 days.
RESULTS: Thirty percent of the LOS was unnecessary. The main causes of the inappropriate hospital stay were delays in several areas. The implementation of the improvement plan reduced almost 50% of the inappropriate hospital stay, enabling the trauma center to admit almost all trauma patients to the TND. After the implementation of the improvements, the average LOS was 8.5 days.
CONCLUSION: Our study shows that Lean Six Sigma is an effective method to reduce inappropriate hospital stay, thereby improving the quality and financial efficiency of trauma care.
BACKGROUND: In 1999, a Level I Trauma Center committed significant resources for development, recruitment of trauma surgeons, and call pay for subspecialists. Although this approach has sparked a national ethical debate, little has been published investigating efficacy. This study examines the price of commitment and outcomes at a Level I Trauma Center.
METHODS: Direct personnel costs including salary, call pay, and personnel expenses were analyzed against outcomes for two periods defined as PRE (1994-1999) and POST (2000-2005). Patient care costs and 1999 to 2000 transition data were excluded. Demographics, outcomes, and direct personnel costs were compared. Significant mortality reductions stratified by age and injury severity score (ISS) were used to calculate lives saved in relation to direct personnel costs. Student's t test and chi were used (significance *p < 0.05).
RESULTS: In the PRE period, there were 7,587 admissions compared with 11,057 POST. There were no significant differences PRE versus POST for age (41.4 +/- 24.4 years vs. 41.3 +/- 24.9 years), gender (62.4% vs. 63.7% male), mechanism of injury (11.5% vs. 11.8% penetrating), and percent intensive care unit admissions (30.1 vs. 29.9). Significant differences were noted for ISS (10.5 +/- 9.7 vs. 11.6 +/- 10.1*), percent admissions with ISS >or=16 (18.5 vs. 27.3*), and revised trauma score (10.8 +/- 2.8 vs. 10.7 +/- 2.8*). Both the average length of stay (6.8 +/- 8.8 vs. 6.5 +/- 9.8*) and percent mortality for ISS >or=16 (23 vs. 17*) were reduced. When mortality was stratified by both age and ISS, significant reductions were noted and a total of 173 lives were saved as a result. However, direct personnel costs increased from $7.6 million to $22.7 million. When cost is allocated to lives saved; the cost of a saved life was more than $87,000.
CONCLUSIONS: Resources for program development, including salary and call pay, significantly reduced mortality. Price of commitment: $3 million per year. The cost of a saved life: $87,000. The benefit: 173 surviving patients who would otherwise be dead.
BACKGROUND: Venous thromboembolism (VTE) is reported to occur among 7% to 58% of trauma patients. Variability in VTE rates might reflect differences in case mix and quality of care, but also screening practices or data capture. We explored the variation in VTE rates across trauma centers to determine its use as a measure of the quality of patient care.
STUDY DESIGN: The National Trauma Data Bank (version 7.1, admission year 2006) was used to capture a cohort at risk for VTE. Crude and adjusted rates of VTE were determined, and the observed and expected rates were compared across centers. Outlier hospitals were defined as those with considerably more (or fewer) patients than expected. We then assessed the level of concordance between outlier status for deep vein thrombosis (DVT) and pulmonary embolism (PE). Intraclass correlation coefficients (ICC) were calculated to evaluate for the presence of a "center" effect using multilevel modeling.
RESULTS: The 22,421 patients met inclusion criteria from 30 trauma centers. There was marked variability in the rate of VTE across centers, ranging from 0.2% to 13.3%, which was more pronounced for DVT (0.2% to 13.1%) than for PE (0% to 1.7%). There was poor concordance for DVT and PE outlier status. Intraclass correlation coefficient was four times greater for DVT (0.23) than for PE (0.06).
CONCLUSIONS: There was substantial variation in rates of VTE across trauma centers. There was no relationship between DVT and PE outlier status, which is counter to the understanding of the biologic relationship between the two. Lastly, the very low Intraclass correlation coefficient for PE compared with DVT suggests that to a large extent, practice variation has very little impact on PE rates. In light of these findings and concerns about patient ascertainment of DVT, VTE rates might not be a useful measure of quality of care.
BACKGROUND: The goal of this study was to examine the association between patient complications and admission to Level I trauma centers (TC) compared with nontrauma centers (NTC).
STUDY DESIGN: This was a retrospective cohort study of data derived from the National Study on the Costs and Outcomes of Trauma (NSCOT). Patients were recruited from 18 Level I TCs and 51 NTCs in 15 regions encompassing 14 states. Trained study nurses, using standardized forms, abstracted the medical records of the patients. The overall number of complications per patient was identified, as was the presence or absence of 13 specific complications.
RESULTS: Patients treated in TCs were more likely to have any complication compared with patients in NTCs, with an adjusted relative risk (RR) of 1.34 (95% CI, 1.03, 1.74). For individual complications, only the urinary tract infection RR of 1.94 (95% CI, 1.07, 3.17) was significantly higher in TCs. TC patients were more likely to have 3 or more complications (RR, 1.83; 95% CI, 1.16, 2.90). Treatment variables that are surrogates for markers of injury severity, such as use of pulmonary artery catheters, multiple operations, massive transfusions (> 2,500 mL packed red blood cells), and invasive brain catheters, occurred significantly more often in TCs.
CONCLUSIONS: Trauma centers have a slightly higher incidence rate of complications, even after adjusting for patient case mix. Aggressive treatment may account for a significant portion of TC-associated complications. Pulmonary artery catheter use and intubation had the most influence on overall TC complication rates. Additional study is needed to provide accurate benchmark measures of complication rates and to determine their causes.
BACKGROUND: Recent studies have suggested worse outcomes for patients hospitalized during the beginning of the academic calendar, though these findings have not been reproduced among trauma patients. This study compares outcomes of patients during the beginning of the academic year with those at the end of the academic year. METHODS: Retrospective trauma registry analysis of a large urban level I trauma center. Patients admitted during April/May (ENDYEAR group) or July/August (FRESH group) between 1998 and 2007 were included. Demographic and injury parameters were recorded, and outcomes compared including crude mortality, complication rate, length of stay (LOS), and intensive care unit LOS (ICU-LOS). TRISS methodology was used to evaluate risk-adjusted performance. RESULTS: Three thousand sixty-seven patients were included in the FRESH group and 3626 in the ENDYEAR group. Groups were similar in age (36 +/- 17 years and 36 +/- 17 years, p = 0.39) and mean Injury Severity Score (8 +/- 11 and 8 +/- 10, p = 0.85). There was no difference in LOS (4.6 +/- 0.2 days versus 4.5 +/- 0.2 days, p = 0.92) or ICU-LOS (5.6 +/- 0.2 days versus 5.3 +/- 0.2 days, p = 0.96). Per patient complication rates for the FRESH and ENDYEAR groups were 6% and 6% (p = 0.8), total complication rates were 12% and 13% (p = 0.07), and crude mortality was 7% and 6% (p = 0.11), respectively. FRESH and ENDYEAR groups had similar W-Statistics (1.0 and 1.2) and z scores (3.5 and 4.4). CONCLUSION: Outcomes were similar between patients injured at the beginning of the academic year compared with the end of the academic year. Our data does not support the concept of a July effect in level I trauma centers.
Between 1999 and 2001, 368 polytrauma patients were treated at the Departments of Traumatology and Surgery of the Karl Franzens University Hospital in Graz, Austria. In 1993, primary interdisciplinary polytrauma management was introduced in the emergency room. Subsequently, responsibilities were reevaluated regularly and cooperation was found to improve steadily.
METHODS:
All polytrauma patients were classified using the polytrauma registry of the German Society for Traumatology (Deutsche Gesellschaft für Unfallchirurgie, DGU) for evaluation and statistical analysis. Additionally, polytrauma cases have been analyzed at weekly interdisciplinary meetings since April 2000 to ensure an objectively high quality in polytrauma diagnosis and treatment.
RESULTS:
For trauma patients with an average Injury Severity Score (ISS) of 26.6, the average lengths of stay in the ICU (8.3 days) and in the hospital (21.8 days), were very short. In the year 2000, actual mortality was lower (18.8%) than that precalculated using Trauma Injury Severity Scale (TRISS). In 2001, this was the 4th best standardized mortality score of all participating trauma facilities.
CONCLUSIONS:
Primary interdisciplinary teamwork in the emergency room of trauma departments is recommended. Selecting the trauma leader depending on the nature of the patient's injuries is the most logical ongoing step towards a specialized medical system in which patients receive optimal treatment under the direction of the most appropriate specialist. In 83% of all polytrauma cases, the trauma leader was an orthopedic trauma surgeon. As this high standard of polytrauma care can only be guaranteed by a quality-management system, there has to be, in addition to the DGU evaluation, a retrospective weekly analysis of the treatment of polytrauma patients in which all of the involved specialists are invited to participate.
