[show abstract][hide abstract] ABSTRACT: In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have mechanisms to identify and intervene with problem drinkers. The aim of this investigation was to determine if a multilevel trauma center intervention targeting both providers and patients would lead to higher quality alcohol screening and brief intervention (SBI) when compared with trauma center mandate compliance without implementation enhancements.
Cluster randomized trial in which intervention site (site n =10, patient n =409) providers received 1-day workshop training on evidence-based motivational interviewing (MI) alcohol interventions and four 30-minute feedback and coaching sessions; control sites (site n =10, patient n =469) implemented the mandate without study team training enhancements.
Trauma centers in the United States of America.
878 blood alcohol positive inpatients with and without traumatic brain injury (TBI).
MI skills of providers were assessed with fidelity coded standardized patient interviews. All patients were interviewed at baseline, and 6- and 12-months post-injury with the Alcohol Use Disorders Identification Test (AUDIT).
Intervention site providers consistently demonstrated enhanced MI skills compared with control providers. Intervention patients demonstrated an 8% reduction in AUDIT hazardous drinking relative to controls over the course of the year after injury (RR =0.88, 95%, CI =0.79, 0.98). Intervention patients were more likely to demonstrate improvements in alcohol use problems in the absence of TBI (p =0.002).
Trauma center providers can be trained to deliver higher quality alcohol screening and brief intervention than untrained providers, which is associated with modest reductions in alcohol use problems, particularly among patients without traumatic brain injury. Key Words: Alcohol, Screening and Brief Intervention, Traumatic Injury, American College of Surgeons, Policy Mandate, Motivational Interviewing, Dissemination and Implementation Research.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Alcohol use may alter mental status and vital signs in injured patients, leading to increased testing during emergency department (ED) evaluation. We hypothesized that alcohol use increases the hospital charges when caring for these injured patients. METHODS: The National Hospital Ambulatory Medical Care Survey collects weighted population-based estimates of ED use. We analyzed injury-related visits of adult patients, and resource use and admission rates were compared by the presence of alcohol. RESULTS: Alcohol was involved in 6.0% of injury-related ED visits. Alcohol-present patients arrived by ambulance more frequently (45% vs 21%, P < .001), had a 26% longer ED stay (211 vs 167 minutes, P < .001), and underwent more diagnostic testing. They were twice as likely to be admitted (14.0% vs 6.5%, P < .001). Additional ED charges were over $217 million. CONCLUSIONS: Patients with alcohol-related injuries use significantly more resources, with a significant added financial burden. Insurance companies in many states can deny coverage for injuries caused by alcohol use, shifting these expenses to trauma centers.
American journal of surgery 04/2013; · 2.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: In 2005, the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high-quality alcohol screening and brief intervention (SBI) services at trauma centers. METHOD: Twenty sites selected from all United States Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma-center-based alcohol SBI with blood-alcohol-positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed. RESULTS: The investigation has successfully recruited provider, patient and trauma center staff samples into the study, and outcomes are being followed longitudinally. CONCLUSION: When completed, the DO-SBIS trial will inform future American College of Surgeons' policy targeting the sustained integration of high-quality alcohol SBI at trauma centers nationwide.
General hospital psychiatry 12/2012; · 2.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N = 878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n = 166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of college policy targeting integrated substance abuse treatment at trauma centers.
Journal of Substance Abuse Treatment. 12/2012; 43(4):410–417.
[show abstract][hide abstract] ABSTRACT: This study applied a geographic information system (GIS) to identify clusters of injury-related deaths (IRDs) within a large urban county (26 cities; population, 2.4 million). All deaths due to injuries in Dallas County (Texas) in 2005 (N = 670) were studied, including the geographic location of the injury event. Out of 26 cities in Dallas County, IRDs were reported in 19 cities. Geospatial data were obtained from the local governments and entered into the GIS. Standardized mortality ratios (SMR, with 95% CI) were calculated for each city and the county using national age-adjusted rates. Dallas County had significantly more deaths due to homicides (SMR, 1.76; 95% CI, 1.54-1.98) and IRDs as a result of gunshots (SMR, 1.23; 95% CI, 1.09-1.37) than the US national rate. However, this increase was restricted to a single city (the city of Dallas) within the county, while the rest of the 25 cities in the county experienced IRD rates that were either similar to or better than the national rate, or experienced no IRDs. GIS mapping was able to depict high-risk geographic "hot spots" for IRDs. In conclusion, GIS spatial analysis identified geographic clusters of IRDs, which were restricted to only one of 26 cities in the county.
Proceedings (Baylor University. Medical Center) 07/2012; 25(3):208-13.
[show abstract][hide abstract] ABSTRACT: The Trauma Quality Improvement Program uses inhospital mortality to measure quality of care, which assumes patients who survive injury are not likely to suffer higher mortality after discharge. We hypothesized that survival rates in trauma patients who survive to discharge remain stable afterward.
Patients treated at an urban Level I trauma center (2006-2008) were linked with the Social Security Administration Death Master File. Survival rates were measured at 30, 90, and 180 days and 1 and 2 years from injury among two groups of trauma patients who survived to discharge: major trauma (Abbreviated Injury Scale score ≥ 3 injuries, n = 2,238) and minor trauma (Abbreviated Injury Scale score ≤ 2 injuries, n = 1,171). Control groups matched to each trauma group by age and sex were simulated from the US general population using annual survival probabilities from census data. Kaplan-Meier and log-rank analyses conditional upon survival to each time point were used to determine changes in risk of mortality after discharge. Cox proportional hazards models with left truncation at the time of discharge were used to determine independent predictors of mortality after discharge.
The survival rate in trauma patients with major injuries was 92% at 30 days posttrauma and declined to 84% by 3 years (p > 0.05 compared with general population). Minor trauma patients experienced a survival rate similar to the general population. Age and injury severity were the only independent predictors of long-term mortality given survival to discharge. Log-rank tests conditional on survival to each time point showed that mortality risk in patients with major injuries remained significantly higher than the general population for up to 6 months after injury.
The survival rate of trauma patients with major injuries remains significantly lower than survival for minor trauma patients and the general population for several months postdischarge. Surveillance for early identification and treatment of complications may be needed for trauma patients with major injuries.
Prognostic study, level III.
The journal of trauma and acute care surgery. 06/2012; 73(3):699-703.
[show abstract][hide abstract] ABSTRACT: The Trauma Quality Improvement Program has shown that risk-adjusted mortality rates at some centers are nearly 50% higher than at others. This "quality gap" may be due to different clinical practices or processes of care. We have previously shown that adoption of processes called core measures by the Joint Commission and Centers for Medicare and Medicaid Services does not improve outcomes of trauma patients. We hypothesized that improved compliance with trauma-specific clinical processes of care (POC) is associated with reduced in-hospital mortality.
Records of a random sample of 1,000 patients admitted to a Level I trauma center who met Trauma Quality Improvement Program criteria (age ≥ 16 years and Abbreviated Injury Scale score 3) were retrospectively reviewed for compliance with 25 trauma-specific POC (T-POC) that were evidence-based or expert consensus panel recommendations. Multivariate regression was used to determine the relationship between T-POC compliance and in-hospital mortality, adjusted for age, gender, injury type, and severity.
Median age was 41 years, 65% were men, 88% sustained a blunt injury, and mortality was 12%. Of these, 77% were eligible for at least one T-POC and 58% were eligible for two or more. There was wide variation in T-POC compliance. Every 10% increase in compliance was associated with a 14% reduction in risk-adjusted in-hospital mortality.
Unlike adoption of core measures, compliance with T-POC is associated with reduced mortality in trauma patients. Trauma centers with excess in-hospital mortality may improve patient outcomes by consistently applying T-POC. These processes should be explored for potential use as Core Trauma Center Performance Measures.
The journal of trauma and acute care surgery. 04/2012; 72(4):870-7.
[show abstract][hide abstract] ABSTRACT: We have preciously demonstrated that trauma patients receive less than two-thirds of the care recommended by evidence-based medicine. The purpose of this study was to identify patients least likely to receive optimal care.
Records of a random sample of 774 patients admitted to a Level I trauma center (2006-2008) with moderate to severe injuries (Abbreviated Injury Scale score ≥3) were reviewed for compliance with 25 trauma-specific processes of care (T-POC) endorsed by Advanced Trauma Life Support, Eastern Association for the Surgery of Trauma, the Brain Trauma Foundation, Surgical Care Improvement Project, and the Glue Grant Consortium based on evidence or consensus. These encompassed all aspects of trauma care, including initial evaluation, resuscitation, operative care, critical care, rehabilitation, and injury prevention. Multivariate logistic regression was used to identify patients likely to receive recommended care.
Study patients were eligible for a total of 2,603 T-POC, of which only 1,515 (58%) were provided to the patient. Compliance was highest for T-POC involving resuscitation (83%) and was lowest for neurosurgical interventions (17%). Increasing severity of head injuries was associated with lower compliance, while intensive care unit stay was associated with higher compliance. There was no relationship between compliance and patient demographics, socioeconomic status, overall injury severity, or daily volume of trauma admissions.
Little over half of recommended care was delivered to trauma patients with moderate to severe injuries. Patients with increasing severity of traumatic brain injuries were least likely to receive optimal care. However, differences among patient subgroups are small in relation to the overall gap between observed and recommended care.
The journal of trauma and acute care surgery. 03/2012; 72(3):585-92; discussion 592-3.
[show abstract][hide abstract] ABSTRACT: 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.
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.
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.
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.
The Journal of trauma 12/2010; 69(6):1367-71. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: Return to work may be easily monitored as a surrogate of long-term functional outcome for benchmarking and performance improvement of trauma systems. We hypothesized that employment rates among survivors of traumatic brain injury (TBI) decrease following injury and remain depressed for an extended period of time. Data were obtained from a statewide surveillance system of 3522 TBI patients (aged >15 years) who were discharged alive from acute care hospitals and followed yearly using telephone interviews (1996-1999). The study population consisted of patients with severe TBI (head abbreviated injury score 3, 4, or 5) and complete follow-up for 3 years postinjury (n = 572). Patients were mostly young males (43 ± 19 years, 65% male) with blunt TBI (92%). The preinjury employment rate was 67%, which declined to 52% (P < 0.001) in the first year and slowly rose in subsequent years but never reached the preinjury level (54% in year 2, P < 0.001; 57% in year 3, P = 0.001). Increasing severity of TBI was associated with a lower employment rate. Patients who remained employed worked the same number of hours as they did before the injury (47.8 ± 10.5 hours). Female employment rates rose similar to rates for males. However, women who were employed full-time before TBI were more likely to work part-time after TBI than men (50% vs 24%, P < 0.001). In conclusion, survivors of severe injury do not attain preinjury employment levels for several years. Once validated in other studies, postinjury employment may be used as an indicator to monitor functional outcomes in trauma registries.
Proceedings (Baylor University. Medical Center) 10/2010; 23(4):355-8.
[show abstract][hide abstract] ABSTRACT: More than 9,000 vehicle occupants die each year in side-impact vehicle collisions, primarily from head injuries. The authors hypothesized that side-curtain air bags significantly improve head and neck safety in side-impact crash testing.
Side-impact crash-test data were obtained from the Insurance Institute for Highway Safety, which ranks occupant protection as good, acceptable, marginal, or poor. Vehicles of the same make and model that underwent side-impact crash testing both with and without side-curtain air bags were compared, as well as the protective effect of these air bags on occupants' risk for head and neck injury.
Of all the passenger vehicles, 25 models have undergone side-impact crash testing with and without side-curtain air bags by the Insurance Institute for Highway Safety. Only 3 models without side-curtain air bags (12%) provided good head and neck protection for drivers, while 21 cars with side-curtain air bags (84%) provided good protection (P < .001). For rear passengers, the added protection from side-curtain air bags was less dramatic but significant (84% without vs 100% with side-curtain air bags, P = .04).
Side-curtain air bags significantly improve vehicle occupant safety in side-impact crash tests. Installation of these air bags should be federally mandated in all passenger vehicles.
American journal of surgery 10/2010; 200(4):496-9. · 2.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: In this paper, the authors' goal was to examine the relationship between transfusion and long-term functional outcomes in moderately anemic patients (lowest hematocrit [HCT] level 21-30%) with traumatic brain injury (TBI). While evidence suggests that transfusions are associated with poor hospital outcomes, no study has examined transfusions and long-term functional outcomes in this population. The preferred transfusion threshold remains controversial.
The authors performed a retrospective review of patients who were admitted with TBI between September 2005 and November 2007, extracting data such as HCT level, status of red blood cell transfusion, admission Glasgow Coma Scale (GCS) score, serum glucose, and length of hospital stay. Outcome measures assessed at 6 months were Glasgow Outcome Scale-Extended score, Functional Status Examination score, and patient death. A multivariate generalized linear model controlling for confounding variables was used to assess the association between transfusion and outcome.
During the study period, 292 patients were identified, and 139 (47.6%) met the criteria for moderate anemia. Roughly half (54.7%) underwent transfusions. Univariate analyses showed significant correlations between outcome score and patient age, admission GCS score, head Abbreviated Injury Scale score, number of days with an HCT level < 30%, highest glucose level, number of days with a glucose level > 200 mg/dl, length of hospital stay, number of patients receiving a transfusion, and transfusion volume. In multivariate analysis, admission GCS score, receiving a transfusion, and transfusion volume were the only variables associated with outcome (F = 2.458, p = 0.007; F = 11.694, p = 0.001; and F = 1.991, p = 0.020, respectively). There was no association between transfusion and death.
Transfusions may contribute to poor long-term functional outcomes in anemic patients with TBI. Transfusion strategies should be aimed at patients with symptomatic anemia or physiological compromise, and transfusion volume should be minimized.
Journal of Neurosurgery 09/2010; 113(3):539-46. · 3.15 Impact Factor
[show abstract][hide abstract] ABSTRACT: Triage attempts to ensure that severely injured patients are transported to a high-level trauma facility to reduce mortality. However, some patients are triaged to the nearest medical facility before transport to a final destination trauma center (TC). We sought to analyze whether initial triage of critically injured patients to a nontrauma center (NTC) is associated with increased mortality.
The Glue Grant Trauma Database of severely injured patients was analyzed. Mortality risk for patients who had an intermediate stop at another facility was compared with patients triaged directly from the scene to the TC. Patient demographics, time from injury to TC arrival, resuscitation volume, transfusions, head injury, initial systolic blood pressure, co-morbidities, and injury severity were included as confounders in a multivariate logistic regression model.
There were 1,112 patients of whom 318 (29%) were initially triaged to an NTC. After adjusting for confounders, this was associated with an increase in prehospital crystalloids (4.2 L vs. 1.4 L, p < 0.05) and a 12-fold increase in blood transfusions (60% vs. 5%, p < 0.001). Age, injury severity score, Acute Physiology and Chronic Health Evaluation II score, and time from injury to TC arrival were independent predictors of mortality. The odds of death were 3.8 times greater (95% CI, 1.6-9.0) when patients were initially triaged to a nontrauma facility.
Triaging severely injured patients to hospitals that are incapable of providing definitive care is associated with increased mortality. Attempts at initial stabilization at an NTC may be harmful. These findings are consistent with a need for continued expansion of regional trauma systems.
The Journal of trauma 09/2010; 69(3):595-9; discussion 599-601. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Trauma Quality Improvement Project has demonstrated significant variations in risk-adjusted mortality rates across the designated trauma centers. It is not known whether the outcome differences are related to provider-level clinical decision making. We hypothesized that centers with good outcomes undertake critical operative interventions aggressively, thereby avoiding complications and deaths.
The previously validated Trauma Quality Improvement Project risk-adjustment algorithm was used to measure observed-to-expected mortality rates (O/E with 90% confidence intervals [CI]) for 152 Level I and II trauma centers participating in the National Trauma Data Bank (version 7.0). Adult patients (>or=16 years) with at least one severe injury (Abbreviated Injury Scale score >or=3) were included (N = 135,654). Operative intervention rates for solid organ injuries (spleen, liver, and kidney) were compared between the centers classified as high mortality (O/E with CI > 1, n = 35 centers) versus low mortality (O/E with CI < 1, n = 37 centers) using nonparametric tests.
Low- and high-mortality trauma centers were similar in designation level, hospital and intensive care unit beds, teaching status, and number of trauma, orthopedic, and neurosurgeons. Despite a similar incidence and severity of solid organ injuries, low-mortality centers were less likely to undertake operative interventions.
Trauma centers with higher risk-adjusted mortality rates are more likely to undertake operative interventions for solid organ injuries. Hence, there is a need to focus quality improvement efforts on medical decision-making and perioperative processes of care.
The Journal of trauma 07/2010; 69(1):70-7. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital compliance with evidence-based processes of care as quality indicators. We hypothesized that compliance with CMS quality indicators would correlate with risk-adjusted mortality rates in trauma patients.
A previously validated risk-adjustment algorithm was used to measure observed-to-expected mortality ratios (O/E with 95% confidence interval) for Level I and II trauma centers using the National Trauma Data Bank data. Adult patients (>or=16 years) with at least one severe injury (Abbreviated Injury Score >or=3) were included (127,819 patients). Compliance with CMS quality indicators in four domains was obtained from Hospital Compare website: acute myocardial infarction (8 processes), congestive heart failure (4 processes), pneumonia (7 processes), surgical infections (3 processes). For each domain, a single composite score was calculated for each hospital. The relationship between O/E ratios and CMS quality indicators was explored using nonparametric tests.
There was no relationship between compliance with CMS quality indicators and risk-adjusted outcomes of trauma patients.
CMS quality indicators do not correlate with risk-adjusted mortality rates in trauma patients. Hence, there is a need to develop new trauma-specific process of care quality indicators to evaluate and improve quality of care in trauma centers.
The Journal of trauma 04/2010; 68(4):771-7. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: To identify risk factors predictive of pulmonary embolus (PE) timing after a traumatic injury.
One hundred eight traumatic injury patients with a confirmed diagnosis of PE were classified as early PE (≤4 days, n = 54) or late PE (>4 days, n = 54). Independent predictors of early versus late PE were identified using multivariate logistic regression.
Half the PEs were diagnosed ≤4 days of injury. Only long bone fractures independently predicted early PE (odds ratio 2.8; 95% confidence interval, 1.1-7.1). Severe head injuries were associated with late PE (odds ratio 11.1; 95% confidence interval, 3.9-31). Established risk factors such as age did not affect timing.
Half the PEs were diagnosed ≤4 days after injury. The risk of early PE appeared highest in patients with long bone fractures, and the benefits of immediate prophylaxis may outweigh risks. Patients with severe head injuries appear to have later PE events. Prospective interventional trials in these injury populations are needed.
American journal of surgery 04/2010; 201(2):209-15. · 2.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: : Previous studies have demonstrated variations in severity-adjusted mortality between trauma centers. However, it is not clear if outcomes vary by the type of injury being treated.
: National Trauma Data Bank was used to identify patients 16 years or older with moderate to severe injuries (Abbreviated Injury score > or =3) treated at level I or II trauma centers (n = 127,439 patients, 105 centers). Observed-to-Expected mortality ratios (O/E ratios, 95% confidence interval [CI]) were calculated for each trauma center within each of the three injury types: blunt multisystem (two or more body regions; n = 27,980; crude mortality, 15%), penetrating torso (neck, chest, or abdomen; n = 9,486; crude mortality, 9%), and blunt single system (n = 89,973; crude mortality 5%). Multivariate logistic regression was used to adjust for age, gender, mechanism, transfer status, and injury severity (Glasgow Coma Scale, blood pressure). For each injury type, trauma centers' performance was ranked as high (O/E with 95% CI <1), low (O/E with 95% CI >1), or average performers (O/E overlapping 1).
: Almost three quarters of the trauma centers achieved the same performance rank in each of the three injury categories. There were 14 low-performing trauma centers in blunt multisystem injuries, six in penetrating torso injuries, and nine in the blunt single system injuries group. None of these centers achieved high performance in any other type of injury.
: Risk-adjusted outcomes are consistent within trauma centers across different types of injuries, suggesting that quality improvement efforts should measure, analyze, and focus on hospital-wide systems of care, rather than on isolated quality domains related to specific types of injury.
The Journal of trauma 03/2010; 68(3):716-20. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: Declining trauma operative experience adversely impacts learning and retention of operative skills. Current solutions, such as acute care surgery, may not provide relevant operative experience. We hypothesized that a structured skills curriculum using fresh cadavers would improve participants' self-confidence in surgical exposure of human anatomic structures for trauma.
The trauma exposure course, a single-day, 8-hour course with two trainees and one instructor per fresh cadaver, was designed by the faculty of a high-volume, urban, level I trauma center. Trainees included all trauma fellows (n = 6) and surgical chief residents (n = 12) in academic year 2007 to 2008. Using a structured, pretested curriculum, participants were trained by trauma faculty in operative exposure of 48 structures in the neck, chest, abdomen, pelvis, and extremities. For each exposure, participants' self-reported levels of operative confidence were measured using the operating score (OR score, 1 = not confident and 5 = highly confident) before the course (pre), immediately afterward (post), and at long-term follow-up (median, 6 months).
Participation in the trauma exposure course resulted in a significant increase in OR scores for 44 of the 48 exposures (median scores, pre 3 vs. post 5, p < 0.0001), with no decline at long-term follow-up. Participants with less previous operative experience were most likely to benefit from the course.
A structured skills curriculum using fresh cadavers improved participants' self-confidence in operative skills required for surgical exposure of human anatomic structures for trauma. This model of training may be beneficial for surgical residents and fellows, as well as practicing trauma surgeons.
The Journal of trauma 11/2009; 67(5):1091-6. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: It has been alleged that smaller hospitals transfer out uninsured trauma patients (wallet biopsy), putting the financial burden on major trauma centers.
We undertook a retrospective analysis of the National Trauma Data Bank to compare patients who received care at major trauma centers after being transferred from another hospital (transfer group, n = 72,900) with patients who received definitive care at a smaller hospital (nontransfer group, n = 6,826).
Transfer patients were more likely to be uninsured (18% vs 14%; P < .001), but were more severely injured (Injury Severity Score, 11 +/- 10 vs 7 +/- 7; P < .001), or had multiple injuries. After adjustment for these differences, uninsured patients were no more likely to be transferred than insured ones (odds ratio, .95; 95% confidence interval, .88-1.04; P = .3).
There was no relationship between lack of insurance and likelihood of transfer to a major trauma center.
American journal of surgery 06/2009; 198(3):e35-8. · 2.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Alcohol intoxication may confound the initial assessment of trauma patients, resulting in increased use of diagnostic and therapeutic procedures, thereby increasing hospital costs. The Uniform Policy Provision Law (UPPL) exists in many states and allows insurance companies to deny payment for medical treatment for alcohol-related injuries. If intoxication increases resource utilization, these denials compound the financial burden of alcohol use on trauma centers. We hypothesized that patients injured while under the influence of alcohol require more diagnostic tests, procedures, and hospital admissions, leading to higher hospital charges.
The National Trauma Databank (2000-2004) was analyzed to identify adult trauma patients (age > or = 16 years) who were discharged alive, had a length of stay < or = 1 day and minor injuries (Injury Severity Score < 9), and were tested for blood alcohol. The study was confined to minimally injured patients to facilitate identification of unexpected resource use most likely attributable to alcohol use. Resource utilization was compared among patients who tested positive or negative for alcohol use. Results are presented as odds ratio (OR) with 95% confidence intervals (CI).
Sixty-eight thousand eight patients met study criteria, of which 31,020 were positive for alcohol. Despite similar baseline characteristics, alcohol-positive patients required significantly more invasive procedures, including intubation (OR 4.16, 95% CI = 3.56-4.85) and Foley catheter insertion (OR 1.52, 95% CI = 1.39-1.67) as well as diagnostic tests (CT scan OR 1.16, 95% CI = 1.12-1.20). They were also less likely to be discharged from the emergency department (OR 0.61, 95% CI = 0.58-0.64), and more frequently required hospital (OR 1.64, 95% CI = 1.57-1.73) or intensive care unit admission (OR 1.82, 95% CI = 1.71-1.94). Mean hospital charges were $1,833 greater ($10,405 +/- 225 vs. 8,572 +/- 68).
A significant amount of trauma center costs are primarily attributable to alcohol use rather than injury severity or outcome. The financial costs associated with alcohol use and UPPL-related cost-shifting to trauma centers is a significant burden to trauma centers. UPPL laws that penalize trauma centers for identifying intoxicated patients should be repealed in states where they exist.
The Journal of trauma 03/2009; 66(2):495-8. · 2.35 Impact Factor