A National Evaluation of the Effect of Trauma-Center Care on Mortality

MacKenzie, Ellen J.; Rivara, Frederick P.; Jurkovich, Gregory J.; Nathens, Avery B.; Frey, Katherine; Egleston, Brian L.; Salkever, David S.; Scharfstein, Daniel O.

doi:10.1056/nejmsa052049

Cited by 2,186 publications

(1,509 citation statements)

References 28 publications

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“…Injury treatment at designated trauma centers can reduce mortality from traumatic injury, [1][2][3][4] but the majority of US residents in rural areas do not have timely access to Level I or II trauma centers. 5 Geographic barriers to trauma care are more likely to impact racial minorities and people living in poverty, 6 paralleling established racial and socioeconomic disparities in trauma mortality.…”

Section: Introductionmentioning

confidence: 99%

Rural risk: Geographic disparities in trauma mortality

Jarman

Castillo

Carlini

et al. 2016

Surgery

116

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Section: Introductionmentioning

confidence: 99%

Rural risk: Geographic disparities in trauma mortality

Jarman

Castillo

Carlini

et al. 2016

Surgery

116

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“…Furthermore, comparisons between trauma centers can be problematic, since trauma patterns differ significantly between countries and areas [13]. In the paper of Wyen et al [14], the injury patterns and diagnostic algorithms in an urban German university trauma center are depicted.…”

Section: Focus On: Diagnostic and Prognosis Of Severely Traumatized Pmentioning

confidence: 99%

“…This new score allows severely traumatized patients to be compared while accounting for their individual patterns. It is one of the main evaluative tools used in the German Trauma Registry, and shows great promise [1,[9][10][11][12].Furthermore, comparisons between trauma centers can be problematic, since trauma patterns differ significantly between countries and areas [13]. In the paper of Wyen et al [14], the injury patterns and diagnostic algorithms in an urban German university trauma center are depicted.…”

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confidence: 99%

Focus on: Diagnostic and prognosis of severely traumatized patients

Trentz¹,

Marzi²

2009

Eur J Trauma Emerg Surg

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Focus on: Diagnostic and Prognosis of Severely Traumatized PatientsMajor trauma, usually associated with hemorrhagic shock, requires the utmost effort to ensure survival and optimal rehabilitation. While the event that caused trauma cannot be influenced, and primary resuscitation depends on various circumstances, emergency room algorithms can be defined and learned. These standards, however, are influenced by advances such as those due to the introduction of new diagnostic methods (ultrasound, CT scan) [1,2] or therapeutic protocols (damage control surgery) [3][4][5][6]. However, severely traumatized patients suffer from a wide variety of injury patterns, a common problem with clinical studies in this field.Predicting survival by determining physiological parameters such as base excess, lactate and pH is one way of defining the severity of hemorrhagic shock. These physiological parameters, which are accounted for in trauma scores, appear to be of the greatest prognostic value when assessed during the first hour after admission, as reported in this issue by Abt et al. [7] from the Zurich Trauma Center. As well as physiological scores, anatomical scores are also very important, and combining both scores seems a reasonable approach. However, the tremendous variety of injury patterns, both anatomically and physiologically, makes them difficult to grade. A further step towards improving trauma scores is presented by Lefering [8], who describes the revised injury severity classification score (RISC), an outcome prediction score that takes the individual pattern of injury into account. This new score allows severely traumatized patients to be compared while accounting for their individual patterns. It is one of the main evaluative tools used in the German Trauma Registry, and shows great promise [1,[9][10][11][12].Furthermore, comparisons between trauma centers can be problematic, since trauma patterns differ significantly between countries and areas [13]. In the paper of Wyen et al. [14], the injury patterns and diagnostic algorithms in an urban German university trauma center are depicted. The predominance of blunt trauma and importance of diagnostic timeliness over a five-year period are discussed. In this respect, optimized diagnostic procedures are warranted to ensure that important pathologies are not overlooked. It seems that missed injuries only lead to a fatal outcome in a minority of cases, as the important study of Sö derlund et al. [15] demonstrates in an eight-year evaluation of early deaths in the emergency room. In certain cases, however, missing diagnoses or interpretations could have saved individual patients.Interestingly, optimal diagnostic procedures not only prevent early trauma deaths; they can also predict the amount of posttraumatic inflammation. Maier et al. [16] demonstrated that the initial detection of lung contusions by spiral CT caused an immediate enhanced inflammatory response in combination with severe lung dysfunction. Moreover, patients with comparable injury severities but without in...

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“…This association likely has many causes, including differences in the adoption rate of evidence-based care (8), provider expertise/staffing models (7,9,10), and referral bias (11). Thus, various professional organizations are actively debating a tiered system of regionalization for patients with VDRF (12,13) that would be similar to existing systems in trauma and high-risk neonatology (14)(15)(16).…”

mentioning

confidence: 99%

Patient and Hospital Characteristics Associated with Interhospital Transfer for Adults with Ventilator-Dependent Respiratory Failure

et al. 2017

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Rationale: Patients with ventilator-dependent respiratory failure have improved outcomes at centers with greater expertise; yet, most patients are not treated in such facilities. Efforts to align care for respiratory failure and hospital capability would necessarily require interhospital transfer.Objectives: To characterize the prevalence and the patient and hospital factors associated with interhospital transfer of adults residing in Florida with ventilator-dependent respiratory failure.Methods: We performed a retrospective, observational study using Florida Healthcare Cost and Utilization Project data. We selected patients 18 years of age and older with International Classification of Diseases, Ninth Revision, codes of respiratory failure and mechanical ventilation during 2012 and 2013, and we identified cohorts of patients that did and did not undergo interhospital transfer. We obtained patient sociodemographic and clinical variables and categorized hospitals into subtypes on the basis of patient volume and services provided: large, medium (nonprofit or for-profit), and small.Results: Interhospital transfer was our primary outcome measure. Patient sociodemographics, clinical variables, and hospital types were used as covariates. We identified 2,580 patients with ventilatordependent respiratory failure who underwent interhospital transfer. Overall, transfer was uncommon, with only 2.9% of patients being transferred. In a hierarchical model, age less than 65 years (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.77-2.45) and tracheostomy (OR, 3.19; 95% CI, 2.80-3.65) were associated with higher odds of transfer, whereas having Medicaid was associated with lower odds of transfer than having commercial insurance (OR, 0.65; 95% CI, 0.56-0.75). Additionally, care in medium-sized for-profit hospitals was associated with lower odds of transfer (OR, 1.37 vs. 2.70) than care in medium nonprofit hospitals, despite similar hospital characteristics. Conclusions:In Florida, interhospital transfer of patients with ventilator-dependent respiratory failure is uncommon and more likely among younger, commercially insured, medically resourceintensive patients. For-profit hospitals are less likely to transfer than nonprofit hospitals. In future studies, researchers should test for geographic variations and examine the clinical implications of selectivity in interhospital transfer of patients with ventilatordependent respiratory failure.

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A National Evaluation of the Effect of Trauma-Center Care on Mortality

Abstract: Our findings show that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization.

Cited by 2,186 publications

References 28 publications

Rural risk: Geographic disparities in trauma mortality

Rural risk: Geographic disparities in trauma mortality

Focus on: Diagnostic and prognosis of severely traumatized patients

Patient and Hospital Characteristics Associated with Interhospital Transfer for Adults with Ventilator-Dependent Respiratory Failure

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