TRAUMA SYSTEM Mazen S. Zenati, M.D, MPH, Ph.D. University of Pittsburgh Department of Surgery and Epidemiology

Significance & Effectiveness

Trauma= Injury Traumatic injury is the leading cause of death for persons age 1 to 44 years old. Traumatic injury is the leading cause of death for persons age 1 to 44 years old. In 1995 alone, injuries were responsible for 147,891 deaths, 2.6 million hospital admissions, and more than 36 million emergency department visits nationwide. In 1995 alone, injuries were responsible for 147,891 deaths, 2.6 million hospital admissions, and more than 36 million emergency department visits nationwide. Injury is America’s most expensive disease process, costing nearly $180 billion/year. Injury is America’s most expensive disease process, costing nearly $180 billion/year. Trauma causes more than 300,000 permanent disabilities annually. Trauma causes more than 300,000 permanent disabilities annually. An estimated 25,000 trauma deaths annually are preventable. An estimated 25,000 trauma deaths annually are preventable. Each year, nearly 25% of all Americans sustain an injury requiring medical attention. Each year, nearly 25% of all Americans sustain an injury requiring medical attention. The death rate from unintentional injury is more than 50% higher in rural areas than in urban areas The death rate from unintentional injury is more than 50% higher in rural areas than in urban areas

Trauma system A trauma system is an organized approach to facilitating multidisciplinary system response to severely injured patients: –in a defined geographic area –that delivers the full range of services –to all trauma patients –and is integrated with the public health system for injury prevention and surveillance Benefits –Increase survival of seriously injured –Reduce burden of trauma-related death and disability –Improve efficiency of system components

Trauma System A trauma system includes : A trauma system includes : –EMS interventions –Emergency department interventions –Intensive and surgical in-hospital care –Rehabilitation –Social services –Injury prevention –Research –Education –Disaster Planning

An organized Trauma System links the necessary resources to maximize patient recovery

Example of system goals Monitor the state’s population-based occurrence of injury Monitor the state’s population-based occurrence of injury Assure integration and coordination of trauma system through effective partnerships Assure integration and coordination of trauma system through effective partnerships Assure secure and adequate financing Assure secure and adequate financing Monitor and track patient outcomes including death and disability as well as system performance Monitor and track patient outcomes including death and disability as well as system performance Coordinate emergency and disaster preparedness with responsible state agencies Coordinate emergency and disaster preparedness with responsible state agencies

Landmark Paper Trauma Mortality in Orange County: The Effect of Implementation of Regional Trauma System Trauma Mortality in Orange County: The Effect of Implementation of Regional Trauma System Cales RH. Ann Emerg Med. 1984; 13:1-10

Preventable death: The impact of trauma systems

Trauma System & Crash Mortality Nathens et.al., 2000

Trauma System & Crash Mortality Nathens et.al., 2000

Hospital volume-performance: the evidence Smith et. al. J. Trauma 1990: Smith et. al. J. Trauma 1990: –Analysis of 1,643 patients with major injuries: inverse relationship between volume & mortality Nathens et. al. JAMA 2001: Nathens et. al. JAMA 2001: –Demonstrated improved outcome for patients admitted to high volume centers with penetrating injury & shock and those in coma Freeman et. al. J Health Serv Res Policy. 2006: Freeman et. al. J Health Serv Res Policy. 2006: –There was evidence that patients with complex needs, such as the multiple injured or those with head injuries, had better outcomes in higher volume centers. Peitzman at. al. Ann Surg. 2000: Peitzman at. al. Ann Surg. 2000: –Annual admissions increased from 813 to 2669 from 1987 to Decreased in deaths, hospital length of stay and in complications. As the trauma center matured, the process of delivering patient care became more efficient. The result was improved survival, fewer complications, and a shorter length of stay.

Hospital volume-performance: the evidence

% of major trauma patients lived % of major trauma patients lived Trauma Outcomes Have Improved Dramatically Since 1995

The Golden hour Early trauma deaths can be impacted by rapid evaluation and resuscitation A well- organized trauma system can prevent 20-40% of deaths

Mortality for Major Trauma in Washington State (ISS>=16, State Criteria, Excluding Transfers) *Partial year

Barriers to Trauma System Competition among providers (EMS, hospitals) Competition among providers (EMS, hospitals) High cost of resources (surgeons, other hospital staff, imaging and other equipment) High cost of resources (surgeons, other hospital staff, imaging and other equipment) The availability of in-call specialized trauma surgeons, nurses and other related personnel The availability of in-call specialized trauma surgeons, nurses and other related personnel High proportion of patients with low-paying (or no) coverage High proportion of patients with low-paying (or no) coverage Maldistribution of resources in relation to risk of injury (particularly rural areas) Maldistribution of resources in relation to risk of injury (particularly rural areas) Inadequate attention to and funding for injury prevention and surveillance Inadequate attention to and funding for injury prevention and surveillance

Threatened Trauma Centers HRSA State Leadership Meeting, Robert C. Mackersie, M.D.

“If a disease were killing our children in the proportion that injuries are, people would be outraged and demand that this killer be stopped.” C. Everett Koop at a meeting of the National Safe Kids Campaign Why we are not so much excited

More than 4 million potential years of productive life are lost annually due to injury, exceeding losses from heart disease, cancer & stroke COMBINED

Everyone pays injury costs THE ANNUAL NATIONAL COST OF INJURY IS ESTIMATED TO BE $ 188 BILLION

In order to succeed, regional trauma systems development must have adequate funding as well as participation from healthcare consumers, local and state government and trauma care providers from all disciplines.

1. By developing trauma care standards 2. By providing professional education 3. By actively promoting prevention activities 4. By enhancing systems of care 5. By improving communications throughout the network Trauma systems save lives !

Tools to Evaluate Trauma