Ten-year trend in survival and resource utilization at a level I trauma center.
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OBJECTIVE: To determine the impact of increasing trauma center experience over time on survival and resource utilization. METHODS: The authors studied a retrospective cohort at a single level I trauma center over a 10-year period, from 1986 to 1995. Patients included all hospital admissions and emergency department deaths. The main outcome measures were the case-fatality rate adjusted for injury severity, hospital length of stay, and costs. RESULTS: A total of 25,979 patients were admitted or died. The number of patients per year increased, from 2063 in 1986 to 3313 in 1995. The proportion of patients transferred from another institution increased from 16.2% to 34.4%. Although mean length of stay declined by 28.4%, from 9.5 to 6.8 days, costs increased by 16.7%, from $14,174 to $16,547. The use of specific radiologic investigations increased; the frequency of operative procedures either remained unchanged (craniotomy, fracture fixation) or decreased (celiotomy). After adjusting for injury severity and demographic factors, the mortality rate decreased over 10 years. The improvement in survival was confined to patients with an injury severity score > or =16. CONCLUSION: Over a 10-year period, the case-fatality rate declined in patients with severe injuries. Overall acute care costs increased, partially because of the increased use of radiologic investigations. Even in otherwise established trauma centers, increasing cumulative experience results in improved survival rates in the most severely injured patients. These data suggest that experience contributes to a decrease in mortality rate after severe trauma and that developing trauma systems should consider this factor and limit the number of designated centers to maximize cumulative experience at individual centers. (+info)
Trauma emergency unit: long-term evaluation of a quality assurance programme.
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OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme. (+info)
Sophisticated hospital information system/radiology information system/picture archiving and communications system (PACS) integration in a large-scale traumatology PACS.
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Picture archiving and communications system (PACS) in the context of an outpatient trauma care center asks for a high level of interaction between information systems to guarantee rapid image acquisition and distribution to the surgeon. During installation of the Innsbruck PACS, special aspects of traumatology had to be realized, such as imaging of unconscious patients without identification, and transferred to the electronic environment. Even with up-to-date PACS hardware and software, special solutions had to be developed in-house to tailor the PACS/hospital information system (HIS)/radiology information system (RIS) interface to the needs of radiologic and clinical users. An ongoing workflow evaluation is needed to realize the needs of radiologists and clinicians. These needs have to be realized within a commercially available PACS, whereby full integration of information systems may sometimes only be achieved by special in-house solutions. (+info)
Paying a premium: how patient complexity affects costs and profit margins.
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OBJECTIVE AND BACKGROUND: Tertiary medical centers continue to be under extreme pressure to deliver high-complexity care, but paradoxically there is considerable pressure within these institutions to reduce their emphasis on tertiary care and refocus their efforts to develop a more community-like practice. The genesis of this pressure is the perceived profitability of routine surgical activity when compared with more complex care. The purpose of this study is to assess how the total cost and profit (loss) margin can vary for an entire trauma service. The authors also evaluate payments for specific trauma-related diagnostic-related groups (DRGs) and analyze how hospital margins were affected based on mortality outcome. MATERIALS AND METHODS: The authors analyzed the actual cost of all trauma discharges (n = 692) at their level I trauma center for fiscal year 1997. Data were obtained from the trauma registry and the hospital cost accounting system. Total cost was defined as the sum of the variable, fixed, and indirect costs associated with each patient. Margin was defined as expected payments minus total cost. The entire population and all DRGs with 10 or more patients were stratified based on survival outcome, Injury Severity Score, insurance status, and length of stay. The mean total costs for survivors and nonsurvivors within these various categories and their margins were evaluated. RESULTS: The profit margin on nonsurvivors was $5,898 greater than for survivors, even though the mean total cost for nonsurvivors was $28,821 greater. Within the fixed fee arrangement, approximately 44% of transfers had a negative margin. Both survivors and nonsurvivors become increasingly profitable out to 20 days and subsequently become unprofitable beyond 21 days, but nonsurvivors were more profitable than survivors. CONCLUSIONS: There is a wide variance in both the costs and margins within trauma-related DRGs. The DRG payment system disproportionately reimburses providers for nonsurvivors, even though on average they are more costly. Because payers are likely to engage in portfolio management, patients can be transferred between hospitals based on the contractual relationship between the payer and the provider. This payment system potentially allows payers to act strategically, sending relatively low-cost patients to hospitals where they use fee-for-service reimbursement and high-cost patients to hospitals where their reimbursement is contractually capped. Although specific to the authors' trauma center and its payer mix, these data demonstrate the profitability of maintaining a level I trauma center and preserving the mission of delivering care to the severely injured. (+info)
Trauma center maturation: quantification of process and outcome.
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BACKGROUND AND OBJECTIVE: The regional trauma system with the trauma center as its center is a model for health care networks. However, trauma center maturation has not been defined in the literature. The authors' hypothesis was that maturation of the trauma center would affect quantitatively both process and patient outcome. MATERIALS AND METHODS: A total of 15,303 trauma patients were admitted from 1987 to 1995. Annual admissions increased from 813 to 2669. Resources were generated as patient volume increased. Time to the operating room, length of stay, and complications were determined. TRISS methodology was used to calculate z scores and w values to compare actual with predicted mortality rates. RESULTS: Time to the operating room for laparotomy decreased from 62+/-73 to 35+/-47 minutes, from 32+/-32 to 20+/-17 minutes in hypotensive patients, and for craniotomy decreased from 88+/-54 to 67+/-49 minutes. The incidence of infectious, airway, neurologic, orthopedic, respiratory, gastrointestinal, and procedure-related complications declined significantly. Z scores and w values increased for penetrating and blunt injuries. Deaths for patients with ISS >15 declined significantly. Hospital length of stay decreased for all ranges of injury severity. CONCLUSIONS: 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. (+info)
Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence.
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OBJECTIVE: Alcoholism is the leading risk factor for injury. The authors hypothesized that providing brief alcohol interventions as a routine component of trauma care would significantly reduce alcohol consumption and would decrease the rate of trauma recidivism. METHODS: This study was a randomized, prospective controlled trial in a level 1 trauma center. Patients were screened using a blood alcohol concentration, gamma glutamyl transpeptidase level, and short Michigan Alcoholism Screening Test (SMAST). Those with positive results were randomized to a brief intervention or control group. Reinjury was detected by a computerized search of emergency department and statewide hospital discharge records, and 6- and 12-month interviews were conducted to assess alcohol use. RESULTS: A total of 2524 patients were screened; 1153 screened positive (46%). Three hundred sixty-six were randomized to the intervention group, and 396 to controls. At 12 months, the intervention group decreased alcohol consumption by 21.8+/-3.7 drinks per week; in the control group, the decrease was 6.7+/-5.8 (p = 0.03). The reduction was most apparent in patients with mild to moderate alcohol problems (SMAST score 3 to 8); they had 21.6+/-4.2 fewer drinks per week, compared to an increase of 2.3+/-8.3 drinks per week in controls (p < 0.01). There was a 47% reduction in injuries requiring either emergency department or trauma center admission (hazard ratio 0.53, 95% confidence interval 0.26 to 1.07, p = 0.07) and a 48% reduction in injuries requiring hospital admission (3 years follow-up). CONCLUSION: Alcohol interventions are associated with a reduction in alcohol intake and a reduced risk of trauma recidivism. Given the prevalence of alcohol problems in trauma centers, screening, intervention, and counseling for alcohol problems should be routine. (+info)
Molecular epidemiological investigation using a randomly amplified polymorphic DNA assay of Burkholderia cepacia isolates from nosocomial outbreaks.
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We experienced two Burkholderia cepacia outbreaks over a 1-year period. During this period, 28 B. cepacia isolates were obtained from clinical specimens, and 2 were obtained from environmental specimens (i.e., from a nebulizer solution and a nebulizer tube). These 30 isolates were subjected to the PCR-based randomly amplified polymorphic DNA (RAPD) assay as well as to pulsed-field gel electrophoresis (PFGE). In the first outbreak, in which eight patients hospitalized in the Trauma and Critical Care Center were involved, the RAPD assay revealed that all 20 isolates obtained from clinical specimens and the 2 isolates from environmental specimens had identical DNA profiles. These RAPD data enabled us to pinpoint a possible source and to take countermeasures to prevent further spread of the epidemic-causing strain. In the second outbreak, two consecutive B. cepacia infection/colonization cases were seen in the surgery ward. The RAPD profiles of four isolates obtained were again identical, but they were distinct from those seen in the first outbreak, clearly indicating that the second outbreak was not related to the first. Thus, our experience demonstrated that the RAPD assay is a useful and reliable tool for epidemiological studies of B. cepacia isolates from nosocomial outbreaks. Since the RAPD assay could provide discriminatory potential and reproducibility comparable to those of the widely used PFGE assay with less complexity and in a shorter time, the introduction of the RAPD assay into hospital microbiology laboratories as a routine technique may help prevent nosocomial outbreaks. (+info)
Watson Jones Lecture. The organisation of trauma services in the UK.
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To provide a high level of orthopaedic trauma care, education and research, across the country, trauma services in the UK require modification. Good information is necessary prior to formulating ideas and proposals. Trauma care provision must be considered comprehensively at both the national and local levels. As a first step, it is important to know just how many acute hospitals there are in the country. It is also important to know about the distribution of surgical specialities and the number of consultant orthopaedic surgeons staffing those hospitals. (+info)