ABSTRACT
BACKGROUND: This study assesses the relationship that the brand of trauma program registry (TPR) has on mortality rate (MR) in the reports prepared by the American College of Surgeons Committee on Trauma (ACSCOT) trauma center (TC) site surveyors. METHODS: Data from 242 ACSCOT adult TC survey reports (88 Level I, 115 Level II, and 39 Level III) were analyzed for annual trauma volume, injury severity score (ISS), MR, and TPR. Six TPR (A through F) were identified; group F was a composite of several infrequently used TPRs. This report focuses on the ISS range 16-24 because of the likelihood that the mean for each TC would be near 20 and MR is high enough so that a difference, if present, could be statistically documented. RESULTS: For the total group, MR showed no correlation with TC volume or TC level for ISS 16-24. MR was significantly different according to which TPR was used by the TCs. The MR is less (4.8%) for 14 high volume TCs (over 1200 admits) using TPR A compared with 33 low volume TCs (below 800 admits) using TPR A (6.34%). CONCLUSION: The MR for ISS 16-24 in ACSCOT-surveyed TCs differs within subgroups based on type of TPR utilized. This may reflect improper use of the software programs. Enhanced skill in the application of software programs designed to generate ISS scores is essential if meaningful studies on the effects of improved trauma care on MR are to be conducted. Hand scored ISS by trained personnel may circumvent this problem.
Subject(s)
Diagnosis-Related Groups/statistics & numerical data , Registries , Trauma Centers/organization & administration , Wounds and Injuries/mortality , Confounding Factors, Epidemiologic , Data Interpretation, Statistical , Humans , Injury Severity Score , United States/epidemiology , Wounds and Injuries/classificationABSTRACT
Patients with closed head injury and expanding epidural (EDH) or subdural (SDH) hematoma require urgent craniotomy for decompression and control of hemorrhage. In remote areas where neurosurgeons are not available, trauma surgeons may occasionally need to intervene to avert progressive neurologic injury and death. In 1990, a young man with rapidly deteriorating neurologic signs underwent emergency burr hole decompression of a combined EDH/SDH at our hospital, with complete recovery. In anticipation of future need, five surgeons at our rural, American College of Surgeons-verified Level III trauma center participated in a neurosurgeon-directed course in emergency craniotomy. Since January 1, 1991, 792 patients have been entered into the trauma registry, including 60 with closed head injury and Glasgow Coma Scale (GCS) score of 13 or less. All but seven were transferred to a regional Level II trauma center, which is a minimum flight time of 1 hour each way. All patients with EDH (5) and 2 of 14 with SDH were deemed too unstable for transport and underwent burr hole decompression followed by immediate transfer. All craniotomies were approved by the consulting neurosurgeon and were done for computed tomography-confirmed lesions combined with neurologic deterioration as demonstrated by (1) GCS score of 8 or less, (2) lateralizing signs (dilated pupil, hemiparesis), or (3) development of combined bradycardia and hypertension. One patient with a GCS score of 3 on arrival died. Seven survivors (mean follow-up, 3.9 years; range, 1-6.5 years), including the index case, function independently, although one survivor has moderate cognitive and motor impairment. We conclude that early craniotomy for expanding epidural and subdural hematomas by properly trained surgeons may save lives and reduce morbidity in properly selected cases when timely access to a neurosurgeon is not possible.
Subject(s)
Craniotomy , Head Injuries, Closed/diagnosis , Head Injuries, Closed/surgery , Adolescent , Adult , Aged , Child , Child, Preschool , Diagnosis, Differential , Emergencies , Female , Glasgow Coma Scale , Hospital Bed Capacity, under 100 , Humans , Infant , Male , Middle Aged , Montana , Rural Health , Trauma Centers , Treatment OutcomeABSTRACT
Trauma victims should in most cases be transported to the nearest trauma center as soon as possible after injury. Since this is not always feasible in underserved rural areas, the community hospital occasionally must function as the trauma center. From 1977 to 1987, while working in a rural community hospital in the northern Rocky Mountains, we operated on 83 patients with visceral and vascular injuries. The typical patient was a young man who sustained multiple injuries from motor vehicle or recreational accidents. Twenty-one patients had 27 major complications, and 2 died. Many small communities cannot afford helicopter-based trauma systems. Conversely, however, distance and geographic barriers limit access to designated centers. Accordingly, rural surgeons cannot opt out of trauma care and must look to trauma surgeons to help in solving access problems.
