How much green does it take to be orange? Determining the cost associated with trauma center readiness.

BACKGROUND: Readiness costs are real expenses incurred by trauma centers to maintain essential infrastructure to provide emergent services on a 24/7 basis. Although the components for readiness are well described in the American College of Surgeons' Resources for Optimal Care of the Injured Patient, the cost associated with each component is not well defined. We hypothesized that meeting the requirements of the 2014 Resources for Optimal Care of the Injured Patient would result in significant costs for trauma centers. METHODS: The state trauma commission in conjunction with trauma medical directors, program managers, and financial officers of each trauma center standardized definitions for each component of trauma center readiness cost and developed a survey tool for reporting. Readiness costs were grouped into four categories: administrative/program support staff, clinical medical staff, in-house operating room, and education/outreach. To verify consistent cost reporting, a financial auditor analyzed all data. Trauma center outliers were further evaluated to validate variances. All level I/level II trauma centers (n = 16) completed the survey on 2016 data. RESULTS: Average annual readiness cost is US $10,078,506 for a level I trauma center and US $4,925,103 for level IIs. Clinical medical staff was the costliest component representing 55% of costs for level Is and 64% for level IIs. Although education/outreach is mandated, levels I and II trauma centers only spend approximately US $100,000 annually on this category (1%-2%), demonstrating a lack of resources. CONCLUSION: This study defines the cost associated with each component of readiness as defined in the Resources for Optimal Care of the Injured Patient manual. Average readiness cost for a level I trauma center is US $10,078,506 and US $4,925,103 for a level II. The significant cost of trauma center readiness highlights the need for additional trauma center funding to meet the requirements set forth by the American College of Surgeons. LEVEL OF EVIDENCE: Economic and value-based evaluations, level III.

Evaluation of the Georgia trauma system using the American College of Surgeons Needs Based Assessment of Trauma Systems tool.

BACKGROUND: The American College of Surgeons Needs Based Assessment of Trauma Systems (NBATS) tool was developed to help determine the optimal regional distribution of designated trauma centers (DTC). The objectives of our current study were to compare the current distribution of DTCs in Georgia with the recommended allocation as calculated by the NBATS tool and to see if the NBATS tool identified similar areas of need as defined by our previous analysis using the International Classification of Diseases, Ninth Revision, Clinical Modification Injury Severity Score (ICISS). METHODS: Population counts were acquired from US Census publications. Transportation times were estimated using digitized roadmaps and patient zip codes. The number of severely injured patients was obtained from the Georgia Discharge Data System for 2010 to 2014. Severely injured patients were identified using two measures: ICISS<0.85 and Injury Severity Score >15. RESULTS: The Georgia trauma system includes 19 level I, II, or III adult DTCs. The NBATS guidelines recommend 21; however, the distribution differs from what exists in the state. The existing DTCs exactly matched the NBATS recommended number of level I, II, or III DTCs in 2 of 10 trauma service areas (TSAs), exceeded the number recommended in 3 of 10 TSAs, and was below the number recommended in 5 of 10 TSAs. Densely populated, or urban, areas tend to be associated with a higher number of existing centers compared with the NBATS recommendation. Other less densely populated TSAs are characterized by large rural expanses with a single urban core where a DTC is located. The identified areas of need were similar to the ones identified in the previous gap analysis of the state using the ICISS methodology. DISCUSSION: The tool appears to underestimate the number of centers needed in extensive and densely populated areas, but recommends additional centers in geographically expansive rural areas. The tool signifies a preliminary step in assessing the need for state-wide inpatient trauma center services. LEVEL OF EVIDENCE: Economic, level IV.

Feasibility and Benefit of Incorporating a Multimedia Cadaver Laboratory Training Program into a Didactics Curriculum for Junior and Senior Surgical Residents.

OBJECTIVE: As operative experience in general surgery decreases and work hour limitations increase there is less exposure of surgical residents to advanced vascular and trauma exposures. Many institutions have demonstrated benefits of cadaver laboratory courses. We have incorporated a multimedia cadaver laboratory course into our general surgery residency didactics curriculum with the objective to demonstrate a benefit of the program as well as the feasibility of incorporation. STUDY DESIGN: This is a prospective study at a tertiary care institution including general surgery residents within our residency program. A curriculum was designed, requiring residents to complete multimedia learning modules before both a trauma cadaver laboratory and vascular exposure cadaver laboratory. Outcome measures included self-efficacy/confidence (precourse and postcourse 5-point Likert surveys), knowledge (net performance on precourse and postcourse multiple choice examinations), and resident perception of the curriculum (postcourse 5-point Likert survey). Data were analyzed using ANOVA paired t-tests. RESULTS: For the vascular cadaver laboratory, resident knowledge improved overall from an average of 41.2% to 50.0% of questions correct (p = 0.032) and self-efficacy/confidence improved by 0.59 from 1.52 to 2.11 out of 5 (p = 0.009). Median confidence is 1.37 out of 5 and 2.32 out of 5, before and after course, respectively. Wilcoxon nonparametric test reveals a p = 0.011. Resident's perception of the usefulness of the laboratory evaluation was 3.85 out 5. There were 85.71% agreed that the laboratory is useful and 14.29% were disagree. The Z-score is -0.1579 (means 0.1579 standard deviations a score of 3.85 below the benchmark). The percentile rank is 56.27%. The coefficient of variation is 24.68%. For the trauma cadaver laboratory, resident knowledge improved overall from an average of 55.89% to 66.17% of questions correct (p = 0.001) and self-efficacy/confidence improved by 0.75 from 1.68 out of 5 to 2.43 out of 5 (p = 0.011). Median confidence level is 1.41 out of 5 before the training course and 2.64 out of 5 after the training course. Wilcoxon signed rank test gives a p value of 0.008. Resident's perception of the usefulness of the laboratory evaluation was 3.94 out 5. There were 72.22% agreed that the laboratory is useful and 27.78% were neutral. The Z-score is -0.098 (means 0.098 standard deviations a score of 3.94 below the benchmark). The percentile rank is 53.90%. The coefficient of variation is 15.48%. CONCLUSIONS: Incorporating a multimedia cadaver laboratory into a residency education didactics curriculum was both feasible and beneficial for resident education. We demonstrate an improvement in knowledge and self efficacy/confidence following both cadaver laboratory courses.

Descriptive Analysis of Venous Thromboembolism in Georgia Trauma Centers Compared with National Trauma Centers Participating in the Trauma Quality Improvement Program.

This study was designed to compare the incidence of venous thromboembolism (VTE) in Georgia trauma centers with other national trauma centers participating in the Trauma Quality Improvement Program (TQIP). The use of chemoprophylaxis and characteristics of patients who developed VTE were also examined. We conducted a retrospective observational study of 325,703 trauma admissions to 245 trauma centers from 2013 to 2014. Patient demographics, rate of VTE, as well as the use, type, and timing of chemoprophylaxis were compared between patients admitted to Georgia and non-Georgia trauma centers. The rate of VTE in Georgia trauma centers was 1.9 per cent compared with 2.1 per cent in other national trauma centers. Overall, 49.6 per cent of Georgia patients and 45.5 per cent of patients in other trauma centers had documented chemoprophylaxis. Low molecular weight heparin was the most commonly used medication. Most patients who developed VTE did so despite receiving prophylaxis. The rate of VTE despite prophylaxis was 3.2 per cent in Georgia and 3.1 per cent in non-Georgia trauma centers. Mortality associated with VTE was higher in Georgia trauma centers compared with national TQIP benchmarks. The incidence of VTE and use of chemoprophylaxis within Georgia trauma centers were similar to national TQIP data. Interestingly, most patients who developed VTE in both populations received VTE prophylaxis. Further research is needed to develop best-practice guidelines for prevention, early detection, and treatment in high-risk populations.

Successful Incorporation of Performance Based Payments for Trauma Center Readiness Costs into the Georgia Trauma System.

As quality and outcomes have moved to the fore front of medicine in this era of healthcare reform, a state trauma system Performance Based Payments (PBP) program has been incorporated into trauma center readiness funding. The purpose of this study was to evaluate the impact of a PBP on trauma center revenue. From 2010 to 2016, a percentage of readiness costs funding to trauma centers was placed in a PBP and withheld until the PBP criteria were completed. To introduce the concept, only three performance criteria and 10 per cent of readiness costs funding were tied to PBP in 2010. The PBP has evolved over the last several years to now include specific criteria by level of designation with an increase to 50 per cent of readiness costs funding being tied to PBP criteria. Final PBP distribution to trauma centers was based on the number of performance criteria completed. During 2016, the PBP criteria for Level I and II trauma centers included participation in official state meetings/conference calls, required attendance to American College of Surgeons state chapter meetings, Trauma Quality Improvement Program, registry reports, and surgeon participation in Peer Review Committee and trauma alert response times. Over the seven-year study period, $36,261,469 was available for readiness funds with $11,534,512 eligible for the PBP. Only $636,383 (6%) was withheld from trauma centers. A performance-based program was successfully incorporated into trauma center readiness funding, supporting state performance measures without adversely affecting the trauma center revenue. Future PBP criteria may be aligned to designation standards and clinical quality performance metrics.

What Are the Costs of Trauma Center Readiness? Defining and Standardizing Readiness Costs for Trauma Centers Statewide.

Trauma center readiness costs are incurred to maintain essential infrastructure and capacity to provide emergent services on a 24/7 basis. These costs are not captured by traditional hospital cost accounting, and no national consensus exists on appropriate definitions for each cost. Therefore, in 2010, stakeholders from all Level I and II trauma centers developed a survey tool standardizing and defining trauma center readiness costs. The survey tool underwent minor revisions to provide further clarity, and the survey was repeated in 2013. The purpose of this study was to provide a follow-up analysis of readiness costs for Georgia's Level I and Level II trauma centers. Using the American College of Surgeons Resources for Optimal Care of the Injured Patient guidelines, four readiness cost categories were identified: Administrative, Clinical Medical Staff, Operating Room, and Education/Outreach. Through conference calls, webinars and face-to-face meetings with financial officers, trauma medical directors, and program managers from all trauma centers, standardized definitions for reporting readiness costs within each category were developed. This resulted in a survey tool for centers to report their individual readiness costs for one year. The total readiness cost for all Level I trauma centers was $34,105,318 (avg $6,821,064) and all Level II trauma centers was $20,998,019 (avg $2,333,113). Methodology to standardize and define readiness costs for all trauma centers within the state was developed. Average costs for Level I and Level II trauma centers were identified. This model may be used to help other states define and standardize their trauma readiness costs.

Thoracic Trauma in the Oldest of the Old: An Analysis of the Nationwide Inpatient Sample.

Thoracic trauma (TT) has the second highest mortality rate in the geriatric population. These injuries cause significant morbidity in elderly patients. Little has been done to describe the demographics and mortality of specific injuries in these patients. ICD-9 codes corresponding with thoracic trauma for patients aged >80 years were extracted from the Nationwide Inpatient Sample database from 2000 to 2010. Characteristics including gender, race, Charlson Comorbidity Index (CCI), length of stay (LOS), and in-hospital mortality (IHM) were analyzed. For females and males, mean CCI was 4.84 and 4.93, respectively (P < 0.0001), and IHM was 5.49 and 2.44 per cent, respectively (P < 0.0001). For white and non-white patients, mean CCI was 4.88 and 4.84, respectively (P < 0.05), and IHM was 3.5 and 3.19 per cent, respectively. This difference was not statistically significant (P = 0.149). Logistic regression revealed correlation coefficient between CCI and mortality was 0.314 (P < 0.0001). Fitting a regression of CCI on LOS adjusting for gender and race, the adjusted effect was 0.146 (P < 0.0001). LOS was significantly less for patients surviving hospitalization. Males had higher CCI and mortality than females. Although whites had a higher CCI than non-whites, there was no difference in IHM between these two groups.

Heterogeneity in Trauma Registry Data Quality: Implications for Regional and National Performance Improvement in Trauma.

BACKGROUND: Led by the American College of Surgeons Trauma Quality Improvement Program, performance improvement efforts have expanded to regional and national levels. The American College of Surgeons Trauma Quality Improvement Program recommends 5 audit filters to identify records with erroneous data, and the Georgia Committee on Trauma instituted standardized audit filter analysis in all Level I and II trauma centers in the state. STUDY DESIGN: Audit filter reports were performed from July 2013 to September 2014. Records were reviewed to determine whether there was erroneous data abstraction. Percent yield was defined as number of errors divided by number of charts captured. RESULTS: Twelve centers submitted complete datasets. During 15 months, 21,115 patient records were subjected to analysis. Audit filter captured 2,901 (14%) records and review yielded 549 (2.5%) records with erroneous data. Audit filter 1 had the highest number of records identified and audit filter 3 had the highest percent yield. Individual center error rates ranged from 0.4% to 5.2%. When comparing quarters 1 and 2 with quarters 4 and 5, there were 7 of 12 centers with substantial decreases in error rates. The most common missed complications were pneumonia, urinary tract infection, and acute renal failure. The most common missed comorbidities were hypertension, diabetes, and substance abuse. CONCLUSIONS: In Georgia, the prevalence of erroneous data in trauma registries varies among centers, leading to heterogeneity in data quality, and suggests that targeted educational opportunities exist at the institutional level. Standardized audit filter assessment improved data quality in the majority of participating centers.

"It takes a village" to raise research productivity: Impact of a Trauma Interdisciplinary Group for Research (TIGR) at an urban, Level 1 trauma center.

BACKGROUND: Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, lab technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies like the National Institutes of Health (NIH). This paper describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an on-going NIH-funded study. METHODS: We utilized a pre-test/post-test design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, threats) analysis was used to develop the intervention which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected N=150). Pre/Post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS: Research products increased from N =12 to N=42; (~ 400%). Research proposals for federal funding increased from N=0 to N=3, with success rate of 66%. Participant screenings for the NIH-funded study increased from N=40 to N=313. Consents increased from N=14 to N=70. Lab service fees were reduced from $300/participant to $5/participant. CONCLUSIONS: Adding diversity to our scientific team via TIGR was exponentially successful in 1) improving research productivity, 2) reducing research costs, and 3) increasing research products and mentoring activities that the team prior to TIGR had not entertained. The team is now well-positioned to apply for more federally funded projects and more trauma clinicians are considering research careers than before.

"It takes a village" to raise research productivity: impact of a Trauma Interdisciplinary Group for Research at an urban, Level 1 trauma center.

BACKGROUND: Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, laboratory technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies such as the National Institutes of Health (NIH). This article describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an ongoing NIH-funded study. METHODS: We used a pretest/posttest design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, and threats) analysis was used to develop the intervention, which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected n = 150). Pre-TIGR/post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS: Research products increased from 12 to 42 (approximately 400%). Research proposals for federal funding increased from 0 to 3, with success rate of 66%. Participant screenings for the NIH-funded study increased from 40 to 313. Consents increased from 14 to 70. Laboratory service fees were reduced from $300 per participant to $5 per participant. CONCLUSION: Adding diversity to our scientific team via TIGR was exponentially successful in (1) improving research productivity, (2) reducing research costs, and (3) increasing research products and mentoring activities that the team before TIGR had not entertained. The team is now well positioned to apply for more federally funded projects, and more trauma clinicians are considering research careers than before.

Nonoperative management of solid organ injury diminishes surgical resident operative experience: is it time for simulation training?

BACKGROUND: Nonoperative management (NOM) of solid abdominal organ injury (SAOI) is increasing. Consequently, training programs are challenged to ensure essential operative trauma experience. We hypothesize that the increasing use and success of NOM for SAOI negatively impacts resident operative experience with these injuries and that curriculum-based simulation might be necessary to augment clinical experience. MATERIALS AND METHODS: A retrospective cohort analysis of 1198 consecutive adults admitted to a Level I trauma center over 12 y diagnosed with spleen and/or liver injury was performed. Resident case logs were reviewed to determine operative experience (Cohort A: 1996-2001 versus Cohort B: 2002-2007). RESULTS: Overall, 24% of patients underwent operation for SAOI. Fewer blunt than penetrating injuries required operation (20% versus 50%, P < 0.001). Of those managed operatively, 70% underwent a spleen procedure and 43% had a liver procedure. More patients in Cohort A received an operation compared with Cohort B (34% versus 16%, P < 0.001). Patient outcomes did not vary between cohorts. Over the study period, 55 residency graduates logged on average 27 ± 1 operative trauma cases, 3.4 ± 0.3 spleen procedures, and 2.4 ± 0.2 liver operations for trauma. Cohort A graduates recorded more operations for SAOI than Cohort B graduates (spleen 4.1 ± 0.4 versus 3.0 ± 0.2 cases, P = 0.020 and liver 3.2 ± 0.3 versus 1.8 ± 0.3 cases, P = 0.004). CONCLUSIONS: Successful NOM, especially for blunt mechanisms, diminishes traditional opportunities for residents to garner adequate operative experience with SAOI. Fewer operative occasions may necessitate an increased role for standardized, curriculum-based simulation training.

Impact of traumatic suicide methods on a level I trauma center.

Suicide is a major, preventable public health issue. Although firearm-related mechanisms commonly result in death, nonfirearm methods cause significant morbidity and healthcare expenditures. The goal of this study is to compare risk factors and outcomes of firearm and nonfirearm traumatic suicide methods. This retrospective cohort study identified 146 patients who attempted traumatic suicide between 2002 and 2007 at a Level I trauma center. Overall, mean age was 40.2 years, 83 per cent were male, 74 per cent were white, and mean Injury Severity Score (ISS) was 12.7. Most individuals (53%) attempted suicide by firearms and 25 per cent died (84% firearm, 16% nonfirearm techniques). Subjects were more likely to die if they were older than 60 years-old, presented with an ISS greater than 16, or used a firearm. On average, patients using a firearm were older and had a higher ISS and mortality rate compared with those using nonfirearm methods. There was no statistical difference between cohorts with regard to gender, ethnicity, positive drug and alcohol screens, requirement for operation, intensive care unit admission, and hospital length of stay. Nonfirearm traumatic suicide prevention strategies aimed at select individuals may decrease overall attempts, reduce mechanism-related mortality, and potentially impact healthcare expenditures.