Statewide variation in the treatment of patients hospitalized with spleen injury.

HYPOTHESIS: Surgeons' treatment decisions for patients with spleen injuries in Washington State from January 1, 1990, through December 31, 1994, were different in rural compared with urban communities. DESIGN AND SETTINGS: Retrospective cohort analyses using the Death and Illness History Database for the state of Washington, which provides a cross-linked record of an individual's sequential hospitalizations. Counties were defined as metropolitan, urban, or rural on the basis of population density. PATIENTS: A total of 1905 patients (1927 hospitalizations) with an International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis code of 865. MAIN OUTCOME MEASURES: Physician management decisions (perform a celiotomy or repair the spleen) were stratified by geographic region. RESULTS: Throughout the state, there was substantial variability in the treatment of spleen-injured patients. Factors associated with higher odds of splenectomy included older age, overall severity of injury, treatment in rural hospitals, and treatment in the earlier years of study. While the frequency of splenic salvage increased over time, hospital length of stay, rehospitalization, and 30-day mortality did not increase. CONCLUSIONS: Injury to the spleen is a common problem for which management decisions vary by geographic region, indicating that a single management protocol does not universally apply. To evaluate appropriateness of care by process measures, such as splenic injury management, will require that decision makers grant some latitude in management variability based on factors such as practice setting.

Trauma system impact on admission site: a comparison of two states.

OBJECTIVE: To introduce a measure assessing statewide hospital admission patterns for trauma and evaluate its utility in identifying significant admission redistributions in neighboring states as a function of trauma system implementation. METHODS: A retrospective claims database analysis was performed of hospitalized trauma patients in Washington and Oregon. The site of hospitalization and diagnostic information were used to determine an admission rate difference for each hospital: the rate of index patient admissions minus the rate of non-index patient admissions. Mean admission rate differences for Level II and III versus other hospitals in each state were compared as a function of time. RESULTS: A bias in favor of admitting more serious injuries to Level II and III hospitals was seen with trauma system implementation in both states, but it was more pronounced in the Oregon trauma system. CONCLUSION: Assessment of admission rate differences is a helpful method of characterizing the evolution of statewide trauma systems.

Adequacy of hospital discharge status as a measure of outcome among injured patients.

CONTEXT: Crude mortality rates at the time of hospital discharge are commonly used to assess the quality of care provided to patients hospitalized following trauma. OBJECTIVES: To evaluate the adequacy of hospital death rates as an outcome measure following trauma and to determine the influence of noninjury illness as a cause of hospital death and the frequency of postdischarge death. DESIGN: Retrospective cohort analyses using hospital discharge data for injured patients cross-linked to death certificate data that provided 1 year of follow-up for all patients discharged alive. PATIENTS: A total of 90048 injured patients admitted to all acute care hospitals in the state of Washington from 1991 through 1993 and discharged with at least 1 diagnosis coded in the International Classification of Diseases, Ninth Revision, Clinical Modification to indicate trauma. MAIN OUTCOME MEASURES: Death in the hospital and death within 30 days of hospital discharge. RESULTS: Among 1912 injured patients with in-hospital deaths, 825 death certificates (43%) listed a noninjury cause of death. The overall mortality rate at hospital discharge was 21.2 per 100000 hospitalized injured patients, and was 12.1 per 100000 for trauma deaths and 9.1 per 100000 for those designated as nontrauma deaths. Patients with trauma-related death designations were younger (mean age, 51.5 years vs 77.9 years), had shorter lengths of stay (median stay, 2 days vs 5 days), and sustained more severe injures (P<.001). Including the 1273 deaths that occurred within 30 days of hospital discharge increased rates for trauma-designated deaths to 14.1 per 100000 and increased rates for nontrauma-designated deaths to 21.3 per 100000. CONCLUSIONS: Hospital discharge death rates are incomplete measures of death frequency for injured patients. Designation of the cause of death, especially among older, hospitalized, injured patients often reflects preexisting medical conditions. Adequate assessment of mortality following trauma requires measurement of the frequency of death following hospital discharge.

Preferential benefit of implementation of a statewide trauma system in one of two adjacent states.

BACKGROUND: Implementation of Oregon's trauma system was associated with a reduction in the risk of death for hospitalized injured patients. An alternative explanation for improved outcome, however, is favorable concurrent temporal trends, e.g., new technologies and treatments. PATIENTS AND METHODS: To control for temporal trends, seriously injured hospitalized patients in Oregon and Washington were compared before either state had a trauma system (1985-1988) and when only the Oregon trauma system had been implemented (1990-1993). The study group consisted of hospitalized injured patients aged 16 to 79 years with one or more index injuries in six body regions, i.e., head, chest, spleen/liver, femur or pelvis fracture, and burns. Hospital discharge claims data were analyzed, converting International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis codes to Abbreviated Injury Scale scores and Injury Severity Scores using a conversion algorithm. Multivariate logistic regression models were used to estimate the differential risk-adjusted odds of death in Oregon compared with Washington after adjustment for demographics, injury type, and injury severity. RESULTS: Findings indicated no difference in the risk-adjusted odds of death between Oregon and Washington while both states functioned under an ad hoc trauma system (1985-1988). A significant reduction in the risk of death, however, was noted in Oregon for patients with an index injury and an Injury Severity Score > 15 compared with Washington (adjusted odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.70-0.91) after trauma system implementation in Oregon (1990-1993). Specifically, reductions in the risk of death were demonstrated for patients with head injuries (adjusted OR = 0.70, 95% CI = 0.59-0.82) or liver/spleen injuries (adjusted OR = 0.73, 95% CI = 0.54-0.99). CONCLUSION: Assuming that the two states demonstrated similar concurrent temporal trends, the findings support the conclusion that improved outcomes among injured patients in Oregon may be attributed to the institution of a statewide trauma system.

Rural hospital transfer patterns before and after implementation of a statewide trauma system. OHSU Rural Trauma Research Group.

OBJECTIVE: To evaluate trauma transfer practices in rural Oregon before and after implementation of a statewide trauma system. METHODS: A pre- vs post-system implementation (historical control) analysis of trauma transfer practices was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. Medical records of patients with specific index injury diagnoses in 4 anatomic regions (head, chest, liver/ spleen, and femur/open-tibia) were reviewed for a 3-year period before statewide trauma system implementation and 3 years after hospital trauma designation. RESULTS: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had head injuries, 34% had chest injuries, 23% had femur/open-tibia injuries, and 12% had spleen/liver injuries. There were 142 (13%) patients with an injury in > 1 index area. After trauma system implementation, there was a significant increase in the proportion of ED trauma patients transferred from Level-4 trauma hospitals (32% vs 68%, p < 0.001), with a corresponding decrease in the number of hospital admissions to these facilities (63% to 29%, p < 0.001). Significant increases in the proportion transferred from Level-4 trauma hospital EDs were noted for all index injury categories (p < 0.001). Trauma patients presenting to Level-4 EDs were significantly more likely to be transferred to Level-2 facilities (66% vs 82%, p = 0.030), while patients at Level-3 facilities were significantly more likely to be transferred to Level-1 centers (2% vs 14%, p = 0.002) following trauma system implementation. Multiple logistic regression modeling indicated that implementation of the statewide trauma system was an independent predictor of rural trauma patient transfer from Level-4 hospitals, while transfers from Level-3 facilities were dependent on type of injury. CONCLUSION: Implementation of the Oregon statewide trauma system was associated with a redistribution of rural trauma patients to trauma hospitals with greater therapeutic resources.

Impact of a statewide trauma system on rural emergency department patient assessment documentation. OHSU Rural Trauma Research Group.

OBJECTIVE: To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level-3 vs Level-4), injury diagnosis, and patient demographics. METHODS: A pre- vs post-system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open-tibia) were reviewed for 3-year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O2, and O2 saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury. RESULTS: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open-tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in > 1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head-injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal. CONCLUSION: The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.

Influence of a statewide trauma system on pediatric hospitalization and outcome.

BACKGROUND: During the years 1987-1991, a statewide trauma system was implemented in Oregon (Ore) but not in Washington (Wash). Incidence of hospitalization, frequency of death and risk-adjusted odds of death for injured children (< 19 years) in the two adjacent states were compared for two time periods (1985-1987 and 1991-1993). METHODS: State populations of injured children (International Classification of Diseases, 9th Revision-Clinical Modification, code 800-959) were identified through a Hospital Discharge Index. Hospitals in counties with a population density < 50 persons/square mile were designated rural. Incidence rates are events/10,000 pediatric population per year. RESULTS: The pediatric population increased in both states (Ore: 687,000-758,000; Wash: 1,159,000-1,336,000). Incidence of hospitalization for all injured children in entire states declined (Ore: 66.5-38.5; Wash: 54-33); also in rural hospitals (Ore: 67.5-32; Wash: 48 to 31). Seriously injured children (score on the Injury Severity Scale > 15) had a lower incidence in 1991-1993 of admission to rural hospitals (Ore: 2.98; Wash: 2.82) compared with incidence for entire states (Ore: 4.61; Wash: 4.62); in 1985-1987 the incidence was not different. Furthermore risk adjusted odds of death for seriously injured children was significantly lower in Oregon than in Washington in the later time period. CONCLUSION: Both states show a similar temporal trend toward a declining frequency of death for children hospitalized with injuries. Injury prevention strategies appear to have reduced the number of serious injuries in both states. However, seriously injured children demonstrated a reduced risk of death in Oregon, consistent with benefit from a statewide trauma system.