TRAUMA SYSTEMTRAUMA SYSTEM

Mazen S. Zenati, M.D, MPH, Mazen S. Zenati, M.D, MPH, Ph.D.Ph.D.

University of PittsburghUniversity of PittsburghDepartment of Surgery and Department of Surgery and

EpidemiologyEpidemiology

Significance & Significance & EffectivenessEffectiveness

Trauma= InjuryTrauma= Injury

Traumatic injury is the leading cause of death for Traumatic injury is the leading cause of death for persons age 1 to 44 years old.persons age 1 to 44 years old.

In 1995 alone, injuries were responsible for In 1995 alone, injuries were responsible for 147,891 deaths, 2.6 million hospital admissions, 147,891 deaths, 2.6 million hospital admissions, and more than 36 million emergency department and more than 36 million emergency department visits nationwide.visits nationwide.

Injury is America’s most expensive disease Injury is America’s most expensive disease process, costing nearly $180 billion/year.process, costing nearly $180 billion/year.

Trauma causes more than 300,000 permanent Trauma causes more than 300,000 permanent disabilities annually.disabilities annually.

An estimated 25,000 trauma deaths annually are An estimated 25,000 trauma deaths annually are preventable.preventable.

Each year, nearly 25% of all Americans sustain an Each year, nearly 25% of all Americans sustain an injury requiring medical attention.injury requiring medical attention.

The death rate from unintentional injury is more The death rate from unintentional injury is more than 50% higher in rural areas than in urban areasthan 50% higher in rural areas than in urban areas

Trauma systemTrauma system

A trauma system is an organized approach to facilitating multidisciplinary system response to severely injured patients:– in a defined geographic areain a defined geographic area– that delivers the full range of servicesthat delivers the full range of services– to all trauma patientsto all trauma patients– and is integrated with the public health system for and is integrated with the public health system for

injury prevention and surveillanceinjury prevention and surveillance Benefits

– Increase survival of seriously injuredIncrease survival of seriously injured– Reduce burden of trauma-related death and disabilityReduce burden of trauma-related death and disability– Improve efficiency of system componentsImprove efficiency of system components

Trauma SystemTrauma System

A trauma system includesA trauma system includes::– EMS interventionsEMS interventions– Emergency department interventionsEmergency department interventions– Intensive and surgical in-hospital careIntensive and surgical in-hospital care– RehabilitationRehabilitation– Social servicesSocial services– Injury preventionInjury prevention– ResearchResearch– EducationEducation– Disaster PlanningDisaster Planning

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

Example of system Example of system goalsgoals Monitor the state’s population-based Monitor the state’s population-based

occurrence of injuryoccurrence of injury Assure integration and coordination of Assure integration and coordination of

trauma system through effective trauma system through effective partnershipspartnerships

Assure secure and adequate financingAssure secure and adequate financing Monitor and track patient outcomes including Monitor and track patient outcomes including

death and disability as well as system death and disability as well as system performanceperformance

Coordinate emergency and disaster Coordinate emergency and disaster preparedness with responsible state agenciespreparedness with responsible state agencies

Landmark PaperLandmark Paper

Trauma Mortality in Orange County: The Effect of Implementation of Trauma Mortality in Orange County: The Effect of Implementation of Regional Trauma SystemRegional Trauma System

Cales RH. Ann Emerg Med. 1984; 13:1-10Cales RH. Ann Emerg Med. 1984; 13:1-10

Preventable death: Preventable death: The impact of trauma The impact of trauma systemssystems

Trauma System & Trauma System & Crash MortalityCrash Mortality

Nathens et.al., 2000Nathens et.al., 2000

Trauma System & Trauma System & Crash MortalityCrash Mortality

Nathens et.al., 2000Nathens et.al., 2000

Hospital volume-Hospital volume-performance: the evidenceperformance: the evidence

Smith et. al. J. Trauma 1990:Smith et. al. J. Trauma 1990:– Analysis of 1,643 patients with major injuries: inverse Analysis of 1,643 patients with major injuries: inverse

relationship between volume & mortalityrelationship between volume & mortality Nathens et. al. JAMA 2001:Nathens et. al. JAMA 2001:

– Demonstrated improved outcome for patients admitted to Demonstrated improved outcome for patients admitted to high volume centers with penetrating injury & shock and high volume centers with penetrating injury & shock and those in comathose 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 There was evidence that patients with complex needs, such

as the multiple injured or those with head injuries, had better as the multiple injured or those with head injuries, had better outcomes in higher volume centers.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 Annual admissions increased from 813 to 2669 from 1987 to

1995. Decreased in deaths, hospital length of stay and in 1995. Decreased in deaths, hospital length of stay and in complications. As the trauma center matured, the process of complications. As the trauma center matured, the process of delivering patient care became more efficient. The result was delivering patient care became more efficient. The result was improved survival, fewer complications, and a shorter length improved survival, fewer complications, and a shorter length of stay.of stay.

Hospital volume-Hospital volume-performance: the evidenceperformance: the evidence

University of Pittsburgh Trauma Center Growth by Year

0

1000

2000

3000

4000

5000

19861987198819891990199119921993199419951996199719981999200020012002200320042005

Year

Tot

al T

raum

a A

dmis

sion

200482% of major trauma patients lived

19951995

75% of major 75% of major trauma patients trauma patients livedlived

Trauma Outcomes Have Improved Dramatically Since 1995

The Golden hourThe 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 Mortality for Major Trauma in Washington StateWashington State (ISS>=16, State Criteria, Excluding (ISS>=16, State Criteria, Excluding Transfers)Transfers)

0%

5%

10%

15%

20%

25%

30%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004*

*Partial year

Barriers to Trauma Barriers to Trauma SystemSystem Competition among providers (EMS, hospitals)Competition among providers (EMS, hospitals) High cost of resources (surgeons, other High cost of resources (surgeons, other

hospital staff, imaging and other equipment)hospital staff, imaging and other equipment) The availability of in-call specialized trauma The availability of in-call specialized trauma

surgeons, nurses and other related personnelsurgeons, nurses and other related personnel High proportion of patients with low-paying High proportion of patients with low-paying

(or no) coverage(or no) coverage Maldistribution of resources in relation to risk Maldistribution of resources in relation to risk

of injury (particularly rural areas)of injury (particularly rural areas) Inadequate attention to and funding for injury Inadequate attention to and funding for injury

prevention and surveillanceprevention and surveillance

Threatened Trauma Threatened Trauma Centers 2001 - 2002Centers 2001 - 2002

HRSA 2003-2004 State Leadership Meeting, Robert C. Mackersie, M.D.HRSA 2003-2004 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 Why we are not so much excited 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 Everyone pays injury costscosts

THE ANNUAL NATIONAL COST THE ANNUAL NATIONAL COST OF INJURY IS ESTIMATED TO BEOF INJURY IS ESTIMATED TO BE

$ 188 BILLION$ 188 BILLION

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

1.1. By developing trauma care standardsBy developing trauma care standards

2.2. By providing professional educationBy providing professional education

3.3. By actively promoting prevention activitiesBy actively promoting prevention activities

4.4. By enhancing systems of care By enhancing systems of care

5.5. By improving communications throughout the By improving communications throughout the networknetwork

Trauma systems save lives !

Tools to Evaluate Tools to Evaluate TraumaTrauma