trauma: a case study in converting research into policy
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Trauma: A case study in converting research into policy. Avery B. Nathens MD MPH, Professor Departments of Surgery & Health Policy, Management, and Evaluation, University of Toronto & Sunnybrook Health Sciences Centre Medical Director, ACS TQIP. Trauma center. Trauma systems. - PowerPoint PPT PresentationTRANSCRIPT
Trauma: A case study in converting research into
policyAvery B. Nathens MD MPH, Professor
Departments of Surgery & Health Policy, Management, and Evaluation, University of Toronto &
Sunnybrook Health Sciences Centre
Medical Director, ACS TQIP
The journey from research to policy
Trauma surgeon and intensivist
Trauma center Trauma systems
Do trauma centers save lives?
How do trauma centers save lives
ACS Trauma QualityImprovement Program
Are trauma systems effective?
Why are trauma systems effective?
ACS Trauma SystemsConsultation Guide
Regional policy“decision maker”
American Civil War: 1861Mortality: 25%Transport time: 72 hrsFactors: +/- ambulance
WW I: 1914Mortality: 8.6%Transport time: 8 hrsFactors: ambulance (motorized)
World War II: 1939 Mortality: 4.5%Transport time: 4 hrsFactors: Ambulance, Medics, Plasma, Antibiotics
Korean War: 1951Mortality: 2.5%Transport time: 1.25 hrsFactors: Helicopter, MASH
Viet Nam War: 1965-1972Mortality 1.9%Transport time: 27 minutesFactors: Helicopter, Medics, Fixed wing
circa 1947
A tale of two countiesWest & Trunkey, 1979
Orange County Trauma patients transported to nearest of 39 facilities
San Francisco County Trauma patients transported to 1 centrally located
trauma facility
Preventable deaths: 43%
Preventable deaths: 1%
NSCOT –National Study of Cost and Outcomes in Trauma CareProspective cohort study
18 level I trauma centers and 51 large non-designated centers in 15 urban regions
Extensive data collection to allow for risk adjustmentFollow-up x 1 year
National Evaluation of the Effect of Trauma Center Care on MortalityN Engl J Med, 2006
25% lower risk of death at one year in trauma centers
N=15,000 patients
NSCOT
Is trauma center care associated with better functional outcomes among survivors?SF-36, functional capacity, return to work Modest benefit (SF-36 scores) only among those
with severe lower extremity trauma (J Bone Joint Surgery, 2008)
Are trauma centers cost effective?One year costs: $80,232 in trauma centers vs
$58, 320 in non-trauma centers$36,319 per life–year gained or $790,931 per
life saved 50-100k per life year gained is considered acceptable
Trauma-related deathsAirway BreathingCirculation – hemorrhage controlEvacuation of intracranial
hematoma .}1st 24 hrs
ICU careICU care }All the rest
......
44%
56%
Do Trauma Centres Do It Faster?Haas & Nathens, JACS, 2009
Time to OR (hrs)Time to OR (hrs)
Adusted RR Adusted RR of deathof death
Brain Brain Injury+MInjury+Mass Effectass Effect
PenetratinPenetrating Truncal g Truncal Injury+ShInjury+Sh
ockock
Trauma Trauma centrecentre
0.61 (0.43-0.61 (0.43-0.86)0.86)
3.33.3 1.01.0
Non-Non-designatedesignated centred centre
ReferenceReference 3.63.6 0.790.79
ICU Care & Mortality After InjuryNathens, Ann Surg, 2006
Intensivist-model ICUDistinct ICU service (led by an intensivist) or were
comanaged with an intensivist (a physician board-certified in critical care)
Level 1 trauma centres: 80% intensivist model
Non-designated centres: ~10% intensivist model
Trauma mortality as a function of ICU model
22% lower risk of death in closed ICU’s
Effects variedGreatest effect if ICU director was a
surgeonElderly patients derived the greatest
benefit
Variations in trauma center care
Care in a trauma center is associated with a lower risk of death after severe injuryExperience? ICU care?
…but are all trauma centers created equal?
Variation in TBI mortality
Annual patient volume
250 350 450 550 650 750 850 950 1050
Penetrating injury with shock Blunt with coma
250 350 450 550 650 750 850 9501050
Mor
talit
y ris
k
Mor
talit
y ris
k
Ttrauma center volume & outcomeNathens, JAMA, 2001
Volume & outcome: implications
Concentration of care in relatively few centers appears to be beneficial
…but considerBenefits only evident in the sickest patients (~5%)Few centers in the US care for >650 ISS>15 per
annum
Fewer centers limits timely access to care
Balance between access to care (benefits many) and concentration of care (benefits few)
Why not figure out what the higher volume centers are
doing right?
ACS TQIP
Trauma Quality Improvement
Traditional approach to trauma quality improvement activities
Identify sentinel eventsCompare this year’s performance to last
year’sFocused case reviews
Few insights into the quality of care
“Quality” simply reflects consistency, rather than a high level of performance
Measurement of Quality
Structure Process
Outcome
Quality defined by structures & processes
Selected Structural ElementsDedicated trauma surgeon on call (2.8)
Published backup call schedule (2.9)
Commitment of institutional governing body and staff to become a trauma center (5.1)
Trauma medical director on call roster (5.6) and member/participant of national/regional trauma organizations (5.8)
Multidisciplinary peer review committee (5.18)
Operating room staffed and immediately available (11.15)
Operating microscope and cardiopulmonary bypass 24/7 (11.23)
Selected ProcessesTrauma program must continuously evaluate its
processes and outcomes (5.2)
Seriously injured patients admitted to/evaluated by credentialed trauma providers (5.12)
Attendance threshold of 80% for presence in the ED (6.6)
Adequate attendance by general surgery at multidisciplinary peer review (6.10)
Attending neurosurgeon available for consultation (8.5)
Neurosurgeon attends>50% of multidisciplinary peer review committee meetings (8.2)
Structure Process
Outcome
Where does TQIP fit?
MortalityRates of PERates of unplanned return to ICU
Outcome
TQIP
TQIP participation
Lessons learnedNo center is a high performer in all areas
Blunt multisystem injuries Penetrating Shock TBI Elderly
Death as the primary focus for TQIP is a major limitation Differences in philosophy of care
DOA vs DIEWithdrawal of care (elderly, TBI)
Processes are much more interesting
Transfers to hospice
Contextual analysisInformative data presented by center to
understand how care is delivered for specific types of patients
TBIICP monitoring
Tracheostomy timingTiming of death (withdrawal of care)
ElderlyTiming to OR for Rx of hip fracturesTiming of death (withdrawal of care)
Pelvic fracturesUse of angiography
Shock(Time to hemorrhage control)(Transfusion practices)
Isolated blunt splenic injurySplenic preservationAngiographyLOS – ICU, hospital
Use the data to tell a storyTBI Mortality
Excess length of stay
ICP monitoring
Time to death
Are we providing futile care?
Tracheostomy practices in TBI
Disposition after Tracheostomy
Do we have a problem with end of life care?
What makes a high performer?
High performer site visits underway
ModifiableProtocols & proceduresEffective communication
Potentially not modifiableExperienceTeamwork
“Get the right patient to the
right place at the right time”
10% reduction in mortality
Effect of regional trauma systems
Effect of trauma systems on motor vehicle crash mortalityNathens, JAMA, 2000
Legislation Effect on crash mortality
Primary restraint laws 13%
Regional trauma system 9%
Secondary restraint laws 3%
65 mph (vs 55 mph) speed limit
Administrative revocation laws
7%
5%
Inclusive vs Exclusive Systems
Level I/IIProvides definitive care - urban
Level III/IV/VInitial care of major trauma – ruralAll centers involved in quality
assuranceEasier identification of need to
transfer to higher level centerDecentralized in case of disasters
Exclusive system
Inclusivesystem
MacKenzie et al., JAMA, 2003;289:1515-1522
NH CTVA OR IATN WVNV NJFLGAME0
20
40
60
80
100
CA COMA MD MONC NYPA SC TXUT WA
% o
f H
osp
ital
s D
esig
nat
ed a
s T
rau
ma
Cen
ters
(L
eve
l I-
V)
Exclusive More Inclusive Most Inclusive
Mortality 7% lower
Mortality 23% lower
Challenges to trauma system design
Too much access
Too little access
Geographic variations in MVC-mortality: Baker et al, 1987
MVC mortality (per 100 000 persons)
2.5
558
Population density (persons/sq mile)
64000
0.2
Esmerelda, NV versus Manhattan, NY
Overcoming the challenges of
geography: Access to trauma centre care in
Ontario
Ontario, Canada
Twice the size of Texas: 416,000 sq mi
13 million people
90% rural15% of the population
>60 miles from a specialist
Very crude system9 adult trauma centersNo coordinationNo standards for ED’s &
no lower level centersNo system PI
Do we have a problem?How do we convince
policy makers we need to adopt an organized system of trauma care?“No problem”“Everything works fine”“No one is dying”
No data=no problem
Trauma centrearrival
Time of incident
Scene transport
Urban
Trauma centrearrival
Interfacilitytransport
Non trauma centre
Time of incident
Scenetransport
Suburban/rural
Mean – 6 hrs; 90% percentile - 11 hrs
Transfer Patients in Ontario
Average time between injury and trauma center arrival: 6 hrs, 90th percentile: 11 hrs
Linkage of ED and inpatient datasets:20% of in-hospital deaths in the region occur in ED’s
while awaiting transfer
Population-based analysisMortality 23% greater in transferred patients
Linkage of ED and call center datasets:Average time to decision to transfer is 2 hrs
The public perspective
What is the knowledge and attitudes of Ontarians with respect to trauma care?
Telephone interviews conducted with 1000 Ontario adults in April, 2011Respondents targeted via Random Digit Dialing (RDD) Interviews conducted by Pollara
ExploredPublic awareness of the leading causes of deathKnowledge and experience with trauma centres/carePerceived value and importance of trauma
centres/care
Knowledge of Trauma Care in ON
All hospitals in ON are inspected to ensure they meet established set of stds
All physicians in EDs are required to have training to care for patients with life threatening injuries
All TC’s have a plan in place to handle a MCI
Almost all hospitals are capable of providing life-saving measures for life threatening injuries
Anyone anywhere in ON can be transported to a TC w/in 1 hr of a 911 call
Current standards do not meet the assumptions of most respondents
Perceptions and Knowledge of Local Hospital Services
There are opportunities to educate people about what a trauma centre is
Importance of Trauma Centre Care
Pts with serious injuries are more likely to survive at a TC
Most hospitals are not TC’s
Have you heard that….
Are you willing to be transported further than the closest hospital for TC care?
Yes- 84%
Ontario Government Priorities
Base size: n=858
A majority feel that trauma care should be a strong priority for the Ontario Government
Reducing amount of time for patients with life-threatening injuries to be transported to TC
Reducing wait times in Emergency Department
Reducing wait times for elective surgery (e.g. hernias, shoulder & hip replacements)
All TCs to have plan in place to handle large # of pts in event of disaster like flood, earthquake,
hurricane, terrorist attack or nuclear event
~22% of all deaths occur in ED’s before transfer
Hospital resources
Physical resources Intensive care unit CT scanner
Human resources General surgery Orthopedic surgery ED staffing
Emergency medicine Mixed Family medicine
Hospital resource availability
General surgery
Orthopedic surgery
ED staffing
ICUCT
scanner
Resource
Rich (22%)Yes Yes
Emergency medicine
Yes Yes
Resource
Variable (59%)Yes/No Yes/No Mixed Yes/No Yes/No
Resource
Limited (19%)No No
Family medicine
No No
ED LOS and centre typeMedian ED LOS: 3.5 hours (IQR 1.7 - 4.6)
Prolonged ED LOS (>75th percentile): > 4.6 hours
p<0.05
Resource
rich
(n = 1,504)
Resource variable
(n = 2,626)
Resource
limited
(n = 406)
Median ED LOS (IQR)* 3.4 (2.0 - 5.0) 2.7 (1.6 - 4.4) 2.5 (1.5 - 3.8)
Proportion with
prolonged ED LOS* 31% 23% 15%
Prolonged ED LOS and centre type
0.0 1.0 2.0 3.0 4.0
Resource-limited (ref)
Resource-variable
Resource-rich
Adjusted OR (95% CI)*
Favours
prolonged ED LOS
Favours
shorter ED LOS
1.3 (0.8 - 2.2)
2.0 (1.2 - 3.4)
*Adjusted for sex, age, comorbidities, mechanism, ISS, severe injury by body region, year and center type
0.0 1.0 2.0 3.0
ED - Family medicine (ref)
ED - Mixed
ED - Emergency medicine
Orthopedic Surgery
General Surgery
Intensive Care Unit
CT - Scanner
Adjusted OR (95% CI)*
Prolonged ED LOS and resources2.0 (1.5 - 2.8)
1.4 (1.0 - 2.0)
*Adjusted for sex, age, comorbidities, mechanism, ISS,
severe injury by body region, year and individual resources
Access to trauma care in Toronto: the tale of triage gone awry
Toronto EMS field trauma triage criteria
If any criteria are met and transport times<30 min, direct to trauma center Paraplegia/quadraplegia Penetrating trauma to the head, neck, trunk or groin GCS < 10
OR
Any 2 of the following: GCS 11-14 SBP< 80 RR < 10 or RR > 24 HR < 50 or HR > 120
What is the compliance with FTT criteria?
Geocoded scene of injury
Road network data used to calculate driving distances from the scene to:
Differential distance
Closest hospital
Closest trauma center
Scene
Results
1,031 patients meeting Toronto FTT criteria
133 were closest to trauma center -excluded
898 patients for analysis
Only half (53%) were transported to a trauma center
Transport destination by Toronto neighborhood
Trauma center n = 477
Non-trauma center n = 421
Male 76% 54%Age > 65 18% 51%Mechanism
FallMVCStab woundGunshot woundOther
30%26%16%14%12%
66%7%3%1%
17%
Patient characteristics
p < 0.05
Patient physiology
Trauma center n = 477
Non-trauma centern = 421
GCS*1511-143-10
14%17%67%
13%26%60%
SBP < 80 23% 24%
Abnormal RR* 45% 22%
Abnormal HR* 38% 25%* p < 0.05
Differential distance from trauma center
Trauma center n = 477
Non-trauma centern = 421
0 - 2.5 km 69 % 31%
2.5 - 5 km 49% 51%
5 - 10 km 45% 55%
> 10 km 51% 49%
p < 0.05
Who is being disadvantaged?
Odds Ratio (95%CI)
Female 0.65 (0.45 – 0.94)
Fall (vs MVC) 0.14 (0.08 - 0.23)
Age > 65 (vs16-24) 0.28 (0.16 – 0.50)
Does lack of timely access affect mortality?
i.e. Is there a need for change?
INCIDENT
TRAUMA CENTER
NON-TRAUMA CENTER
ED death
Transfer
ED-DEATH GROUP
TRANSFER GROUPUNDERTRIAGE
GROUP
DIRECT GROUP
What is the excess mortality associated with undertriage?
Unadjusted OR
Adjusted OR
Adjusted OR, patients surviving > 1 hr
Median time to death at non-trauma center 2.7 hours (IQR 1.2- 4.6)
1.5 (1.4-1.7)
1.2 (1.1-1.4)
1.2 (1.1-1.3)
20% greater risk of dying if first transported to a non-trauma center
From practice to policy
Trauma systems are effectiveACS Trauma systems consultation guide
Defines system expectations for regions and states
Trauma center evaluationTQIPMeasurement (TQIP) will become part of the ACS trauma
center verification process
Local trauma system evaluationChair, Ontario Trauma Systems Advisory Committee
Beginnings of an inclusive system
Reflections
The purpose of health services research is to improve the delivery of care
The work does not end with manuscript publication
Take advantage of your expertise and positionLearn how to advocateWork with and not against decision/policy makersAim for constant, gentle pressure and slow,
incremental change