trauma: a case study in converting research into policy

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