kentucky trauma system evaluationexecsum …...1 executive summary kentucky trauma system evaluation...
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Executive Summary Kentucky Trauma System Evaluation 2016
Julia F. Costich, JD, PhD and Peter J. Rock, MPH Kentucky Injury Prevention & Research Center
Prepared with support from the Kentucky Department for Public Health
Overview
Kentucky counties have a wide range in fatalities, as depicted in the map below, which focuses on motor vehicle crashes. While access to definitive trauma care is not the only factor behind the four-fold disparity in motor vehicle crash death rates by county, the rates are far lower in areas near Level I and II trauma centers.
A June 2016 National Academies of Science (NAS) study found that one-fifth of deaths from traumatic injuries are preventable, and that a comprehensive trauma system has the potential to reduce the proportion of preventable deaths.1 This finding updates longstanding evidence that trauma systems can save lives, as set out in the NAS report: treating severe injuries in Level I or Level II trauma centers has well-documented benefits for survival, quality of life, and cost-effectiveness.2,3
The Kentucky trauma system was established in 2008 by state law (KRS 211.490 et seq.; 902 KAR 28:040. A Trauma Advisory Committee (TAC), the membership of which is set out in KRS 211.494(3), directs the trauma system. All trauma centers designated by the Commissioner for Public Health maintain trauma registries that are compatible with the National Trauma Data Bank (NTDB) standards established in the National Trauma Data Standard Data Dictionary. The number of trauma registry cases increased
Kenton
Hart
Hardin
Christian
Warren
Leslie
Hopkins
Union Daviess
Shelby
Scott
Bullitt
Lyon
Madison
Clark
Henry
Grant
Jefferson
Henderson
Muhlenberg
Boone
Fayette
Bourbon
McLean
Rockcastle
Simpson
Franklin
Oldham
Anderson
Carroll
Gallatin
Livingston
Campbell
Jessamine
Montgomery
Robertson
Ohio
Trigg
Bell
Pulaski
Wayne
Laurel
Carter
Bath
Nelson
Whitley
Morgan
Larue
Monroe
Fleming
Rowan
Greenup
Caldwell
Webster
Marshall
Mercer
Boyle
Boyd
Johnson
Pendleton Bracken
McCracken
Garrard
Hancock
Woodford
Logan
Lewis
Graves
Adair
Todd
Barren
Harlan
Floyd
Allen
Grayson
Meade
Lincoln
Taylor
McCreary
Letcher
LawrenceElliott
Wolfe
Ballard
Russell
Mason
Martin
Fulton
Edmonson
Powell
Menifee
Washington
Spencer
Nicholas
Pike
Clay
Knox
Casey
Butler
KnottPerry
Owen
Lee
Breathitt
Estill
Marion
Green
Breckinridge
Calloway
Jackson
Harrison
Crittenden
Magoffin
Metcalfe
Hickman Clinton
Owsley
Carlisle
Cumberland
Trimble
Rate of Fatal Crashes Per 100 Million Vehicle--Miles (2010-2014)
0 50 10025 Miles
Fatal Crash Rate
0.50 - 1.2
1.3 - 1.7
1.8 - 2.4
2.5 - 4.6
±Data Source: KY Transportation Center: Analysis of TrafficCrash Data in Kentucky (2010-2014)Aurthor: Kentucky Injury Prevention and Research CenterDate: July 1, 2016
Map 1:
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from 6,643 in 2008 to 13,159 in 2014, as seen in Figure 1. A large proportion (58% in 2014) of these cases came from Level I facilities, but trauma patients also receive care at other verified trauma facilities in the Kentucky trauma system.
The increase in cases recorded in the trauma registry reflects the increase in reporting hospitals, not an increase in the number of injured Kentucky patients. The following map presents the current coverage (defined by 30/60 minute drive time) of verified and pending-verification facilities. In comparison, the hash-marked area represents the original coverage from 2008.
U
U
U
U
U
U
U
U
U
U
U
^
^
2015 Trauma Registry Facilities for Kentuckywith 30/60 Minute Drive-Time Coverage and 2008 Coverage Area
0 50 10025 Miles ±
Verified Trauma Centers
Level 1
Level 2
Level 3
Level 4
^ Pediatric Trauma Center
U Pending Verification
Drive Times
30 minutes
60 minutes
County
2008 Coverage
60 minutes
Map 2:
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The following map depicts the rate of trauma registry cases per 10,000 population based on the patients’ counties of residence. The county of residence is not necessarily the site of injury, although the majority of injuries occur within 10 miles of home.4 The low rates in the southwest portion of the state are in large part due to the absence of verified Kentucky trauma centers in that region. Trauma patients in those areas are commonly taken to Tennessee hospitals.
Quality metrics
Using data from the comprehensive statewide dataset maintained by the Kentucky Hospital Association, we find that since 2008, there has been a consistent increase in the proportion of injury patients being seen at trauma centers (Fig. 2).
PikeOhio
Clay
Hart
BellTrigg
Hardin
Pulaski
Logan
Lewis
Christian
Adair
ToddGraves
KnoxWarren Barren
Butler
Floyd
Laurel
Harlan
AllenWayne
Casey
Leslie
HopkinsKnott
Carter
Union
Bath
Nelson
Whitley
Owen
Grayson
Daviess
BreathittLee
ShelbyScott
Bullitt
Estill
Lyon
Madison
Marion
MorganClark
Henry
Lincoln
Grant
Green
Taylor
Larue
Letcher
Calloway McCreary
Fleming
Monroe
Jefferson Elliott
Greenup
Wolfe
Fayette
Mason
Boyle
Carlisle
Perry
Meade
Breckinridge
Lawrence
Henderson
Jackson
Caldwell
Rowan
Muhlenberg
Webster
Marshall
Boone
Ballard
Russell
Martin
Harrison
MercerMagoffin
Crittenden
Bourbon
Metcalfe
Livingston
Fulton
McLean
Boyd
Johnson
Garrard
ClintonHickman
Rockcastle
Edmonson
Pendleton
Powell
Simpson
Owsley
Franklin
Menifee
Washington
Cumberland
Bracken
Oldham
McCracken
Kenton
Spencer
Nicholas
Hancock
Anderson
TrimbleCarroll
Woodford
Campbell
Jessamine
Montgomery
Gallatin
Robertson
2014 Kentucky Trauma Registry Encounter Rate by County
0 50 10025 Miles
Record Rate (per 10,000 population)
0 - 3.7
3.8 - 18.1
18.2 - 27.1
27.2 - 46
46.1 - 157.3
±
Map 3:
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State trauma experts also developed a set of ICD-9 codes to identify injuries warranting care at a Level I facility. The distribution of severe injuries in relation to Level I trauma center utilization is depicted in Fig. 3. In more recent years, about 50% of severe injuries have been seen at Level I trauma centers.
The following graph shows changes in age-adjusted death rates for any-injury inpatients with 95% confidence intervals calculated following the CDC WONDER methodology.5 The increase in age-adjusted death rate for the Level I centers during the 2000-2006 period may be a function of the increasing proportion of severely injured patients being cared for in Kentucky trauma centers rather than out of state during the early years of system development.
5
Figure 5 compares observed to expected death ratios using the risk adjustment methods developed by the American College of Surgeons (ACS).6 The trend shows an overall decrease in risk-adjusted death ratios over time. The death ratio in 2012-2014 is statistically significantly lower than the 2008 ratio, indicating real improvement in the state trauma system’s ability to provide life-saving care.
Strategic challenges
Kentucky’s trauma system is under the administrative oversight of the Kentucky Department for Public Health (DPH), although it also has a relationship with the Kentucky Board of Emergency Medical Services (KBEMS), which is part of the Kentucky Community and Technical College System (KCTCS). This administrative home was the result of several historical factors that are no longer relevant, and the question of an appropriate home for the trauma system deserves further consideration. Because the trauma system has little common ground with KCTCS, its administrative parent cannot be relied upon to advocate for critically needed system funding.
While the trauma system enabling legislation includes a provision addressing the use of funds, the system itself has no reliable funding source. Funding for the trauma registry has been available for the past six years through the Kentucky Transportation Cabinet’s Office of Highway Safety, using federal awards from the National Highway Traffic Safety Administration. The TAC leadership has demonstrated initiative and creativity in its attempts to identify potential funding sources. Other states fund their trauma systems from general fund appropriations, assessments on speeding drivers, insurance surcharges, foundation and corporate donations, and fees from participating hospitals. In the 2016 fiscal year, the state Department for Public Health provided one-time support for enhanced education and outreach.
6
Current resources fall far short of addressing basic trauma system funding needs. A proposal to the 2016 Kentucky General Assembly for minimal funding was unsuccessful. The lack of funding seems to signal legislative undervaluation of the enormous effort by TAC leadership, past and present. The sustainability of the system’s dependence on volunteers’ effort must be called into question.
Large geographic areas in Kentucky still lack timely access to definitive trauma care. Limiting analysis to the state borders is somewhat misleading because there are Level I centers in Cincinnati OH, Huntington WV, Evansville IN, and Nashville TN that are closer to some Kentucky regions than in-state facilities. However, there are clearly some gaps in the state’s coverage, particularly in the southwest part of the state. Efforts are ongoing to support interested hospitals in their explorations of participation.
Many states’ trauma systems are administratively co-located with state EMS organizations. This topic may deserve closer attention, particularly with regard to the prospect of integrating EMS data more completely with trauma registry reporting. Some 92% of state EMS providers now report electronically. Access to these data would help answer longstanding questions, e.g., the number of motor vehicle crashes that are undetected for hours, problematic recoveries and extractions, and quality metrics.
Conclusion and next steps
Kentucky’s trauma system has made significant progress since the enabling legislation was enacted, yet it cannot achieve its full potential until major obstacles are overcome. Among these are lack of funding to support core activities, geographically inconsistent participation, and integration of EMS data. The ability of Kentuckians to survive traumatic injury should not depend on where they are injured, yet motor vehicle fatality rates across counties continue to vary almost four-fold. Finding the political will to support a comprehensive system that provides both excellent and equitable care is a longstanding challenge. Until Kentucky overcomes that challenge, it falls to a small and dedicated group of clinicians and laypersons to press forward towards the trauma system’s goal of providing the right care at the right time in the right place.
1 National Academies of Sciences, Engineering, and Medicine. 2016. A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: The National Academies Press. doi:10.17226/23511. 2 Bailey J, Trexler S, Murdock A, Hoyt D. Verification and regionalization of trauma systems: the impact of these efforts on trauma care in the United States. Surg Clins NA 2012; 92(4):1009‐1024. 3 MacKenzie EJ, Rivara FP, Jurkovich GJ et al. The value of trauma center care. J Trauma 2010; 69(1):1‐10. 4 Haas B, Doumouras AG, Gomez D, et al. Close to home. J Trauma Acute Care Surg. 2015;78(4):860‐865. doi:10.1097/TA.0000000000000595.
5 Fay MP, Feuer EJ. Confidence intervals for directly standardized rates: A method based on the gamma distribution. Stat Med. 1997;16(7):791‐801. doi:10.1002/(SICI)1097‐0258(19970415)16:7<791::AID‐SIM500>3.0.CO;2‐#.
6 Newgard CD, Fildes JJ, Wu L, et al. Methodology and analytic rationale for the american college of surgeons trauma quality improvement program. J Am Coll Surg. 2013;216(1):147‐157. doi:10.1016/j.jamcollsurg.2012.08.017.