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Trauma: A case study in converting research into policy

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.

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Trauma: A case study in converting research into policy

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  1. 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

  2. Trauma center Trauma systems Do trauma centers save lives? Are trauma systems effective? How do trauma centers save lives Why are trauma systems effective? ACS Trauma Quality Improvement Program Regional policy “decision maker” ACS Trauma Systems Consultation Guide The journey from research to policy Trauma surgeon and intensivist

  3. American Civil War: 1861 Mortality: 25% Transport time: 72 hrs Factors: +/- ambulance WW I: 1914 Mortality: 8.6% Transport time: 8 hrs Factors: ambulance (motorized)

  4. World War II: 1939 Mortality: 4.5% Transport time: 4 hrs Factors: Ambulance, Medics, Plasma, Antibiotics

  5. Korean War: 1951 Mortality: 2.5% Transport time: 1.25 hrs Factors: Helicopter, MASH

  6. Viet Nam War: 1965-1972 Mortality 1.9% Transport time: 27 minutes Factors: Helicopter, Medics, Fixed wing

  7. circa 1947

  8. 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%

  9. NSCOT –National Study of Cost and Outcomes in Trauma Care • Prospective cohort study • 18 level I trauma centers and 51 large non-designated centers in 15 urban regions • Extensive data collection to allow for risk adjustment • Follow-up x 1 year

  10. N=15,000 patients 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

  11. 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

  12. } 1st 24 hrs } ICU care All the rest Trauma-related deaths • Airway • Breathing • Circulation – hemorrhage control • Evacuation of intracranial hematoma . . . . . . .

  13. Do Trauma Centres Do It Faster?Haas & Nathens, JACS, 2009

  14. ICU Care & Mortality After InjuryNathens, Ann Surg, 2006 • Intensivist-model ICU • Distinct 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

  15. Trauma mortality as a function of ICU model • 22% lower risk of death in closed ICU’s • Effects varied • Greatest effect if ICU director was a surgeon • Elderly patients derived the greatest benefit

  16. Variations in trauma center care • Care in a trauma center is associated with a lower risk of death after severe injury • Experience? • ICU care? • …but are all trauma centers created equal?

  17. Variation in TBI mortality

  18. Penetrating injury with shock Blunt with coma Mortality risk Mortality risk 250 350 450 550 650 750 850 950 1050 250 350 450 550 650 750 850 950 1050 Ttrauma center volume & outcomeNathens, JAMA, 2001 Annual patient volume

  19. Volume & outcome: implications • Concentration of care in relatively few centers appears to be beneficial • …but consider • Benefits 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)

  20. Why not figure out what the higher volume centers are doing right?

  21. ACS TQIP

  22. Trauma Quality Improvement • Traditional approach to trauma quality improvement activities • Identify sentinel events • Compare this year’s performance to last year’s • Focused case reviews • Few insights into the quality of care • “Quality” simply reflects consistency, rather than a high level of performance

  23. Measurement of Quality Process Structure Outcome

  24. Quality defined by structures & processes

  25. Selected Structural Elements • Dedicated 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)

  26. Selected Processes • Trauma 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)

  27. Where does TQIP fit? Structure Process Outcome Mortality Rates of PE Rates of unplanned return to ICU TQIP Outcome

  28. TQIP participation

  29. Lessons learned • No 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 DIE • Withdrawal of care (elderly, TBI) • Processes are much more interesting

  30. Transfers to hospice

  31. Contextual analysis • Informative data presented by center to understand how care is delivered for specific types of patients • TBI • ICP monitoring • Tracheostomy timing • Timing of death (withdrawal of care) • Elderly • Timing to OR for Rx of hip fractures • Timing of death (withdrawal of care) • Pelvic fractures • Use of angiography • Shock • (Time to hemorrhage control) • (Transfusion practices) • Isolated blunt splenic injury • Splenic preservation • Angiography • LOS – ICU, hospital

  32. Use the data to tell a storyTBI Mortality

  33. Excess length of stay

  34. ICP monitoring

  35. Time to death Are we providing futile care?

  36. Tracheostomy practices in TBI Disposition after Tracheostomy Do we have a problem with end of life care?

  37. What makes a high performer? • High performer site visits underway • Modifiable • Protocols & procedures • Effective communication • Potentially not modifiable • Experience • Teamwork

  38. “Get the right patient to the right place at the right time”

  39. Effect of regional trauma systems 10% reduction in mortality

  40. Effect of trauma systems on motor vehicle crash mortalityNathens, JAMA, 2000 Legislation Effect on crash mortality Regional trauma system  9%  13% Primary restraint laws  3% Secondary restraint laws  7% 65 mph (vs 55 mph) speed limit Administrative revocation laws  5%

  41. Inclusive vs Exclusive Systems • Level I/II • Provides definitive care - urban • Level III/IV/V • Initial care of major trauma – rural • All centers involved in quality assurance • Easier identification of need to transfer to higher level center • Decentralized in case of disasters Exclusive system Inclusive system

  42. MacKenzie et al., JAMA, 2003;289:1515-1522

  43. Mortality 23% lower Mortality 7% lower

  44. Challenges to trauma system design • Too much access • Too little access

  45. Geographic variations in MVC-mortality: Baker et al, 1987 Population density (persons/sq mile) MVC mortality (per 100 000 persons) 558 0.2 2.5 64000 Esmerelda, NV versus Manhattan, NY

  46. Overcoming the challenges of geography: Access to trauma centre care in Ontario

  47. Ontario, Canada

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