Enhanced trauma program commitment at a level I trauma center: effect on the process and outcome of care.

HYPOTHESIS

With advances in surgical care, the occurrences of major adverse outcomes have become a rare event. The effect of a surgical service can be more comprehensively evaluated by following the Donabedian model, looking at the triad of structure, process, and outcome. It is hypothesized that the implementation of a focused program commitment at a trauma center is associated with improvements in process of care and patient outcomes.

DESIGN

Evaluation of prospectively collected information in a trauma registry for the 3-year periods immediately before (1995-1997) and after (1999-2001) the implementation (in 1998) of the full-time trauma service.

SETTING

Level I university-affiliated trauma center.

PATIENTS

Patients meeting criteria for major trauma.

INTERVENTION

The implementation of a full-time trauma service, featuring 24-hour in-house attending coverage, dedicated trauma admitting unit, regular trauma core curriculum, regular multidisciplinary quality assurance meetings, and state designation for level I status.

MAIN OUTCOME MEASURES

Process of care measures, including time in the emergency department (ED) and trauma "bypass" hours (ie, time spent in the trauma resuscitation area). Outcome measures, including lengths of stay, overall mortality and mortality, excluding ED deaths.

RESULTS

The total number of patients with major trauma increased from 2240 (1995-1997) to 2513 (1999-2001). The average time in the ED for patients going to the operating room, intensive care unit, and observation wards all decreased significantly (84 vs 52 minutes, 197 vs 118 minutes, and 300 vs 140 minutes, respectively; all with P<.01). The number of hours that the trauma center was closed owing to ED overcrowding also decreased significantly, from 56 to 2.7 hours per month (P<.01). After excluding ED deaths, there was a trend on bivariate analyses toward lower overall mortality rates (4.5% vs 3.4%, P =.07) and mortality rates among patients with severe head injury (23.8% vs 17.2%, P =.07). On further analyses with multiple logistic regression, controlling for age, Injury Severity Score, Abbreviated Injury Score (for a head injury), and admission blood pressure, the later period is associated with a 31% decrease in overall odds of death (P =.047) and a 42% decrease in odds of death among patients with severe head injury (an Abbreviated Injury Score, >or=3; P =.03).

CONCLUSION

The implementation of a full-time trauma service is associated with improved timeliness of triage and therapeutic interventions and improved patient outcomes.