PALM BEACH, FLA. – Florida’s statewide trauma triage system, one of America’s oldest and best organized state systems, did an increasingly better job over time from 1996 through 2010 funneling severely injured children and adults to one the state’s 22 designated trauma centers, according to data collected by the state government.
Florida’s program has had less clear-cut success triaging the elderly population with severe, acute trauma injuries to designated trauma centers, but the raw data may be misleading, Dr. David J. Ciesla, FACS, said at the annual meeting of the Southern Surgical Association.
David J. Ciesla
Data collected by Florida’s Agency for Health Care Administration showed that during 2010, 41% of severely injured patients older than 65 years were discharged from a designated trauma center (DTC), compared with an 85% rate among adults 16-65 years old, and a 93% rate among children under age 16, said Dr. Ciesla, medical director of the Regional Trauma Program at Tampa General Hospital.
But the strikingly lower rate of elderly patient referral to a DTC may be an artifact of how Dr. Ciesla and his associates defined severe injury in their analysis. Their definition relied on survival. Using the ICD-9 Injury Severity Score (ICISS) to rate a patient’s need for DTC referral, they rated patients with ICISS of less than 0.85 (a less than 85% survival rate) as severely injured and candidates for DTC triage. But this criterion starts to break down for older patients, he explained.
"We defined injury severity as the risk of death, but that can be age related as well as injury related. It could be that older patients are more elderly than they are injured," he said.
Many of the elderly patients who were hospitalized for trauma "may be injured, but were they severely injured, or did they have high mortality because of their age or their comorbidities?" Dr. Ciesla said in an interview.
"I think the Florida system works well. We have shown [in these data] that the system can identify severely injured children and adults and get them to designated trauma centers. The elderly patients we’re calling ‘severely injured’ may just be elderly who can be appropriately treated in community hospitals," he said.
Michael F. Rotondo
This interpretation received support from several surgeons who heard the talk at the meeting.
"The distribution of trauma centers on the basis of need is a critical issue in the 21st century health care paradigm. While we must assure equitable access to care delivered at the highest standard, and matched to the patient’s needs, we must assure that this is accomplished in a fiscally responsible way which avoids unnecessary duplication of resources and services. The work presented here today begins to probe this highly complex challenge," commented Dr. Michael F. Rotondo, FACS, professor and chairman of surgery at East Carolina University in Greenville, N.C.*
"Does Florida have enough trauma centers? These data basically say yes, we have enough," said Dr. Joseph J. Tepas III, FACS, professor and chief of pediatric surgery at the University of Florida in Jacksonville and a coauthor of the study. "Ninety percent of the patients were direct transfers" to a DTC, indicating that "paramedic triage discretion seems to work quite well" in routing injured patients to the appropriate hospital, he said.
The study run by Dr. Ciesla, Dr. Tepas, and their associates reviewed all patients discharged from Florida hospitals during 1996-2010 using data collected by the state agency. The researchers identified injured patients by their diagnostic codes, and analyzed them by their discharge hospital and by their home zip codes. The analysis showed that the percent of severely injured patients discharged from a DTC rose from fewer than half of the state’s patients in this category in 1996 to 63% in 2010.
Among 225 severely injured children, 210 (93%) were discharged from a DTC, with only 15 children who did not receive DTC treatment. The 2010 database also included 7,469 severely injured adults, with 85% discharged from a DTC, and 7,825 elderly patients, with 41% discharged from a DTC.
The analysis of DTC discharges of severely injured patients by their home zip codes identified an area of the Florida panhandle, near Panama City, where several adult patients failed to receive care at a DTC, suggesting that residents in this area of the state might be better served by opening another, nearby DTC, said Dr. Ciesla, who is also director of acute care surgery at the University of South Florida in Tampa.
"You need enough centers to cover everyone geographically, but not so many that you dilute" patient volume at individual centers, he said. The researchers have not yet analyzed the best DTC volume to produce optimal patient outcomes, he added.