Impact of a Trauma Service on Trauma Care in a University Hospital Christopher C. Baker, MD, New Haven, Connecticut Linda C. Degutls, MSN, New Haven, Connecticut Joseph DeSantis, MD, New Haven, Connecticut Arthur E. Baue, MD, New Haven, Connecticut Multiple t r a u m a patients require extensive individual and institutional resources in order to minimize tbe chance of sickness and death. T h e magnit u d e of the problem of t r a u m a was highlighted by a landmark white paper published by the National Academy of Sciences in 1966 which called trauma the "neglected disease of m o d e r n society" [•]. Major efforts directed at improving prehospital care in the early I970s led to an increase in the n u m b e r of salvageable patients presenting to hospital emergency rooms. F r e y et al [2] raised the concern in 1978 t h a t "hospital care of the acutely injured patient has not" improved commensurately." Based on military organizational experience gained in Vietnam, efforts were made to organize t r a u m a centers where a standardized approach to the t r a u m a patient could be mounted. Categorization guidelines for these centers were promulgated by the American College of Surgeons [3] to aid in these efforts. West et al [4] compared the results of trauma care in Orange County to t h a t in San Francisco County in an autopsy study and concluded t h a t "survival rates for major t r a u m a can be improved by an organized system of t r a u m a care t h a t includes the resources of a t r a u m a center." A subsequent follow-up s t u d y b y West et al [5] suggested t h a t organization of trauma care along designated trauma center lines resulted in an improvement in outcome. Within that framework, t h e concept of an integrated t r a u m a service t h a t can coordinate the care of the multiply injured p a t i e n t has assumed an important place [6]. Although the t r a u m a service is an accepted method of organization in m a n y major t r a u m a centers, few data exist o n the impact on patient outcome when a dedicated t r a u m a service is instituted in a znajor hospital t h a t is already providing care for a From the Department of Surgery, Yale Univers~tySchool of Medicine, New Haven, Connectlct.,t. Requests for reprints should be addressed to Chrtstopher C. ~.ker, MD, Depmtment of Surgery, Yale University School of Medicine, 333 Cedar Styeet, New Haven, Connecticut 06510. Presented at the 65th Annual Meeting of tt)e New England St~gical Society, Dlxvllle Notch. New Hampshire, October 12-14, 1984. Volume 14g, Apr~ 1~S large volume of trauma patients. Herein we describe the experience at Yale-New Haven Hospital before and after the institution of an iutegrated t r a u m a service. Material and Methods Yale-New Haven Hospital is an 863 bed facility that was designated a trauma center by the Department of Health, Education and Welfare in February 1980. Prehospit~ care is delivered by trained emergency medical technicians and paramedics working for the fire department and commercial ambulance services. The hopsital meets the criteria of a category I trauma center as delineated by the American College of Surgeons [3]. The hospital has a 50 bed emergency service, a 17 room operating suite, a 22 bed recovery room, and 3 surgical intensive care units (surgery 11 beds, neurosurgery and neurology I0 beds, and cardlothoracic surgery 14 beds). Before July 1983, multiple trauma patients were cared for on one of two general surgery services. Patients b-ere admitted to one of these services on an alternating-day basis, but the staffs of both services continued to perform surgery in elective cases. Starting in July 1983, reorganization took place by which all elective surgery patients were admitted to one service and trauma patients, emergency surgical patients (patients with surgical infections, acute conditions within the abdomen, and so on), and consultations were handled by the trauma service. Concommitant with this reorganization, organized trauma protocols were disseminated, attending rounds were conducted on a regular basis, and a weekly trauma conference on didactic and case material was instituted. In addition, training levels were improved by ensuring that all attendings and residents (postgraduate year 3) on call for the trauma service had completed the Advanced Trauma Life Support Course sponsored by the American College of Surgeons, and an intensive care unit team consisting of surgery and anesthesia residents (postgraduate year 2 or 3) and a critical care fellow was organized. During the time of the study, a trauma registry was implemented and data were gathered prospedtively on all adult (16 years of age or older) trauma patients admitted to the surgical intensive care units from July 1982 through June 1984. Variables analyzed included demographic data, injury severity score, as described by Baker et al [7], and clinical course and outcome. Patients who died were analyzed in detail, and attempts were made independently (by 4,53 Baker et al TABLE I I~mographl¢ Oats Betor{) and Aflsr Institution of the Trauma Service ('IS) Before TS After TS Age" Sex (%) Male Female Race (%) White 34.7 :E 13.1 33.5 -I- 18.1 70 30 73 27 84 85 Other 4 4 Parameters Black 12 11 • Mean :E standard deviation. TABLE III Tot31 Nonsurvlvors Injury Blunt trauma Motor vehicle accident Motorcycle accident Pedestrlan Fa,q/other Subtotal Penetrating trauma Gunshot wound Stab wound Subtotal Burn Total Before TS n % n After TS ....... 66 35 8 48 157 34 18 4 25 81 63 26 3 38 128 37 15 2 21 75 14 15 29 7 193 7 8 15 4 100 12 12 24 12 170 7 7 14 11 100 Percentage 76 18 94 16 3 19 27 20 25 82 5 6.1" " Significantly lower (p <0.05) by chl-square analysis. CCB and LCD) to classify the deaths as preventable, possibly preventable, or not preventable. As a separate part of the study, one of us (JGD) studied physiologicvariables on admission for all surgical intensive care unit patients versus outcome before (June 1982 through September 1982) and after (July 1983 through August 1983) the institution of the trauma service. Data were analyzed by the SAS program at the Yale computer center. Comparisons of groups were made using chi-square or Z-score analysis when appropriate. Results T h e d a t a f o r t h e e m e r g e n c y service are as f o l l o w s : F r o m J u l y 1982 t h r o u g h J u n e 1983, t h e r e was a t o t ~ o f 78,095 v i s i t s a n d 9,673 a d m i s s i o n s , 1,108 o f w h i c h w e r e t r a u m a a d m i s s i o n s w i t h 193 o f these p a t i e n t s brought to the intensive care units. From July 1983 through June 1984, there was a total of 67,535 visits and 10,038 admissions to the emergency service, 1,023 of which were trauma admissions with 170 of these patients brought to the intensive care units. For the combined study periods 35 percent of the visits involved surgical emergencies. Over the course of the study, the number of visits decreased as is the case in many hospitals. T h e admission rate, however, increased from 12.3 percent to 14.8 percent in the second year of the study. T h e number of trauma admissions also decreased slightly in the second year, as did the number of trauma intensive care unit admissions. On the other hand, the percentage of trauma patients admitted to an intensive care unit 454 Meghanlsms ut InJm¥ TS = trauma service. Surgical Intensive Care Unit Data July 1982 to June 1983 General surgery Other service Total July 1983 to June 1984 Trauma service TABLE II remained relatively constant in the period from July 1982 through June 1983 (17.4 percent) to the period from July 1983 through June 1954 (16.6 percent). Demographic data for the intensive care unit trauma admissions are listed in Table I. As in other series, patients tended to be young, healthy, and predominantly male. The racial makeup roughly paralleled t h a t of the greater New Haven area. Mechanisms of injury are shown in Table II. In contrsst to several trauma series in larger urban centers, the majority of patients in this series sustained blunt trauma (79 percent), with the most common cause of injury being a motor vehicle accident (36 percent) [81. Injury severity scores (mean :E standard deviation) were calculated prospectively in all patients [7]. Before the trauma servic~ was instituted, the overall score (193 patients) was 22.5 :E 13.2 and that for the nonsurvivors (31 patients), 52.3:1: 20.4. After its institution, the scores were 26.3 4- 12.8 (170 patients) and 47 :l: 19.7 (20 patients), respectively. As can be seen, the injury severity score data were similar for all patients during the 2 years of study, but the mean injury severity score for the period after the trauma service was instituted was somewhat higher. Conversely, the mean injury severity score before the trauma service was slightly higher for nonsurvivors than in the latter period. During both periods, the mean injury severity score for nonsurvivors was double that for the overall group and was significantly higher by Z-score analysis (p <0.05). Prospective data.were collected on all trauma patients who required admission to one of three surgical intensive care units during the 2 years of the study. Particular attention was paid to the surgical intensive care unit where the general surgery services admitted patients. When trauma patients admitted to the surgical intensive care unit were considered separately (Table IH), the mortality rate on the general Th~ AmericanJotm~! of Surg(~ Trauma Service In a University Hospital T A B L E IV C a u s e s of D e a t h in T r a u m a Patients Before TS _ n % Cause CNS Injury Burns • (no. with sepsis) Hemorrhage Sepsis & MOF Total % mortality overall Possibly preventable After TS n % 15 4 46 13 8 7 40 35 3 9 31 10 29 100 16.1 32 2 3 20 10 15 100 11.7 15 "1() . "3 • Before the trauma service, two of four patients had sepsis; after Its Institution, five of seven patients had sepsis. CNS = central nervous system; MOF = multiple organ failure. surgery service was 27 percent as compared with a 25 percent mortality for all surgical intensive care unit trauma patients admitted to all services before institution of the trauma service. After institution of the trauma service in July 1983, the mortality rate for surgical intensive care unit trauma patients decreased significantly to 6.1 percent (p <0.05 by chisquare analysis). Although the overall number of patients was somewhat lower after institution of the trauma service, the percentage of trauma patients admitted t~ an intensive care unit (17.4 percent versus 16.6 procent) and to the surgical intensive care unit (8.4 percent versus 8.2 percent) was not significantly different between the two study periods. The overall mortality rate for intensive care unit trauma patients was 16.1 percent before formation of the TABLE V trauma service and 11.8 percent after the trauma service was begun. Although there was a lower mort ~ i t y rate in the second study period, the difference was not statistically significant. When nonsurviving patients were analyzed in detail, several facts emerged. As can be seen in Table IV, the percentage of deaths due to hemorrhage remained relatively constant whereas deaths due to central nervous system injury decreased and those resulting from burns increased from the first year to the second year of the study. The more striking finding was the rather substantial reduction in the number and percentage of deaths due to sepsis and multiple organ failure after institution of the Trauma Service. Attempts were made to identify possibly preventable deaths (Table V). Despite the subjective nature of such a determination, there seemed to be fewer preventable deaths in the second year of the study (15 percent of patients) compared with the first year (32 percent of patients). To assess the impact of the trauma service on other general surgical patients, outcome data for all surgical intensive care unit admissions to the general surgery services were collected for the 2 years of the study (Table VI). Before the trauma service, there were 245 general surgery patients (elective, trauma, and other emergency cases) admitted to the surgical intensive care unit with a 13.5 percent mortality. After inception of the trauma service, there was a similar number of patients (total of 250) with a significantly lower mortality rate (6 percent) (p <0.01). During this time period, the total number of admis- Preventable Deaths Patient Age (yr) & Sex 1 31, M MVA: aortic tear, flail chest, transferred to YNHH 2 3 4 5 93, M 51, F 21, M 36, M 6 7 18, F 74, M 38, F 29, M 62, M MVA: rib fractures, hemothorax MVA: aortic tear, spleen & liver injuries, multiple fractures MVA: diaphragmatic tear, multiple rib fractures, pneumothorax, head injury Plane crash: pulmonary contusion ? aspiration, retroperitoneal hematoma, multiple fractures MVA: subdural hematoma, tiblal & fibular fracture, transferred to YNHH MVA: splenic rupture, multiple fractures MVA: closed head injury, rib fractures, splenic rupture MCA: closed head injury, aortic tear, transferred to YNHH MVA: transecte d colon, ruptured jejunum, splenic tear Injury Cause of Death Before Trauma Service (July 1982 to June 1983) 8 9 10 Technical problems In OR, delay In transfer Aspiration Sepsis, MOF Sepsis, MOF Delay In transport to ED, sepsis, MOF ~.¢t~y 4'3 h) in transfer head injury Sep-31s, MOF Head injury (late bleed) Head injury (SDH, no surgery) Sepsis, MOF With Trauma Service (July 1983 to June 1984) 11 12 13 49, M 35, M 84, F MVA: multiple fractures Stab wound: laceration of intercostal artery Fall: massive hemothorax Unrecognized aortic tear Sepsis, MOF Hemorrhage, MOF • Patients 3, 4, 5, 7, 8, and 10 died while on the general surgery service. ED = emergency department; MCA = motorcycle accident; MOF = multiple organ failure; MVA ----motor vehicle accident; OR = operating room; SDH -- subdural hematoma; YNHH = Yale-New Haven Hospital. Volume 149, April 1985 455 B a k e r et al TABLE V| Surgical Patients SICU Admissions Total (tl) ......... Mortality (%) Overall Admissions Total (11} . . . . . Mortality (%) Before Trauma Service (July 1982 to June 1983) Combined services 245 13.5 733 4.2 605 4.7 495 1,095 0.2 2.7 With Trauma Service (July 1983 to June 1984) Trauma service Trauma patients Other emergency Elective service Total 186 8.1 82 104 64 250 6.1 10.4 0 6" • Significantly (p <0.01) decrease compared with mortality before trauma service by chl-square analysis. SICU = surgical intensive care unit. sions to the surgical intensive care unit increased by 9 percent (from 914 to 993 patients), whereas the mortality rate decreased slightly from 7.8 percent before the trauma service to 6.1 percent after its institution. Comments Assessing the impact of any new method of care can be difficult in clinical studies. It would be hard to conduct this study in a randomized fashion since, by definition, a dedicated trauma service runs on the principle that all multiply injured patients are admitted to that 3ervice. This study suffers from the use of historical control subjects for the first study period, albeit only I year earlier than the second period. On the other hand, all data were gathered on a prospective basis, and clinical decisions about outcome were made independently by two of us (CCB and LCD). The two groups of trauma patients being compared in this study were similar with regard to age, sex, race, and mechanism of injury. Injury se.verity scores were comparable during both study periods; in fact, the mean injury severity score was higher in the trauma service group. Therefore, one can say that the two groups of patients ought to be comparable. Before the study, prehospital care was at a good level in our geographic area, but no major advances (for example, endotracheal intubation in the field) were made during the study. On the other band, several improvements in emergency service and inhospital care were made as outlined in "Materials and Methods." In addition, by the second study period, nursing protocols for trauma care in the emergency service had been formalized, and nurses in the emergency service and surgical intensive care unit had completed Advanced Cardiac Life Support courses. Given the aforementioned provisos, it is ~.lotpossible to prove that institution of the traur.,a service caused the changes observed between the two study 456 periods. Nonetheless, these changes were temporally associated with the start of the trauma ser-ice in a setting where littleelse was changL,~g. The only other major change was the formation of an intensive care unit team, which, in fact,w ~ des~ned to work closely with and complementthe trauma service. After institution of the trauma service, overall intensive care unit mortality for trauma patients decreased from 16.1 percent to 11.8 percent. W h e n the trauma patients cared for by the general surgery service are considered, the reduction in mortality rate is even more impressive, being 27 percent before the trauma service was instituted and 6.1 percent afterward. The concentration of criticallyillpatients on one service also led to improvements in the care of critically ill general surgery patients. As seen in Table VII, this reorganization was associated with a decrease in mortality for general surgery intensive care unit patients from 13.5 percent to 6 percent. Although it is possible to argue that these data do not conclusively prove a cause-and-effect relationship, it is hard to ignore the trends identified herein. Perhaps the most cogent argument for the positive impact of the trauma service is not identified in the tables shown. None of the three preventable deaths in the second year occurred in patients on the trauma service, whereas 5 of the 10 possibly preventable deaths in the previous years occurred in patients cared for on the general surgery services. In the first year, the majority of trauma patients with sepsis or multiple organ failure were on the general surgery services, whereas no cases of death due to these causes occurred on the trauma service in the second year. This change appears to be largely responsible for the differences in mortality between the two study periods. Although it is not possible to prove, our experience suggests that aggressive preventive management (earlier rapid resuscitation for shock, better respiratory management, nutritional support, and surveillance for and treatment of sepsis) in the setting of an organized trauma service led to a re- lq'm Amerlcaa Joumai of Sort,sty Trauma Service in a University Hospital duction in mcr'~ality due to multiple organ failure and sepsis. T h e advm,~ges of a dedicated trauma service are several. First, concentration of trauma patients on one service allows housestaff to gain more experience in caring for these patients. Second, care of the trauma patient can be coordinated by the general surgeon, and.care can be standardized through implementation of protocols. Third, educational programs (that is, rounds and conferences) can be better organized around the problem of trauma, and clinical and research protocols can be implemented more easily. Resident education particularly seems to be improved. When residents are on the trauma service, they expect to be working at night and with emergency cases, and they adjust accordingly. Conversely, the elective surgical experience becomes a major reading and learning period unhampered by numerous sleepless nights. Fourth, consultation advice to the medical services improves since the trauma service residents are often out of the operating room during the day and can see consults promptly. In addition, the cost-effectiveness of the trauma service cannot be underestimated. Although it is difficult to place a value on life, estimates have been made that a life saved is worth $10,000 per year [9]. If this figure were to be applied to our data, one could estimate that the implementation of the trauma service was associated with a cost savings to society of at least $100,000 during its first year of existence. Although cost-effectiveness was not measured specifically in this study, the reduction in mortality occurred in patients with similar, and even higher, injury severity scores during the second year of the study. Costs associated with formation of the trauma service, on the other hand, were negligible. Associated phenomena include a decreased level of complications leading to decreases in lengths of intensive care unit and hospital stays [DeSantis J: personal communication]. Future studies will need to look carefully at long-term follow-up of trauma patients with regard to work status, health status, and so on. Finally, we found that during the first year of the trauma service, major improvements in coordination of care of the multiply injured patients occurred. Due to the concentration of patients on a single service, implementation of protocols and consistency of care were achieved much more readily than in previous years. Because trauma patients were concentrated on one service, case review was easier and changes were more rapidly implemented when problems or questions arose in patient care. As a result of these factors, quality assurance o f patient care was more effective. In addition, confusion as to the initial resuscitation and workup of the trauma patient was minimized by admitting the majority of patients with multiple injuries to the trauma service. As can be seen in Table VI, the total number of admissions to the general surgical services increased by nearly 50 per- Volume 149, AIxl11985 cent in the second year of the study, largely due to admissions to the trauma service. Coordination by the general surgery trauma service allowed better continuity of care and led to improved communication and coordination with the many subspecialties involved in the care of the trauma patient. Summary This study describes the experience in a major university hospital for a year before and a year after the institution of a trauma service. Demographic data and severity of injury were similar before and after the trauma service was instituted. Nonetheless, mortality for all trauma patients admitted to an intensive care unit decreased somewhat (from 16.1 to 11.8 percent) in the second period of study. When outcome for trauma patients admitted to the surgical intensive care unit was examined, the difference was more impressive, with a reduction in mortality from 27 percent to 6.1 percent. This reduction seemed to be due largely to a decrease in the number of patients who died from sepsis, multiple organ failure, or both. We suggest that trauma care can be significantly improved by an organized approach to the care of the multiply injured patient. A powerful argument can be made for organizing care of injured patients in major hospitals along the lines of a dedicated trauma service. Acknowledgment: We thank Keith Indeck for compiling data on the emergency service patients, Dr. Ulrich Well for his direction of the emergency service and support of the trauma service, and Patricia Lyman for her expert a~istance in preparing the manuscript. References I. Accidental death and disability: the neglected disease of modem society. Committee on Trauma and Committee on Shock. Division of Medical Sciences, National Academy of Sciences, Washington, DE' 1966. 2. Frey CF, Blaisdell FW, Davis J e t al. Hospital care of the trauma patient. JAMA 1978;240:1723-4. 3. Committee on Trauma, American College of Surgeons. Hospital resources for optimal care of the injured patient. Bull Am Coil Surg 1979. 4. We,~tJG, Trunkey DD, Lin RC. Systems of trauma care: a study of two counties. Arch Surg 1979; 114:455-60. 5. West JG, Cares RH, Gazzan!ga AB, impact of reglonallzafion: the Orange County experience. Arch Surg 1983;118:7404. 6. Maull KI, Haynes BW Jr. The integrated trauma service concept. J Am Coil Emerg Phys 1977;6:497-9. 7. Baker SP, O'Neill B, Hadden W, et at. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14:187-96. 8. Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epldemlology of trauma deaths. Am J Surg 1980;140:14450. 9. Abt C. The issue of social costs in cost-benefit analysis of surgery. In: Bunker JP, Barnes BA, Mosteller F eds, Cost, risks, and benefits in surgery. New York: Oxford University Press, 1977:40-55. 457 Baker et al Discussion J a m e s H. Foster (Farmington, CT): It seems that you propose the benefit comes from the decrease in septic deaths. It seems to me you doubled the number of deaths due to burns and halved the ones due to sepsis; if you add the two together, it doesn't mean much. C h r i s t o p h e r C. B a k e r (closing): Dr. Foster, what may not have come out in the report is that in the first year, burns were present in 4 percent of the patients and caused 11 percent of the deaths; in the second year, 11 percent of the patients were burn victims and burns caused 35 percent of the deaths. The number of deaths decreased, and the overall percentage of deaths decreased. The burn patients are not taken care of on the trauma service, they are taken care of on the plastic surgery service at Yale; therefore, I cannot say that there is any relationship to the trauma team. In defense of the plastic surgery service, the burn cases were very grave, most of them being in elderly persons with tile burns covering more than 60 percent of the body surface area. This discussion section has been abbreviated due to space limitations. The lull text can be obtained from the reprints author listed on the title page. 458 The Amerlcam Journal Qf Surgery