A newly developed Trauma Surge Index (TSI) can help hospitals assess how periods of suddenly increased trauma patient volume, such as during mass shootings, public transit accidents, terrorist attacks, or similar catastrophic events, stretch hospital resources and affect trauma patient mortality.
Trauma patients seen during high-surge periods were twice as likely to die as those during low-surge periods, according to a study using this new measure, published June 16 in the Journal of the American College of Surgeons. Therefore, the authors suggest, hospitals can use this new index, adapted to the particular patterns and parameters of each hospital, to identify the center’s capabilities during a surge and how capacity strain affects trauma patient mortality.
“Hospital performance during trauma surges appears to depend on patient acuity, mechanism of injury, and volume, as well as individual hospital trauma admission patterns,” write Peter C. Jenkins, MD, from the Department of Surgery, Indiana University, Indianapolis, and colleagues. “Stakeholders involved in trauma system preparedness and response can use the TSI to examine surge response capacity retrospectively and allocate scarce healthcare resources in an evidence-based manner.”
Past measures of capacity strain have not accounted for the severity of patient injuries or for differences in hospitals’ capacity or resources. Therefore, these previous measures could not provide a sufficiently reliable snapshot of actual resource needs and management during trauma surges for a hospital to determine how it might improve its preparedness and response during high volume.
Dr Jenkins and colleagues used the American College of Surgeons Trauma Quality Improvement Program to analyze retrospective data for a cohort of 230,621 trauma patients discharged from 156 participating institutions between January 2010 and December 2011. The data included the date and time of hospital admission and discharge for each adult trauma patient with an Abbreviated Injury Scale Score of at least 3 that resulted in an Injury Severity Score of at least 9.
The TSI measure uses each patient’s Injury Severity Score, the time and date of hospital admission, and a unique hospital identifier, thereby reflecting the severity of high-surge trauma patients’ injuries while accounting for annual trauma admission variation and the particular characteristics of individual centers.
Overall in-hospital mortality was 6.3%, but when the researchers compared trauma mortality using the TSI, patients had twice the odds of dying when the TSI exceeded 3 (during a 48-hour period) than when it was 3 or lower (9.9% vs 6.3%; odds ratio [OR], 2.05; 95% confidence interval [CI], 1.36 – 3.10). Only 0.14% of the study population (332 patients at 33 hospitals) had a TSI score greater than 3. Comparatively, the researchers did not find any difference between patient mortality during surge and nonsurge periods when applying the established criteria of mass casualty events (OR, 0.94; 95% CI, 0.88 – 1.01), which refers to 10 trauma admissions within a 24-hour period, regardless of injury severity or hospital characteristics or resources.
Patients with firearm injuries had more than seven times greater odds of dying during high-surge periods than during low-surge periods, using the TSI (42.0% vs. 15.5%; P = .002; OR, 7.29; 95% CI, 2.13 – 24.91), whereas the mortality of patients without firearm injuries rose from 5.8% during low-surge periods to 8.5% during high-surge periods (P = .004).
Slightly tweaking the length of a surge period produced different relationships with trauma patient mortality. With 12-hour periods, mortality was not significant different between high- and low-surge periods (OR, 1.20; 95% CI, 0.93 – 1.56), but with 24-hour periods, it increased (OR, 1.51; 95% CI, 1.01 – 2.27). With 60-hour periods, it peaked (OR, 2.37; 95% CI, 1.60 – 3.48), and then dropped to no significant difference with 72-hour periods (OR, 1.24; 95% CI, 0.76 – 2.01).
“In its current form, the TSI is most appropriate for retrospective analyses of surge response capacity and subsequent root cause analyses of associated, increased mortality in trauma patients,” the authors write.
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