Elsevier

Surgery

Volume 140, Issue 1, July 2006, Pages 34-43
Surgery

Original communication
Analysis of trends in the Florida Trauma System (1991-2003): Changes in mortality after establishment of new centers

https://doi.org/10.1016/j.surg.2006.01.012Get rights and content

Background

This study analyzes trends in hospitalization and outcome for adult, elderly, and pediatric trauma victims in the Florida Trauma System (FTS) from 1991 to 2003, during which time the number of centers nearly doubled from 11 to 20.

Methods

Administrative data was queried for all admissions with at least one trauma related discharge. Patients were stratified by age as pediatric (age, 0 to 15 years), adult (age, 16 to 64 years), or elderly (age, >64 years). Volume of admissions, severity, and mortality were analyzed over time. A logistic regression model was used to test the existence of an organizational experience curve after the designation of a new trauma center.

Results

Injury-related hospitalizations increased for the elderly, stayed the same for adults, and declined for children. As the system matured, a larger percentage of victims, particularly the most severely injured, were triaged to trauma centers, indicating more effective triage. In contrast to adults and pediatric patients, the majority of elderly trauma victims were managed at non-trauma centers. The trauma mortality rate per 1,000 population among the elderly increased during the study period (P < .01). Multivariate analysis indicated that for adult and pediatric victims it took up to 3 years after the designation of trauma center status before the odds of mortality reached parity with that of established centers.

Conclusions

The FTS has grown with its population and has matured to treat a larger percentage of trauma victims. Trauma victims transported to established trauma centers (4+ years) have a survival advantage compared to their counterparts transported to newly created centers. The reduction in the odds of mortality does not occur immediately after trauma center designation.

Section snippets

Florida trauma centers

Florida’s first trauma legislation, passed in 1982, required the Department of Health and Rehabilitative Services to define criteria for trauma center designation, verify hospital compliance with these criteria, and designate appropriately qualified hospitals as Level I, II, or Regional Pediatric Trauma Referral Centers (RPTRC). In 1991, the initial year of this study, there were 11 DTCs. Six additional centers were established between 1992 and 1994 whereas 3 others were added in, respectively,

Data and methods

This analysis combines information from the Florida Inpatient Hospital Discharge and Financial Datasets compiled by Florida’s Agency for Health Care Administration (AHCA). The datasets cover all acute care hospitals in the state. The discharge dataset contains demographic and case-mix related characteristics, including age, gender, ethnic origin, up to 9 diagnoses and procedures, source of admission, and discharge status of all hospitalized patients. The financial dataset contains data

Trauma admissions

Figure 1 shows the quarterly trend for trauma cases in all Florida hospitals from 1991 to 2003. The first quarter of each year is indicated by a solid bar, followed by outlined bars for the remaining three quarters. The solid line flowing from left to right is the annual moving average of trauma cases. Fig 1 A includes all cases and indicates a clear seasonal pattern, with a steady reduction in the number of trauma cases during the second and third quarters, followed by a sharp increase during

Results of multivariate analysis: The role of experience

The multivariate model was executed separately for 2 different specifications of the time elapsed since trauma center designation. The results are shown in the Table. Only the estimates associated with the time variables are shown in the Table. The statistical control factors are discussed in previous reports and are not included here to conserve space but are available from the authors on request. The first set of equations contained a single variable indicating the number of years elapsed.

Trends

This trend analysis of an established state trauma system demonstrates areas of dramatic change as well as evolving challenges to future function. Many of these trends are unique to specific patient age groups. Trauma admissions increased for ELD (relative and absolute), decreased for PEDS (relative and absolute), and were unchanged for ADLT (absolute). Unlike PEDS and ELD, ADLT trauma hospitalizations did not exhibit a seasonal pattern. Trauma hospitalizations for the elderly peaked in winter,

Conclusions

In Florida, the annual number of trauma victims increased among non-elderly adults and the elderly from 1991 to 2003. For the elderly, the upward trend is both absolute and relative to the size of the population. For children, trauma hospitalizations decreased both in absolute terms and as a percentage of the population. On average, adult patients admitted to more established DTCs had a lesser probability of mortality compared to trauma victims admitted to newly designated trauma institutions.

References (35)

  • J.J. Reilly et al.

    Use of a state-wide administrative database in assessing a regional trauma systemthe New York City experience

    J Am Coll Surg

    (2004)
  • L.J. Scheetz

    Effectiveness of prehospital trauma triage guidelines for the identification of major trauma in elderly motor vehicle crash victims

    J Emerg Nurs

    (2003)
  • G. Kane et al.

    Impact of the Los Angeles County Trauma System on the survival of seriously injured patients

    J Trauma

    (1992)
  • J.R. Hedges et al.

    Oregon Trauma Systemchange in initial admission site and post-admission transfer of injured patients

    Acad Emerg Med

    (1994)
  • R.J. Mullins et al.

    Outcome of hospitalized injured patients after institution of a trauma system in an urban area

    JAMA

    (1994)
  • E. Barquist et al.

    Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes region of New York State

    J Trauma

    (2000)
  • R.J. Mullins et al.

    Influence of a statewide system on location of hospitalization and outcome of injured patients

    J Trauma

    (1996)
  • J.S. Sampalis et al.

    Trauma center designationinitial impact on trauma-related mortality

    J Trauma

    (1995)
  • F.B. Rogers et al.

    Population-based study of hospital trauma care in a rural state without a formal trauma system

    J Trauma

    (2001)
  • N.C. Mann et al.

    Survival among injured geriatric patients during construction of a statewide trauma system

    J Trauma

    (2001)
  • J.H. Abernathy et al.

    Impact of a voluntary trauma system on mortality, length of stay, and cost at a level I trauma center

    Am Surg

    (2002)
  • S.M. Melton et al.

    Motor vehicle crash-related mortality is associated with prehospital and hospital-based resource availability

    J Trauma

    (2002)
  • R.J. Mullins et al.

    Preferential benefit of implementation of a statewide trauma system in one of two adjacent states

    J Trauma

    (1998)
  • A.B. Nathens et al.

    Effectiveness of state trauma systems in reducing injury-related mortalitya national evaluation

    J Trauma

    (2000)
  • G.E. O’Keefe et al.

    Ten-year trend in survival and resource utilization at a Level I trauma center

    Ann Surg

    (1999)
  • C.R. Boyd et al.

    Evaluating trauma care: the TRISS method. Trauma score and injury score

    J Trauma

    (1987)
  • T. Osler et al.

    ICISSan International Classification of Disease-9 based injury severity score

    J Trauma

    (1996)
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