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Meaningful reporting of quality metrics relies on detecting a statistical difference when a true difference in performance exists. Larger cohorts and longer time frames can produce higher rates of statistical differences. However, older data are less relevant when attempting to enact change in the clinical setting. The selection of time frames must reflect a balance between being too small (type II errors) and too long (stale data). We explored the use of power analysis to optimize time frame selection for trauma quality reporting.Using data from 22 Level III trauma centers, we tested for differences in 4 outcomes within 4 cohorts of patients. With bootstrapping, we calculated the power for rejecting the null hypothesis that no difference exists amongst the centers for different time frames. From the entire sample for each site, we simulated randomly generated datasets. Each simulated dataset was tested for whether a difference was observed from the average. Power was calculated as the percentage of simulated datasets where a difference was observed. This process was repeated for each outcome.The power calculations for the 4 cohorts revealed that the optimal time frame for Level III trauma centers to assess whether a single site's outcomes are different from the overall average was 2 years based on an 80% cutoff.Power analysis with simulated datasets allows testing of different time frames to assess outcome differences. This type of analysis allows selection of an optimal time frame for benchmarking of Level III trauma center data.

Open long-bone fractures represent a complex injury within the trauma system. Guidelines recommend antibiotics be given within 60 minutes of patient arrival to the emergency department. We sought to measure and improve the timeliness of antibiotic administration at the patient, hospital, and population level within a collaborative quality initiative.Trauma collaborative quality initiative data (January 2017 to December 2020) were analyzed from 34 American College of Surgeons Committee on Trauma verified level 1 and level 2 trauma centers. Inclusion criteria were adult patients (≥16 years), injury severity score ≥5, and open tibia or femur fracture. After the baseline year, hospitals were scored annually on a pay-for-performance metric based on patients receiving antibiotics within 120 minutes of emergency department arrival. Univariate tests examined the differences between baseline and subsequent year(s) performance. A multivariable logistic regression assessed the factors associated with meeting this target time.There were 2,624 patients with an open long-bone fracture. In the baseline year (2017), 76.9% of patients received antibiotics in ≤120 minutes, with a mean time of 57.9 ± 63.3 minutes. After implementing collaborative quality initiative-wide targets, performance significantly improved in subsequent years (2018, 2019, 2020). The collaborative quality initiative achieved their goal of ≥85% of patients receiving antibiotics in ≤120 minutes in 2019 (87.9%) and 2020 (88.5%), with a mean time of 43.3 ± 54.8 minutes (P.05 vs 2017).A pay-for-performance process measure within a statewide trauma collaborative quality initiative improved the timely administration of antibiotics to patients with open fractures. Work remains to align compliance with the guideline target of60 minutes and to identify factors involved in the delay of administration.

BACKGROUND Accurate and reliable data are pivotal to credible risk-adjusted modeling and hospital benchmarking. Evidence assessing the reliability and accuracy of data elements considered as variables in risk-adjustment modeling and measurement of outcomes is lacking. This deficiency holds the potential to compromise benchmarking integrity. We detail the findings of a longitudinal program to evaluate the impact of external data validation on data validity and reliability for variables utilized in benchmarking of trauma centers. METHODS A collaborative quality initiative-based study was conducted of 29 trauma centers from March 2010 through December 2018. Case selection criteria were applied to identify high-yield cases that were likely to challenge data abstractors. There were 127,238 total variables validated (i.e., reabstracted, compared, and reported to trauma centers). Study endpoints included data accuracy (agreement between registry data and contemporaneous documentation) and reliability (consistency of accuracy within and between hospitals). Data accuracy was assessed by mean error rate and type (under capture, inaccurate capture, or over capture). Cohen's kappa estimates were calculated to evaluate reliability. RESULTS There were 185,120 patients that met the collaborative inclusion criteria. There were 1,243 submissions reabstracted. The initial validation visit demonstrated the highest mean error rate at 6.2% ± 4.7%, and subsequent validation visits demonstrated a statistically significant decrease in error rate compared with the first visit (p < 0.05). The mean hospital error rate within the collaborative steadily improved over time (2010, 8.0%; 2018, 3.2%) compared with the first year (p < 0.05). Reliability of substantial or higher (kappa ≥0.61) was demonstrated in 90% of the 20 comorbid conditions considered in the benchmark risk-adjustment modeling, 39% of these variables exhibited a statistically significant (p < 0.05) interval decrease in error rate from the initial visit. CONCLUSION Implementation of an external data validation program is correlated with increased data accuracy and reliability. Improved data reliability both within and between trauma centers improved risk-adjustment model validity and quality improvement program feedback.

The appropriate triage of acutely injured patients within a trauma system is associated with improved rates of mortality and optimal resource utilization. The American College of Surgeons Committee on Trauma (ACS-COT) put forward six minimum criteria (ACS-6) for full trauma team activation (TTA). We hypothesized that ACS-COT-verified trauma center compliance with these criteria is associated with low undertriage rates and improved overall mortality.Data from a state-wide collaborative quality initiative was used. We used data collected from 2014 through 2016 at 29 ACS verified Level I and II trauma centers. Inclusion criteria are: adult patients (≥16 years) and Injury Severity Score of 5 or less. Quantitative data existed to analyze four of the ACS-6 criteria (emergency department systolic blood pressure ≤ 90 mm Hg, respiratory compromise/intubation, central gunshot wound, and Glasgow Coma Scale score9). Patients were considered to be undertriaged if they had major trauma (Injury Severity Score15) and did not receive a full TTA.51,792 patients were included in the study. Compliance with ACS-6 minimum criteria for full TTA varied from 51% to 82%. The presence of any ACS-6 criteria was associated with a high intervention rate and significant risk of mortality (odds ratio, 16.7; 95% confidence interval, 15.2-18.3; p0.001). Of the 1,004 deaths that were not a full activation, 433 (43%) were classified as undertriaged, and 301 (30%) had at least one ACS-6 criterion present. Undertriaged patients with any ACS-6 criteria were more likely to die than those who were not undertriaged (30% vs. 21%, p = 0.001). Glasgow Coma Scale score less than 9 and need for emergent intubation were the ACS-6 criteria most frequently associated with undertriage mortality.Compliance with ACS-COT minimum criteria for full TTA remains suboptimal and undertriage is associated with increased mortality. These data suggest that the most efficient quality improvement measure around triage should be ensuring compliance with the ACS-6 criteria. This study suggests that practice pattern modification to more strictly adhere to the minimum ACS-COT criteria for full TTA will save lives.Care management, level III.

BACKGROUND: Venous thromboembolism (VTE) is a common complication in trauma patients. Pharmacologic prophylaxis is utilized in trauma patients to reduce their risk of a VTE event. The Eastern Association for the Surgery of Trauma guidelines recommend use of low-molecular-weight heparin (LMWH) as the preferred agent in these patients. However, there is literature suggesting that unfractionated heparin (UFH) is an acceptable, and less costly, alternative VTE prophylaxis agent with equivalent efficacy in trauma patients. We examined data from the Michigan Trauma Quality Improvement Program to perform a comparative effectiveness study of UFH versus LMWH on outcomes for trauma patients. METHODS: We conducted an analysis of the Michigan Trauma Quality Improvement Program data from January 2012 to December 2014. The data set contains information on date, time, and drug type of the first dose of VTE prophylaxis. Thirty-seven thousand eight hundred sixty-eight patients from 23 hospitals were present with an Injury Severity Score of 5 or greater and hospitalization for more than 24 hours. Patients were excluded if they died within 24 hours or received no pharmacologic VTE prophylaxis or agents other than UFH or LMWH while admitted to the hospital. We compared patients receiving LMWH to those receiving UFH. Outcomes assessed were VTE event, pulmonary embolism, deep vein thrombosis, and mortality during hospitalization. We used a generalized estimating equation approach to fit population-averaged logistic regression models with the type of first dose of VTE prophylaxis as the independent variable. Unfractionated heparin was considered the reference value. Timing of the first dose of VTE prophylaxis was entered into the model in addition to standard covariates. Odds ratios were generated for each of the dependent variables of interest. RESULTS: The analysis cohort consisted of 18,010 patients. Patients administered LMWH had a decreased risk of mortality (odds ratio, 0.64; confidence interval, 0.49–0.83), VTE (odds ratio, 0.67; confidence interval, 0.53–0.84), pulmonary embolism (odds ratio, 0.53; confidence interval, 0.35–0.79), and deep vein thrombosis (odds ratio, 0.73; confidence interval, 0.57–0.95) when compared with UFH following risk adjustment and accounting for hospital effect. The reduced risk of a VTE event for patients receiving LMWH was most pronounced for patients in the lower injury-severity categories. CONCLUSIONS: In our examination of VTE prophylaxis drug effectiveness, LMWH was found to be superior to UFH in reducing the incidence of mortality and VTE events among trauma patients. Therefore, LMWH should be the preferred VTE prophylaxis agent for use in hospitalized trauma patients. LEVEL OF EVIDENCE: Therapeutic, level III.

American College of Surgeons verified trauma centers and a third-party payer within the state of Michigan built a regional collaborative quality initiative (CQI). The Michigan Trauma Quality Improvement Program began as a pilot in 2008 and expanded to a formal program in 2011. Here, we examine the performance of the collaborative over time with regard to patient outcomes, resource utilization, and process measures.Data from the initial 23 hospitals that joined the CQI in 2011 were analyzed. Performance trends from 2011 to 2015 were evaluated for outcomes, resource utilization, and process measures using univariate analysis. Risk-adjustment was performed to confirm results observed in the unadjusted data. To calculate the potential number of patients impacted by the CQI program, the maximum absolute change was multiplied by the number of trauma patients treated in the 23 hospitals during 2015.Membership in a CQI program significantly reduced serious complications (8.5 vs. 7.3%, p = 0.002), decreased resource utilization, and improved process measure execution in trauma patients over 5 years time. Similar results were obtained in unadjusted and risk-adjusted analyses. The CQI program potentially avoided inferior vena cava filter placement in 167 patients annually. Decreased venous thromboembolism rates mirrored increased compliance with venous thromboembolism pharmacologic prophylaxis.This study confirms our hypothesis that participation in a regional CQI improves patient outcomes and decreases resource utilization while promoting compliance with processes of care.Economic/therapeutic care, level V.

Background Although race, socioeconomic status, and insurance individually are associated with trauma mortality, their complex interactions remain ill defined. Methods This retrospective cross-sectional study from a single Level I center in a racially diverse community was linked by socioeconomic status, insurance, and race from 2000 to 2009 for trauma patients aged 18-64 years with an injury severity score more than 9. The outcome measure was inpatient mortality. Multiple logistic regression analyses were performed to investigate confounding variables known to predict trauma mortality. Results A total of 4,007 patients met inclusion criteria. Individually, race, socioeconomic status, and insurance were associated with increased mortality rate; however, in multivariate analysis, only insurance remained statistically significant and varied by insurance type with age. Odds of death were higher for Medicare (odds ratio [OR] = 3.63, p = .006) and other insurance (OR = 3.02, p = .007) than for Private Insurance. However, when grouped into ages 18-40 years versus 41-64 years, the insurance influences changed with Uninsured and Other insurance (driven by Tricare) predicting mortality in the younger age group, while Medicare remained predictive in the older age group. Conclusions Insurance type, not race or socioeconomic status, is associated with trauma mortality and varies with age. Both Uninsured and Tricare insurance were associated with mortality in younger age trauma patients, whereas Medicare was associated with mortality in older age trauma patients. The lethality of the Tricare group warrants further investigation.

Objective: Youth violence recidivism remains a significant public health crisis in the United States. Violence prevention is a requirement of all trauma centers, yet little is known about the effectiveness of these programs. Therefore, this systematic review summarizes the effectiveness of trauma center–based youth violence prevention programs. Methods: A systematic review of articles from MEDLINE, CINAHL, and PsychINFO databases was performed to identify eligible control trials or observational studies. Included studies were from 1970 to 2013, describing and evaluating an intervention, were trauma center based, and targeted youth injured by violence (tertiary prevention). The social ecological model provided the guiding framework, and findings are summarized qualitatively. Results: Ten studies met eligibility requirements. Case management and brief intervention were the primary strategies, and 90% of the studies showed some improvement in one or more outcome measures. These results held across both social ecological level and setting: both emergency department and inpatient unit settings. Conclusions: Brief intervention and case management are frequent and potentially effective trauma center–based violence prevention interventions. Case management initiated as an inpatient and continued beyond discharge was the most frequently used intervention and was associated with reduced rearrest or reinjury rates. Further research is needed, specifically longitudinal studies using experimental designs with high program fidelity incorporating uniform direct outcome measures. However, this review provides initial evidence that trauma centers can intervene with the highest of risk patients and break the youth violence recidivism cycle.

The drivers of trauma disparities are multiple and complex; yet, understanding the causes will direct needed interventions. The aims of this article are to (1) explore how the injured patient, his or her social environment, and the health care system interact to contribute to trauma disparities and examine the evidence in support of interventions and (2) develop a conceptual framework that captures the socioecological context of trauma disparities. Using a scoping review methodology, articles were identified through PubMed and CINAHL between 2000 and 2015. Data were extracted on the patient population, social determinants of health, and interventions targeting trauma disparities and violence. Based on the scoping review of 663 relevant articles, we inductively developed a conceptual model, The Social Determinants of Trauma: A Trauma Disparities Framework, based on the categorization of articles by: institutional power (n = 9), social context-place (n = 117), discrimination experiences (n = 59), behaviors and comorbidities (n = 57), disparities research (n = 18), and trauma outcomes (n = 85). Intervention groupings included social services investment (n = 54), patient factors (n = 88), hospital factors (n = 27), workforce factors (n = 31), and performance improvement (n = 118). This scoping review produced a needed taxonomy scheme of the drivers of trauma disparities and known interventions that in turn informed the development of The Social Determinants of Trauma: A Trauma Disparities Framework. This study adds to the trauma disparities literature by establishing social context as a key contributor to disparities in trauma outcomes and provides a road map for future trauma disparities research.

Importance The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) provides feedback to hospitals on risk-adjusted outcomes. The Michigan Trauma Quality Improvement Program (MTQIP) goes beyond the provision of feedback alone, focusing on collaborative quality improvement. It is unknown whether the addition of a collaborative approach to benchmark reporting improves outcomes. Objective To evaluate the association of hospital participation in the ACS TQIP (benchmark reporting) or the MTQIP (benchmark reporting and collaborative quality improvement) with outcomes compared with control hospitals that did not participate in either program. Design, Setting, and Participants In this cohort study, data from the National Trauma Data Bank from 2009 to 2015 were used. A total of 2 373 130 trauma patients 16 years or older with an Injury Severity Score of 5 or more were identified from 98 ACS TQIP hospitals, 23 MTQIP hospitals, and 429 nonparticipating hospitals, based on program participation status in 2011. A difference-in-differences analytic approach was used to evaluate whether hospital participation in the ACS TQIP or the MTQIP was associated with improved outcomes compared with nonparticipation in a quality improvement program. Exposures Hospital participation in MTQIP, a quality improvement collaborative, compared with ACS TQIP participation and nonparticipating hospitals. Main Outcomes and Measures In-hospital mortality, mortality or hospice, major complications, and venous thromboembolism events were assessed. Results Of the 2 373 130 included trauma patients, 64.2% were men and 73.0% were white, and the mean (SD) age was 50.7 (21.9) years. After accounting for patient factors and preexisting time trends toward improved outcomes, there was a statistically significant improvement in major complications after (vs before) hospital enrollment in the MTQIP collaborative compared with nonparticipating hospitals (odds ratio [OR], 0.89; 95% CI, 0.83-0.95) or ACS TQIP hospitals (OR, 0.88; 95% CI, 0.82-0.94). A similar result was observed for venous thromboembolism (MTQIP vs nonparticipating: OR, 0.78; 95% CI, 0.69-0.88; MTQIP vs ACS TQIP: OR, 0.84; 95% CI, 0.74-0.95), for which MTQIP targeted specific performance improvement efforts. Hospital participation in both ACS TQIP and MTQIP was associated with improvement in mortality or hospice (ACS TQIP vs nonparticipating: OR, 0.90; 95% CI, 0.87-0.93; MTQIP vs nonparticipating: OR, 0.88; 95% CI, 0.81-0.96). Hospitals participating in MTQIP achieved the lowest overall risk-adjusted mortality in the postenrollment period (4.2%; 95% CI, 4.1-4.3). Conclusions and Relevance This study demonstrates that hospital participation in a regional collaborative quality improvement program is associated with improved patient outcomes beyond benchmark reporting alone while promoting compliance with processes of care.

BACKGROUND Although evidence suggests that quality improvement to reduce complications for trauma patients should decrease costs, studies have not addressed this question directly. In Michigan, trauma centers and a private payer have created a regional collaborative quality initiative (CQI). This CQI program began as a pilot in 2008 and expanded to a formal statewide program in 2010. We examined the relationship between outcomes and expenditures for trauma patients treated in collaborative participant and nonparticipant hospitals. METHODS Payer claims and collaborative registry data were analyzed for 30-day episode payments and serious complications in patients admitted with trauma diagnoses. Patients were categorized as treated in hospitals that had different CQI status: (1) never participated (Never-CQI); (2) collaborative participant, but patient treated before CQI initiation (Pre-CQI); or (3) active collaborative participant (Post-CQI). DRG International Classification of Diseases--9th Rev. codes were crosswalked to Abbreviated Injury Scale (AIS) 2005 codes. Episode payment data were risk adjusted (age, sex, comorbidities, type/severity of injury, and year of treatment), and price was standardized. Outcome data were risk adjusted. A serious complication consisted of one or more of the following occurrences: acute lung injury/adult respiratory distress syndrome, acute kidney injury, cardiac arrest with cardiopulmonary resuscitation, decubitus ulcer, deep vein thrombosis, enterocutaneous fistula, extremity compartment syndrome, mortality, myocardial infarction, pneumonia, pulmonary embolism, severe sepsis, stroke/cerebral vascular accident, unplanned intubation, or unplanned return to operating room. RESULTS The risk-adjusted rate of serious complications declined from 14.9% to 9.1% (p < 0.001) in participating hospitals (Post-CQI, n = 26). Average episode payments decreased by $2,720 (from $36,043 to $33,323, p = 0.08) among patients treated in Post-CQI centers, whereas patients treated at Never-CQI institutions had a significant year-to-year increase in payments (from $23,547 to $28,446, p < 0.001). A savings of $6.5 million in total episode payments from 2010 to 2011 was achieved for payer-covered Post-CQI treated patients. CONCLUSION This study confirms our hypothesis that participation in a regional CQI program improves outcomes and reduces costs for trauma patients. Support of a regional CQI for trauma represents an effective investment to achieve health care value. LEVEL OF EVIDENCE Economic/value-based evaluation, level III.

Overwhelming evidence shows that air bags save lives and reduce morbidity associated with MVCs. The resulting benefits far outweigh the risks of air bag injury or death. Emergency nurses play a pivotal role in educating the public about active seat belt use in conjunction with passive restraint systems such as air bags. Air bags cannot be viewed as a single solution or panacea to occupant protection. Air bags are designed as supplemental devices to be used with seat belts and require the active participation of the user for maximum benefit and safety.

Background: Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes. Methods: The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission. Results: The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%). Conclusion: GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.