The economic impact of gunshot wounds on an urban level 1 trauma center

IntroductionFirearm-related injuries impact the healthcare system, taxpayers, and injured patients due to lost productivity and reduced quality of life. The goal was to quantify the economic costs related to hospitalization for gunshot wounds (GSWs) at a single urban level 1 trauma center.Materials and Methods941 patients over 27 months were treated for GSW. Elements related to hospitalization including length of stay, surgical procedures, medications and therapies, and subsequent readmission were identified, and costs were determined, inclusive of fixed and variable direct and indirect costs of facility care. Costs were classified based on body region: abdominal, chest, soft tissue, extremity or pelvic girdle, and head/neck/face.ResultsMean age was 30 years, with 94% male. Most patients (81%) were admitted, and 8% sustained fatal injuries. Overall, 12% were seen previously or subsequently for additional, unrelated GSWs. Mean costs per patient were: $66,780 for abdominal GSWs; $3,986 for chest; $3,509 for soft tissue; $19,875 for extremities; $64,533 for head or neck, and means of $25,249 for two regions and $26,638 for three regions. Over the prospective period, 941 individuals sustained GSWs (approximately 35 per month). 37% were to the extremities, 23% were within the skin/subcutaneous tissue, 7% to the abdomen, 7% to the chest, 6% to the head or neck, and 20% to two or more body regions. Total facility costs for these 941 GSWs was $18.9 million, or $698,960 per month. 55% of the patients had Medicaid, and 33% were uninsured, resulting in substantial uncompensated expenses for the trauma center.ConclusionFirearm-related injuries generate considerable expense. Our data underestimated cost, as professional services and indirect costs associated with lost economic productivity of patients and caregivers were excluded. No objective assessment of the disastrous personal and social impact was projected. Moving forward, interventions to prevent initial injury and recidivism in this high-risk population are crucial.Level of EvidenceLevel III     

Recidivism in an urban trauma center.

The incidence of recurrent injury requiring evaluation and treatment at an urban trauma center was assessed by examination of data from the registry of an urban trauma unit. A subgroup of 342 recidivists sustained 711 traumatic injuries. This represented 6.4% of trauma service activations or consultations. The rates of recurrence in random groups of 100 patients with trauma and 50 patients with traumatic deaths were 5% and 12%, respectively. These rates of recurrent injury are lower than those of several previous reports. Comparison of patients with recurrent episodes of trauma with patients who experience a single episode of trauma revealed significant differences in age, sex distribution, mechanism of injury, and fatal outcomes. Recidivists averaged only 7.9 months between episodes of injury. In patients with recurrent trauma with fatal outcomes, the mean interval between initial injury and death was 18.8 months. Early identification of patients at high risk for recurrence may provide an opportunity for behavior modification.     

Management of upper extremity arterial injuries at an urban level I trauma center

Although relatively uncommon, upper extremity arterial injuries are serious and may significantly impact the outcome of the trauma patient. Management of upper extremity arterial injuries at an urban level I trauma center was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome. Upper extremity trauma patients with arterial injury who presented between January 2005 and December 2006 were included in this retrospective review. Data collected included age, gender, race, mechanism of injury, type of injury, associated upper extremity injuries, concomitant injuries, injury severity score (ISS), diagnostic modalities employed, surgical procedures and interventions, mortality, length of stay, and discharge disposition. Statistical analysis between blunt and penetrating arterial injuries as well as between proximal and distal arterial injuries also was conducted. During a 2-year period, 28 patients with 30 upper extremity arterial injuries were admitted, yielding an incidence of 0.48%. The study population was comprised primarily of young Caucasian males, with a mean ISS of 9.0. The majority (89.3%) of patients suffered concomitant upper extremity injuries. Twenty-two nerve injuries were identified in 16 (57.1%) patients. The most common injury mechanism was cut by glass (39.3%). Arterial injuries were categorized into 18 (60.0%) penetrating and 12 (40.0%) blunt injuries. Involved artery distribution was as follows: 12 (40.0%) brachial, eight (26.7%) ulnar, seven (23.3%) radial, and three (10.0%) axillary. Over half (56.7%) of the injuries resulted from lacerations. Injuries were managed as follows: 14 (46.7%) primary repairs, eight (26.7%) ligations, six (20.0%) saphenous vein graft bypasses, and two (6.7%) endovascular procedures. Eleven (39.3%) patients required intensive care unit (ICU) admission. The overall mean length of hospitalization for these patients was 7.4 days compared to a mean length of hospitalization of 2.0 days for the 17 (44.7%) patients who did not require ICU admission. The overall limb salvage rate was 96.4% as arterial injuries were successfully repaired in 27 of 28 patients. No patients expired and all were discharged home. Equivalent demographics, mechanisms of injury, surgical management approaches, and successful hospital outcomes were demonstrated between penetrating and blunt injuries as well as between proximal and distal arterial injuries. The current management approach, including use of angiography and prompt surgical management, results in successful outcomes after upper extremity arterial injuries and will continue to be utilized.     

The incidence of recurrent penetrating trauma in an urban trauma center

In spite of the fact that penetrating trauma is an increasingly frequent cause of death and disability in America, little epidemiologic information is available on the recurrence rate or natural history of patients sustaining such injuries. The current study therefore was carried out to determine the recurrence rate of penetrating trauma in our institution. During the 12-month study period (August 1984 through July 1985), 556 (2%) of the 26,728 patients examined in our surgical emergency department had sustained penetrating trauma. After excluding patients who died at the time of their original injury and patients whose records were incomplete, 389 (70%) of the 556 patients were available for analysis. As of January 1990, 127 (32.6%) of the 389 patients had sustained two or more documented episodes of penetrating trauma. The incidence of recurrent penetrating trauma in the patients treated and released from the emergency department (35%) was similar to that of the patients requiring admission for their index injuries (31%). Based on the fact that the incidence of recurrent trauma was highest in men (p less than 0.01), blacks (p less than 0.01), and the uninsured (p = 0.03), it appears that recurrent penetrating trauma is a major societal as well as a medical problem.     

Mandibular fractures in an urban trauma center

The hospital records of 307 patients sustaining mandibular fractures between 1980 and 1984 were reviewed. The patient population consisted of 79% males, with precipitating events usually being fist fights (47%) and assaults with a blunt object (18%). The most common fracture involved the body (30%), followed by the angle (21%) and the condyles (19%). Intermaxillary fixation (IMF) was the preferred method of treatment (42%); however, a large number of patients were treated by internal fixation (31%) or external stabilization (11%). Despite the large number with internal fixation procedures, the complication rate was relatively low (18%). This review suggests changing trends in mandibular fractures. Motor vehicle accidents no longer comprise the most common etiology, so that condylar fractures are no longer the most common, and fractures of the body and angle are more common. Although most patients still are initially treated by intermaxillary fixation, the number of open reductions appears to be increasing. Despite this trend, the complication rate has remained relatively low.     

Analysis of organ procurement failure at an urban trauma center and the impact of HIV on organ procurement at a regional transplantation center.

A 42-month experience with 100 patients with fatal head injuries was analyzed to identify areas of organ procurement failure. Thirty-six patients were ineligible for organ donation. Reasons for exclusion included advanced age (7), sepsis (16), hepatitis (1), systemic illnesses (3), and HIV infection or risk (9). Resuscitation failure (17 patients) and late deaths from failed support (16 patients) left 31 potential donors. Of the 30 families asked to donate, 17 consented (56.7%). Annual consent rates were 25%, 71%, 75%, and 67%. Efforts to improve organ procurement should focus on resuscitation and physiologic support of potential donors. To assess the impact of HIV infection or risk on organ procurement, a 3-year experience of the regional transplantation center (RTP) was reviewed. Of 1,714 referrals to the RTP from 102 hospitals, 1,120 were from trauma centers. The incidence of rejection because of HIV risk or infection was significantly higher in the trauma center group than in the group from non-trauma centers, 17.2% versus 10.2% (p less than 0.004). A similar difference was noted between metropolitan and suburban hospitals (p less than 0.0001). Hepatitis risk was comparable, 3.9% vs. 3.2%. The risk of HIV infection is emerging as a factor limiting organ donation at urban trauma centers.     

Vascular injuries in the urban battleground: experience at a metropolitan trauma center

The increasing frequency and severity of urban violence and vehicular injuries have brought with them a rise in the number of complex vascular injuries. To examine the cause, incidence, management, and outcome of this problem, we created a vascular trauma registry which includes all such cases treated at a Level I metropolitan trauma center over the past nine years. This constitutes a summary report of that registry. During the period 1979-1988, 411 patients (355 men, 56 women) with 478 vascular injuries were treated. There were 18 deaths (4%). Primary diagnosis was grouped by anatomic region: (1) head and neck vessels, 62 (15%); (2) thoracic, 39 (10%); (3) abdominal and pelvic, 63 (15%); (4) upper extremity, 161 (39%); and (5) lower extremity, 86 (21%). Surgery was required in 241 cases (60%). Operative techniques consisted of ligation or resection in 26 (12%) and direct repair in 212 (88%). Associated procedures included: (1) laparotomy (n = 83); (2) craniotomy (n = 4); (3) thoracotomy (n = 49); (4) orthopedic procedures (n = 118); and (5) peripheral neurological repair (n = 70). Mechanisms of injury were: (1) gunshot wounds (32%); (2) stab wounds (45%); (3) motor vehicle accidents (18%); (4) fall (3%); and (5) other mechanisms (2%). We conclude: (1) vascular injuries were found frequently in the severely injured patient; (2) multiple vascular repairs were required in a significant proportion of these patients; and (3) outcome is dependent more upon associated trauma than on the vascular injuries themselves.     

Impact of minimal injuries on a level I trauma center.

Overtriage (i.e.; transport of patients with minimal injuries to a trauma center) has been accepted as necessary to avoid missing clinically significant injuries. We reviewed our experience with 344 patients (ISS less than or equal to 4) who were admitted to a level I trauma center during a 2-year period. The trauma team was activated for 209 patients (TA), and emergency department referrals accounted for 135 (ED). One hundred seventy-three patients (TA = 64%, ED = 36%) met American College of Surgeons' Committee on Trauma (ACSCOT) field triage criteria (FTC). Mechanism of injury, especially ejection from a motor vehicle, was the most frequently utilized FTC indicator. We found no differences between the TA and ED groups relative to Trauma Score, Glasgow Coma Scale score, Injury Severity Score, length of stay, or ICU days. Mean total costs were higher for the TA group than for the ED group. The TA group had a higher nursing acuity level than the ED group. Compliance with FTC yields an inherent overtriage of minimally injured patients; however, noncompliance with FTC compounds the overtriage rate. Failure to comply with FTC is costly, labor intensive, and may represent misuse of the trauma system. We propose continual re-education of prehospital personnel, increased responsibility of all hospitals in the trauma center catchment area, and protocols for "downstaging" trauma resuscitation in minimally injured patients.     

The effect of trauma center designation and trauma volume on outcome in specific severe injuries

OBJECTIVE: The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries. BACKGROUND: Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated. METHODS: The National Trauma Data Bank study, which included patients >14 years of age and had injury severity score (ISS) >15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and II trauma centers and between centers within the same level designation but different volumes of severe trauma (<240 vs > or =240 trauma admissions with ISS >15 per year). The outcomes were adjusted for age (<65 > or =65), gender, mechanism of injury, hypotension on admission, and ISS (< or =25 and >25). RESULTS: A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71-0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44-0.69; P < 0.001) than level II centers. Subgroup analysis showed that cardiovascular injuries (N = 2004) and grades IV-V liver injuries (N = 1415) had a significantly better survival in level I than level II trauma centers (adjusted P = 0.017 and 0.023, respectively). Overall, there was a significantly better functional outcome in level I centers (adjusted P < 0.001). Subgroup analysis showed level I centers had significantly better functional outcomes in complex pelvic fractures (P < 0.001) and a trend toward better outcomes in the rest of the subgroups. The volume of trauma admissions with ISS >15 (<240 vs > or =240 cases per year) had no effect on outcome in either level I or II centers. CONCLUSIONS: Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation.     

Experience with railroad injuries at a major urban trauma center serving the United States-Mexico border

BACKGROUND: In the United States (US), railroads are commonly used to transport humans and commerce, especially along the US-Mexico border. Some people will use freight trains to travel within the US. Some of these people will suffer a train-related injury with extensive soft tissue and bone trauma. There is little information about the demographics, injuries, or outcomes of these patients, and the financial expense of providing care for these individuals. We attempt to provide insight into some of these issues. METHODS: We performed a retrospective chart review of patients from the University of Texas Health Science Center at San Antonio from January 1996 to September 2003. Various demographic, total hospital costs, operative procedures, and outcomes were examined. RESULTS: Men were well represented (61 of 67 patients), and the overall mean age was 28.8 years. Hispanics (58 of 67 patients) were the main ethnic group and 61% were undocumented aliens (41 of 67 patients). Bony and soft tissue injuries were common, necessitating an amputation in 38 patients. The mean operative procedures per patient were 2.97. Follow-up was poor. Total hospital cost for all the patients was $2,468,004.47 with a mean of $36,835.89 ($1,305.00-$331, 452.74) per patient. CONCLUSION: Victims of train-related injuries were predominantly young and male. Many patients required an amputation. Multistaged and complex reconstructive procedures may not be realistic in a group of patients in whom follow-up is poor.     

The impact of managed care and current governmental policies on an urban academic health care center

BACKGROUND: Managed care and governmental policies have restructured hospital reimbursement. We examined reimbursement trends in trauma care to assess the impact of this market driven change on an urban academic health center. METHODS: Patients injured between January 1997 and December 1999 were analyzed for Injury Severity Score (ISS), length of hospital stay, hospital cost, payer, and reimbursement. RESULTS: Between 1997 and 1999, the volume of patients with an ISS less than 9 increased and length of stay decreased. In addition, overall cost, payment, and profit margin increased. Commercially insured patients accounted for this margin increase, because the margins of managed care and government insured patients experienced double-digit decreases. Patients with ISS of 9 or greater also experienced a volume increase and a reduction in length of stay; however, costs within this group increased greater than payments, thereby reducing profit margin. Whereas commercially insured patients maintained their margin, managed care and government insured patients did not (double- and triple-digit decreases). CONCLUSIONS: Managed care and current governmental policies have a negative impact on urban academic health center reimbursement. Commercial insurers subsidize not only the uninsured but also the government insured and managed care patients as well. National awareness of this issue and policy action are paramount to urban academic health centers and may also benefit commercial insurers.     

Missed injuries in a level I trauma center

BACKGROUND: Major trauma presents major diagnostic and therapeutic problems. Any delay in providing the treatment necessary may lead to increased morbidity and mortality, prolonged length of hospital stay, and increased cost. This study was undertaken to determine the extent, contributing factors, and implication of missed injuries and relate them to the three surveys in a Danish Level I trauma center. METHODS: The records of all major traumatized patients admitted to the Odense University Hospital from January 1996 through December 1999 have been studied to determine the extent and type of missed injuries. The initial examination is carried out by the trauma team in the A&E department according to standard protocols. Resuscitation is carried out according to Advanced Trauma Life Support principles and details are documented in the patient journal and in a special trauma journal. RESULTS: Sixty-four of 786 patients (incidence, 8.1%) had 86 missed injuries. The missed injuries averaged 1.3 injuries per patient. There were 45 male and 19 female patients, with a median age of 33 years (range, 12-81 years). The median ISS was 17 (range, 4-50); 14%, 38%, and 48% of the injuries were missed in primary, secondary, and tertiary surveys, respectively. CONCLUSION: Our study demonstrates that missed injuries can occur at any stage of the management of patients with major trauma. Repeated assessments, both clinical and radiologic, are mandatory to diminish the problem. In initial assessment, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain throughout the patient's stay in hospital.