August 14, 2003

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Dedicated Trauma Program Improves Patient Outcomes

A dedicated trauma service staffed by full-time specialists at hospitals can significantly reduce patient triage times in the emergency department (ED), help reduce ED overcrowding and lower death rates, a Johns Hopkins study shows.

Researchers compared trauma registry data at The Johns Hopkins Hospital for the three-year time periods immediately before (1995-1997) and after (1999-2001) the hospital's 1998 implementation of a full-time trauma service. Their report is published in the August issue of the Archives of Surgery.

"In a community like ours, where 80 percent of trauma patients live within a five-mile radius of the hospital, and where every other night there is a patient who needs to go directly to the operating room, it is imperative to have trauma specialists available around the clock," says Edward E. Cornwell III, M.D., lead author of the paper and trauma chief at Johns Hopkins. "Sometimes by the time I get from my office to the ED in response to a call, the patient is already being brought in."

While physicians at The Johns Hopkins Hospital have always treated trauma patients, it was not until 1998 that the hospital was designated a Level I trauma center, featuring 24-hour, in-house coverage by an attending trauma surgeon, a dedicated two-bed trauma admitting unit and a regular trauma core curriculum for physicians, nurses and medical students.

The number of major trauma patients increased from 2,240 to 2,513 over the two time periods. The average time in the ED for patients going to the operating room, intensive care unit or observation wards all decreased significantly: from 84 minutes to 52 minutes for operating room patients, from 197 minutes to 118 minutes for intensive care unit patients, and from 300 minutes to 140 minutes for patients headed to the observation wards.

In addition, the number of hours that the trauma center was closed to new patients because of ED overcrowding also decreased significantly, from 56 hours to 2.7 hours per month. The time period after the hospital enhanced its commitment to trauma is associated with a 31 percent decrease in overall risk of death and a 42 percent decrease in risk of death among patients with severe head injuries.

The study also found a decline in hospital lengths of stay among trauma patients, from 4.3 days to 3.8 days, and a reduction in mortality rates among blunt trauma patients from 7.2 percent to 5 percent.

Cornwell noted that during the study period, gunshot wounds decreased in number but were more lethal. "All the resources in the world won't help that," he said.

"Each trauma center that treats large numbers of gunshot wound victims should have an active violence prevention program, working within the local community," he added. "True violence prevention cannot really be done in the hospital — it's like trying to give swimming lessons from the bottom of the pool."

Cornwell is working on several violence prevention initiatives, including bringing children in to the trauma unit to see gunshot wound and other trauma patients.

Study coauthors were David C. Chang, Ph.D., M.P.H., M.B.A.; Judith Phillips, R.N.; and Kurtis A. Campbell, M.D.

Cornwell, E.E. et al, "Enhanced Trauma Program Commitment at a Level I Trauma Center: Impact on the Process and Outcome of Care,"Archives of Surgery, August 2003, Vol. 138: pages 838-843.


Archives of Surgery


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