Emergency and Trauma systems

Active Projects

PI: Scott Lorch, MD, MSCE, Children's Hospital of Philadephia

The objective of this retrospective analysis is to identify the structures and processes of care that optimize outcomes of pediatric trauma patients, by obtaining an unbiased estimate of the relationship between structures, processes of care, and outcomes in pediatric trauma patients.

Impact of Pediatric Trauma Centers on Outcomes of Injured Children 

 

PI: Brendan Carr, MD, MA, MS, Thomas Jefferson University and Doug Wiebe, PhD, University of Pennsylvania

This project aims to develop an empirically defined geographic “denominator” that describes the population for which groups of hospitals share the responsibility of population health; to identify variability in acute care prevention quality indicators; and to inform how cooperation might be facilitated across the multisectoral health system.

The Geography of Acute Care

PI: Scott Halpern, MD, PhD, University of Pennsylvania

The primary goals are to determine which patients with ARF and/or sepsis benefit from ICU admission, and which emergency department, ward, and ICU characteristics and processes of care contribute to such net ICU benefits.

Benefits of ICU Admission for Patients with Acute Respiratory Failure or Sepsis

Publications

Funded by NIH, Leonard Davis Institute, and the Permanente Medical Group, Inc.

The objective of this retrospective analysis was to determine whether intensive care unit (ICU) capacity strain is associated with initial level of inpatient care and outcomes for emergency department (ED) patients being hospitalized for sepsis. The research team concluded the odds that patients in the ED with sepsis who do not require life support therapies will be admitted to the ICU are reduced when those ICUs experience high occupancy, but not high levels of other previously explored measures of capacity strain. Patients with sepsis admitted to the wards during times of high ICU occupancy had increased odds of hospital mortality

Funded by NIA & NICHD

Under the guidance of Dr. Delgado, LDI fellow Elinore Kaufman used State Emergency Department and Inpatient Databases for 6 states to conduct a retrospective cohort study of patients with severe, isolated head injury in elderly patients and compare outcomes between trauma and non-trauma centers. We found that patients with isolated, severe head injury have better outcomes if initially treated in designated trauma centers. 

Funded by NHLBI

Failure to rescue (FTR) is an outcome metric that reflects a center’s ability to prevent mortality after a major complication. We used data, prospectively collected from 2009 to 2013, on patients ≥16 years old with minimum Abbreviated Injury Score ≥2 from a single institution. Major complications (per Pennsylvania Trauma Systems Foundation definitions), mortality, and FTR rates were examined by location [prehospital, emergency department, operating room, intensive care unit (ICU), and interventional radiology] and by day post admission. FTR rates were highest early after injury, but the majority of cases occurred in the ICU. 

Funded by Robert Wood Johnson Foundation Physician Faculty Scholars Program

This study evaluated the cost-effectiveness of current field trauma triage practices compared with the national targets of ≥95% sensitivity and ≥65% specificity.  Incremental differences in survival, quality-adjusted life years, costs, and the incremental cost-effectiveness ratio were estimated for each triage strategy during a 1-year and lifetime horizon. This indicated that a high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective, but rather the most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.

Funded by NHLBI

Along with Doug Wiebe and Dan Holena, we tested the feasibility of applying the methodology recommended by the Trauma Quality Improvement Program to develop risk-adjusted mortality models for a statewide trauma system. We conducted a retrospective cohort study and the main outcome measure was observed-to-expected mortality ratios.  It is feasible to use Trauma Quality Improvement Program methodology to develop risk-adjusted models for statewide trauma systems. Even with smaller numbers of trauma centers that are available in national datasets, it is possible to identify high and low outliers in performance.

Funded by NHLBI

The current model of failure to rescue is defined as death after an adverse event. However this model lack face validity in trauma.  Using 3 years of single-state adult trauma registry from 30 trauma centers, we constructed a hybrid metric to exclude expected deaths but otherwise include patients without recorded adverse events in failure to rescue analysis to improve face validity and reliability to existing models. 

Funded by NHLBI

Under the guidance of Dr. Delgado, LDI fellow Elinore Kaufman compared police transport with ambulance transport using the Pennsylvania Trauma Outcomes study registry data from 2006-15 where bluntly injured adult patients transported to all 8 trauma centers in Philadelphia were identified. There were no significant differences presenting physiology between PT and EMS patients.Police transports affected a small minority of blunt trauma patients, and did not appear associated with higher mortality. However, PT patients included many who might have benefited from proven, prehospital intervention.

This study examined differences in regional patient boarding times across the United States and in regions at risk for public health emergencies. There was a retrospective cross-sectional analysis using two different ED databases, including spatial hot spot analysis to examine boarding time spatial clustering.  The outcome was that urban, coastal areas have the longest boarding times and are clustered with other high-boarding-time HRRs, which leads to a heightened level of vulnerability and a need to enhance surge capacity.  

Funded by NHLBI

The objective of this study is to look at injured patients transferred from one emergency department (ED) to another and to determine factors associated with being discharged from the second ED without procedures, admission, or observation.  Using multivariable hierarchical logistic regression, we found over a third of patients transferred to another ED for traumatic injury are discharged from the second ED without admission, observation, or procedures.  This led us to the conclusion that increasing access to hand, facial, neurosurgical, and ophthalmology specialists might reduce some of these transfers and the associated financial and logistical burdens on patients, physicians, and hospitals.

Funded by National Heart, Lung, and Blood Institute

We aimed to assess patient- and hospital-level variation for emergency department (ED) management of uncomplicated kidney stones.  Using ED visits and sample-weighted logistic regression to determine the association between hospital admission and having a urologic procedure with patient and hospital characteristics, we found that for patients with uncomplicated renal colic, there is variation in the management associated with nonclinical factors, namely insurance.

Funded by the National Heart, Lung, and Blood Institute

The failure to rescue (FTR) rate is the probability of death after a major complication and is defined in elective surgical cohorts.  This study hypothesized that the use of high quality data would result precedence rates in higher than those derived from national datasets and characterize the nature of those deaths not preceded by major complications.  This study used prospectively collected data from 2006 to 2010 from a single level I trauma centre.  We found that the use of data with near-complete ascertainment of complications results in precedence rates much higher than those from national datasets and patients were dying without precedent complications at our centre largely succumbed to progression of neurologic injury.

Funded by the United States National Heart, Lung, and Blood Institute 

The goal of this study was to determine which evidence-based geriatric protocols were correlated with decreased mortality in Pennsylvania's trauma centers.  The survey data was merged with risk-adjusted mortality data for patients ≥65 from a statewide database to compare mortality outlier status and processes of care. We found no link between adoption of geriatric best-practices trauma guidelines and reduced mortality at PA trauma centers. The increased susceptibility of elderly to adverse consequences of injury, combined with the rapid growth rate of this demographic, emphasizes the importance of identifying interventions tailored to this population.

Funded by National Center for Research Resources and the National Center for Advancing Translational Sciences

The goal of this study is to determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non–trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients.  This study was a retrospective analysis of the 2009 Nationwide Emergency Department Sample.  The study quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for various variables.  We found that patients with severe injuries initially evaluated at non–trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care; therefore, there should be efforts in monitoring and optimizing trauma interhospital transfers.

Funded by the Agency for Healthcare Research and Quality

This study aimed to develop and validate rates of potentially preventable emergency department (ED) visits as indicators of community health using empirical analyses and structured panel reviews.  It was found that ED Prevention Quality Indicators rates varied widely across U.S. communities. Indicator rates were significantly associated with county-level poverty, median income, Medicaid insurance, and levels of uninsurance; therefore, validating the hypothesis, in circumstances of public reporting, population health improvement, and research.

Funded by National Institute of Child Health & Human Development

Although forty percent of U.S. emergency departments report having an insurance linkage program, this is the first national study to examine the characteristics of EDs that offer or do not offer these programs.  This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008-09 that compared EDs with and without insurance programs across demographic and operational factors using univariate analysis.  Results concluded that availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED.

The goal of this study was to develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions. Using cross-sectional, retrospective, population-based analysis, we analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shape files for emergency care service regions.  We then created 10 emergency care service regions for Pennsylvania, allowing regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.

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Kit.Delgado@uphs.upenn.edu

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