Improved Outcomes for Trauma Patients in a Military Treatment Facility After Initiation of an American College of Surgeons–Verified Trauma Program

ABSTRACT

Introduction

The National Defense Authorization Act of 2017 indicated the need for a national strategy to improve trauma care among military treatment facilities (MTFs). Part of the proposed strategy to improve trauma outcomes was to convert identified MTFs into verified trauma centers. The American College of Surgeons (ACS) verifies trauma centers through an evaluation process based on available resources at a facility. It has been proven that trauma centers, specifically those verified by the ACS, have improved trauma outcomes. In 2017, we implemented steps to become a level III trauma program, according to the standards for designation by the state and verification through the ACS. The goal of this retrospective review is to evaluate the impact of this implementation with regard to both patient care and the MTF.

Materials and Methods

Data from a single-MTF trauma registry from 2018, at the initiation of the trauma program, to present were reviewed. Outcomes were selected based upon the ACS verification criteria. Specifically, emergency department length of stay (ED LOS), nonsurgical admissions, injury severity score, diversion rates, and time to operating room were reviewed. Statistical analyses were performed using Student’s t-tests. Institutional review board (IRB) approval was not required for this study as it was performed as a quality improvement project using deidentified data.

Results

ED LOS decreased significantly after implementation of the trauma program from an average of 6.43 h in 2018 to 4.73 h in 2019 and 4.6 h in 2020 (P < .04). Nonsurgical admissions decreased significantly from 57.8% in 2018, with rates of <20% in all subsequent years (P < .01). The average injury severity score increased from 5.61 in 2018 to 7.52 in 2020 (P < .01) and 7.27 in 2021 (P < .01). Diversion rates also decreased from >5% in 2018 to 0% in 2021.

Conclusions

The establishment of a trauma program in accordance with the standards of the ACS for verification improved metrics of care for trauma patients at our MTF. This implementation as part of the local trauma system also led to increased injury severity seen by the MTF, which enhances readiness for its providers.

INTRODUCTION

The National Defense Authorization Act of 2017 indicated the need for a national strategy to improve trauma care among military treatment facilities (MTFs). Part of the proposed strategy to improve trauma outcomes was to convert identified MTFs into verified trauma centers, with the verification level determined by the capability of each facility. The American College of Surgeons (ACS) verifies trauma centers through an evaluation process based on available resources at a facility. It has been proven that trauma centers, specifically those verified by the ACS, have improved trauma outcomes.^1,2

In 2017, we implemented steps to become a level III trauma program, according to the standards for designation by the state and verification through the ACS. A staff surgeon was assigned the role of a trauma director, and a trauma program coordinator was hired. Our MTF established trauma activation criteria to ensure that all patients who might have suffered a traumatic injury undergo comprehensive evaluation upon presentation to the hospital. A total of 35 standard operating procedures for trauma were created. A trauma admission policy was established, prioritizing admission to a surgical service for any patient found to have a traumatic injury per the ACS protocol. Additionally, transfer agreements were formed with local trauma centers to ensure adequate care for patients who sustained injuries requiring capabilities not available at our MTF, such as neurosurgery. An active trauma registry was created, which allowed for data to be tracked and quarterly reports to be sent to the Defense Health Agency, the state of Georgia, the Joint Trauma System, and the National Trauma Data Bank. At the time of this study, our facility had completed the initial ACS consultative visit.

The goal of this retrospective review is to evaluate the impact of this implementation with regard to patient care metrics at our MTF. We hypothesize that initiation of trauma protocols, consistent with the requirements for ACS verification, would lead to improved metrics of care for trauma patients at our MTF.

METHODS

This study is a retrospective analysis of outcome data from a single-MTF trauma registry following the initiation of the trauma program. Data from 2018 to 2021 were reviewed. This includes all patients who met the established criteria for a level 1 or level 2 trauma activation, as well as patients for whom trauma consults were placed by the emergency department based on injuries diagnosed during their workup. There were no patients excluded from this analysis. All patient data were deidentified prior to analysis.

Outcomes were selected based upon the ACS verification criteria. Specifically, emergency department length of stay (ED LOS), nonsurgical admissions, injury severity score (ISS), diversion rates, and time to operating room (OR) were reviewed. ED LOS was defined as time from initial presentation to the ED until disposition, to include admission, transfer, or discharge. Nonsurgical admission was defined as an admission to a nonsurgical specialty, such as family medicine or internal medicine, serving as the admitting service (as opposed to the patient being admitted to trauma surgery or orthopedic surgery), excluding patients who were discharged home, were transferred to another facility, or died in the trauma bay. ISS was calculated by the trauma program coordinator following the completion of the trauma workup, based on the established formula developed by Baker et al.^3,4 Diversion rates were obtained by dividing the total time the MTF spent on trauma divert, measured in hours, by the total amount of hours in the year. All years were calculated to have 8,760 h, with the exception of 2020, which was calculated to have 8,784 h because it is a leap year. Time to the OR was defined as time from initial presentation until transfer to the OR or the interventional radiology (IR) suite, for patients who underwent emergent procedures.

Statistical Analysis

Initial analysis of quantitative variables (ED LOS, admission to nonsurgical surgical services, and ISS) was performed using analysis of variance (ANOVA). Data were categorized by the year of patient presentation. Further analysis was then performed using paired t-tests between years.

There were not enough patients who required emergent procedures over the course of the study to perform a valid statistical analysis of the data for time to the OR.

RESULTS

Data from trauma patients evaluated at our MTF from 2018 to 2021 were included in this study. A total of 392 patients were evaluated during this time period. The most trauma patients were evaluated in 2019, with a total of 107 patients (Table S1, Supplemental Material).

Emergency Department Length of Stay

Out of the 392 total patients included in the study, a total of 24 patients had incomplete data for ED LOS. Data were analyzed for a total of 368 patients. Of the 81 trauma patients who presented in 2018, the average ED LOS was 386.0 min (6.43 h). All subsequent years had a decreased average ED LOS (Fig. S1, Supplemental Material). The year with the shortest average ED LOS was 2020, with an average of 280.2 min (4.67 h).

An analysis of variance comparing the average ED LOS between each year noted a statistically significant difference between years (P = .02). Paired t-tests were then performed between the data from 2018 and each year following (Table S2, Supplemental Material). ED LOS was noted to be significantly reduced in 2019 (P = .04) and 2020 (P = .05), as compared to 2018. While ED LOS was noted to be decreased in 2021, there was no statistical significance from 2018 (P = .11).

Nonsurgical Admission Rate

Out of the 392 total patients included in the study, 315 patients were admitted to our MTF. Over the study time period, one patient was discharged home without admission, three patients were discharged to the institution that they presented from (such as a jail or a long-term care facility) without admission, and 73 patients were transferred to another hospital for care. There were a total of 85 patients admitted in 2018, 90 patients admitted in 2019, 67 patients admitted in 2020, and 73 patients admitted in 2021.

An analysis of variance comparing the rate of admission to a nonsurgical service between years was performed, which noted a statistically significant difference in the data set (P < .01). The rate of admission to a nonsurgical service was highest in 2018, with a rate of 57.6% (Fig. S2, Supplemental Material). Paired t-tests comparing 2018 to all subsequent years demonstrated significantly decreased rates of admission to nonsurgical services, with rates of 18.9% in 2019 (P < .01), 7.4% in 2020 (P < .01), and 16.4% in 2021 (P < .01) (Table S3, Supplemental Material).

Injury Severity Score

Out of the 392 total patients included in the study, 386 patients had a calculated ISS. The average ISS in 2018, among 95 patients, was 5.61. There were 107 patients with a calculated ISS in 2019, with an average score of 5.66. The average ISS increased in both 2020 (n = 85) and 2021 (n = 99), with averages of 7.52 and 7.27, respectively (Fig. S3, Supplemental Material).

An analysis of variance comparing the average ISS between years was performed, which noted a statistically significant difference in the dataset (P < .01). Paired t-tests comparing 2018 to all subsequent years demonstrated a significantly increased average ISS in 2020 (P < .01) and 2021 (P < .01) (Table S4, Supplemental Material). There was no statistically significant difference in the average ISS between 2018 and 2019 (P = .91).

Diversion Time

Data were not available for the total hours spent on trauma divert at our MTF in 2018; however, the MTF noted that it was on divert for >5% of the year. In 2019, the MTF was on trauma divert for 231.2 h. In 2020, the MTF was on trauma divert for 160.1 h. The MTF was not on trauma divert for the entirety of 2021. The percentage of time spent on divert decreased each year (Table S5, Supplemental Material).

Time to OR

A total of four patients required emergent procedures over the studied time period. Three of these patients went to the OR, whereas one went to the IR suite. One patient went to the OR in 2018, one patient went to the OR and one patient went to the IR suite in 2019, and one patient went to the OR in 2020. No patients underwent emergent procedures in 2021. The time to the OR in 2018 was 78 min. The average time to the procedure area (whether the OR or the IR suite) in 2019 was 176 min. The time to the OR in 2020 was 58 min. No statistical analysis was performed with these data, as there was not a sufficient sample size to produce a valid result.

DISCUSSION

The initiation of our trauma program followed the National Defense Authorization Act of 2017 mandate. The goal was for all MTFs to establish trauma programs, so as to improve outcomes for trauma patients seen at these facilities. There was a clear need, as our facility routinely treated trauma patients prior to initiation of a trauma program or the initiation of the ACS verification process. There are only two ACS-verified trauma centers within a 50-mi radius of our facility, which further highlights the need for quality trauma care at our facility.

There is a significant amount of data that demonstrate superior outcomes for ACS-verified trauma centers. Piontek et al. demonstrated a significant reduction in expected mortality rates, severity-adjusted length of stay, and readmission rates after ACS verification, as well as overall decreased patient costs.⁵ A more recent meta-analysis by Batomen et al. similarly showed decreased mortality associated with care at a verified trauma center.⁶ Currently, our facility mainly sees elderly trauma patients, and the observed effect is consistent in this patient population as well, as elderly patients seen at trauma centers demonstrated significantly better injury-adjusted mortality rates.⁷ However, to our knowledge, no studies specifically evaluating the improvement in trauma outcomes in military facilities following ACS verification have been performed.

Our study shows a similar effect to previous studies. The initiation of trauma protocols, consistent with the guidelines for ACS verification, led to significantly improved trauma metrics at our MTF. We were able to demonstrate significantly decreased ED LOS and significantly decreased rates of nonsurgical admissions, while simultaneously noting a significantly increased ISS. Additionally, initiation of trauma protocols led to increased preparedness of our facility to receive and resuscitate trauma patients, with steadily decreasing diversion times each year. Our data suggest that other military facilities will similarly benefit from the initiation of trauma protocols and ACS verification, consistent with data from civilian centers. This is notable, particularly because the general surgery department at our facility is staffed with active-duty general surgeons, all of whom have trauma experience and previous deployments. Our data highlight the importance of formal trauma protocols, even with experienced providers.

There is strong evidence of a relationship between improved trauma outcomes and increased patient volume. Nathens and Maier showed decreased relative odds of death and decreased length of stay in patients admitted to high-volume centers with shock following either penetrating abdominal injury or coma following multisystem blunt trauma.⁸ This is relevant to our study, as it is reasonable to assume that ACS verification would lead to increased patient volumes, as local Emergency medical services (EMS) services recognize our facility as capable of trauma care. As patient volumes increase, it is likely that patient outcomes would also improve. Notably, our data set did not differentiate between civilian and military patients, so it is unclear if initiation of trauma protocols led to an influx of civilian trauma patients.

Initiation of trauma protocols also led to subjective improvements noted by the surgery department. Resident consensus was that trauma activations ran more smoothly and were better staffed following the implementation of trauma protocols although no surveys were conducted to quantify this improvement. There was also perceived improvement in care of nontrauma acute surgical patients, such as decreased time to the OR, but this datum has not been investigated. Future studies to investigate for improvement in nontrauma acute surgical patient metrics are warranted to see if initiation of trauma protocols improves patient care more broadly within the military health system. No information about staff retention or staff recruitment is available, as the institution was under a hiring freeze during a portion of the study time frame.

This study has several limitations. First, it is retrospective in nature, which may lead to selection bias or confounders not identified in this study. Our data were limited by the small sample size for some data points, such as time to the OR, which limits the ability to draw conclusions from these data. Additionally, this study did not include patient outcome data, such as 30-day mortality or hospital length of stay. Therefore, the authors cannot definitively conclude that initiation of this trauma program decreased mortality or patient complications. Finally, this study did not stratify our data based on the level of trauma activation, which could potentially lead to different results. Future studies should be performed to analyze the impact on patient outcomes. These studies can also compare the differences in hospital metrics and outcome data based upon the level of trauma activation at the time of presentation, the mechanism of injury, and the patient’s injury complex or ISS.

CONCLUSION

The establishment of a trauma program, in accordance with the standards of the ACS for verification, improved metrics of care for trauma patients at our MTF. This implementation as part of the local trauma system may also lead to increased injury severity seen by the MTF, which enhances readiness for its providers.

SUPPLEMENTARY MATERIAL

Supplementary Material is available at Military Medicine online.

FUNDING

No funding was obtained for this project.

CONFLICT OF INTEREST STATEMENT

None declared.

REFERENCES

Author notes