Trauma Systems & Centres

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And that's my concern as well. I dont think shutting down small trauma centers is the solution to the problem. And I dont think that all big trauma centers are performing according to gold standards and that this translates to high quality. 
  One problem is that having low number of complications or low mortality rate does not always mean that the quality of care is high in a given trauma center. If you look at outcomes studies in trauma, you will see that there is a lot of variability in those measures that is likely due to some kind of heterogeneity across trauma centers (e.g., non-adherence to treatment or prophylaxis standards, certain beliefs or attitudes about pt management, different screening thresholds etc) due to which quality is not at a level it should be. 
  Although NSQIP and some other outcomes programs are doing a good job, we need something like Surgical Clinical Outcomes Assessment Program (SCOAP) where surgeons genuinely discuss the processes in their hospitals (e.g., whether guidelines are followed or not or what are the patterns in a given hospital that might be a thwart to actuall quality improvement etc) that is not a threat to small hospitals.
  And when I say 'we should bite the bullet' I speak of the ACS and trauma center regulating bodies, who should sit together and discuss matters. By 'increasing volume' I mean relative increase, ina sense that if you have trauma specialists in a given center, that center may get into registry as a certain level center (also depending on resources of course) and then they are more likely not to be bypassed when a trauma pt gets picked up by EMS, and more likely to receive that pt. This concerns small centers. 
  I think quality improvement is an important issue that needs more discussion and more in-depth analysis than what Quality Improvement programs are doing.
   
  Cheers
  KH
   
   
   
   
   What is interesting, is what the fate of small trauma centers will be.
> If, for a mere reason of low volume, they cannot meet the 'gold standard'
> (assuming that we've adjusted for other confounders) should they be shut
> down or penalized?


*A small trauma center that serves a large geographical area (albeit
probably sparsely populated) will never see enough patients to meet any one
of several proposed benchmarks, given a stable increase in local population
growth.  Shut them down and you are now forcing local EMS agencies to travel
much greater distances to deliver the injured to the 'nearest' trauma
center.  So ask yourself these questions: Can the local infrastructure
support this?  More helicopters, perhaps?  Will eliminating the local Level
II or III facility with 'low' numbers actually improve outcomes in these
patients who are now spending much more time in a pre-hospital setting due
to greater travel times to definitive care?  Will the  'gold standard'
destination trauma center cope well with the sudden increase in the number
of patients arriving at its door?  *


> Or should we bite the bullet, send specialists to these centers and try to
> increase the volume?


*Who is the 'we' of which you speak?  The American College of Surgeons?  The
local/state agencies that regulate trauma centers?  The nearest
University-affiliated teaching hospital?  The military?  And how do you
propose that trauma volume be increased?  How will any given geographic area
increase the incidence / prevalence of serious injury, outside of inciting
riots and dispensing free tequila and Glocks outside bars?*


> Finally, does meeting the 'gold standard' and becoming a center of
> excellence equal improved quality?


*Ahh...well, that depends on whom you read.  Practice does make perfect; the
question is, how much practice? *

>
>  KH
>

*CMU*


       
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