The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

The Covid-19 Pandemic: Lessons Learned for Sustained Trauma Preparedness and Responses

The emergence of coronavirus disease 2019 (COVID-19) that is caused by the SARS-CoV-2 virus has led to an overwhelming strain on healthcare delivery. This pandemic has created a sustained stress on the modern healthcare system, with unforeseen and potential drastic effects. Although the initial focus during this pandemic has been preparedness and response directed to the pandemic itself, traumatic injury has continued to remain a common problem that requires immediate evaluation and care to provide optimal outcomes. The State of Washington had the first reported case and death related to COVID-19 in the United States. Harborview Medical Center, which serves as the sole Level-1 adult and pediatric trauma center for the state, was rapidly affected by COVID-19, but still needed to maintain preparedness and responses to injured patients for the region. Although initially the focus was on the emerging pandemic on institutional factors, it became obvious that sustained efforts for regional trauma care required a more global focus. Because of these factors, Harborview Medical Center was quickly entrusted to serve as the coordinating center for the regions COVID-19 response, while also continuing to provide optimal care for injured patients during the pandemic. This response allowed the care of injured patients to be maintained within designated trauma centers during this pandemic. This present report summarizes the evolution of trauma care delivery during the first phase of this pandemic and provides informative recommendations for sustained responses to the care of injured patients during the pandemic based on lessons learned during the initial response.

Iodine Redistribution During Trauma, Sepsis, and Hibernation: An Evolutionarily Conserved Response to Severe Stress

OBJECTIVE

We performed these studies to learn how iodine in the form of free iodide behaves during stress.

DESIGN

Prospective observational trial using samples obtained from human trauma patients and retrospective observational study using remnant samples from human sepsis patients and arctic ground squirrels. Preclinical interventional study using hind-limb ischemia and reperfusion injury in mice.

SETTING

Level I trauma center emergency room and ICU and animal research laboratories.

SUBJECTS

Adult human sepsis and trauma patients, wild-caught adult arctic ground squirrels, and sexually mature laboratory mice.

INTERVENTIONS

Ischemia and reperfusion injury was induced in mice by temporary application of tourniquet to one hind-limb. Iodide was administered IV just prior to reperfusion.

MEASUREMENTS AND MAIN RESULTS

Free iodide was measured using ion chromatography. Relative to iodide in plasma from normal donors, iodide was increased 17-fold in plasma from trauma patients and 26-fold in plasma from sepsis patients. In arctic ground squirrels, iodide increases over three-fold during hibernation. And during ischemia/reperfusion injury in mice, iodide accumulates in ischemic tissue and reduces both local and systemic tissue damage.

CONCLUSIONS

Iodide redistributes during stress and improves outcome after injury. Essential functions of iodide may have contributed to its evolutionary selection and be useful as a therapeutic intervention for human patients.

Inter-rater reliability of the Abbreviated Injury Scale scores in patients with severe head injury shows good inter-rater agreement but variability between countries. An inter-country comparison study

INTRODUCTION

Substantial difference in mortality following severe traumatic brain injury (TBI) across international trauma centers has previously been demonstrated. This could be partly attributed to variability in the severity coding of the injuries. This study evaluated the inter-rater and intra-rater reliability of Abbreviated Injury Scale (AIS) scores of patients with severe TBI across three international level I trauma centers.

METHODS

A total 150 patients (50 per center) were randomly selected from each respective trauma registry: University Medical Center Utrecht (UMCU), the Netherlands; John Hunter Hospital (JHH), Australia; and Harborview Medical Center (HMC), the United States. Reliability between coders and trauma centers was measured with the intraclass correlation coefficient (ICC).

RESULTS

The reliability between the coders and the original trauma registry scores was 0.50, 0.50, and 0.41 in, respectively, UMCU, JHH, and HMC. The AIS coders at UMCU scored the most AIS codes of ≥ 4. Reliability within the trauma centers was substantial in UMCU (ICC = 0.62) and HMC (ICC = 0.78) and almost perfect in JHH (ICC = 0.85). Reliability between trauma centers was 0.70 between UMCU and JHH, 0.70 between JHH and HMC, and 0.59 between UMCU and HMC.

CONCLUSION

The results of this study demonstrated a substantial and almost perfect reliability of the AIS coders within the same trauma center, but variability across trauma centers. This indicates a need to improve inter-rater reliability in AIS coders and quality assessments of trauma registry data, specifically for patients with head injuries. Future research should study the effect of differences in AIS scoring on outcome predictions.

Transjugular intrahepatic portosystemic shunt for trauma?

We report a case of successful emergency TIPS placement to control intra-abdominal bleeding after blunt abdominal trauma in a patient with severe cirrhosis and portal hypertension.

The LIFE TRIAD of emergency general surgery

Emergency General Surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital by general emergency surgeons and other specialists. It is the most diffused surgical discipline in the world. To live and grow strong EGS necessitates three fundamental parts: emergency and elective continuous surgical practice, evidence generation through clinical registries and data accrual, and indications and guidelines production: the LIFE TRIAD.

Modulation of endotoxin-induced endothelial activity by microtubule depolymerization

BACKGROUND

Endotoxin not only activates the Toll-mediated signaling pathway within endothelial cells that leads to neutrophil migration but also causes the polymerization of microtubules. The potential role of this polymerization event, however, is unknown.

METHODS

Human umbilical vein endothelial cells stimulated with endotoxin were pretreated with or without the microtubule depolymerizing agent colchicine. Toll-mediated signaling events and protein production were in turn investigated by Western blot, gel shift, and enzyme-linked immunosorbent assay. Finally, neutrophil adhesion was assayed fluorometrically under the various conditions.

RESULTS

Endotoxin led to activation of the various Toll-mediated pathways, production of intercellular adhesion molecule-1 and interleukin-8, and subsequent neutrophil adhesion. Pretreatment with colchicine led to selective inhibition of anti-dual phosphorylated extracellular signal-regulated kinase-1/2, anti-dual phosphorylated c-jun N-terminal kinase, and adaptor protein-1; selective enhancement of p38; and no effect on nuclear factor-kappaB. This selective modulation of intracellular signaling resulted in attenuated intercellular adhesion molecule-1, interleukin-8 and prostaglandin E2 production, but enhanced cyclooxygenase-2 expression. As a result, microtubule disruption led to a significant reduction in neutrophil adhesion.

CONCLUSION

Microtubule formation is essential to optimal endotoxin-induced intracellular signaling through anti-dual phosphorylated extracellular signal-regulated kinase-1/2, anti-dual phosphorylated c-jun N-terminal kinase, and adaptor protein-1. Failure of these signaling events is associated with a marked reduction in the formation of a proadhesive phenotype that may prove to be beneficial in modulating neutrophil recruitment during sepsis.

Protein kinase C: a potential pathway of endothelial cell activation by endotoxin, tumor necrosis factor, and interleukin-1

Human endothelial cells exposed to lipopolysaccharide (LPS), tumor necrosis factor (TNF), or interleukin-1 (IL-1) in vitro acquire a cell surface property that promotes the adherence of neutrophils (PMNs). The common mechanism by which endothelial cells are activated by these agents is unknown. We examined adherence of PMNs to cultured human umbilical vein endothelium (HUVE) pretreated with LPS (100 ng/ml), TNF (100 U/ml), and IL-1 (1 U/ml) in medium alone or medium containing protein kinase inhibitors H-7 or HA-1004. Both compounds inhibit a similar spectrum of protein kinases, but H-7 is an effective inhibitor of protein kinase C, whereas HA-1004 is not. We found that H-7 (25 mumol/L) reduced the adherence of PMNs to LPS-, TNF-, and IL-1-stimulated HUVE monolayers to 16.7% +/- 3.0%, 12.1% +/- 2.5%, and 18.3% +/- 2.9% of control, respectively (mean plus or minus standard error of three experiments); HA-1004 (25 mumol/L) did not inhibit endothelial adhesiveness. Cytotoxicity of H-7 was less than 10% in LPS-, TNF-, and IL-1-treated HUVE. Protein synthesis, as measured by the incorporation of tritiated amino acids, was not significantly impaired in LPS-treated HUVE concurrently exposed to H-7. We conclude that protein kinase C appears to be a necessary common mediator of endothelial cell activation by LPS, TNF, and IL-1.

Ketoconazole inhibits alveolar macrophage production of inflammatory mediators involved in acute lung injury (adult respiratory distress syndrome)

BACKGROUND

Acute inflammatory lung injury (adult respiratory distress syndrome [ARDS]) causes significant morbidity and death in surgical patients. The alveolar macrophage elaborates proinflammatory mediators implicated in acute pulmonary injury. The macrophage products, leukotriene B4 (LTB4), thromboxane A2 (TXA2), and procoagulant activity (PCA), initiate inflammatory cascades that lead to microvascular thrombosis and neutrophil infiltration, two common features of ARDS. One potential method of preventing or attenuating lung injury is to inhibit the production of inflammatory mediators. Preliminary studies indicate that ketoconazole, known primarily for its antifungal properties, may prevent ARDS.

METHODS

LTB4, TXB2, and PCA production by rabbit alveolar macrophages was measured after treatment with endotoxin or Ca ionophore and ketoconazole or selective 5-lipoxygenase (MK 886) and thromboxane synthetase (imidazole) inhibitors.

RESULTS

Ketoconazole significantly inhibits alveolar macrophage production of LTB4, TXB2, and PCA. Ketoconazole inhibition of PCA is independent of effects on 5-lipoxygenase and thromboxane synthetase.

CONCLUSIONS

Ketoconazole inhibition of alveolar macrophage proinflammatory mediators may be of benefit in preventing ARDS by minimizing neutrophil infiltration and microvascular thrombosis. Inhibition of 5-lipoxygenase and thromboxane synthetase, without affecting cyclooxygenase, may offer a selective advantage by allowing production of other homeostatic eicosanoids.

Early management of adult traumatic spinal cord injury in patients with polytrauma: a consensus and clinical recommendations jointly developed by the World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS)

BACKGROUND

The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies.

METHODS

A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted.

RESULTS

A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak).

CONCLUSIONS

This consensus provides practical recommendations to support a clinician's decision making in the management of tSCI polytrauma patients.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.

GMM, Maegele M, Maggiore D, Magnone S, Maier RV, Maier RV, Major P, Manangi M, manetti A, Mantoglu B, Marafante C, Mariani F, Marinis A, Mariot ES, Marseglia GR, Martãnez-Pãrez A, Martines G, Perez AM, Martino C, Mascagni P, Massalou D, Matãas-Garcãa B, Mazzarella G, Mazzarolo G, Melo RB, Mendoza-Moreno F, Meric S, Meyer J, Miceli L, Michalopoulos NV, Milana F, Mingoli A, Mishra TS, Mohamed M, Mohamed MIEA, Mohamedahmed AY, Mohammed MJS, Mohan R, Moore EE, Morales-Garcia D, Muhrbeck M, Mulita F, Mustafa SMS, Muttillo EM, Naimzada MD, Navsaria PH, Negoi I, Nespoli L, Nguyen C, Nidaw MK, Nigri G, Nikolopoulos I, O’Connor DB, Ogundipe HD, Oliveri C, Olmi S, Ong ECW, Orecchia L, Osipov AV, Othman MF, Pace M, Pacilli M, Pagani L, Palomba G, Pantalone D, Panyko A, Paolillo C, Papa MV, Papaconstantinou D, Papadoliopoulou M, Papadopoulos A, Papis D, Pararas N, Parreira JG, Parry NG, Pata F, Patel T, Paterson-Brown S, Pavone G, Pecchini F, Pellino G, Pelloni M, Peloso A, del Pozo EP, Pereira RG, Pereira BM, perez AL, Perra T, Perrone G, Pesce A, Petagna L, Petracca G, Phupong V, Picardi B, Picciariello A, Piccoli M, Piccolo D, Picetti E, Pikoulis Pikoulis E, Pintar T, Pirozzolo G, Piscioneri F, Podda M, Porcu A, Privitera F, Punzo C, Quaresima S, Quiodettis MA, Qvist N, Rahim R, de Almeida FR, Ramely RB, Rasa HK, Reichert M, Reinisch-Liese A, Renne A, Riccetti C, Rodriguez-Luna MR, Roizblatt D, Romanzi A, Romeo L, Roscio FPM, Rosnelifaizur RB, Rossi S, Rubiano AM, Ruiz-Úcar E, Sakakushev BE, Salamea JC, Sall I, Samarakoon LB, Sammartano F, Arteaga AS, Sanchez-Cordero S, Santoanastaso DPM, Sasia D, Sato N, Savchuk A, Sawyer RG, Scaioli G, Schizas D, Sebastiani S, Seeliger B, Lohse HAS, Seretis C, Sermonesi G, Serradilla-Martin M, Shelat VG, Shlyapnikov S, Sidiropoulos T, Simoes RL, Siragusa L, Siribumrungwong B, Slavchev M, Solaini L, soldini G, Sopuev A, Soreide K, Sovatzidis A, Stahel PF, Strickland M, Sultan MAH, Sydorchuk R, Sydorchuk L, Syed SMAM, Syed AM, Tallon-Aguilar L, Tamburini AM, Tamini N, Tan ECTH, Tan JH, Tarasconi A, Tartaglia N, Tartaglia G, Tartaglia D, Taylor JV, Tebala GD, Gonsaga RAT, Teuben M, Theodorou A, Tolonen M, Tomasicchio G, Toro A, Torre B, Triantafyllou T, Trigiante Trigiante G, Tripepi M, Trostchansky J, Tsekouras K, Turrado-Rodriguez V, Tutino R, Uccelli M, Uchikov PA, Ugarte-Sierra B, Ukkonen MT, Vailas M, Vassiliu PG, Vazquez AG, Vazquez RG, Verde JE, Verde JM, Veroux M, Viganò J, Vilallonga R, Visconti D, Vittori A, Waledziak M, Wannatoop T, Widmer LW, Wilson MSJ, Wong TH, Xenaki S, Yu B, Yule S, Zachariah SK, Zacharis G, Zaghi C, Zakaria AD, Zambrano DA, Zampitis N, Zampogna B, Zanghã S, Zapsalis K, Zattoni F, Zese M, Farre SP, Atanasov BT, Pegoraro V, Zantedeschi M, Reitano E, Pizzocaro E. Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

BACKGROUND

Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.

METHODS

Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society's website, and shared on the society's Twitter profile.

RESULTS

A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.

DISCUSSION

Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Mitogen-activated protein kinases

The cellular control switches are regulated through an extensive network of interactive intracellular signal transduction pathways, such as the mitogen-activated protein kinase (MAPK) family. The MAPK pathways may play an important role in the inappropriate inflammatory responses that lead to systemic inflammatory response syndrome or multiple organ dysfunction syndrome. Therefore, elucidating the activation status of the MAPK pathways may be a method to identify patients at risk for systemic inflammatory response syndrome/multiple organ dysfunction syndrome. Also, manipulating the proper pathways may improve patients' outcomes. However, the MAPK family is part of a complex interactive network, which may initiate an unpredictable reaction to the indiscriminate inhibition or activation of a single component. A major challenge is to elucidate the principles by which the network is assembled, so a more tissue- and temporal-specific approach can be used.

Pulmonary effects of continuous endotoxin infusion in the rat

A major hindrance to the elucidation of the pathogenesis of the adult respiratory distress syndrome (ARDS) is the lack of an animal model consistent with the clinical course in humans. A continuous intravenous infusion of endotoxin (LPS) over a several day period was used to more closely parallel the clinical setting. Male Sprague-Dawley rats infused with LPS via indwelling right atrial catheters become tachypneic, lethargic and anorectic with a steady loss in body weight. Serial blood gas analyses demonstrate an early respiratory alkalosis followed by increasing acidosis and hypoxia. Lungs demonstrate 1) pulmonary leukoaggregation, 2) interstitial and intraalveolar edema, 3) Type I pneumocyte injury, 4) proliferation of Type II pneumocytes, and 5) thickening of the microvascular walls. Differential neutrophil count in bronchoalveolar lavage (BAL) fluid increased from 1% to a peak of 59.1% +/- 3.0% and protein content was elevated. A prolonged infusion of LPS in the rat produces a lung injury which mimics many of the pathophysiologic and histologic features associated with sepsis-induced ARDS in humans.

Retroperitoneal giant lymph node hyperplasia. A case report and review of the literature

Giant lymph node hyperplasia (GLNH) is a rare tumor. The authors have reviewed the literature and brought the reported total to 235 cases. There are two types of GLNH, a hyaline-vascular and plasma-cell type. The usual presentation is as an asymptomatic solitary mass, though multicentric lesions are found. Symptoms are most frequent with the plasma-cell type. A syndrome of anemia, growth retardation, and hypergammaglobulinemia is seen in the plasma-cell type in children. The etiology is unknown, though immunologic studies indicate a reactive phenomenon. Radiologic studies are nonspecific. Therapy is surgical excision, which is usually curative.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Cost estimates for statewide reporting of injuries by E coding hospital discharge abstract data base systems

A key element in the study of trauma problems is the design and development of adequate and affordable surveillance systems. One proposed method is the use of data available from hospital discharge abstract data base systems. However, surveillance systems based on existing data bases usually do not include codes that can identify the external causes of injuries, a critical limitation of the ability to determine the mechanisms of injuries. One obstacle to adding external cause of injury codes, known as E codes under the International Classification of Diseases, to uniform hospital discharge abstract data base systems is the cost of such a change. This study provided an estimate of the type and size of the costs for one State, based upon a survey of hospitals, information system vendors, and medical records experts. Two categories of the costs involved in adding E codes to hospital discharge abstract data base systems were identified. One-time implementation costs, which include modification of the computerized data base and the coding guidelines used by medical record personnel, average $600 per hospital. Annual costs resulting from increased operating expenses to include E codes average about $600 per hospital, because of the increased workload of coding and entry of the additional data. Adding E codes to hospital discharge abstract data base systems appears to be financially feasible for statewide surveillance of serious injury.

The relationship between trauma center volume and outcome

In spite of the limited direct evidence available, increasing data support a positive volume-outcome association in trauma care. When coupled with the extensive indirect data suggesting that regions with organized systems of trauma care are associated with lower trauma-related mortality rates than regions where the number of centers and their level of commitment are unlimited and untested, there is little doubt that experience improves outcome and that volume plays a critical role in the accrual of experience. Although regionalization of trauma care has the inevitable consequence of increased prehospital transport times, particularly in rural areas remote from large trauma centers, some states have designed inclusive systems where a large number of smaller centers have been verified and designated as lower level trauma centers (i.e., level 3-5). The process of trauma center verification holds these smaller volume centers to a standard of care such that the quality of care of the trauma patient may exceed that of other, less-regulated aspects of medical or surgical care. Several reports have suggested that trauma outcomes in smaller rural level 3 centers or centers with dedicated trauma programs with appropriate, functional triage protocols are comparable to national norms, thus reflecting the importance of commitment to outcome. These data suggest that quality of care does not only follow volume, particularly when stipulations and requirements are clear regarding the process of care and ongoing quality assurance.

Progress in the development of trauma systems in the United States. Results of a national survey

OBJECTIVE

To examine the status of trauma system development and key structural and operational characteristics of these systems.

DESIGN AND SETTING

National survey of trauma systems with enabling state statute, regulation, or executive orders and for which designated trauma centers were present.

PARTICIPANTS

Trauma system administrators and directors of 37 state and regional organizations that had legal authority to administer trauma systems, which represented a response rate of 90.2%.

MAIN OUTCOME MEASURES

Trauma system components that had been implemented or were under development.

RESULTS

From 1988 to 1993, the number of states meeting one set of criteria for a complete trauma system criteria increased from two to five. The most common deficiency in establishing trauma systems was failure to limit the number of designated trauma centers based on community need. Although most existing trauma systems have developed formal processes for designating trauma centers, prehospital triage protocols to allow hospital bypass, and centralized trauma registries, several systems lack standardized policies for interhospital transfer and systemwide evaluation.

CONCLUSION

State and regional organizations have accomplished a great deal but still have substantial work ahead in developing comprehensive trauma systems. Research is needed to better understand the relationship between trauma volume and outcomes of care as well as the impact of trauma system structure and operational characteristics on care delivery. Improved measures of patient outcome are also needed so that effective system evaluation can take place.