Injury severity score, head injury, and patient wait days: contributions to extended trauma patient length of stay

Trauma patient heterotopic ossification diagnosis is associated with increased hospital length of stay

BACKGROUND

Traumatic heterotopic ossification (tHO) refers to the development of extra-skeletal bone in muscle and soft tissues following tissue insult secondary to surgery or trauma. This presents a persistent clinical concern associated with significant patient morbidity and expense to diagnose and treat. Traumatic HO is a substantial barrier to rehabilitation for trauma-injured patients. As such, the development of tHO after burn and other trauma is hypothesised to prolong inpatient length of stay (LOS) and thus increase health care costs.

OBJECTIVE

To investigate the association between an inpatient tHO diagnosis and hospital LOS in trauma patients.

METHODS

A retrospective audit of trauma patients over a 14-year period was completed using data from four WA hospitals. Burn and neurological trauma patients diagnosed with tHO as an inpatient (tHO+) and control subjects (tHO-), matched (1:3) by age, gender, and injury severity factors, were identified using medical diagnostic codes. Data relating to patient and injury-related determinants of LOS from tHO+ and tHO- subjects were analysed to model the association of tHO on total hospital length of stay.

RESULTS

188 identified patients were hospitalised due to traumatic injury; 47 patients with tHO following burn injury (n = 17), spinal cord injury (n = 13) and traumatic brain injury (n = 17), and 141 control patients. Those who developed tHO during hospitalisation had a significantly higher median LOS than matched trauma patients who did not develop tHO (142 days vs. 61 days). Multivariate regression analyses identified the following independent predictive factors of a prolonged hospital LOS: tHO diagnosis, mechanical ventilation hours, injury to the hip region and thigh area, other ossification disorder, pressure injury, admission to intensive care unit and deep vein thrombosis. Trauma patients diagnosed with tHO during their hospital admission stayed 1.6 times longer than trauma patients matched for injury severity without a tHO diagnosis (IRR 1.56, 95% CI 1.35-1.79, p<0.001).

CONCLUSION

Traumatic heterotopic ossification is an independent explanatory factor for increased hospital LOS in patients following burns, spinal cord, and traumatic brain injury. Early diagnosis may assist in reducing the impact of tHO on acute hospital stay after trauma.

Investigating Length of Stay Patterns and Its Predictors in the South Wales Trauma Network

Background

Length of stay (LOS) is frequently employed as a performance metric for trauma care. Following the establishment of the trauma network worldwide, the assessment and prediction of LOS in different levels of trauma centres have been extensively studied. However, assessing the total patient length of stay from a whole trauma network perspective is unclear. The objective of this study was to systematically analyse the overall Length of Stay (LOS) pattern within the SWTN before its establishment and in the immediate time after its foundation and, secondly, to assess the association between relevant impact factors and LOS.

Methodology

A retrospective secondary analysis based on the trauma admission dataset from Trauma Audit and Research Network(TARN) dataset was conducted. The studied sample covered around 18000 patients admitted to trauma centres from South Wales Major trauma network between January 2012 and October 2021. The primary outcome is the total length of stay in the trauma network. Statistical tests were applied to examine the difference between normal and outlier LOS. Data visualisation was utilised to demonstrate the LOS patterns and potential association between LOS and relevant demographic and clinical predictors.

Results

The distribution of length of stay in SWTN follows a right-skewed distribution with a median of 10 (IQR, 5-18) and a mean of 15.92 days. There were 1520 patients with outliers for LOS. A significant difference (p¡ 0.05) was found between the normal and outlier groups of LOS based on demographic (age, gender and residential information) and clinical characteristics(ward type, maximum of anatomically-based injury severity score(AIS) and probability of survival). Age group, maximum AIS score on specific injured region, ward type and its interaction effect with the number of admissions may associated with the LOS. Specifically, patients admitted to the geriatric ward exhibited notably prolonged LOS, and individuals with more than 2 admissions to long-term care and recovery-related wards such as neurosurgical rehabilitation, spinal injuries and burns wards also displayed elevated LOS.

Conclusion

Our finding supports prior evidence indicating elderly people are vulnerable to longer stays. Moreover, concerning the types of admission wards, patients admitted to rehabilitation wards who underwent more than 2 hospitalisations also faced an increased risk of prolonged stay. Based on these results, policymakers and healthcare providers should contemplate expanding the allocation of medical resources to this demographic to mitigate the length of stay and optimise associated healthcare costs.

What factors affect length of hospital stay among trauma patients? A single-center study, Southwestern Iran

PURPOSE

Trauma is a major health concern. Length of hospital stay (LOS) has been targeted as an important metric to assess trauma care. This study aims to evaluate the risk factors that affect LOS among trauma patients in a trauma center in Southwestern Iran.

METHODS

This cross-sectional study was conducted on patients admitted to Rajaee Trauma Center, Shiraz, Iran between January 1, 2018 and December 30, 2018. The inclusion criteria were age above 15 years and having traffic accident injuries, including car, motorcycle and pedestrian injury mechanisms. The exclusion criteria were existing diseases including cardiovascular, cerebral, renal, and pulmonary diseases prior to this study, dead upon arrival or within 48 h after admission, and stay at the hospital for less than 6 h. The risk variables analyzed for prolonged LOS were age, gender, mechanism of traffic accident injury, infection during hospital stay, type of injury, injury severity score, surgery during hospitalization, and survival. Poisson regression was performed to evaluate the partial effects of each covariate on trauma hospitalization (≥3 days as longer stay).

RESULTS

This study was conducted on 14,054 patients with traffic accident injury and the mean age was (33.89 ± 15.78) years. Additionally, 74.35% of the patients were male, with male to female ratio of 2.90. The result of Poisson regression indicated that male patients, higher age, combination of thoracic injuries, onset of infected sites, and surgery patients were more susceptible to have a longer LOS. Considering the site of injury, patients with face injuries followed by those with thorax injuries had the highest means of LOS (3.74 days and 3.36 days, respectively). Simultaneous existence of surgical intervention and infection in a patient had the greatest impact on prolonged LOS.

CONCLUSION

This study identified that age, gender, mechanism of injury, infection, type of injury, survival, and ISS could lead to prolongation of LOS, but the affect can be reduced by eliminating modifiable risk factors.

Resource use for older people hospitalised due to injury in a Canadian integrated trauma system: a retrospective multicenter cohort study

BACKGROUND

Injuries represent one of the leading causes of preventable morbidity and mortality. For countries with ageing populations, admissions of injured older patients are increasing exponentially. Yet, we know little about hospital resource use for injured older patients. Our primary objective was to evaluate inter-hospital variation in the risk-adjusted resource use for injured older patients. Secondary objectives were to identify the determinants of resource use and evaluate its association with clinical outcomes.

METHODS

We conducted a multicenter retrospective cohort study of injured older patients (≥65 years) admitted to any trauma centres in the province of Quebec (2013-2016, N = 33,184). Resource use was estimated using activity-based costing and modelled with multilevel linear models. We conducted separate subgroup analyses for patients with trauma and fragility fractures.

RESULTS

Risk-adjusted resource use varied significantly across trauma centres, more for older patients with fragility fractures (intra-class correlation coefficients [ICC] = 0.093, 95% CI [0.079, 0.102]) than with trauma (ICC = 0.047, 95% CI = 0.035-0.051). Risk-adjusted resource use increased with age, and the number of comorbidities, and varied with discharge destination (P < 0.001). Higher hospital resource use was associated with higher incidence of complications for trauma (Pearson correlation coefficient [r] = 0.5, 95% CI = 0.3-0.7) and fragility fractures (r = 0.5, 95% CI = 0.3-0.7) and with higher mortality for fragility fractures (r = 0.4, 95% CI = 0.2-0.6).

CONCLUSIONS

We observed significant inter-hospital variations in resource use for injured older patients. Hospitals with higher resource use did not have better clinical outcomes. Hospital resource use may not always positively impact patient care and outcomes. Future studies should evaluate mechanisms, by which hospital resource use impacts care.

Hospital and Intensive Care Unit Length of Stay for Injury Admissions: A Pan-Canadian Cohort Study

OBJECTIVE

To assess the variation in hospital and intensive care unit (ICU) length of stay (LOS) for injury admissions across Canadian provinces and to evaluate the relative contribution of patient case mix and treatment-related factors (intensity of care, complications, and discharge delays) to explaining observed variations.

BACKGROUND

Identifying unjustified interprovider variations in resource use and the determinants of such variations is an important step towards optimizing health care.

METHODS

We conducted a multicenter, retrospective cohort study on admissions for major trauma (injury severity score >12) to level I and II trauma centers across Canada (2006-2012). We used data from the Canadian National Trauma Registry linked to hospital discharge data to compare risk-adjusted hospital and ICU LOS across provinces.

RESULTS

Risk-adjusted hospital LOS was shortest in Ontario (10.0 days) and longest in Newfoundland and Labrador (16.1 days; P < 0.001). Risk-adjusted ICU LOS was shortest in Québec (4.4 days) and longest in Alberta (6.1 days; P < 0.001). Patient case-mix explained 32% and 8% of interhospital variations in hospital and ICU LOS, respectively, whereas treatment-related factors explained 63% and 22%.

CONCLUSIONS

We observed significant variation in risk-adjusted hospital and ICU LOS across trauma systems in Canada. Provider ranks on hospital LOS were not related to those observed for ICU LOS. Treatment-related factors explained more interhospital variation in LOS than patient case-mix. Results suggest that interventions targeting reductions in low-value procedures, prevention of adverse events, and better discharge planning may be most effective for optimizing LOS for injury admissions.

Transfusion of red blood cells in patients with traumatic brain injuries admitted to Canadian trauma health centres: a multicentre cohort study

BACKGROUND

Optimisation of healthcare practices in patients sustaining a traumatic brain injury is of major concern given the high incidence of death and long-term disabilities. Considering the brain's susceptibility to ischaemia, strategies to optimise oxygenation to brain are needed. While red blood cell (RBC) transfusion is one such strategy, specific RBC strategies are debated. We aimed to evaluate RBC transfusion frequency, determinants of transfusions and associated clinical outcomes.

METHODS

We conducted a retrospective multicentre cohort study using data from the National Trauma Registry of Canada. Patients admitted with moderate or severe traumatic brain injury to participating hospitals between April 2005 and March 2013 were eligible. Patient information on blood products, comorbidities, interventions and complications from the Discharge Abstract Database were linked to the National Trauma Registry data. Relative weights analyses evaluated the contribution of each determinant. We conducted multivariate robust Poisson regression to evaluate the association between potential determinants, mortality, complications, hospital-to-home discharge and RBC transfusion. We also used proportional hazard models to evaluate length of stay for time to discharge from ICU and hospital.

RESULTS

Among the 7062 patients with traumatic brain injury, 1991 patients received at least one RBC transfusion during their hospital stay. Female sex, anaemia, coagulopathy, sepsis, bleeding, hypovolemic shock, other comorbid illnesses, serious extracerebral trauma injuries were all significantly associated with RBC transfusion. Serious extracerebral injuries altogether explained 61% of the observed variation in RBC transfusion. Mortality (risk ratio (RR) 1.23 (95% CI 1.13 to 1.33)), trauma complications (RR 1.38 (95% CI 1.32 to 1.44)) and discharge elsewhere than home (RR 1.88 (95% CI 1.75 to 2.04)) were increased in patients who received RBC transfusion. Discharge from ICU and hospital were also delayed in transfused patients.

CONCLUSIONS

RBC transfusion is common in patients with traumatic brain injury and associated with unfavourable outcomes. Trauma severity is an important determinant of RBC transfusion. Prospective studies are needed to further evaluate optimal transfusion strategies in traumatic brain injury.

Hospital length of stay after admission for traumatic injury in Canada: a multicenter cohort study

OBJECTIVE

To describe acute care length of stay (LOS) over all consecutive hospitalizations for the injury and according to level of care [intensive care unit (ICU), intermediate care, general ward], compare observed and expected LOS, and identify predictors of LOS.

BACKGROUND

Prolonged LOS has important consequences in terms of costs and outcome, yet detailed information on LOS after trauma is lacking.

METHODS

This multicenter retrospective cohort study was based on adults discharged alive from a Canadian trauma system (1999-2010; n = 126,513). Registry data were used to calculate index LOS (LOS in trauma center with highest designation level) and were linked to hospital discharge data to calculate total LOS (all consecutive hospitalizations for the injury). Expected LOS was obtained by matching general provincial discharge statistics to study data by year, age, and sex. Potential predictors of LOS were evaluated using linear regression.

RESULTS

Mean index and total LOS were 8.6 and 9.4 days, respectively. ICU, intermediate care unit, and general ward care constituted 8.9%, 2.5%, and 88.6% of total hospital days. Observed mean index and ICU LOS in our trauma patients were 2.9 and 1.3 days longer than expected LOS (P < 0.0001). The strongest determinants of index LOS were discharge destination, age, transfer status, and injury severity.

CONCLUSIONS

Results suggest that acute care LOS after injury is underestimated when only information on the index hospitalization is used and that ICU or intermediate care constitute an important part of LOS. This information should be used to inform the development of an informative and actionable quality indicator.

Breaking down the barriers! Factors contributing to barrier days in a mature trauma center

BACKGROUND

As we enter the brave new world of the Patient Protection and Affordable Care Act of 2010, it is imperative that trauma centers provide not only excellent but also cost-effective trauma care. To that end, we sought to determine those factors that contribute significantly to barrier days (BDs), when a patient is medically cleared for discharge but unable to leave the hospital. We hypothesized that there would be significant demographic and payor factors associated with BDs.

METHODS

All trauma admissions to a Level II trauma center discharged alive from 2010 to 2012 were queried from the trauma registry. BDs were identified and recorded at daily sign-out. Patients with a hospital length of stay of 24 hours or less or transferred to another hospital were excluded. Univariate logistic regression was used to analyze which factors were significant (p ≤ 0.05) for BDs. Significant variables were then included in a multivariate logistic regression model.

RESULTS

A total of 3,056 patients were included in the study, 105 (3.44%) of whom had at least one BD. Multivariate analysis revealed that patients awaiting nursing home placement and rehabilitation placement were at 6.39 and 2.79 times higher odds of having significant barriers to discharge, respectively, compared with patients who were discharged home. The multivariate model also showed that Medicaid coverage, one or more comorbidities, Injury Severity Score of 9 or greater, and one or more ventilation days had a significant correlation with the incidence of BDs.

CONCLUSION

This study suggests that discharge destination is a significant factor associated with BDs. Understanding what type of patient is prone to develop barriers to discharge will allow case managers and social workers to intervene with discharge planning early in that patient's hospital course to secure placement and possibly reduce health care costs and improve functional outcome.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Early predictors of mortality after spine trauma: a level 1 Australian trauma center study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To identify early independent mortality predictors after spine trauma.

SUMMARY OF BACKGROUND DATA

Spine trauma consists of spinal cord and spine column injury. The ability to identify early (within 24 hours) risk factors predictive of mortality in spine trauma has the potential to reduce mortality and improve spine trauma management.

METHODS

Analysis was performed on 215 spine column and/or spinal cord injured patients from July 2008 to August 2011. Univariate and multivariate logistic regression models were applied to investigate the effects of the Injury Severity Score, age, mechanism of injury, blood glucose level, vital signs, brain trauma severity, morbidity before trauma, coagulation profile, neurological status, and spine injuries on the risk of in-hospital death.

RESULTS

Applying a multivariate logistic regression model, there were 7 independent early predictive factors for mortality after spine injury. They were (1) Injury Severity Score more than 15 (odds ratio [OR] = 3.67; P = 0.009), (2) abnormal coagulation profile (OR = 6; P < 0.0001), (3) patients 65 years or older (OR = 3.49; P = 0.007), (4) hypotension (OR = 2.9; P = 0.033), (5) tachycardia (OR = 4.04; P = 0.005), (6) hypoxia (OR = 2.9; P = 0.033), and (7) multiple comorbidities (OR = 3.49; P = 0.007). Severe traumatic brain injury was also associated with mortality but was excluded from multivariate analysis because there were no patients with this variable in the comparison group.

CONCLUSION

Mortality predictors for spine trauma patients are similar to those for general trauma patients. Spine injury variables were shown not to be independent predictors of spine trauma mortality.

Infectious complications after vehicular trauma in the United States

BACKGROUND

The purpose of this analysis was to evaluate and define the rates of infectious complications (IC) after vehicular trauma. Secondary goals were to identify the injuries associated with the greatest risk of nosocomial infection and to measure the utilization of hospital resources associated with IC and vehicular trauma.

METHODS

A secondary analysis of the Nationwide Inpatient Sample (2003-2007) was performed to classify major vehicular trauma injuries utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Emergency (E) codes. The post-traumatic IC evaluated were pneumonia, urinary tract infection (UTI), sepsis, and surgical site infection (SSI). All data were analyzed by χ(2) analysis, multivariable logistic regression, and the Cochran-Armitage test for trends.

RESULTS

A total of 784,037 vehicular trauma patients were identified (462,543 [59.0%] motor vehicle drivers, 142,283 [18.2%] motor vehicle passengers, 98,767 [12.6%] motorcyclists; 6,568 [<1%] motorcycle passengers, and 73,876 [9.4%] pedestrians). Of those sustaining injuries, 44,331 [5.7%] had post-traumatic IC. Pneumonia and UTI were most common after spinal cord injury (SCI), whereas sepsis and SSI were most common after colon injuries. After adjustment by age, sex, and co-morbidities, patients with SCI were 4.4 times as likely (95% confidence interval [CI] 4.20-4.63) and those with cranial injuries were 2.1 times as likely (95% CI 2.06-2.19) to develop IC as patients without these injuries. Secondary infection increased significantly the length of stay and hospital charges in all groups.

CONCLUSIONS

Patients sustaining vehicular trauma in combination with SCI had the highest rate of IC. Infectious complications increased hospital resource utilization significantly after vehicular trauma. Future root-cause analysis of high-risk groups may decrease complications and hospital utilization.

Wasted Hospital Days Impair the Value of Length-of-Stay Variables in the Quality Assessment of Trauma Care

Hospital length of stay (LOS) is frequently used to evaluate the quality of trauma care but LOS may be impacted by nonmedical factors as well. We reviewed our experience with delays in patient discharge to determine its financial consequences and its impact on LOS. We performed an analysis of linked trauma registry and “delayed discharge” databases. Actual LOS (A-LOS) values were compared with calculated ideal LOS (I-LOS) values, and the per cent increase in LOS was calculated. Linear regression analysis was used to identify significant predictors of prolonged LOS. One thousand, five hundred and seventeen patients were studied, with an A-LOS of 6.54 days. Seven per cent of patients experienced discharge delays, resulting in 580 excess hospital days. Calculated I-LOS was 6.15 days, 6.34 per cent lower than A-LOS. Other I-LOS estimates were as much as 25 per cent lower than A-LOS. Estimated excess patient charges associated with delayed discharges were $4,000,000 to $15,000,000. Discharge delays are an infrequent, although costly, occurrence that has a significant impact on LOS. LOS therefore may not be an appropriate metric for assessing the quality of trauma care, and should only be used if it has been corrected for discharge delays. Concerted efforts should be directed towards identifying and correcting the factors responsible for delayed discharge in trauma patients.

Reasons for delayed discharge of trauma patients

BACKGROUND

In the trauma population, increased length of stay is associated with age, comorbidities, and injury severity. We hypothesized that a significant contributor to a delay in length of stay was unrelated to these variables.

MATERIALS AND METHODS

All trauma patients admitted for > 48 h with acute injury from 7/1/2000 to 9/30/2000 were evaluated daily for discharge readiness. Actual discharge time was recorded from the time discharge orders were written. A discharge-ready patient not discharged within 24 h was a Delay discharge. Discharge delay was categorized as availability of rehabilitation beds, family reasons, or system-related delay. Payer was classified as commercial, government, Medicare, or uninsured. Actual hospital costs were used.

RESULTS

One hundred twenty-eight patients were evaluated; 30 patients had a delay in discharge. The average delay was 2 days (range 1-15 days). Mean hospital stay for Delay patients was 13.4 days, and 8.1 days for Timely patients (P < 0.05). Injury severity, age, and comorbidities were not different among groups. The main reason for delay was lack of a rehabilitation bed. Hospital costs were $39,013 per patient in the Delay group and $24,414 in the Timely group. Delay patients were more likely to be uninsured, have an orthopedic injury, and require ICU care.

CONCLUSION

Discharge delays significantly lengthen hospital stay for nonmedical reasons in trauma patients. Improved efficiency in a trauma system will require changes from acute care to rehabilitation.

The effect of polytrauma in persons with traumatic spine injury. A prospective database of spine fractures

STUDY DESIGN

A mixed cross-sectional survey and cohort study using a prospectively gathered database of persons with traumatic spine injury.

OBJECTIVES

To identify demographic and injury mechanism factors that predict greater injury severity, and to determine the effect of injury severity on outcomes in traumatic spine fracture.

SUMMARY OF BACKGROUND DATA

Traumatic spine fracture outcome studies have focused on defining type and level of vertebral fracture without considering the severity of associated injuries. In the trauma population, greater injury severity has been shown to be related to worse outcome. No studies have been reported on the effect of injury severity on outcome in the traumatic spine fracture population.

METHODS

Prospectively collected data on 830 persons with traumatic spine injury who were admitted to a trauma hospital were reviewed. Patient demographics; injury mechanism; hospital events; and disability, employment, and pain status at discharge, 1 year, and 2 years after injury were recorded. Associations between these factors and trauma severity (Injury Severity Score) were explored using Pearson's correlation and analysis of variance.

RESULTS

Trauma was more severe in patients who had been married previously, who were involved in a motor vehicle accident, were ejected from the vehicle, had loss of consciousness, had higher-level and multiple complicated vertebral fractures, or had neurologic deficit. Those more severely injured had longer lengths of stay, more surgery, more complications, higher mortality, more disability, and less return to work.

CONCLUSIONS

Persons with traumatic spine injury and polytrauma have poorer short- and long-term outcomes. This high-risk group may require aggressive interventions, more hospital resources, and close follow-up observation after discharge from hospital to optimize outcome.

Summary report: evidence for the effectiveness of rehabilitation for persons with traumatic brain injury

We evaluated the evidence for effectiveness of rehabilitation methods throughout the phases of recovery from traumatic brain injury (TBI) in adults. MEDLINE, HealthSTAR, CINAHL, PsycINFO, and the Cochrane Library were searched, and a total of 3,098 abstracts were reviewed. The strongest studies were critically appraised and their data placed in evidence tables. Results showed that to determine the effectiveness of rehabilitation interventions for persons with TBI, a commitment must be made to population-based studies, strong controlled research design, standardization of measures, adequate statistical analysis, and specification of health outcomes of importance to persons with TBI and their families.

[Is the metabolic response self-limited in head trauma? Analysis of acute phase proteins and glycemia]

There are many reports supporting a self-limitation mechanism involved with hypermetabolic response after severe cranial injury. It was proposed a study with severe head injury patients, in three stages of the evolution. The first 7 days after admission (moment 1-M1), the second three days latter (M2) and the last 7 days after the first (M3). Among male patients with severe head injury, attended between January 1992 and December 1993 in University Hospital of Botucatu, UNESP, were selected 28 male patients, with Glasgow severity scale between 4 and 6, with pO2 < 70 mm Hg, weighting 60 kg or more. Among these patients, 6 finished the study, including analysis of the excretion of N, acute phase proteins, glycemia, triglycerides and amine nitrogen. During the study there were no changes in nitrogen balance and there was a decrease in protein C-reative. Glycemia tends to fall within two weeks after injury. The authors make some considerations about possible mechanisms involved in brain modulation associated with the period of dependence of hypermetabolism and hypercatabolism after closed brain injury. There are some evidences that the brain responds to head trauma with a gobal non specific way, which tends to be reorganized beyond the first two weeks after lesion. The study does not show any influence of the type and severity of head trauma.

Modeling injury outcomes using time-to-event methods

BACKGROUND

Mortality is an important measurement of injury outcomes, but measurements reflecting disability or cost are also important. Hospital length of stay (LOS) has been used as an outcome variable, but reduced LOS could be achieved either by improved care or by increased mortality. A solution to this statistical problem of "competing risks" would enable injury outcomes based on LOS to be modeled using time-to-event methods.

METHODS

Time-to-event methodology was applied to 2,106 cases with complete data from the 1991-1994 registry of a regional trauma center. LOS was used as the outcome variable, modified by assigning an arbitrarily long LOS to any fatal case. A combination of proportional hazards and logistic regression models was used to explore the effects of potential predictive variables, including Trauma Score (TS), Injury Severity Score (ISS), components of TS or ISS, age, sex, alcohol use, and whether a patient was transferred.

RESULTS

The "TRISS" combination of TS, ISS, and age previously shown to predict mortality also predicted "modified LOS" (Wald p value less than 0.001 for each variable). Models using only age and certain components of ISS or TS fit our data even better, with fewer parameters. Other variables were not predictive. Modified Kaplan-Meier plots provided easily interpreted graphical results, combining both mortality and LOS information.

CONCLUSIONS

With a simple modification to allow for competing risks, time-to-event methods enable more informative modeling of injury outcomes than binary (lived/died) methods alone. Such models may be useful for describing and comparing groups of hospitalized trauma patients.

Cost effectiveness in trauma care

The above discussion brings together a vast body of data that together proclaim with fervent clarity: Traumatic injuries are expensive. The expense is paid in productive lives lost, in permanent disability, in pain and suffering, and in health care resources consumed. As local and regional trauma systems struggle for development and survival, competition for the health care dollar casts in the additional necessity of providing the service of trauma care with maximum efficiency. Despite the variety of cost-efficiency measures described above, a majority of trauma centers continue to operate "in the red." Such cannot continue indefinitely. Fiscal responsibility dictates that health care institutions must balance budgets in order to maintain operations. Four primary strategies for cost containment appear from the above discussion: 1. Improve reimbursement rates from trauma patients. 2. Increase outside funding from government sources. 3. Improve cost efficiency of diagnostic and therapeutic procedures used in trauma patient management. 4. Increase efforts aimed at primary prevention of intentional and unintentional injuries. In the final analysis, most authors agree that the last strategy offers the best hope. As stated in their article, "The Economic Impact of Injuries," Harlan and colleagues conclude that "the most effective medical and cost reduction strategy would be prevention." The same article goes on to detail how greater funding for research into optimal prevention modalities could reap societal and economic benefits far beyond the value of the initial outlay. Yet such research funding continues to be inadequate. For every dollar spent on medical care of cancer patients, nine cents is directed to research. For every dollar spent on trauma care, less than a penny is spent on research. Until the public recognizes the terrible toll trauma extracts in lives, livelihood, and money wasted and until it realizes the pre-eminent importance of prevention, care of the trauma patient cannot truly achieve cost efficiency.