Search

Trauma systems provide an organized approach to the care of injured patients within a defined geographic region. When fully operational, the systems ensure a continuum of care involving public access through 911 calls, emergency medical services, timely triage and transport to acute care, and transfer to rehabilitation services. Substantial progress has been made in establishing statewide trauma systems, which are seen as the prototype for regionalized care for other time-sensitive, emergency conditions such as stroke. Trauma systems provide a model of care that is consistent with the goals of the Affordable Care Act, which authorizes $100 million in annual grants to ensure the continued availability of trauma services. Full funding of these provisions is needed to stabilize statewide systems that are struggling to survive. We describe the components of a regionalized trauma system, review the evidence in support of this approach, and discuss the challenges to sustaining systems that are accountable and affordable.

Background and Objectives: HydroMARK® is a newly available biopsy marker for image-guided needle biopsies of non-palpable breast lesions. Objective was to determine if the marker could be utilized independently for lesion localization using intra-operative ultrasound alone., Methods: A single institution retrospective review identified patients who underwent surgical excision of breast lesions after placement of the HydroMARK®. Endpoints included intra-operative visualization of the marker, successful excision of the lesion, and presence of the marker on specimen radiograph., Results: The study included 31 lesions in 25 patients. Twenty-nine (93.6%) HydroMARKSs® were adequately visualized by intra-operative ultrasound. Intra-operative ultrasound without pre-operative placement of a localizing device was successful for localization in six cases (19.4%). Intra-operative difficulties were encountered in 16 of 31 (51.6%) procedures. This included either extrusion of the marker when the biopsy tract was transected in 14 (45.2%) cases or migration of the marker prior to the procedure in two (6.4%) cases. The marker was visualized on specimen radiograph in 15 (48.4%) cases., Conclusions: While intraoperative sonographic visibility was excellent, a large number of excisions were associated with extrusion of the marker. Modifications are needed to improve acceptability of this marker for intra-operative localization independent of pre-operative wire or seed localization., (Copyright © 2011 Wiley Periodicals, Inc.)

Background: The role of air medicine in traumatic brain injury (TBI) has been studied extensively using trauma registries but remains unclear. Learning algorithms, such as artificial neural networks (ANN), support vector machines (SVM), and decision trees, can identify relationships between data set variables but are not empirically useful for hypothesis testing., Objective: To use ANN, SVM, and decision trees to explore the role of air medicine in TBI., Methods: Patients with Head Abbreviated Injury Score 3+ were identified from our county trauma registry. Predictive models were generated using ANN, SVM, and decision trees. The three best-performing ANN models were used to calculate differential survival values (actual and predicted outcome) for each patient. In addition, predicted survival values with transport mode artificially input as "air" or "ground" were calculated for each patient to identify those who benefit from air transport. For SVM analysis, chi was used to compare the ratio of unexpected survivors to unexpected deaths for air- and ground-transported patients. Finally, decision tree analysis was used to explore the indications for various transport modes in optimized survival algorithms., Results: A total of 11,961 patients were included. All three learning algorithms predicted a survival benefit with air transport across all patients, especially those with higher Head Abbreviated Injury Score or Injury Severity Score values, lower Glasgow Coma Scale scores, or hypotension., Conclusion: Air medical response in TBI seems to confer a survival advantage, especially in more critically injured patients.

Motor vehicle rollover crashes result in complex occupant kinematics with the potential for severe injury. Five cases of fatal asphyxia in occupants suspended from their safety belt upside down after a rollover crash are presented. These fatalities accounted for 13.5% of all motor vehicle related asphyxia deaths in San Diego County over a 10-year period. This study supports previous research noting that incapacitation due to other injuries, alcohol, or obesity may be associated with fatal positional asphyxia due to inversion during rollovers. Safety belts are proven to prevent serious injury in motor vehicle crashes and should always be worn. However, redesign of the buckle could be considered to permit easier release by an occupant. We also suggest that pre-existing heart disease may contribute to the possibility of a fatal asphyxia outcome. Although this is a rare cause of motor vehicle related death, our results suggest that these are potentially preventable deaths.

Background: Liver injuries (LIs) are one of the most serious and common consequences of motor vehicle crashes (MVCs). In the unstable patient, early detection of LI based on clinical suspicion will improve acute trauma care and outcomes. The specific objectives of this analysis are to identify crash scene and occupant risk factors for LI from MVC., Methods: Crash Injury Research and Engineering Network data were used to identify risk factors for LI; age, sex, safety belt use, air bag deployment, DeltaV (change in velocity), principal direction of force, vehicle crush, and intrusion. Occupants with LI were compared with four control groups without LI; (1) no abdominal (ABD) injury (NO&#95;ABD), (2) any ABD (ANY&#95;ABD), (3) ABD Abbreviated Injury Scale score of 1 to 2 (ABD&#95;1-2), and (4) ABD Abbreviated Injury Scale score of 3 or more (ABD&#95;3+). LI occupants were compared with each control group and odds ratios (OR) for risk of LI were computed., Results: There were 311 Crash Injury Research and Engineering Network subjects aged 5 or more years with LI. The total mean Injury Severity Score was 37.6. LI was strongly and significantly associated with safety belt restraint use without air bag deployment, compared with each control group: Liver injury - restrained + air bag not deployed versus (1) NO&#95;ABD, N = 1,519; OR = 4.4, (2) ANY&#95;ABD, N = 317; OR = 2.6, (3) ABD&#95;1 to 2, N = 155; OR = 3.1, (4) ABD&#95;3+, N = 217; OR = 2.4 (p < 0.001). This association was independent of driver or passenger status and principal direction of force. LIs were also strongly and significantly associated with greater vehicle interior intrusion., Conclusions: LIs were strongly associated with a safety belt restraint in use in the absence of air bag deployment during MVC. This data may have profound importance to the trauma surgeon as an early indicator for LI during resuscitation. These findings also have important implications for future research efforts to improve safety systems in motor vehicles and reduce morbidity and mortality from MVCs in the United States.

The calcaneous is the largest tarsal bone in the foot and plays an important role in walking and running. Motor vehicle crashes and falls from elevation have been associated with calcaneal fractures. Although not life-threatening, these injuries may result in permanent disability. This study used the Crash Injury Research and Engineering Network (CIREN) database to describe calcaneal fractures and concomitant lower extremity skeletal injury patterns for occupants involved in motor vehicle crashes. Sixty-three drivers and 7 front row passengers with calcaneal fractures were identified in the CIREN database during 1997-2005. Almost all these occupants were involved in severe (based on the delta V and vehicle crush) frontal or off-set frontal crashes with toe pan intrusion. Eighty-four percent of the calcaneal fractures were intra-articular or partially articular. Overall, 93% of occupants also had injury to other body regions with 84% having other lower extremity fractures. One year after the crash, most occupants had not returned to their prior level of physical functioning. Surgically managing patients with calcaneal fractures for an optimal outcome remains a challenge for orthopedic surgeons. Because lower extremity injuries, including calcaneal fractures, may cause permanent disability, it is important to prevent these injuries through structural improvements in motor vehicle design.

Background: Traumatic cardiac and thoracic aortic injuries are hypothesized to result from rapid deceleration of occupants during a motor vehicle crash. The purpose of this study was to identify potential risk factors for motor vehicle-related cardiac and thoracic aortic (HTA) injury using the Crash Injury Research Engineering Network (CIREN) database., Methods: CIREN data were used to test the hypothesis that there is no difference between occupants with HTA injury and occupants with thoracic injury other than the heart or aorta (non-HTA). Occupant variables (restraint use, airbag deployment, Glasgow Coma Scale score, Injury Severity Score, concomitant injuries, driver versus passenger status, height, and comorbidity) and crash variables (principal direction of force, change in velocity, vehicle crush, intrusion, and vehicle type) were compared for these two groups. Odds ratios were used to quantify the potential risk factors for HTA injury compared with non-HTA injury., Results: There were 168 occupants with an HTA injury and 731 with a non-HTA injury. Greater crash severity (based on vehicle crush and change in velocity), improper safety belt use, and lack of safety belt use were significantly associated with HTA injury. Unrestrained occupants had almost three times the chance of having an HTA injury (odds ratio = 2.86; p < 0.05). For restrained drivers, 41.4% of HTA injuries were caused by vehicle interior components. When not protected by both safety belts and air bags, 45.7% of driver HTA injuries were caused by the steering wheel. For passengers, the vehicle interior (armrests, side interior, and B-pillars) accounted for most HTA injuries regardless of safety system status. More than half of all occupants wearing safety belts who sustained an HTA injury were improperly wearing their safety belts., Conclusion: The high mortality associated with cardiac and aortic injuries supports the need to prevent these injuries from occurring during motor vehicle crashes. These results suggest proper use of safety belts is necessary to prevent cardiac and thoracic aortic injuries. However, other important potential risk factors, such as motor vehicle size and crash severity, might continue to present a challenge to motor vehicle safety professionals.

The purpose of this research was to determine occupant, vehicle, and crash characteristics predicting serious injury during rollover crashes. We compared 27 case occupants with serious or greater severity injuries with 606 control occupants without injury or with only minor or moderate injury. Odds ratios (OR) for individual variables and logistic regression were used to identify predictive variables for serious injury associated with rollovers. Cases more often had thorax, spine, or head injury compared to controls that more often had extremity injuries. Intrusion (especially roof rail or B-pillar intrusion) at the occupant's position, the vehicle interior side and roof as sources of injury, and improper safety belt use were significantly associated with serious injury. Even when safety belt use or proper use was controlled for, occupants with greater magnitude of intrusion at their seat position were about 10 times more likely to receive serious injury. Although prevention of rollover crashes is the ultimate goal, it is important to develop safer vehicles and safety systems to better protect occupants who are involved in rollover crashes. This also requires improvement in data collection systems documenting these types of crashes.

Background: Glasgow Coma Scale (GCS) scores are widely used to quantify level of consciousness in the prehospital environment. The predictive value of field versus arrival GCS is not well defined but has tremendous implications with regard to triage and therapeutic decisions as well as the use of various predictive scoring systems, such as Trauma Score and Injury Severity Score (TRISS). This study explores the predictive value of field GCS (fGCS) and arrival GCS (aGCS) as well as TRISS calculations using field (fTRISS) and arrival (aTRISS) data in patients with moderate-to-severe traumatic brain injury (TBI)., Methods: Major trauma victims with head Abbreviated Injury Scores of 3 or greater were identified from our county trauma registry over a 16-year period. The predictive ability of fGCS with regard to aGCS was explored using univariate statistics and linear regression modeling. The difference between aGCS and fGCS was also modeled against mortality and the composite endpoint using logistic regression, adjusting for fGCS. The predictive value of preadmission GCS (pGCS), defined as either fGCS or aGCS in nonintubated patients without a documented fGCS, with regard to mortality and a composite endpoint representing the need for neurosurgical care (death, craniotomy, invasive intracranial pressure monitoring, or intensive care unit care >48 hours) was determined using receiver-operator curve (ROC) analysis. Finally, fTRISS and aTRISS predicted survival values were compared with each other and to observed survival., Results: A total of 12,882 patients were included. Mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336), and a strong correlation (r = 0.67, 95% CI 0.66-0.69, p < 0.0001) was observed between them. The difference between fGCS and aGCS was also predictive of outcome after adjusting for fGCS. Good predictive ability was observed for pGCS with regard to both mortality and neurosurgical intervention. Both fTRISS and aTRISS predicted survival values were nearly identical to observed survival. Observed and fTRISS predicted survival were nearly identical in patients undergoing prehospital intubation, Conclusions: Values for fGCS are highly predictive of aGCS, and both are associated with outcome from TBI. A change in GCS from the field to arrival is highly predictive of outcome. The use of field data for TRISS calculations appears to be a valid methodological approach, even in severely injured TBI patients undergoing prehospital intubation.

Gender differences in outcomes from major trauma have been described previously, and exogenous female hormone administration appears to be neuroprotective following traumatic brain injury (TBI). This analysis explored outcomes in pre- and post-menopausal females versus age-matched males. A total of 13,437 patients (n = 3,178 females, n = 10,259 males) with moderate-to-severe TBI (head AIS > or = 3) were identified from our county trauma registry. Overall mortality was similar between males and females (22% for both). Logistic regression was used to compare gender outcome differences, with a separate analysis performed for premenopausal (< 50 years) versus postmenopausal (> or = 50 years) patients, and after stratification by decade of life. No statistically significant difference in outcomes was observed for pre-menopausal females versus males (odds ratio [OR] 1.06; 95% confidence interval [CI] 0.83, 1.35; p = 0.633), but outcomes were significantly better in postmenopausal females versus males (OR 0.63, 95% CI 0.48-0.81, p < 0.001) after adjusting for age, mechanism of injury, Glasgow Coma Scale (GCS), hypotension (SBP < or = 90 mm Hg), head Abbreviated Injury Score (AIS), and Injury Severity Score (ISS). Stratification by decade of life revealed the gender survival differential inflection point to occur between ages 40-49 (OR 1.06, 95% CI 0.66-1.71, p = 0.798) and ages 50-59 (OR 0.38, 95% CI 0.20-0.74, p = 0.005). In addition, Revised Trauma Score and Injury Severity Score (TRISS) was used to calculate probability of survival (PS); all patients were then stratified by decade of life, and males and females were compared with regard to mean survival differential (outcome - PS). The identical pattern of improved outcomes in post-menopausal but not pre-menopausal females versus age-matched males was observed. These data suggest that endogenous female sex hormone production is not neuroprotective.

Study Objective: Aeromedical crews offer an advanced level of practice and rapid transport to definitive care; however, their efficacy remains unproven. Previous studies have used relatively small sample sizes or have been unable to adequately control for the effect of other potentially influential variables. Here we explore the impact of aeromedical response in patients with moderate to severe traumatic brain injury., Methods: This was a retrospective analysis using our county trauma registry. All patients with head Abbreviated Injury Score of 3 or greater were included; interfacility transfers were excluded. The impact of aeromedical response was determined using logistic regression, adjusting for age, sex, mechanism, preadmission Glasgow Coma Scale score, head Abbreviated Injury Score, Injury Severity Score, and the presence of preadmission hypotension. Propensity scores were used to account for variability in selection of patients to undergo air versus ground transport. Patients with moderate and severe traumatic brain injury, as defined by head Abbreviated Injury Score and Glasgow Coma Scale score, were compared. Finally, aeromedical patients undergoing field intubation were compared with ground patients undergoing emergency department (ED) intubation., Results: A total of 10,314 patients meeting all inclusion and exclusion criteria and with complete data sets were identified and included 3,017 transported by aeromedical crews. Overall mortality was 25% in the air- and ground-transported cohorts, but outcomes were significantly better for the aeromedical patients when adjusted for age, sex, mechanism of injury, hypotension, Glasgow Coma Scale score, head Abbreviated Injury Score, and Injury Severity Score (adjusted odds ratio [OR] 1.90; 95% confidence interval [CI] 1.60 to 2.25; P<.0001). Good outcomes (discharge to home, jail, psychiatric facility, rehabilitation, or leaving against medical advice) were also higher in aeromedical patients (adjusted OR 1.36; 95% CI 1.18 to 1.58; P<.0001). The primary benefit appeared to be in more severely injured patients, as reflected by head Abbreviated Injury Score and Glasgow Coma Scale score. Improved survival was also observed for air-transported patients intubated in the field versus ground-transported patients given emergency intubation in the ED (adjusted OR 1.42; 95% CI 1.13 to 1.78; P<.001)., Conclusion: Here we analyze a large database of patients with moderate to severe traumatic brain injury. Aeromedical response appears to result in improved outcomes after adjustment for multiple influential factors in patients with moderate to severe traumatic brain injury. In addition, out-of-hospital intubation among air-transported patients resulted in better outcomes than ED intubation among ground-transported patients. Patients with more severe injuries appeared to derive the greatest benefit from aeromedical transport.

Objective: A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome., Methods: A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection., Results: Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2. 4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5. 1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning., Conclusions: Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.

Prophylaxis for stress ulceration is considered standard care for most critically ill patients, but may be overutilized. We determined the incidence of stress ulceration in 33,637 major trauma patients treated in a regionalized trauma system from 1985 to 1991 using trauma registry data and chart review. Injury-related risk factors for stress ulceration and other associated infectious and organ failure complications were identified by regression analysis. Clinical stress ulceration developed in 57 patients (0.17%) despite prophylaxis. Eighteen patients (0.05%) developed severe ulceration with either gastroduodenal perforation (3 patients) or a > 2 U blood transfusion requirement (16 patients). Independent risk factors with odds ratios (OR) were identified as follows: Injury Severity Score (ISS) > or = 16, OR = 12.6; spinal cord injury, OR = 2.0; and age > 55, OR = 2.4. Other serious complications, including pneumonia, sepsis, and organ failure (adult respiratory distress syndrome and renal and hepatic failure), were significantly associated with the development of stress ulceration. Clinically significant stress ulceration after trauma is uncommon, but occurs despite prophylaxis. Severe injury (ISS > 16) and spinal cord injury were identified as independent injury-related risk factors. All patients with severe ulceration had either one of these injury-related risk factors or a significant infectious complication or organ failure. Standard prophylaxis may be inadequate in high-risk patients, who should be targeted for increased surveillance and aggressive prophylaxis. On the other hand, routine prophylaxis in low-risk patients may be overutilized.

Despite prophylaxis, pulmonary embolism (PE) remains a major cause of posttraumatic morbidity and mortality in high-risk patients. We studied injury-related risk factors associated with the occurrence of PE despite routine prophylaxis. A review of 9721 trauma patients discharged from January 1, 1985 through December 31, 1992, identified 36 patients (0.4%) who suffered clinically evident PE despite a policy of routine prophylaxis against deep venous thrombosis that included use of prophylactic inferior vena caval filters. (Twenty-nine patients had an inferior vena caval filter placed for prophylaxis against PE.) A detailed analysis of injury-related risk factors was performed. Four high-risk patterns of injury were identified, representing common combinations of significant risk factors. These patient groups have an absolute risk of PE despite prophylaxis ranging from 1.5% to 3.8%. The relative risk is approximately ten times that of control patients. Identification of appropriate high-risk groups is necessary to allow optimization of prophylactic measures, including placement of inferior vena caval filter.

An in-depth understanding of the economic problems confronting trauma centers is essential for their continued development and to address impending changes of health care reform. A comprehensive financial and demographic survey was sent to 839 hospitals identified as potential trauma centers. A total of 313 surveys from 48 states were returned. Extensive information was collected in several areas including financial status (58% reported serious financial problems and 36% reported minor financial problems; 68% reported a financial loss), cost containment and management strategies, marketing, "halo" effect (53% reported positive effect), operational impacts, physician support (47% reported problems), malpractice (92% reported no special problem), role of auto insurance reimbursement, and access to rehabilitation. Detailed financial data of actual costs and reimbursements (95 respondents) were analyzed with the costing method used by the Health Care Financing Administration (HCFA). These data will allow us to develop better strategies to deal with the problems of uncompensated and underfunded trauma care and improve trauma center viability.

Injury is our nation's leading public health problem. Victims of violence need expert and immediate medical attention. A model exists for optimal care of the injured patient--the trauma care, the components of the ideal, inclusive history of trauma care, the components of the ideal, inclusive trauma care system, its efficacy, and the challenges and opportunities facing those who advocate such systems.

The purpose of auditing trauma care is to maintain quality assurance and to guide quality improvement. This study was conducted to identify the incidence, type, and setting of errors leading to morbidity and mortality in trauma patients. Determinations of the Medical Audit Committee of San Diego County were reviewed and classified by the authors for identification of preventable errors leading to morbidity or mortality. Errors were classified by type and categorized by phase of care. Errors were identified in the cases of 4% of all patients admitted for trauma care over a 4-year period. Of all trauma patient deaths, 5.9% were considered preventable or potentially preventable. The most common single error across all phases of care was failure to appropriately evaluate the abdomen. Although errors in the resuscitative and operative phases were more common, critical care errors had the greatest impact on preventable death. The detected error rate of 4% may represent the baseline error rate in a trauma system. While regionalized trauma care has dramatically reduced the incidence of preventable death after injury, efforts to further reduce preventable morbidity and mortality may be guided by an identification of common errors in a trauma system and their relationship to outcome.

There is a widespread perception that many trauma centers are poorly reimbursed, and many hospitals that once cared for trauma victims no longer do so, primarily for financial reasons. The problem is blamed on both uninsured and underinsured patients, but data supporting this perception are lacking. To determine the validity of these perceptions and to better understand the nature of trauma center reimbursement, a survey was conducted. A questionnaire on the volume of trauma seen annually and the reimbursement experience for trauma center (TC) and hospital (HO) patient populations was mailed to representative but nonrandomly chosen trauma centers. Seventy-one surveys were mailed and 25 were returned (35%). There were 15 Level I and 10 Level II centers; 16 were urban, seven were suburban, and two were rural. Eighteen centers (72%) reported significant underfunding of the TC in contrast to the HO, and 11 indicated that they would not be able to continue their current level of TC services with present reimbursement. For Medicare patients, HO cost recovery rates averaged 93%, but recovery rates were only 64% for TCs. For Medicaid beneficiaries, the HO cost recovery rate averaged 85%, but it was only 49% for TCs. Thirty-one percent of TC patients had no insurance coverage at all, in contrast to only 9% of HO patients. An aggregate loss equal to 19.9% of total costs was reported by respondents. This survey, while not representative of trauma centers as a whole throughout the United States, does suggest that there is a basis for the perception of underfunding of trauma care and indicates that such underfunding results from the combination of adverse selection and disproportionate share. We also describe a new method for assessing and comparing trauma center reimbursement.

The regionalization of trauma care has led to a decrease in preventable death after injury. This decrease has been attributed to earlier resuscitation and surgical intervention. Little emphasis, however, has focused on the critical care phase of trauma patient management. This study was undertaken to determine the significance of critical care errors (CCEs) on preventable mortality and morbidity in a regionalized system of trauma care. The records of 12,910 trauma patients admitted to six trauma centers over a three-year period were reviewed. The cause and preventability of death was determined by a panel of trauma experts. Critical care errors occurred in 151 (23%) of all patients with errors occurring during any phase of care. The CCEs were identified in 38 of 125 (30%) deaths of patients with errors in some phase of care. The CCEs were implicated as the cause of death in 30 (48%) of the 62 preventable deaths. The proportion of preventable deaths attributable to CCEs was higher than the proportion of preventable death attributable to errors in the resuscitative and operative phases of care (p less than 0.001, chi-square). These data indicate that CCEs significantly contribute to preventable mortality and morbidity in trauma patients. It is imperative that physicians caring for trauma patients possess expertise in the critical care management of injured patients.

Preventing amputation continues to be a significant challenge when popliteal vascular injuries occur. A retrospective review of cases from the San Diego County (California) Trauma System identified 108 patients with 76 blunt and 32 penetrating arterial injuries. The limb preservation rate was 88%; there were 13 amputations. The fracture-dislocated knee injury and close-range shotgun blasts were particularly limb threatening. In general, the trauma system achieved rapid evaluation of injuries and early operative intervention. All 13 patients who underwent amputations presented with signs of severe ischemia. Concomitant injuries to the popliteal vein, tibial nerves, and soft tissue were significantly more frequent in patients who underwent amputations. The importance of complete fasciotomy for compartment hypertension, early reconstructive management of soft-tissue injuries, and expeditious arterial repair, frequently without preoperative roentgenographic suite arteriography, is emphasized. An aggressive, multidisciplinary approach is required to achieve a functional extremity when popliteal vascular trauma occurs.

A multidisciplinary concurrent audit of the quality of medical care within a trauma system was carried out by a committee of physicians, nurses, and health officials representing trauma centers, nontrauma hospitals, and the public agency administrating the trauma system. Care was audited with regard to timeliness and appropriateness of diagnosis and therapy. Complications were classified as being due to an error in diagnosis, judgment, or technique. Deaths were classified as nonpreventable, potentially salvageable, or frankly preventable. During the first 22 months of operation (1 August 1984-30 May 1986), 7,936 cases were audited. Of the 224 deaths occurring at nontrauma hospitals, 17 (7.6%) were felt to be frankly preventable. Of 541 deaths occurring at trauma centers, 11 (2.0%) were felt to be frankly preventable (p less than 0.001). The most common problem implicated in preventable deaths at nontrauma center hospitals was an error in diagnosis. Preventable deaths at trauma centers were most commonly due to an error in technique. Complications or protocol violations occurred in 595 of 6,564 surviving trauma patients (9.1%). During the first 12 months of system operation, 7,200 person-hours were required to perform the audit. Personnel costs alone for audit in the first year were $300,420.

The extraperitoneal approach is not usually used for reconstruction of the abdominal aorta; however, herein we have made an attempt to influence vascular surgeons to modify this practice. The results in 200 patients approached extraperitoneally have been compared with those of 70 patients explored by the traditional transperitoneal route. The expeditious technique of extraperitoneal exploration described results in significantly less postoperative morbidity due to the pulmonary complications of atelectasis and pneumonia. Intestinal ileus is uniformly brief, and rarely requires nasogastric suction. Patients explored extraperitoneally have demonstrably less pain and were discharged from the hospital sooner. Furthermore, prosthetic graft patency and mortality were comparable in both groups. Thus, the retroperitoneal approach should be the preferred method of aortoiliac reconstruction since the postoperative convalescence period is smoother and shorter.

To assess the need for a trauma system in San Diego County, a concurrent audit of trauma care was performed by an independent consultant in 1982. During the study period from 15 March through 15 June 1982, 591 consecutive major trauma victims (MTV) were collected by the 30 participating hospitals. All medical records, including autopsy reports, were audited for the timeliness and appropriateness of diagnosis and definitive care. Deaths were classified as being not preventable, potentially salvageable, or preventable. A trauma system subsequently became functional on 1 August 1984, with five adult centers and one pediatric center. A Medical Audit Committee composed of physicians and nurses from designated and nondesignated hospitals was organized to perform a monthly concurrent audit of trauma care. Between 1 August and 31 December 1984, 1,366 MTV were triaged to trauma centers. The care of MTV was considered suboptimal in 32% of patients before regionalization, compared to 4.2% after regionalization (p less than 0.01). Preventable deaths occurred in 13.6% of fatalities occurring before implementation of a trauma system, compared to 2.7% after implementation (p less than 0.01). Regionalization of trauma care significantly reduced delays, inadequate care, and preventable deaths due to trauma.