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Using Trauma and Injury Severity Score (TRISS)-Based Analysis in the Development of Regional Risk Adjustment Tools to Trend Quality in a Voluntary Trauma System: The Experience of the Trauma Foundation of Northeast Ohio

Mancuso, Charlene RN; Barnoski, Anita RN; Tinnell, Charles RN; Fallon, William Jr. MD

Journal of Trauma-Injury Infection & Critical Care: April 2000 - Volume 48 - Issue 4 - pp 629-636
Annual Meeting Articles

Background: Presently, no trauma system exists in Ohio. Since 1993, all hospitals in Cuyahoga County (CUY), northeast Ohio (n = 22) provide data to a trauma registry. In return, each received hospital-specific data, comparison data by trauma care level and a county-wide aggregate summary. This report describes the results of this approach in our region.

Methods: All cases were entered by paper abstract or electronic download. Interrater reliability audits and z score analysis was performed by using the Major Trauma Outcome Study and the CUY 1994 baseline groups. Risk adjustment of mortality data was performed using statistical modeling and logistic regression (Trauma and Injury Severity Score, Major Trauma Outcome Study, CUY). Trauma severity measures were defined.

Results: In 1995, 3,375 patients were entered. Two hundred ninety-one died (8.6%). Severity measures differed by level of trauma care, indicating differences in case mix. Probability of survival was lowest in the Level I centers, highest in the acute care hospitals. Outcomes z scores demonstrated survival differences for all levels.

Conclusions: In a functioning trauma system, the most severely injured patients should be cared for at the trauma centers. A low volume at acute care hospitals is desirable. By using Trauma and Injury Severity Score with community-specific constants, NE Ohio is accomplishing these goals. The Level I performance data are an interesting finding compared with the data from the Level II centers in the region

The State of Ohio currently has no legislated trauma system. In 1995, 5,200 Ohioans died, 20,000 were disabled (Udell, 1993/Columbus Dispatch 1997). However, in 1991, Cuyahoga County (CUY), the most populous county in Ohio and the 17th most populous county in the United States, 1 took the lead and implemented a voluntary trauma system to provide consistent optimal trauma care to all the county’s citizens. The system mandates that trauma patients be transferred only to American College of Surgeons’ (ACS) verified trauma centers. 2

A principle component of the voluntary trauma system is the CUY Trauma Registry. It began data collection in 1994 and first reported data in 1996. The CUY Registry resides within The Trauma Foundation of Northeast Ohio, a 501-C3 nonprofit corporation, which was developed to continue the work of the CUY Trauma Registry and to maintain the neutrality of the data. The Registry is unique in the United States because it is currently the only community-based trauma registry collecting and analyzing risk-adjusted major trauma data. Most state or regional trauma registries contain data from individual hospitals, usually trauma centers. Research done with such data is often criticized for its narrow focus and for not necessarily being indicative of trauma incidence and care in the community as a whole.

The CUY Trauma Registry collects data from all prehospital providers and hospitals within the county on a voluntary basis. (Currently, all 22 hospitals within the county participate). The data collected by the CUY Registry includes injury type, incidence, location, prehospital care provided, hospital care given, and outcomes for major trauma patients cared for within the county.

The ultimate goals of the CUY Trauma Registry are to provide a data-driven vehicle to enhance hospital specific quality improvement initiatives, to evaluate current trauma care provided in the county, and to ensure access for all citizens to a trauma delivery system that provides timely, optimal quality care.

An important component of the CUY Registry is confidentiality. All CUY Trauma Registry data are owned by the respective participating hospitals. Annually, a public report is written and distributed to the community that provides aggregate data analyses and community performance descriptors evaluated through various outcome measures described herein. Each participating hospital also receives its own hospital-specific data with comparison aggregate data by trauma care level (Level I, Level II, and acute care hospital) and county-wide summary data to assist the quality improvement efforts. Comparative risk adjusted mortality data by using the Major Trauma Outcome Study (MTOS) model 3 and county specific models was also released to each facility for review. The MTOS mortality data set serves as a national standard, whereas the CUY models developed may be more suitable for evaluation of hospital-specific performance in this region, and are emerging as a regional standard.

From the Trauma Foundation of Northeast Ohio, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio and Clinical Data Management, Inc., Conifer, Colorado.

Address for reprints: Charlene Mancuso, RN, MetroHealth Medical Center, Department of Surgery H-943, 2500 MetroHealth Drive, Cleveland, OH 441109-1998.

Submitted for publication February 12, 1999.

Accepted for publication December 31, 1999.

Presented at the 12th Annual Meeting of the Eastern Association for the Surgery of Trauma, January 13–16, 1999, Orlando, Florida.

© 2000 Lippincott Williams & Wilkins, Inc.