Gentilello, Larry M. MD
From the Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas.
Submitted for publication December 21, 2004.
Accepted for publication December 21, 2004.
Supported in part by Robert Wood Johnson Foundation Innovators Combatting Substance Abuse grant 046488.
This article was written for the proceedings from a conference entitled Alcohol Problems among Hospitalized Trauma Patients: Controlling Complications, Mortality, and Trauma Recidivism, in Arlington, Virginia, May 28–30, 2003. It does not reflect the official policy/opinions of the participating agencies, the U.S. Department of Health and Human Services, or the Centers for Disease Control and Prevention, and does not constitute an endorsement of the authors or their programs by the Centers for Disease Control and Prevention, the U.S. Department of Health and Human Services, or the federal government, and none should be inferred.
Address for reprints: Larry M. Gentilello, MD, Division of Burns, Trauma and Critical Care, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd., Dallas, TX 75390-9158; email: email@example.com.
The history of trauma care in the United States has been one of extraordinary success. A committed group of leaders laid the foundation for nationwide implementation of regional trauma systems. Their studies demonstrated that specialized trauma care reduces mortality after major injury. The most notable study compared motor vehicle crash victims treated in Orange County with crash victims treated in San Francisco County.1 Patients injured in San Francisco County were transported to a trauma center, whereas patients injured in Orange County were transported to the nearest hospital. A panel of experts blinded to where patients were treated reviewed the medical and autopsy records of all patients who died. Although patients treated in Orange County were younger and less severely injured, one third of the brain injury-related deaths and two thirds of the nonbrain injury-related deaths in that group were classified as preventable (i.e., a result of inadequate expertise or resources). Only one death was so judged among those patients in San Francisco County.
The founders of modern trauma care did not rest with these findings. They required hospitals maintain a trauma registry to facilitate research and to analyze outcomes. A remarkable set of standardized patient care protocols were developed, as embodied by the Advanced Trauma Life Support program.2 Trauma centers were also required to document adherence to rigorous quality improvement programs. Finally, trauma surgeons and their colleagues in other specialties generated considerable public and political support, which led to the development of regionalized trauma systems in most of the heavily populated regions, although not in every state. Because of these efforts, the preventable death rate in trauma centers has been reduced from 40% 30 years ago to 4% or less today.
The current low preventable death rate suggests that future reductions in trauma mortality in regions served by trauma centers are not likely to result from further attempts to improve the process of delivering trauma care. In a report subtitled “As Good as it Gets,” Hoyt and colleagues studied trauma mortality over a 12-year period at a single institution. Despite rigorous efforts to improve the quality of care and implement new protocols, the incidence of preventable deaths and major complications remained the same. The researchers concluded that within a mature trauma system, current methods to reduce trauma mortality appear to have reached the limits of their effectiveness.3
It is also unlikely the discovery of new and better treatments will considerably reduce mortality among trauma patients. Stewart et al. analyzed 753 deaths at a Level I trauma center in San Antonio.4 Over 40% of patients who died had CPR on or shortly after arrival to the emergency department. Traumatic brain injury caused most deaths (51%); most of these patients had an initial Glasgow Coma Scale score of 3 or 4, suggesting the presence of a nonsurvivable brain injury at the time of admission. Stewart et al. concluded that nearly 90% of in-hospital trauma deaths occur in patients who have injuries that are physiologically and anatomically not survivable, and consequently, further improvements in trauma care will not change their outcome.
Deaths that do not occur immediately as the result of nonsurvivable injuries occur later in the intensive care unit as a result of acute respiratory distress syndrome, sepsis, multiple organ failure, secondary brain injury, or pulmonary embolism. These late deaths account for only 6% of in-hospital trauma patient deaths.5 In other words, even if all research efforts and new therapies aimed at preventing or curing these complications were successful, the percentage reduction in trauma mortality would not be large.
Even these statistics overstate the potential for medical advances to reduce mortality, because more than half of all trauma deaths occur at the scene of the injury—not in the hospital. A recent analysis of trauma patient autopsy reports concluded that most field deaths occur within the first minute after injury, before any health care provider has had an opportunity to respond.5 Deaths occurring this rapidly are unlikely to be prevented by improved treatment in the foreseeable future. Reduction of injury-related mortality will only come from prevention efforts aimed at reducing the incidence of the “causes” of injuries.
These findings suggest that it is time for trauma centers to pursue innovative strategies to further reduce the risk of injury-related morbidity and mortality. The most promising approach would be to focus on prevention and recurrence of injuries. Although regionalized trauma care has existed for several decades, injury prevention is a relatively new field.
ALCOHOL, DRUGS, AND TRAUMA CENTERS
One of the first steps in developing any prevention strategy is to determine the vector or environmental factor that causes the disease. Trauma centers have always known that alcohol use is the leading cause of the injuries they treat. Pooled data from six regional trauma centers involving 4,063 patients indicate that 40% of patients have a positive blood alcohol concentration (BAC) at admission.6 If drug use is included, up to 60% of patients test positive for one or more intoxicants.6,7
Most trauma patients with a positive BAC meet criteria for having an alcohol problem. A study by Rivara and colleagues at Harborview Medical Center in Seattle supports this conclusion. They administered the Michigan Alcohol Screening Test (MAST), a widely used questionnaire to identify patients with potential alcohol problems, to 2,657 intoxicated trauma patients—75% screened positive.8 Alcohol problems and resultant high risk of injury are so common in trauma patients that 26% of patients with a negative BAC also screen positive on the MAST, which is nearly three times the screen-positive rate of the U.S. population.8,9 It is unlikely that significant progress in injury prevention will occur if the leading cause of injury is not addressed. Therefore, any realistic approach to reducing injuries must address alcohol problems through medical, legal, and public policy means.
There is substantial evidence that alcohol problems are treatable and that intervention does work. The Cochrane Library is a regularly updated collection of systematic reviews of health care interventions. Reviews are highly structured, with evidence included or excluded on the basis of explicit quality criteria. The 2004 issue contains a review, “Interventions for Preventing Injuries in Problem Drinkers,”9 which reports that interventions for problem drinking reduce incidences of suicide attempts, domestic violence, falls, drinking-related injuries, and injury hospitalizations and deaths—reductions range from 27% to 65%. Trauma centers do not routinely provide interventions for problem drinking to prevent recurrent injuries. This constitutes a missed opportunity to reduce trauma morbidity and mortality.
In the past 10 years, significant energy, funding, and emphasis have been directed toward motivating primary care physicians to incorporate screening and brief interventions into their practice. In any given year, patients with alcohol problems are more likely to receive treatment for an injury rather than to visit a primary care doctor for a medical problem—23% require an emergency department visit and 4% require hospital admission.10 Furthermore, an average size metropolitan region will have hundreds of primary care physicians but only a few trauma centers. Trying to change the practice of a diverse group of primary care physicians, although a worthwhile goal, has been likened to trying to transport frogs in a wheelbarrow. In contrast, incorporating brief interventions into trauma care within a given region only requires changing the practice patterns in a few hospitals.
Trauma centers have another characteristic that provides them with a unique opportunity to reduce injuries through alcohol interventions. Unlike most medical services, trauma centers are “franchised” by the state or county. Hospitals that choose to participate in trauma care must undergo a site visit to demonstrate that certain criteria are met (i.e., specialty availability, equipment, facilities, and range of services). Most states have adopted the criteria developed by the American College of Surgeons Committee on Trauma, as outlined in the monograph Resources for Optimal Care of the Injured Patient.11 Almost no other type of medical service is overseen and franchised in this manner. The franchise characteristic and the verification process that trauma centers must undergo ensures that improvements in trauma center practices can be incorporated systematically. Once new therapies are demonstrated as best trauma care, the American College of Surgeons Committee on Trauma can requires the nation’s trauma centers to adopt these practices.
There is growing support for the provision of alcohol interventions in trauma centers. A recent survey conducted by Schermer and colleagues indicates that 83% of trauma surgeons believe a trauma center is an appropriate place to provide alcohol interventions.12 Most surgeons (86%) also agree that it is important to talk to injured patients about their harmful alcohol consumption. Screening trauma patients for BAC was rare a decade ago. Currently, however, three of four trauma surgeons who responded to the survey indicate that they often or always measure BAC in injured patients.
A variety of federal, expert, and consensus group panels conclude that the scientific basis for recommending routine screening and intervention in trauma centers has already been established and that it is time to move beyond clinical trials and toward national implementation.13–20 This conference, along with one sponsored by the Centers for Disease Control and Prevention and other federal agencies on alcohol interventions for injured patients treated in the emergency department, demonstrate the expanding interest in this field on the part of multiple stakeholders.21
Many trauma surgeons have been practicing long enough to have witnessed the development of a prehospital system that can be activated from virtually anywhere in the United States by using the integrated 911 emergency call system. Activating this system results in transport to a trauma center from all but the most remote areas of the country. Nearly 1,200 hospitals dispersed in all 50 states are designated as trauma centers by a state or regional authority, or verified by the American College of Surgeons Committee on Trauma. The number of trauma centers has more than doubled since 1991.22 The extensive staffing, structural, equipment, and organizational changes required to make this happen did not occur because of an abundance of funding available to the health care system. Changes occurred because trauma surgeons are tireless advocates who insist on nothing less than optimal care of the injured patient.
The intense focus on acute care was appropriate for that time and for that era. The document entitled Optimal Resources for Care of the Injured Patient, by the American College of Surgeons Committee on Trauma, defines optimal care. We now know that optimal care cannot be defined as the expenditure of an extraordinary amount of personal and financial resources to mend our patients’ broken bones and patch up their internal organs only to have them return to our streets and highways with the same underlying problem. Treatment of the injury without treatment of the primary underlying substance use disorder enables patients to continue behavior that causes injury (sometimes permanent or fatal injury) to themselves or other people. “Optimal care” should be redefined to include prevention efforts. These efforts must address the burden of alcohol and drug problems among our patients, and the current generation of trauma surgeons should, as did their forebears, rally to meet this challenge.
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