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A multidimensional approach to identifying high-performing trauma centers across the United States
Doulia M Hamad1, Haris Subacius, Arielle Thomas
1From the Department of Surgery (D.M.H., M.P.G., B.H., A.B.N.), Sunnybrook Health Sciences Center and the University of Toronto; Institute of Health Policy, Management, and Evaluation (D.M.H., A.B.N.), University of Toronto, Toronto, Ontario, Canada; The Society of Thoracic Surgeons (H.S.), Chicago, Illinois; Medical College of Wisconsin (A.T.), Milwaukee, Wisconsin; Interdepartmental Division of Critical Care (B.W.T., B.H.), University of Toronto; Tory Trauma Program (B.W.T., A.B.N.), Sunnybrook Health Sciences Center; Department of Medicine (B.W.T.), Division of Respirology and Critical Care Medicine, University Health Network; Sunnybrook Research Institute (B.W.T., A.J., B.H., A.B.N.), Sunnybrook Health Sciences Centre; Department of Anesthesia (A.J.), Sunnybrook Health Sciences Center University of Toronto; Department of Critical Care Medicine (B.H.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and American College of Surgeons (A.B.N.), Chicago, Illinois.
Introduction:
The differentiators of centers performing at the highest level of quality and patient safety are likely both structural and cultural. We aimed to combine five indicators representing established domains of trauma quality and to identify and describe the structural characteristics of consistently performing centers.
Methods:
Using American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2020, we evaluated five quality measures across several care domains for adult patients in levels I and II trauma centers: (1) time to operating room for patients with abdominal gunshot wounds and shock, (2) proportion of patients receiving timely venous thromboembolism prophylaxis, (3) failure to rescue (death following a complication), (4) major hospital complications, and (5) mortality. Overall performance was summarized as a composite score incorporating all measures. Centers were ranked from highest to lowest performer. Principal component analysis showed the influence of each indicator on overall performance and supported the composite score approach.
Results:
We identified 272 levels I and II centers, with 28 and 27 centers in the top and bottom 10%, respectively. Patients treated in high-performing centers had significant lower rates of death major complications and failure to rescue, compared with low-performing centers ( p < 0.001). The median time to operating room for gunshot wound was almost half that in high compared with low-performing centers, and rates of timely venous thromboembolism prophylaxis were over twofold greater ( p < 0.001). Top performing centers were more likely to be level I centers and cared for a higher number of severely injured patients per annum. Each indicator contributed meaningfully to the variation in scores and centers tended to perform consistently across most indicators.
Conclusion:
The combination of multiple indicators across dimensions of quality sets a higher standard for performance evaluation and allows the discrimination of centers based on structural elements, specifically level 1 status, and trauma center volume.
Level Of Evidence:
Therapeutic /Care Management; Level IV.
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