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Executive Summary Kentucky Trauma System Evaluation 2016

Julia F. Costich, JD, PhD and Peter J. Rock, MPH Kentucky Injury Prevention & Research Center

Prepared with support from the Kentucky Department for Public Health

Overview

Kentucky counties have a wide range in fatalities, as depicted in the map below, which focuses on motor vehicle crashes. While access to definitive trauma care is not the only factor behind the four-fold disparity in motor vehicle crash death rates by county, the rates are far lower in areas near Level I and II trauma centers.

A June 2016 National Academies of Science (NAS) study found that one-fifth of deaths from traumatic injuries are preventable, and that a comprehensive trauma system has the potential to reduce the proportion of preventable deaths.1 This finding updates longstanding evidence that trauma systems can save lives, as set out in the NAS report: treating severe injuries in Level I or Level II trauma centers has well-documented benefits for survival, quality of life, and cost-effectiveness.2,3

The Kentucky trauma system was established in 2008 by state law (KRS 211.490 et seq.; 902 KAR 28:040. A Trauma Advisory Committee (TAC), the membership of which is set out in KRS 211.494(3), directs the trauma system. All trauma centers designated by the Commissioner for Public Health maintain trauma registries that are compatible with the National Trauma Data Bank (NTDB) standards established in the National Trauma Data Standard Data Dictionary. The number of trauma registry cases increased

Kenton

Hart

Hardin

Christian

Warren

Leslie

Hopkins

Union Daviess

Shelby

Scott

Bullitt

Lyon

Madison

Clark

Henry

Grant

Jefferson

Henderson

Muhlenberg

Boone

Fayette

Bourbon

McLean

Rockcastle

Simpson

Franklin

Oldham

Anderson

Carroll

Gallatin

Livingston

Campbell

Jessamine

Montgomery

Robertson

Ohio

Trigg

Bell

Pulaski

Wayne

Laurel

Carter

Bath

Nelson

Whitley

Morgan

Larue

Monroe

Fleming

Rowan

Greenup

Caldwell

Webster

Marshall

Mercer

Boyle

Boyd

Johnson

Pendleton Bracken

McCracken

Garrard

Hancock

Woodford

Logan

Lewis

Graves

Adair

Todd

Barren

Harlan

Floyd

Allen

Grayson

Meade

Lincoln

Taylor

McCreary

Letcher

LawrenceElliott

Wolfe

Ballard

Russell

Mason

Martin

Fulton

Edmonson

Powell

Menifee

Washington

Spencer

Nicholas

Pike

Clay

Knox

Casey

Butler

KnottPerry

Owen

Lee

Breathitt

Estill

Marion

Green

Breckinridge

Calloway

Jackson

Harrison

Crittenden

Magoffin

Metcalfe

Hickman Clinton

Owsley

Carlisle

Cumberland

Trimble

Rate of Fatal Crashes Per 100 Million Vehicle--Miles (2010-2014)

0 50 10025 Miles

Fatal Crash Rate

0.50 - 1.2

1.3 - 1.7

1.8 - 2.4

2.5 - 4.6

±Data Source: KY Transportation Center: Analysis of TrafficCrash Data in Kentucky (2010-2014)Aurthor: Kentucky Injury Prevention and Research CenterDate: July 1, 2016

Map 1:

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from 6,643 in 2008 to 13,159 in 2014, as seen in Figure 1. A large proportion (58% in 2014) of these cases came from Level I facilities, but trauma patients also receive care at other verified trauma facilities in the Kentucky trauma system.

The increase in cases recorded in the trauma registry reflects the increase in reporting hospitals, not an increase in the number of injured Kentucky patients. The following map presents the current coverage (defined by 30/60 minute drive time) of verified and pending-verification facilities. In comparison, the hash-marked area represents the original coverage from 2008.

U

U

U

U

U

U

U

U

U

U

U

^

^

2015 Trauma Registry Facilities for Kentuckywith 30/60 Minute Drive-Time Coverage and 2008 Coverage Area

0 50 10025 Miles ±

Verified Trauma Centers

Level 1

Level 2

Level 3

Level 4

^ Pediatric Trauma Center

U Pending Verification

Drive Times

30 minutes

60 minutes

County

2008 Coverage

60 minutes

Map 2:

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The following map depicts the rate of trauma registry cases per 10,000 population based on the patients’ counties of residence. The county of residence is not necessarily the site of injury, although the majority of injuries occur within 10 miles of home.4 The low rates in the southwest portion of the state are in large part due to the absence of verified Kentucky trauma centers in that region. Trauma patients in those areas are commonly taken to Tennessee hospitals.

Quality metrics

Using data from the comprehensive statewide dataset maintained by the Kentucky Hospital Association, we find that since 2008, there has been a consistent increase in the proportion of injury patients being seen at trauma centers (Fig. 2).

PikeOhio

Clay

Hart

BellTrigg

Hardin

Pulaski

Logan

Lewis

Christian

Adair

ToddGraves

KnoxWarren Barren

Butler

Floyd

Laurel

Harlan

AllenWayne

Casey

Leslie

HopkinsKnott

Carter

Union

Bath

Nelson

Whitley

Owen

Grayson

Daviess

BreathittLee

ShelbyScott

Bullitt

Estill

Lyon

Madison

Marion

MorganClark

Henry

Lincoln

Grant

Green

Taylor

Larue

Letcher

Calloway McCreary

Fleming

Monroe

Jefferson Elliott

Greenup

Wolfe

Fayette

Mason

Boyle

Carlisle

Perry

Meade

Breckinridge

Lawrence

Henderson

Jackson

Caldwell

Rowan

Muhlenberg

Webster

Marshall

Boone

Ballard

Russell

Martin

Harrison

MercerMagoffin

Crittenden

Bourbon

Metcalfe

Livingston

Fulton

McLean

Boyd

Johnson

Garrard

ClintonHickman

Rockcastle

Edmonson

Pendleton

Powell

Simpson

Owsley

Franklin

Menifee

Washington

Cumberland

Bracken

Oldham

McCracken

Kenton

Spencer

Nicholas

Hancock

Anderson

TrimbleCarroll

Woodford

Campbell

Jessamine

Montgomery

Gallatin

Robertson

2014 Kentucky Trauma Registry Encounter Rate by County

0 50 10025 Miles

Record Rate (per 10,000 population)

0 - 3.7

3.8 - 18.1

18.2 - 27.1

27.2 - 46

46.1 - 157.3

±

Map 3:

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State trauma experts also developed a set of ICD-9 codes to identify injuries warranting care at a Level I facility. The distribution of severe injuries in relation to Level I trauma center utilization is depicted in Fig. 3. In more recent years, about 50% of severe injuries have been seen at Level I trauma centers.

The following graph shows changes in age-adjusted death rates for any-injury inpatients with 95% confidence intervals calculated following the CDC WONDER methodology.5 The increase in age-adjusted death rate for the Level I centers during the 2000-2006 period may be a function of the increasing proportion of severely injured patients being cared for in Kentucky trauma centers rather than out of state during the early years of system development.

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Figure 5 compares observed to expected death ratios using the risk adjustment methods developed by the American College of Surgeons (ACS).6 The trend shows an overall decrease in risk-adjusted death ratios over time. The death ratio in 2012-2014 is statistically significantly lower than the 2008 ratio, indicating real improvement in the state trauma system’s ability to provide life-saving care.

Strategic challenges

Kentucky’s trauma system is under the administrative oversight of the Kentucky Department for Public Health (DPH), although it also has a relationship with the Kentucky Board of Emergency Medical Services (KBEMS), which is part of the Kentucky Community and Technical College System (KCTCS). This administrative home was the result of several historical factors that are no longer relevant, and the question of an appropriate home for the trauma system deserves further consideration. Because the trauma system has little common ground with KCTCS, its administrative parent cannot be relied upon to advocate for critically needed system funding.

While the trauma system enabling legislation includes a provision addressing the use of funds, the system itself has no reliable funding source. Funding for the trauma registry has been available for the past six years through the Kentucky Transportation Cabinet’s Office of Highway Safety, using federal awards from the National Highway Traffic Safety Administration. The TAC leadership has demonstrated initiative and creativity in its attempts to identify potential funding sources. Other states fund their trauma systems from general fund appropriations, assessments on speeding drivers, insurance surcharges, foundation and corporate donations, and fees from participating hospitals. In the 2016 fiscal year, the state Department for Public Health provided one-time support for enhanced education and outreach.

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Current resources fall far short of addressing basic trauma system funding needs. A proposal to the 2016 Kentucky General Assembly for minimal funding was unsuccessful. The lack of funding seems to signal legislative undervaluation of the enormous effort by TAC leadership, past and present. The sustainability of the system’s dependence on volunteers’ effort must be called into question.

Large geographic areas in Kentucky still lack timely access to definitive trauma care. Limiting analysis to the state borders is somewhat misleading because there are Level I centers in Cincinnati OH, Huntington WV, Evansville IN, and Nashville TN that are closer to some Kentucky regions than in-state facilities. However, there are clearly some gaps in the state’s coverage, particularly in the southwest part of the state. Efforts are ongoing to support interested hospitals in their explorations of participation.

Many states’ trauma systems are administratively co-located with state EMS organizations. This topic may deserve closer attention, particularly with regard to the prospect of integrating EMS data more completely with trauma registry reporting. Some 92% of state EMS providers now report electronically. Access to these data would help answer longstanding questions, e.g., the number of motor vehicle crashes that are undetected for hours, problematic recoveries and extractions, and quality metrics.

Conclusion and next steps

Kentucky’s trauma system has made significant progress since the enabling legislation was enacted, yet it cannot achieve its full potential until major obstacles are overcome. Among these are lack of funding to support core activities, geographically inconsistent participation, and integration of EMS data. The ability of Kentuckians to survive traumatic injury should not depend on where they are injured, yet motor vehicle fatality rates across counties continue to vary almost four-fold. Finding the political will to support a comprehensive system that provides both excellent and equitable care is a longstanding challenge. Until Kentucky overcomes that challenge, it falls to a small and dedicated group of clinicians and laypersons to press forward towards the trauma system’s goal of providing the right care at the right time in the right place.

1 National Academies of Sciences, Engineering, and Medicine. 2016. A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: The National Academies Press. doi:10.17226/23511.  2 Bailey J, Trexler S, Murdock A, Hoyt D. Verification and regionalization of trauma systems: the impact of these efforts on trauma care in the United States.  Surg Clins  NA 2012; 92(4):1009‐1024.  3 MacKenzie EJ, Rivara FP, Jurkovich GJ et al. The value of trauma center care.  J Trauma 2010; 69(1):1‐10.  4 Haas B, Doumouras AG, Gomez D, et al. Close to home. J Trauma Acute Care Surg. 2015;78(4):860‐865. doi:10.1097/TA.0000000000000595. 

5 Fay MP, Feuer EJ. Confidence intervals for directly standardized rates: A method based on the gamma distribution. Stat Med. 1997;16(7):791‐801. doi:10.1002/(SICI)1097‐0258(19970415)16:7<791::AID‐SIM500>3.0.CO;2‐#. 

6 Newgard CD, Fildes JJ, Wu L, et al. Methodology and analytic rationale for the american college of surgeons trauma quality improvement program. J Am Coll Surg. 2013;216(1):147‐157. doi:10.1016/j.jamcollsurg.2012.08.017.