Academic literature on the topic 'Trauma centers – New South Wales'

Objective This research examines the existing funding model for in-hospital trauma patient episodes in New South Wales (NSW), Australia and identifies factors that cause above-average treatment costs. Accurate information on the treatment costs of injury is needed to guide health-funding strategy and prevent inadvertent underfunding of specialist trauma centres, which treat a high trauma casemix. Methods Admitted trauma patient data provided by 12 trauma centres were linked with financial data for 2008–09. Actual costs incurred by each hospital were compared with state-wide Australian Refined Diagnostic Related Groups (AR-DRG) average costs. Patient episodes where actual cost was higher than AR-DRG cost allocation were examined. Results There were 16 693 patients at a total cost of AU$178.7 million. The total costs incurred by trauma centres were $14.7 million above the NSW peer-group average cost estimates. There were 10 AR-DRG where the total cost variance was greater than $500 000. The AR-DRG with the largest proportion of patients were the upper limb injury categories, many of whom had multiple body regions injured and/or a traumatic brain injury (P < 0.001). Conclusions AR-DRG classifications do not adequately describe the trauma patient episode and are not commensurate with the expense of trauma treatment. A revision of AR-DRG used for trauma is needed. What is known about this topic? Severely injured trauma patients often have multiple injuries, in more than one body region and the determination of appropriate AR-DRG can be difficult. Pilot research suggests that the AR-DRG do not accurately represent the care that is required for these patients. What does this paper add? This is the first multicentre analysis of treatment costs and coding variance for major trauma in Australia. This research identifies the limitations of the current AR-DRGS and those that are particularly problematic. The value of linking trauma registry and financial data within each trauma centre is demonstrated. What are the implications for practitioners? Further work should be conducted between trauma services, clinical coding and finance departments to improve the accuracy of clinical coding, review funding models and ensure that AR-DRG allocation is commensurate with the expense of trauma treatment.

From its beginning, mankind suffered injuries through falling, fire, drowning and human aggression [1]. Although the frequency and the kinetics modifiy over millennia, trauma continues to represent an important cause of morbidity and mortality even in the modern society [1]. Significant progresses in the trauma surgery were due to military conflicts, which next to social sufferance came with important steps in injuries’ management, further applied in civilian hospitals. The foundation of modern trauma systems was started by Dominique Jean Larrey (1766-1842) during the Napoleonic Rin military campaign from 1792. The wounded who remained on the battlefield till the end of the battle to receive medical care, usually more than 24 hours, from that moment were transported during the conflict with flying ambulances to mobile hospitals. Starting with the First World War, through the usage of antiseptics, blood transfusions, and fracture management, the mortality decreased from 39% in the Crimean War (1853–1856) to 10%. One of the most preeminent figures of the Second World War was Michael DeBakey, who created the Mobile Army Surgical Hospitals (MASH), concept very similar to the Larrey’s unit. In 1941, in England, Birmingham Accident Hospital was opened, specially designed for injured people, this being the first trauma center worldwide. During the Golf War (1990–1991) the MASH were used for the last time, being replaced by Forward Surgical Teams, very mobile units satisfying the necessities of the nowadays infantry [1]. Nowadays, trauma meets the pandemic criteria, everyday 16,000 people worldwide are dying, injuries representing one of the first five causes of mortality for all the age groups below 60 [2]. A recent 12-month analysis of trauma pattern in the Emergency Hospital of Bucharest revealed 141 patients, 72.3% males, with a mean age of 43.52 ± 19 years, and a mean New Injury Severity Score (NISS) of 27.58 ± 11.32 [3]. The etiology was traffic related in 101 (71.6%), falls in 28 (19.9%) and crushing in 7 (5%) cases. The overall mortality was as high as 30%, for patients with a mean NISS of 37.63 [3]. At the scene, early recognition of severe injuries and a high index of suspicion according to trauma kinetics may allow a correct triage of patients [4]. A functional trauma system should continuously evaluate the rate of over- and under-triage [5]. The over-triage represents the transfer to a very severe patient to a center without necessary resources, while under-triage means a low injured patient referred to a highly specialized center. If under-triage generates preventable deaths, the over-triage comes with a high financial and personal burden for the already overloaded tertiary centers [5]. To maximize the chance for survival, the major trauma patients should be transported as rapid as possible to a trauma center [6]. The initial resuscitation of trauma patients was divided into two time intervals: ten platinum minutes and golden hour [6]. During the ten platinum minutes the airways should be managed, the exsanguinating bleeding should be stopped, and the critical patients should be transported from the scene. During the golden hour all the life-threatening lesions should be addressed, but unfortunately many patients spend this time in the prehospital setting [6]. These time intervals came from Trunkey’s concept of trimodal distribution of mortality secondary to trauma, proposed in 1983 [7]. This trimodal distribution of mortality remains a milestone in the trauma education and research, and is still actual for development but inconsistent for efficient trauma systems [8]. The concept of patients’ management in the prehospital setting covered a continuous interval, with two extremities: stay and play/treat then transfer or scoop and run/ load and go. Stay and play, usually used in Europe, implies airways securing and endotracheal intubation, pleurostomy tube insertion, and intravenous lines with volemic replacement therapy. During scoop and run, used in the Unites States, the patient is immediately transported to a trauma center, addressing the immediate life-threating injuries during transportation. In the emergency department of the corresponding trauma center, the resuscitation of the injured patients should be done by a trauma team, after an orchestrated protocol based on Advanced Trauma Life Support (ATLS). The modern trauma teams include five to ten specialists: general surgeons trained in trauma care, emergency medicine physicians, intensive care physicians, orthopedic surgeons, neurosurgeons, radiologists, interventional radiologists, and nurses. In the specially designed trauma centers, the leader of the trauma team should be the general surgeon, while in the lower level centers this role may be taken over by the emergency physicians. The implementation of a trauma system is a very difficult task, and should be tailored to the needs of the local population. For example, in Europe the majority of injuries are by blunt trauma, while in the United States or South Africa they are secondary to penetrating injuries. In an effort to analyse at a national level the performance of trauma care, we have proposed a national registry of major trauma patients [9]. For this registry we have defined major trauma as a New Injury Severity Score higher than 15. The maintenance of such registry requires significant human and financial resources, while only a permanent audit may decrease the rate of preventable deaths in the Romanian trauma care (Figure 1) [10]. Figure 1 - The website of Romanian Major Trauma Registry (http://www.registrutraume.ro). USA - In the United States of America there are 203 level I centers, 265 level II centers, 205 level III or II centers and only 32 level I or II pediatric centers, according to the 2014 report of National Trauma Databank [11]. USA were the first which recognized trauma as a public health problem, and proceeded to a national strategy for injury prevention, emergency medical care and trauma research. In 1966, the US National Academy of Sciences and the National Research Council noted that ‘’public apathy to the mounting toll from accidents must be transformed into an action program under strong leadership’’ [12]. Considerable national efforts were made in 1970s, when standards of trauma care were released and in 1990s when ‘’The model trauma care system plan’’[13] was generated. The American College of Surgeons introduced the concept of a national trauma registry in 1989. The National Trauma Databank became functional seven years later, in 2006 being registered over 1 million patients from 600 trauma centers [14]. Mortality from unintentional injury in the United States decreased from 55 to 37.7 per 100,000 population, in 1965 and 2004, respectively [15]. Due to this national efforts, 84.1% of all Americans have access within one hour from injury to a dedicated trauma care [16]. Canada - A survey from 2010 revealed that 32 trauma centers across Canada, 16 Level I and 16 Level II, provide definitive trauma care [18]. All these centers have provincial designation, and funding to serve as definitive or referral hospital. Only 18 (56%) centers were accredited by an external agency, such as the Trauma Association of Canada. The three busiest centers in Canada had between 798–1103 admissions with an Injury Severity Score over 12 in 2008 [18]. Australia - Australia is an island continent, the fifth largest country in the world, with over 23 million people distributed on this large area, a little less than the United States. With the majority of these citizens concentrated in large urban areas, access to the medical care for the minority of inhabitants distributed through the territory is quite difficult. The widespread citizens cannot be reached by helicopter, restricted to near-urban regions, but with the fixed wing aircraft of the Royal Flying Doctor Service, within two hours [13]. In urban centers, the trauma care is similar to the most developed countries, while for people sparse on large territories the trauma care is far from being managed in the ‘’golden hour’’, often extending to the ‘’Golden day’’ [19]. Germany - One of the most efficient European trauma system is in Germany. Created in 1975 on the basis of the Austrian trauma care, this system allowed an over 50% decreasing of mortality, despite the increased number of injuries. According to the 2014 annual report of the Trauma Register of German Trauma Society (DGU), there are 614 hospitals submitting data, with 34.878 patients registered in 2013 [20]. The total number of cases documented in the Trauma Register DGU is now 159.449, of which 93% were collected since 2002. In the 2014 report, from 26.444 patients with a mean age of 49.5% and a mean ISS of 16.9, the observed mortality was 10% [20]. The United Kingdom - In 1988, a report of the Royal College of Surgeons of England, analyzing major injuries concluded that one third of deaths were preventable [21]. In 2000, a joint report from the Royal College of Surgeons of England and of the British Orthopedic Association was very suggestive entitled "Better Care for the Severely Injured" [22]. Nowadays the Trauma Audit Research network (TARN) is an independent monitor of trauma care in England and Wales [23]. TARN collects data from hospitals for all major trauma patients, defined as those with a hospital stay longer than 72 hours, those who require intensive care, or in-hospital death. A recent analysis of TARN data, looking at the cost of major trauma patients revealed that the total cost of initial hospital inpatient care was £19.770 per patient, of which 62% was attributable to ventilation, intensive care and wards stays, 16% to surgery, and 12% to blood transfusions [24]. Global health care models Countries where is applied Functioning concept Total healthcare costs from GDP Bismarck model Germany Privatized insurance companies (approx. 180 nonprofit sickness funds). Half of the national trauma beds are publicly funded trauma centers; the remaining are non-profit and for-profit private centers. 11.1% Beveridge model United Kingdom Insurance companies are non-existent. All hospitals are nationalized. 9.3% National health insurance Canada, Australia, Taiwan Fusion of Bismarck and Beveridge models. Hospitals are privatized, but the insurance program is single and government-run. 11.2% for Canada The out-of-pocket model India, Pakistan, Cambodia The poorest countries, with undeveloped health care payment systems. Patients are paying for more than 75% of medical costs. 3.9% for India GDP – gross domestic product Table 1 - Global health care models with major consequences on trauma care [17]. Traumas continue to be a major healthcare problem, and no less important than cancer and cardiovascular diseases, and access to dedicated and timely intervention maximizes the patients’ chance for survival and minimizes the long-term morbidities. We should remember that one size does not fit in all trauma care. The Romanian National Trauma Program should tailor its resources to the matched demands of the specific Romanian urban and rural areas.

The New South Wales Department of Corrective Services has introduced a number of suicide prevention measures in order to deal with the problem of inmate suicides. This article describes the measures. The article also shows that the characteristics of the incarcerated population differ greatly from those in the community. Findings from the self-harm database 1991-1995 show that, nevertheless, there are some unique characteristics of the group of self-harmers and fatal self-harmers. These findings are discussed in relation to the preventive measures that are introduced in the NSW correctional centers.

Aim The purpose of the study was to formally identify trauma care delivery problems at the study institution, implement a solution in the form of trauma case management (TCM), and measure the effect of TCM on staff satisfaction, clinical coding accuracy and patient outcomes, using practice-specific outcome variables such as in-hospital complication rates, length of stay, resource use and allied health service intervention rates. This research also aimed to make a unique contribution to the international trauma literature by addressing the lack of any evidence specifically measuring the impact of trauma case management intervention. Methods St George Hospital is a 600 bed urban Teaching Hospital of the University of NSW. It is a designated Trauma Centre, seeing around 200 severely injured patients and around 2500 injury admissions per year. A series of focus groups and a staff satisfaction survey identified perceived problems associated with trauma care, and a trauma case management program was implemented. A preliminary study was conducted with positive results and funding was obtained to provide TCM seven days a week to all trauma patient admissions. A larger clinical trial was conducted and data from 754 patients were collected over fourteen months after TCM was introduced at the study hospital. These data were compared with 777 matched patients from the previous 14 months as a control group. An audit was conducted on trauma patient clinical coding using the daily progress record kept by the trauma case manager. The data were analysed with SPSS. The statistical tests used were Mann-Whitney U, chi-squared (2) logistic regression and generalised linear models. Results Focus groups and the staff satisfaction survey identified communication and coordination as the main problems associated with trauma care delivery. Following the initial implementation of the program, staff support for TCM was overwhelming. TCM greatly improved the rate of and time to Allied Health intervention (p<0.0001). Results demonstrated a decrease in the occurrence of deep vein thrombosis (p<0.038), coagulopathy (p=0.041) and respiratory failure. A reduced hospital length of stay (LOS), particularly in the paediatric (p<0.05) and 45 - 64 years age group was noted. There were 6621 fewer pathology tests performed (p<0.0001) and the total number of bed days was 483 days less than predicted from the control group. Many hospital clinical coding errors and omissions were highlighted by the TCM record comparison. The use of TCM records resulted in Twenty eight percent of recoded records having their Australian national diagnostic related group (AN-DRG) changed, which resulted in the identification over $39,000 in unidentified funding. Conclusion TCM improves staff satisfaction, communication and clinical coding accuracy. The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution. This initiative demonstrates that TCM results in improvements to quality of care, trauma patient morbidity, financial performance and resource use. This research makes an important and original contribution to the international trauma literature by providing the results of a clinical trial formally measuring the impact of trauma nursing case management intervention.

Child road trauma poses a preventable public health burden to the community. This PhD research aimed to: 1) quantify the magnitude of child passenger injuries in New South Wales (NSW), Australia; 2) evaluate the effectiveness of different restraint use to prevent fatalities among child passengers; and 3) estimate the benefit in the general child population from different intervention targets relating to restraint use. It comprised two studies to validate methodology and four independent epidemiological studies. The first study to validate methodology assessed the data item availability and categorization across different road traffic injury surveillance data collections in NSW in relation to World Health Organization recommended data item lists and necessary data item lists for road traffic injury research. Exclusion of, or insufficient categorization of, crucial data items such as restraint use and injurious outcome existed for each data collection. The other study to validate methodology assessed the performance (in terms of incidence estimates, sensitivity, and specificity) of several methods for removing multiple counting when conducting analyses on hospital separation data for child passenger injuries under either primary-diagnosis or all-diagnoses based injury definition, using linkage methods as a comparison. The "readmission"-based criterion consistently best approximated the linkage-method-derived incidence rate. Two epidemiological studies used NSW hospital separation datasets and quantified the magnitude of child road trauma in NSW in terms of hospitalisation rates. One study examined the trend in hospitalised injury incidence rates during the period of July 1998 to June 2005 using a non-parametric estimation method, and reported a non-significant decline of hospitalised injuries to child passengers over time. The second study used Poisson regression to demonstrate that rural NSW children were two times more likely to suffer hospitalised injuries compared with their urban counterparts. The third epidemiological study used the Fatality Analysis Reporting Systems (FARS) from the United States (US) and estimated the association between different restraint uses and child passenger fatality using a matched cohort method. Improperly using restraints significantly elevated the risk of death for child passengers involved in a crash compared to any other restraint use. The advantage of child restraints over seat belts in terms of fatality reduction was not statistically significant, although previous studies have shown an advantage for serious injury reduction. The last study was performed to quantify the relative public health benefit in terms of reduction in child passenger deaths and injuries for different interventions relating to restraint use in the general population using a case-based population attributable risk fraction method. Results support the ongoing child restraint legislation change in Australia to require compulsory child restraint uses for children up to their 7th birthday, and an increasing proper use of age-appropriate restraints would provide the greatest reduction in fatalities and injuries among child passengers assuming equal population uptake for all interventions. In conclusion, this thesis demonstrates that child road trauma remains a public health burden to the Australian community; and highlights the importance of properly using age-appropriate restraints in preventing injuries to child passengers.

It is always difficult to measure urban resilience, but never more so when the trauma results from civil unrest, as opposed to a natural disaster or enemy attack.With natural disasters, it is frequently difficult to place blame, even if “acts of God” are sometimes all too intertwined with ill-advised decisions to site buildings in vulnerable areas. Wars and other attacks usually entail clear enemies, and eventually come to some negotiated halt, accompanied by greater territorial clarity. With riots and civil unrest, by contrast, destruction is community-based. Victims and perpetrators live in close proximity; violence is often inflicted within the very neighborhoods that feel most aggrieved; and recovery entails the need to redress not just physical damage but also deeply ingrained mistrust. Rebuilding, in this sense, requires not just investment in real estate, but also a variety of human capital—local infusions of community dynamism, neighborly cooperation, and no small measure of hope. In the United States, Los Angeles, California, stands out as the site of two generations of civil unrest: the Watts riots of 1965 and the civil unrest of 1992. The 1992 disturbance was the most damaging urban riot in American history, killing fifty-four people and causing hundreds of millions of dollars in property damage. Touched off by the acquittal on April 29 of white police officers accused of beating black motorist Rodney King, the rampage lasted several days and spread to an area much larger than the earlier riots in Watts. The disturbance ranged across dozens of square miles, mostly along the lengthy commercial strips in the southern part of the city of Los Angeles, including many areas not traditionally viewed as part of South Central. It even spilled northward above the Santa Monica Freeway into Hollywood, the traditionally Jewish Fairfax district, and other neighborhoods far from the traditional centers of African-American residence. This chapter investigates a full decade of efforts to rebuild South Central Los Angeles, following the trial of King’s assailants. In so many ways, Los Angeles is a city like no other—a vast but low-rise city, dense and sprawling at the same time. Auto-oriented and generally without high-rises, Los Angeles might seem different from a more traditional metropolis such as New York.

Post-traumatic stress disorder (PTSD) presents a puzzling pathology of memory. An event, usually experienced with great fear and distress, is remembered not through typical recollections of past occurrences, upsetting as they may be, but instead as repeated and intrusive re-experiencing of the event as if happening once again. This is more or less the description of a disorder officially recognized by the American Psychiatric Association in 1980, but whose history can be traced back to the middle of the nineteenth century. As critical accounts by Ian Hacking, Ruth Leys, and Allan Young have shown, the very notion of traumatic memory is a distinctively modern development, which introduced new dimensions to the understanding of human memory more generally. In the spirit of modern progress, pathology of memory calls for therapy of memory, and the question of how to treat post-trauma inevitably involves the question of how to penetrate traumatic memory. That this memory is such that resists normal memorization renders any therapy a form of intermediating between past and present. In fact, it might be possible to run through the history of trauma therapies as a story of the challenge of accessing and retrieving traumatic memory. This chapter ventures no such enterprise. But its subject matter might be considered as a most recent episode in that story, in which access and retrieval of traumatic memory are performed by means of digital media technology. Virtual Reality Exposure Therapy (VRET) is a clinical therapy project that employs digital virtual reality platform for treating war-related PTSD. Developed chiefly by psychologist Albert “Skip” Rizzo at the Institute for Creative Technology of the University of South California, the project draws on principles of exposure therapy, a cognitive-behavioral method whereby the patient is exposed to stimuli associated with the fearful event in order to achieve habituation. Its most recent configuration is Virtual Iraq- Afghanistan: an Xbox videogame- based platform currently in use at more than sixty locations, including hospitals, military bases, and university centers.