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Less is More: Dissecting Trauma Centers by Procedural Volume
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Louis J. Magnotti, *Sai Krishna Bhogadi, *Tanya Anand, *Collin Stewart, *Christina Colosimo, *Audrey Spencer, Bellal Joseph
The University of Arizona, Tucson, AZ
Objective: Although the American College of Surgeons Committee on Trauma has long recognized annual trauma admission volume as a hard criterion for trauma center (TC) verification, little attention has been given to the overall importance of procedural (operative and angiographic) interventions as a potential quality indicator. The aim of this study was to examine the relationship between procedural intervention (PI) volume and overall trauma admission volume of Level I TCs.
Methods: All patients managed at ACS level I TCs were identified from the Trauma Quality Improvement Database over 5 years, ending in 2021. TCs were identified using facility keys and stratified into quartiles based on overall trauma admission volume into low, low-medium, medium-high, and high volume. TCs were also stratified into tertiles (low volume [LV], medium volume [MV], high volume [HV]) based on PI volume by assessing the annual number of laparotomies, thoracotomies, craniotomies/ectomies, angioembolizations, vascular repairs, and long bone fixations performed at each center. Cohen's κ statistic was used to assess the concordance between overall and PI volume status.
Results: 182 Level I TCs were identified: 76 low (≤2073 admissions/year), 47 low-medium (2074-2727 admissions/year), 35 high-medium (2728-3610 admissions/year), and 24 high (≥3611 admissions/year) volume TCs. The most common PI was laparotomy with a median [IQR] number of 60 [32-106] per year per center, followed by craniotomy/ectomies (46 [33-62] per year per center), and angioembolization (23 [14-37] per year per center). Overall, 31% of HV laparotomy centers, 30% of HV thoracotomy centers, 22% of HV craniotomy/ectomy centers, 33% of HV angioembolization centers, and 32% of HV long bone fixation centers contributed to the overall number of low and low-medium volume TCs. Moreover, among high-volume TCs, 37% were medium to low laparotomy volume, 25% were medium to low thoracotomy volume, 30% were medium to low craniotomy/ectomy volume, and 21% were medium to low angioembolization volume centers (
Table) A comparison of hospital volume status using overall trauma admission volume and PI volume demonstrated poor concordance (Overall vs. laparotomy: κ = 0.330, Overall vs. thoracotomy: κ = 0.301, Overall vs. craniotomy/ectomy: κ = 0.331, Overall vs. angioembolization: κ = 0.366, Overall vs. vascular repair: κ = 0.454, Overall vs. long bone fixation: κ = 0.302).
Conclusion: Overall trauma admission volume does not reflect the procedural (both operative and angiographic) interventions performed. Based on our findings, a combination of the PI and the overall trauma admission volume should be considered when evaluating a trauma center. Such an assessment may provide a more accurate picture of the clinical experience for any given TC.
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