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New System Helps EDs Prepare for the Unforeseeable

INDIANAPOLIS, IN – Can emergency departments really be completely prepared for the crush of trauma patients from catastrophic events such as the Boston Marathon bombing in 2013 or even the Amtrak train crash in Philadelphia a few months ago?

Maybe not, but a trauma scoring system, reported recently in an article published online by the Journal of the American College of Surgeons, might be able to help. The Trauma Surge Index (TSI) was developed by surgeon Peter C. Jenkins, MD, MSc, and a team of investigators from Indiana University.

"Overall, hospitals are poorly equipped to recognize these events," said Jenkins. "People identify events that are renown, like 9-11 or the Boston Marathon bombing, but there are other periods of high-capacity strain on hospital trauma centers that often just fly under the radar, especially if the hospital concurrently receives patients from multiple events – a bus accident over here, a fire over there, and a shooting."

Making sure an ED is prepared for a surge can be lifesaving, the study authors emphasized. Using the TSI, investigators determined that trauma patients admitted to the hospital during high-surge periods died at much higher rates than patients admitted on other occasions, 9.9% compared to 6.3%. For patients with gunshot wounds, the risk was significantly greater: a death rate of 42% during high surge periods vs. 15.5% normally.

Two variables are included in the TSI: the severity of each patient's injury, and the time and date of each patient's admission to the hospital. Surge activity is ranked on a scale from 0 to "greater than 8,” which is the highest score. A retrospective measure, the TSI tracks annual volume and severity of trauma injury for an individual hospital so that physicians and hospital administrators can make sure the ED is ready for whatever comes along.

The study, which included 233,623 patients admitted to 156 TQIP-participating trauma centers in 2010 and 2011.

Part of the problem with past measures, according to the investigators, is that they failed to consider the severity of injuries and the differences in the sizes of varying hospitals. "To say 10 patients over a 12-hour period is a surge is arbitrary," Jenkins said. "That might be true for a low-volume community hospital, but for a high-volume trauma center, that's an average day."

To account for the severity of patients' injuries, the TSI employs the Injury Severity Score. It also includes data from the Trauma Quality Improvement Program of the American College of Surgeons.

Jenkins called the increased death rate among shooting victims "one interesting and unexpected result,” explaining that gunshot wounds can be extremely resource intensive and difficult to manage during high surge periods.