Quality of Treatment of Trauma Patient. A comparative study of the trauma data of
Hadassah Ein-Kerem and 51 trauma level I hospitals in the USA.
Project participants: Dr. Yoav Mintz, Prof. Avraham Rivkind and Dr. Rony Braunstein
Background: In Israel, Hadassah and five other hospitals have trauma centers
defined as level-I because of their expertise and capacity to handle trauma
injuries of all kind. The current study compares survival at Hadassah to those in
level I trauma hospitals in the USA.
Methods: Data on trauma patients at Hadassah derives from the Israeli national
trauma registry system, including a total of 7,391 patients, and operated by the
Gertner institute for epidemiology and health policy in Israel. U.S. data on
trauma patients derives the National Trauma Data Bank (NTDB) of the American
College of Surgeons Committee on Trauma, covering 51 level-I trauma centers,
including a total of 263,524 patients. The timeframe is from year 1999 thru
2003.
Results: The major outcome, the average rate of death, was 2.6% at Hadassah
compared to 5.8% in the USA. Mortality rates were also compared stratified
according to the gravity of trauma, estimated by the Injury Severity Scale (ISS)
and the analysis is shown in Figure 1 below.
Figure 1
Death Rate by ISS
40%
30%
35.2%
Hadassah
28.2%
NTDB
20%
7.3%
10%
0.1% 0.9%
0.5%
2.5%
1.5%
0%
ISS 1-8
ISS 9-14
ISS 16-24
ISS 25+
From Figure 1, it appears that for each sub-group of injury severity, the death
rate at Hadassah is lower than the mean death rate in the U.S. (NTDB) data.
A similar finding can be noticed when one examines the death rate by Injury
Mechanism (IM). For most types of injury mechanism, as shown in Figure 2 below,
the death rate at Hadassah appears lower than the mean death rate in the U.S.
(NTDB) data (only in the category of cuts and stabs is the death rate in Hadassah
higher (1.0%) than the average death rate (0.6%) of the NTDB data).
Figure 2
Death Rate by IM
15%
Hadassah
16.0%
NTDB
9.1%
10%
5%
4.6%
5.6%
3.7%
6.5%
2.6%
1.3%
5.3%
4.9%
1.7%
0.6%
1.0% 0.6%
2.2%
0.0%
0%
Falls
Road
Accidents
Burns
Injury from Cuts & Stabs Injury from
Objects
Machines
Firearms
Other
Unspecified
As shown in Figure 3 below, for each year from 1999 to 2003, the death rate at
Hadassah (triangles) appears is lower than the average death rate of the U.S.
(NTDB) data (circles). This conclusion holds both for total mortality (shown in
closed symbols) and for the mortality of most severe patients (defined as having
an injury score over 16, ISS 16+, shown in open symbols).
Figure 3
Death Rate by Year 1999-2003
30%
20%
Hadassah - Total Mortality
NTDB - Total Mortality
Hadassah - ISS 16+ Mortality
NTDB - ISS 16+ Mortality
19.7%
18.4%
20.9%
14.4%
20.2%
20.5%
13.6%
13.4%
19.6%
11.5%
10%
5.3%
5.8%
5.5%
3.2%
2.6%
2.7%
5.8%
2.9%
6.7%
2.1%
0%
1999
2000
2001
2002
2003
Conclusion and future plans: Hadassah appears to have an overall lower death
rate (2.6%) than 51 U.S. level-I trauma centers (where the death rate is 5.8%).
If improved survival at Hadassah is related to higher performance, such quality
applied to the 263,524 patients in the US trauma centers, would have prevented
about 8,400 deaths.
The data were sent for review to Prof. Ellen J. MacKenzie, Ph.D., Director,
Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public
Health. She replied: “The data you sent on is most interesting! You must be doing
something right at Hadassah!”. Attempts will be made to further analyze these
data by adjustments for confounding factors and alternate modeling,1 and to
focus our comparison with the most experienced units in the U.S. A possible
reason for improved performance at Hadassah could relate, at least in part, to
the general availability of senior trauma, orthopedic and other specialty surgeons
at critical times, during evening and night shifts, while similar cases would often
be handled, in the U.S, by residents and non-specialist surgeons.
1
Frankema SPG, Steyerberg EW, Edwards MJR, van Vugt AB. Comparison of Current Injury Scales
for Survival Chance Estimation: An Evaluation Comparing the Predictive Performance of the ISS,
NISS, and AP Scores in a Dutch Local Trauma Registration. Journal of Trauma-Injury Infection &
Critical Care March. 2005;58(3):596-604.