Clinical and Health Affairs
Epidemiology of Trauma in Minnesota
By Jon Roesler, M.S., Mark Kinde, M.P.H., Anna Gaichas, M.S., Curtis Fraser, and Mark Phillips
Abstract
Injury accounts for more than 2,500 deaths and 300,000 hospital admissions in Minnesota each year. Using the 2002 Minnesota hospital discharge database, we examined the subset of hospital-treated injuries that received trauma care and categorized claims into trauma-related deaths, cases of nonfatal major trauma, and other cases that received specialized trauma care. We also examined where trauma patients received their care, the leading diagnoses for trauma deaths and nonfatal major trauma, and whether a statewide trauma system that would identify and equip more hospitals as trauma centers would have significant potential for improving trauma care in Minnesota.
Morbidity and mortality caused by injuries have been persistent problems in Minnesota, as well as in the rest of the United States and the world. Of the 105 deaths that occur in Minnesota each day, 7 are caused by injuries.1 In Minnesota, injuries, including those caused by acts of violence, account for 30% of all lost years of productivity.2 In addition, the more than 300,000 nonfatal injuries treated in Minnesota hospitals each year account for more than $593 million in charges.3
Care of the injured patient has been fundamental in the practice of medicine since recorded history. Trauma, a term derived from the Greek word for “wound,” generally refers to any bodily injury that requires medical care, and often hospitalization. Major trauma is often referred to as the subset of severe injury that requires care at a trauma center—a specialized hospital distinguished by the 24-hour availability of surgeons, specialists, anesthesiologists, and/or nurses; the presence of resuscitation and life- support equipment; and the ability to provide definitive care to severely injured patients.4
Of Minnesota’s 148 hospitals, 136 are considered acute-care facilities, and 128 have 24-hour emergency departments.5 Minnesota has 10 self-identified trauma hospitals that together make up the Minnesota Trauma Registry Alliance; 6 of these hospitals are verified trauma centers by the American College of Surgeons.6 Five of the 10 hospitals in the Minnesota Trauma Registry Alliance are located in the Twin Cities metro area (Hennepin County Medical Center in Minneapolis, Mercy Hospital in Coon Rapids, North Memorial Medical Center in Robbinsdale, Regions Hospital in St. Paul, and Unity Hospital in Fridley); the others are Immanuel St. Joseph’s Hospital in Mankato, St. Cloud Hospital in St. Cloud, St. Luke’s Hospital and St. Mary’s Medical Center in Duluth, and Saint Marys Hospital in Rochester. Of the state’s 5 million residents, 54% live in the Twin Cities metro area.
Methods
The database used for this analysis is based on the Uniform Bill, 1992 version (UB-92). It consists of both inpatient and outpatient claims data voluntarily submitted by Minnesota acute-care hospitals to the Minnesota Hospital Association. Ninety-six hospitals reported data, representing approximately 92% of inpatient discharges from Minnesota hospitals.7 The data set, which was reported for the 2002 calendar year, was modified to remove duplicate cases.
We used the database to report on the nature (eg, intracranial injury, burn, fracture), mechanisms (eg, firearm, motor vehicle, fall), outcome (eg, death, hospitalization, emergency department visit), intent or manner (eg, assault, self-inflicted, unintentional), as well as combinations (eg, fatal, self-inflicted gunshot wound to the head) of injuries. Classification into groups was done for both diagnostic codes and external causes of injury.8,9 Cases of trauma that met the criteria for trauma in a proposed statewide trauma plan (see p.36) were identified from among injury patients treated in hospitals.10 This included most inpatients with primary or secondary discharge ICD-9-CM diagnosis codes of 800.00–959.9 (most injuries), 987.9 (smoke inhalation), 991.0-3 (frostbite), 994.0 (lightning), 994.1 (drowning), 994.7 (asphyxiation and strangulation), and 994.8 (electrocution).11 Cases of trauma were grouped into the mutually exclusive categories of trauma deaths, nonfatal major trauma, and other trauma care.12
Findings
In Minnesota in 2002, the leading causes of trauma were falls and motor vehicle crashes (Table 1). The leading diagnosis for both trauma deaths and nonfatal major trauma was traumatic brain injury. Upper- and lower-extremity injuries were the leading causes for other trauma care (Table 2).
Of the 641 trauma deaths reported in Minnesota that year, 241 (38%) occurred in hospitals that were not among the state’s 10 trauma hospitals. Of the 1,699 nonfatal major trauma cases, 558 (33%) were treated in facilities other than trauma hospitals. Of the 20,263 other trauma cases reported, 11,086 (55%) were treated at facilities that were not trauma hospitals. Most of the trauma deaths (60%) happened in Twin Cities hospitals, as did treatment of 63% of other nonfatal traumatic injuries and 59% of other trauma injuries. Fifty-five percent of the patients who died as a result of trauma were men, as were 68% of those who suffered major nonfatal injuries. Adults age 65 and older account for most trauma deaths (60%), whereas youths (ages 15 to 24) and young adults (ages 25 to 44) account for almost half of all nonfatal major trauma (48%). Children up to 14 years of age account for less than 10% of all trauma care.
Altogether, hospital charges for trauma care in Minnesota exceeded $450 million in 2002. Of that, trauma deaths accounted for more than $22 million in charges. Nonfatal major injuries accounted for more than $82 million, while other trauma care accounted for more than $345 million in charges.
Conclusion
Trauma care is essential to mitigating the impact of severe injury. Minnesota’s 6 verified trauma centers and its 4 other self-identified trauma hospitals provide care for most major trauma cases; yet the other 126 acute-care hospitals in the state provide the majority of other trauma care. In 2002, 38% of the people who died from trauma never made it to a trauma facility for treatment; 33% of those with major nonfatal trauma received care at hospitals other than those identifying themselves as a trauma hospital; and 55% of other trauma cases were seen in hospitals other than the 10 hospitals in Minnesota’s Trauma Registry Alliance.
Falls and motor vehicle crashes are the leading causes of major trauma in Minnesota. Both are heterogeneous in nature, and there is no silver bullet to address either cause. Although a number of agencies and organizations are working to further reduce motor vehicle–related injuries, programs to prevent falls are only beginning to appear.
Traumatic brain and spinal cord injury account for more than half of all major trauma. Research has shown that efforts to improve trauma systems should focus on treating patients with head injuries.13 Clearly, Minnesota would benefit from a trauma system with such a focus.
Trauma care cases represent about 7% of all injuries treated in hospitals. Yet provision of trauma care by Minnesota’s hospitals, including treatment of patients who die as a result of trauma or who sustain other major trauma, accounts for more than half of all injury-related hospital charges. If Minnesota moves forward with its plan for a statewide trauma system, trauma care could be considered a growth area for hospitals, as the education and quality improvement required to attain trauma center designation would equip medical staff to provide most trauma care in the community in which the injury occurs, potentially reducing the need to transport patients to trauma facilities in urban areas.
Empirical evidence demonstrates that establishing a regionalized system of trauma services can reduce mortality and inappropriate care. More specifically, research suggests that the major factors leading to improved outcomes are reduced prehospital time, direct transport from the scene to a trauma center, and treatment at a trauma center.14,15 Yet even with an established trauma system, the quality of care can vary significantly among trauma centers; this study does not evaluate the effectiveness of existing trauma care in Minnesota. Nonetheless, with so much of Minnesota’s trauma care taking place in hospitals that are not trauma centers, a statewide trauma system would appear to have significant potential for improving outcomes, including patient survival rates. Our data suggest that identifying and equipping more hospitals as trauma centers and focusing on the care of head and spinal cord injuries would be the hallmarks of a well-planned trauma system. MM
Jon Roesler is a senior epidemiologist, Mark Kinde is a unit manager, Anna Gaichas is a research analyst, Curtis Fraser and Mark Phillips are information technology specialists in the Injury and Violence Prevention Unit at the Minnesota Department of Health.
References
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2. Centers for Disease Control and Prevention: WISQARS Years of Potential Life Lost Reports, 1999 – 2001 for Minnesota. Available at: http://webappa.cdc.gov/sasweb/ncipc/ypll10.html. Accessed December 6, 2004.
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