title: Resource commitment to improve outcomes and increase value at a level I trauma center.
abstract: BACKGROUND
  Optimal care of trauma patients requires cost-effective organization and commitment of trauma center resources. We examined the impact of creating a dedicated trauma care unit (TCU) and adding advanced practice nurses on the quality and cost of care at an adult Level I trauma center.
  
  
  METHODS
  Patient demographic and injury data, length of stay, complications, outcomes, and total direct cost of care were evaluated for four 1-year intervals in the recent history of our trauma center: Year A, a trauma team of in-house trauma surgeons and resident physicians; Year B, the addition of nurse practitioners to the trauma team 5 days/week; Year C, the creation of a dedicated TCU for all non intensive care unit trauma patients; and Year D, the addition of a permanent clinical nurse specialist and an increase in nurse practitioner coverage to 7 days/week. For each year, value was determined by calculating the median cost of a survivor and the median cost of a survivor with no complications. Significance was attributed to p<0.05.
  
  
  RESULTS
  Patient volume increased from 1,927 in year A to 2,546 by year D. Over the period of study, there was an increase in blunt trauma (87.1-89.9%; p<0.05), median Injury Severity Score (5-6; p<0.05), and patients aged ≥65 years (11.4-19.8%; p<0.05). However, risk-adjusted mortality was unchanged. There was a decrease in patients with a complication (20.8-14.9%; p < 0.05), median intensive care unit length of stay (39.5-23.4 hours; p < 0.05), and median cost of care ($4,306-$3,698; p<0.05). Value increased: both the median costs of a survivor and of a survivor with no complications decreased from $4,259 to $3,658 (p<0.05) and from $3,898 to $3,317 (p<0.05), respectively. The median cost of a survivor with severe injury (Injury Severity Score ≥15) decreased from $17,651 to $12,285 (p<0.05).
  
  
  CONCLUSIONS
  The addition of a dedicated TCU and advanced practice nurses improved the quality and reduced the cost of care, resulting in increased value at an adult Level I trauma center.
authors: Trauma Service, Scripps Mercy Hospital, 4077 5th Avenue, San Diego, CA 92103, USA. sise.beth@scrippshealth.org
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