Eye trauma centers improve outcomes for some injuries

Baltimore-A subspecialty eye trauma center, particularly one that is open 24 hours a day, is only feasible in certain large markets. Such centers, however, have better outcomes for patients with blunt, penetrating, chemical, and other eye injuries, according to Michael P. Grant, MD, PhD, FACS, director of cosmetic facial services and assistant professor of ophthalmology and plastic surgery, Wilmer Eye Institute, School of Medicine, Johns Hopkins University, Baltimore.

"Certainly, from the voluminous work that has been done in looking at outcomes associated with Level I general trauma centers, we know that for people with significant injuries, the outcomes are significantly better at those sort of centers," he said.

"This [finding] has been extended to some subspecialty centers, such as burn trauma centers, where we, again, see a better outcome in patients with severe injuries treated at these centers" than at facilities providing a lower level of care, he continued.

Discussing the motivations for establishment of a 24/7 eye-trauma center at the Wilmer Eye Institute several years ago, Dr. Grant cited a recent paper reviewing experiences at several trauma centers. The study found that better outcomes are achieved at Level I centers than at lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes.

Ophthalmologists rarely need to worry about mortality with eye trauma cases, Dr. Grant added, but they continually face the prospect of poor outcomes in patients who are not treated appropriately in the initial stages of their injuries.

Dr. Grant relayed two cases that illustrate this point.

The first case involved a patient who came to the eye trauma center 3 days after sustaining an eye injury at work while hammering metal on metal and wearing inadequate protective eye gear. The patient initially went to a local emergency department, where normal vision and a foreign body sensation were documented. He was sent home and presented to the trauma center 48 hours later with post-traumatic endophthalmitis. The problem was not able to be fixed at that point, but early intervention probably would have saved the patient's eye and some of his vision, Dr. Grant said.

A different situation occurred with another patient, who was hospitalized at another institution for almost 48 hours because of concern about increased intracranial pressure after a low-energy entry into the organ. The patient was experiencing repeated nausea, vomiting, eye pain, and double vision. After the patient was transferred to the pediatric intensive care unit at the Wilmer Eye Institute, an ophthalmologist correctly diagnosed a trap door fracture in the left orbit.

Planning considerations

When planning an eye trauma center, Dr. Grant recommended it should be designed to offer 24/7 coverage, the ability to diagnose and treat the full spectrum of ocular and orbital injuries, access to appropriate consultants, and maintenance of a patient registry. On the institutional side, the required resources include a facility and staffing, a quality-assurance mechanism, and financial support.

The eye trauma center at Wilmer was built with three examination rooms and an isolation room as well as a procedure room, he said. The center is contiguous with the inpatient unit. Six dedicated operating rooms within the Wilmer Eye Institute are available for trauma cases. Pre- and postoperative areas are staffed around the clock.

The professional staff includes physicians; surgeons; a director; an associate director who also is the assistant chief of service and completed fellowship training at Wilmer; residents; and consultants who are called as needed, including neurologists, plastic surgeons, otolaryngologists, and social workers.

The nursing staff includes a nurse director; two head nurses who run the operating room and the eye care pavilion, respectively; and emergency-room nurses. All of the nurses are cross-trained to perform multiple functions.

Quality-assurance steps include being able to assess the triage level and wait times. The staff of the eye trauma center at Wilmer developed its own quality indicators for the state of Maryland to ensure that they were suitable for an eye trauma center. In addition, quarterly reports are sent to an internal performance improvement committee.

Another component of a well-run eye trauma center is good communication, Dr. Grant said.

"Feedback to referring physicians is key in this because it also fulfills our educational mission," he said.

For example, a report from the trauma center noting that an eye with a chemical injury was patched instead of irrigated would help the referring physician learn the appropriate way to initially manage such injuries.

The financial performance of any emergency service can be a challenging issue, and the Wilmer trauma center is no exception, Dr. Grant said. The emergency service has been operating at a deficit, he said, adding, however, that the amount of the deficit has declined. Fifty-one percent of the patients treated have either no insurance or are on medical assistance and considered underinsured, Dr. Grant said.

Several years ago, the Maryland state legislature addressed the issue of financing trauma care by passing the Maryland Trauma Physician Services Act, which is funded through a tax on automobile registrations. It initially provided compensation for six subspecialty service areas, such as trauma surgery, emergency medicine, anesthesiology, orthopedics, and neurosurgery. These limitations left some gaps, however, Dr. Grant said.

"The scenario would exist in our own hospital where the ER physician who saw the patient and diagnosed the problem-or called us to diagnose the problem-and the anesthesiologist who put the patient to sleep while we fixed the problem would be compensated for treating that patient, but we would not be," he said.

The fund established by the legislature accumulated a $10 million surplus after several years, so a group of health-care professionals involved in trauma care lobbied to amend the law. In 2006, the initial law was changed to open the fund to any subspecialist or specialist in a designated center who treated a trauma patient.

"This for us was a real plus in that we could now start billing for our professional fees associated with treating either uninsured or underinsured patients within our institute," Dr. Grant said.

Although this adjustment will not erase the entire deficit that the eye trauma center has incurred, it helps, he added, noting that some of the expenses are related to the method of cost allocation within the hospital and don’t reflect the true operating deficit of the service alone.

Other approaches

Dr. Grant said that he hopes to motivate other clinicians to consider approaches for addressing trauma care.

"The way we've chosen to deal with it may or may not be feasible in [every] institution, but it certainly is a way to organize a center and then try to obtain some sort of funding for that center," he said.

A tax on automobile registrations was used as a funding mechanism in Maryland because of a strong commitment to treating victims of motor vehicle trauma, he said. In other states, a tax might be applied to gasoline or tobacco instead, Dr. Grant said.