Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma

The environmental context of patient safety and medical errors

The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural: healthcare organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events associated with learning, information flows, triage and transfer decisions, and culture of safety). Relevant organizational theories and strategies fo medical error reduction and prevention in rural health care settings were identified. Financial and technical assistance are needed to support the systematic collection of data from rural hospitals and other entities and to enhance relevant patient safety practices for rural America.

[Evaluation of costs incurred for patients with multiple trauma particularly from the perspective of the hospital]

The aim of this study was to evaluate the costs involved in treating severely injured patients at the clinic differentiated by several characteristics (injury, age), sectors (emergency room, surgery, intensive and normal care), and kinds of costs (fixed costs, variable costs) and to determine influencing factors regarding costs based on the register of the DGU (Deutsche Gesellschaft für Unfallchirurgie). All patients were taken into account who had an injury severity score (ISS) of at least 16. On this basis costs of 3702 patients were analyzed. They were compared by using analysis of variance for different groups of patients classified according to kind of injury, severity of injury, and age. Moreover, multiple regression was performed to control the common influence of demographic factors and the type of injury on costs. The average ISS of the analyzed patients was 30.6 (+/-11.6) points. The average costs of the clinic were 32,166 (+/-25,404) EUR per patient. More than half of the costs was incurred by intensive care and about one-fourth by surgery. On average 30.6% were variable costs and 69.4% were fixed costs. The analysis of variance revealed that costs increased with advancing age and severity of injury (ISS). Multiple regression confirmed these interrelations indicating that extremities are very cost intensive. Due to the high portion of fixed costs, the overall costs strongly depend on the capacity utilization and less on hospital stay. That is why it may be necessary in the future to create centers for trauma care to maintain economic efficiency for treatment of these patients. Besides large differences of costs within closely defined groups of patients, hospitals carry a high economic risk so that a more complex reimbursement system should be discussed than implemented by the German DRGs.

Advanced statistics: the propensity score--a method for estimating treatment effect in observational research

Observational studies assessing the effect of a particular treatment or exposure may be subject to bias, which can be difficult to eliminate using standard analytic techniques. Multivariable models are commonly used in observational research to assess the relationship between a certain exposure or treatment and an outcome, while adjusting for important variables necessary to ensure comparability between the groups. Large differences in the observed covariates between two study groups may exist in observational studies in which the investigator has no control over who was allocated to each treatment group, and these differences may lead to biased estimates of treatment effect. When there are large differences in important prognostic characteristics between the treatment groups, adjusting for these differences with conventional multivariable techniques may not adequately balance the groups, and the remaining bias may limit valid causal inference. Use of a propensity score, described as a conditional probability that a subject will be "treated" based on an observed group of covariates, may better adjust covariates between the groups and reduce bias. The purpose of this article is to describe the use of propensity scores to adjust for bias when estimating treatment effects in observational research and to compare use of this technique with conventional multivariable regression. The authors present three methods for integrating propensity scores into observational analyses using a database collected on head-injured trauma patients. The article details the methods for creating a propensity score, analyzing data with the score, and explores differences between propensity score methods and conventional multivariable methods, including potential benefits and limitations. Graphical representations of the analyses are provided as well.

Selection bias found in interpreting analyses with missing data for the prehospital index for trauma

OBJECTIVE

To evaluate the effects of missing data on analyses of data from trauma databases, and to verify whether commonly used techniques for handling missing data work well in theses settings.

STUDY DESIGN AND SETTING

Measures of trauma severity such as the Pre-Hospital Index (PHI) are used for triage and the evaluation of trauma care. As conditions of trauma patients can rapidly change over time, estimating the change in PHI from the arrival at the emergency room to hospital admission is important. We used both simulated and real data to investigate the estimation of PHI data when some data are missing. Techniques compared include complete case analysis, single imputation, and multiple imputation.

RESULTS

It is well known that complete case analyses and single imputation methods often lead to highly misleading results that can be corrected by multiple imputation, an increasingly popular method for missing data situations. In practice, unverifiable assumptions may not hold, meaning that it may not be possible to draw definitive conclusions from any of the methods.

CONCLUSION

Great care is required whenever missing data arises. This is especially true in trauma databases, which often have much missing data and where the data may not missing at random.

Implementation of a Trauma Care System: Evolution Through Evaluation

BACKGROUND

The regionalization of trauma services has been implemented in many health care systems and communities over the past 10 to 20 years. As these trauma systems mature and evolve, changes are made to improve the care and efficiency of the system. Trauma care regionalization was introduced in Quebec in 1993. This study looked at the evolution of trauma care in Quebec over the past 13 years, from the preregionalization era to the present.

METHODS

A retrospective review scientifically evaluated a trauma system, the implementation of evidence-based changes, and the efficacy of these changes.

RESULTS

Various changes have been made in the Quebec trauma system since the introduction of regionalization. These changes have led to an incremental decrease in mortality caused by severe trauma from 51.8% in 1992 to 8.6% in 2002.

CONCLUSION

A trauma system is fluid and constantly evolving. Research and constant reevaluation are necessary for continuous evaluation of the system and improvement of its outcomes and efficiency.

A geographic information system simulation model of EMS: reducing ambulance response time

Response time is a very important factor in determining the quality of prehospital EMS. Our objective was to model the response by Israeli ambulances and to offer model-derived strategies for improved deployment of ambulances to reduce response time. Using a geographic information system (GIS), a retrospective review of computerized ambulance call and dispatch logs was performed in two different regional districts, one large and urban and the other rural. All calls that were pinpointed geographically by the GIS were included, and their data were stratified by weekday and by daily shifts. Geographic areas (polygons) of, at most, 8 minutes response time were simulated for each of these subgroups to maximize the timely response of calls. Before using the GIS model, mean response times in the Carmel and Lachish districts were 12.3 and 9.2 minutes, respectively, with 34% and 62% of calls responded within 8 minutes. When ambulances were positioned within the modeled polygons, more than 94% of calls met the 8-minute criterion. The GIS simulation model presented in this study suggests that EMS could be more effective if a dynamic load-responsive ambulance deployment is adopted, potentially resulting in increased survival and cost-effectiveness.

Impact of helicopter transport and hospital level on mortality of polytrauma patients

BACKGROUND

Despite numerous studies analyzing this topic, specific advantages of helicopter transport of blunt polytrauma patients as compared with ground ambulances have not yet been identified unequivocally.

METHODS

Four possible pathways in 403 polytrauma patients (Injury Severity Score [ISS] > 16) who were in reach of the helicopter emergency medical service (HEMS) Dresden were analyzed as follows: HEMS-UNI group (n = 140), transfer by HEMS into a university hospital; AMB-REG group (n = 102), transfer by ground ambulance into a regional (Level II or III) hospital; AMB-UNI group (n = 70), transfer by ground ambulance into the university hospital; and INTER group (n = 91), transfer by ground ambulance into a regional hospital, followed by transfer to the university hospital. Scores used were the ISS and the TRISS. Tests used for statistical analysis included chi2 and Fisher's tests. Statistical significance was set at p > 0.05.

RESULTS

Age, gender, and mean ISS (range, 33.3-35.6) revealed extensive homogeneity of the groups. Mortality of the AMB-REG group was almost doubled (41.2%) compared with HEMS-UNI (22.1%) patients (p = 0.002). The AMB-UNI group displayed the lowest mortality (15.7%, p = not significant). TRISS analysis (PRE-Chart) revealed identical outcome for AMB-UNI and HEMS-UNI patients. Rescue time averaged 90 +/- 29 minutes for HEMS-UNI patients, 68 +/- 25 minutes for AMB-UNI patients, and 69 +/- 26 minutes for the AMB-REG group.

CONCLUSION

Primary transfer by HEMS into a Level I trauma center reduces mortality markedly. In principle, this benefit can be attributed to superior preclinical therapy, primary admission to a Level I trauma center, or both. However, the identical probability of survival of the AMB-UNI and HEMS-UNI groups in this and comparable studies does not confirm generally better survival rates on account of a more aggressive on-site approach.

Fractures in access to and assessment of trauma systems

BACKGROUND

Trauma is a major public health problem and organized systems of trauma care have been shown to substantially reduce trauma-related mortality. Currently California and many other states have incompletely developed systems of trauma care delivery. This study was undertaken to determine how frequently patients incurring serious trauma in California receive treatment at a trauma center.

STUDY DESIGN

Hospital discharge records for 360,743 acute trauma patients for 1995 to 1997 were analyzed. Abbreviated Injury Scale scores were calculated from discharge diagnosis codes. Severity of trauma and the need for trauma center treatment was defined by eight Abbreviated Injury Scale criteria combined with patient age and type of injury.

RESULTS

According to study criteria, 67,718 patients needed trauma center care and 56% were treated at a trauma center. Among patients less than 55 years of age, 62% were treated at a trauma center compared with 40% of those aged 55 years or more (p < 0.0001). For patients less than 55 years old with brain injuries, 66% were treated at a trauma center compared with 44% for patients aged 55 years or more (p < 0.0001). Of the 29,849 patients who met Abbreviated Injury Scale criteria but were not treated at trauma centers, 59% were in counties with designated trauma centers and 41% were in counties without trauma centers.

CONCLUSIONS

Only 56% of seriously injured patients in California were treated at trauma centers, despite most of the injuries occurring in the catchment areas of designated trauma care systems. Substantial undertriage of serious trauma patients to trauma centers appears to be occurring, especially in older persons and in persons with brain injuries. Efforts to understand why undertriage is occurring so frequently are hampered by fragmentation of the systems of care, inadequate data management systems, and lack of trauma care performance reporting by non-trauma center hospitals.

The Effect of Interfacility Transfer on Outcome in an Urban Trauma System

BACKGROUND

Transporting all trauma patients to regional trauma centers is inefficient; however, the bypass of nearer, nondesignated hospitals in deference to regional trauma centers decreases mortality in the severely injured. One approach to improving efficiency is to allow the initial assessment of selected patients at lower level (Level III/IV) designated centers. We set out to evaluate whether patients initially assessed at these centers and then transferred to a Level I facility were adversely affected by delays to definitive care.

METHODS

This is a retrospective cohort study in which the primary exposure being evaluated is initial assessment at a Level III or IV trauma center before transport to a Level I center in an urban setting. The outcomes in this transfer cohort were compared with outcomes in patients transported directly from the scene to a Level I center (direct cohort). The outcomes of interest were mortality, length of stay, and hospital charges. Multivariate analyses were used to adjust for differences in baseline characteristics across these two cohorts.

RESULTS

Crude length of stay was comparable, whereas mortality was lower and charges were 40% higher in the transfer cohort (n = 281) compared with the direct cohort (n = 4,439). After adjusting for confounders, mortality and length of stay were similar and total charges were significantly greater in the transferred patients.

CONCLUSION

Interfacility transfers in a mature urban trauma system do not appear to impact on clinical outcome. However, transfer patients use significantly greater resources as measured by hospital charges. This effect is likely because of the nature of their injuries or, alternatively, delays in reaching definitive care.

Major trauma transfer in Western Australia

BACKGROUND

The transfer of critically injured patients in a rural Australian setting presents a unique challenge to medical services due to the constraints of distance and time. The purpose of this study is to analyse which injuries are being transferred, how they occur, pretransfer intervention, transfer methods and transfer times.

METHODS

The Trauma Registry Database collected data prospectively on all major rural trauma cases attending the Royal Perth Hospital between August 1994 and January 2000. Patients were divided into rural and metropolitan groups on the basis of trauma location, and the latter group used as a control.

RESULTS

A total of 1275 major trauma patients were treated of which 566 (44%) were from rural areas. Driver road traffic trauma was the most common cause of injury throughout, although most prominent in rural areas (30%vs 18%). For rural patients, the Royal Flying Doctor Service was responsible for 440 (79%) of transfers of which 83% had a doctor and a nurse escort. The most commonly transferred injuries from rural areas were head injury (63%) and thoracic injury (55%). A total of 450 (93%) rural patients were transferred to Royal Perth Hospital within 24 h of trauma although the mean transfer time was over 9 h.

CONCLUSIONS

This data produces a realistic framework of how major trauma in rural areas is treated in Western Australia. It highlights some areas of good practice, such as transfer methods and escorts, but also highlights problem areas such as transfer times and pretransfer intervention.

Anaesthesia in trauma

Trauma patients may need to be anaesthetized at the scene of an accident, in the emergency department or most commonly in the operating theatre. The principles of safe management of anaesthesia in each of these very different environments are discussed along with the common anaesthetic problems encountered and advice on their solution.

[Advanced life support: care provided to motor vehicle crash victims]

OBJECTIVE

To analyze the performance of Advanced Life Support care mode (ALS) applied to car crash victims using indicators by means of the Revised Trauma Score (RTS) in prehospital phase.

METHODS

It were analyzed 643 reports of car crash victims cared by public ALS services that occurred in highways of the city of São Paulo, from April 1999 to April 2000. Time intervals assessed were: response time, on-scene time, transport time, and total time. Correct screening decision analysis considered RTS< or = 1 for tertiary hospitals. Changes in RTS and its parameters were observed using the following equation: RTSfinal - RTSinitial.

RESULTS AND CONCLUSIONS

Of 643 victims, 90.8% were RTS=12 and 5.2% were RTS < or = 0. The response time ranged from 8 to 9 minutes, while on-scene and transport time were higher in RTS < or = 0 cases. Of RTS < or = 0 victims, 45.5% were correctly transported to tertiary hospitals. Screening decision misjudgments were identified. Maintenance or improvement of RTS values occurred in 98.8% of the cases. Respiratory rate was the parameter that showed better improvement followed by systolic blood pressure.

Characteristics of twice-transferred, rural trauma patients

OBJECTIVE

Undertriage has seldom been evaluated in the trauma population. In rural states patients often go to the nearest hospital first, where they are evaluated and, if necessary, transferred to another hospital. If they are undertriaged when transferred to the second hospital, they will require a second transfer to a higher-level trauma center.

METHODS

The authors retrospectively reviewed the charts of all trauma patients at a level I trauma center from 1996 to 1999 who were seen at two acute care facilities because of a single acute traumatic event before reaching the trauma center. Ninety-three patient charts were analyzed.

RESULTS

Forty-six percent of the patients were victims of a motor vehicle crash. Patients were mostly transferred to the level I trauma center for non-spine orthopedic injuries (28%), followed by spine injuries (14%) and head injuries (13%). These patients were stable, as manifested by an average trauma score of 11.6. However, there was a significant positive interaction between injury severity score and time to definitive care.

CONCLUSIONS

The authors infer from the data analysis that more serious or complex injuries took longer to evaluate. Since these patients were physiologically stable, reducing the number of twice-transferred trauma patients will involve refining transfer protocols concerning the need for specialty care.

Predictors of compliance with the evidence-based guidelines for traumatic brain injury care: a survey of United States trauma centers

BACKGROUND

In 1995, evidence-based guidelines for the management of severe traumatic brain injury (TBI) were published and disseminated. Information regarding their implementation is limited.

METHODS

During 1999 to 2000, we contacted all designated U.S. trauma centers caring for adults with severe TBI to determine the degree of guideline compliance and to identify predictors.

RESULTS

Of 924 centers identified, 828 participated (90%). Four hundred thirty-three with intensive care units caring for severe TBI were surveyed. Three hundred ninety-five centers transferring patients were excluded. Full guideline compliance was rare (n = 68 [16%]). In multivariate analyses, treatment protocols (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.9-6.6), neurosurgery residency program (OR, 5.0; 95% CI, 2.6-9.8), and state (OR, 2.7; 95% CI, 0.62-12) or American College of Surgeons (OR, 5.1; 95% CI, 1.1-23) designation increased the likelihood of full compliance versus noncompliance.

CONCLUSION

Although evidence-based guidelines were published and disseminated in 1995, implementation is infrequent. Focus must turn to changing physician practice and transport decisions to provide guideline-compliant care and improve patient outcome.

Predicted impact on Victoria's ambulance services of a new major trauma system

BACKGROUND

In 1999, a new major trauma system was proposed for the state of Victoria, Australia. The guidelines for the new system were aimed at delivering major trauma cases to definitive trauma care in the least time possible. The aim of the present study was to analyse the potential effect of this system on Victoria's ambulance services.

METHODS

The present study modelled the workload of major trauma cases in Victoria's ambulance service for one year pre- and post-introduction of the guidelines. Cases were analysed regarding whether their first hospital destination would change under the proposed guidelines, and, subsequently, whether they would require interhospital transport to a higher level trauma service. The impact on the ambulance services was modelled as annual changes in distances travelled due to predicted changes in hospital destinations.

RESULTS

Analysis of the predicted changes indicated that, in general, Victoria's metropolitan and rural road ambulance crews would not be greatly affected. However, some metropolitan road crews may have to travel extra distances for up to 110 cases per year. The major impact was on air retrieval crews, where the annual number of interhospital transfers is predicted to increase from approximately 150 to 330.

CONCLUSIONS

The present study demonstrated that most of the impact of a new trauma system on Victoria's ambulance services could be readily absorbed into the current workload. However, it also highlighted areas affected disproportionately within the ambulance services; in particular, air retrieval. Such studies are important to enable the effective implementation of new trauma systems.

Preventability of vehicle-related fatalities

Several different methods have been used to evaluate the survivability of traffic injuries. Previously published methods were reviewed to develop a specific method for vehicle-related fatalities. All fatally injured victims (n = 474) of vehicle-related crashes in the four northern-most counties of Sweden during a 5-year period were studied. Almost half (48%) of the victims had non-survivable injuries. The remaining cases were classified into different injury groups according to the Injury Severity Score (ISS) including 56 (12%) with an ISS < 25, 150 (32%) with ISS 25-49 and 42 (9%) with ISS 50-74. The median distance from the scene to the nearest hospital was 49 km. In the cases with ISS < 50 the medical care was further analyzed. In close to half of these cases, the victim did not receive optimal care in time with transportation time being of major importance. The absence of first aid was judged to have contributed to the death in 4% of the cases.

Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system

BACKGROUND

Injury mortality in rural regions remains high with little evidence that trauma system implementation has benefited rural populations.

OBJECTIVE

To evaluate risk-adjusted mortality in remote regions of Oregon before and after implementation of a statewide trauma system.

RESEARCH DESIGN

A retrospective cohort study assessing injury mortality through 30 days after hospital discharge.

SETTING

Nine rural Oregon hospitals serving counties with populations <18 persons per square mile.

SUBJECTS

Severely injured patients presenting to four level-3 and five level-4 trauma hospitals 3 years before and 3 years after trauma system implementation.

MEASURES

Interhospital transfer, hospital death, and demise within 30 days following hospital discharge.

RESULTS

A total of 940 patients were analyzed. After trauma system implementation, patients presenting to level-4 hospitals were more likely transferred to level-2 facilities (P <0.001). Interhospital transfer times from level-3 hospitals lengthened significantly after system implementation (P <0.001). Overall mortality rates were higher in the postsystem period (8.3%) than the presystem period (6.7%), but not significantly. Controlling for covariates, no additional benefit to risk-adjusted mortality was associated with trauma system implementation. Additional deaths, occurring after trauma system implementation, included head-injured patients transferred from rural hospitals to nonlevel-1 trauma center hospitals.

CONCLUSIONS

Increased injury survival after Oregon trauma system implementation, demonstrated in urban and statewide analyses, was not confirmed in remote regions of the state. Efforts to improve trauma systems in rural areas should focus on the processes of care for head-injured patients transferred to higher designation trauma centers.

[Is the direct admission to the recovery service or to the intensive care unit of patients cared for by the Smur system justified?]

STUDY DESIGN

The French system of Samu-Smur allows the admission of patients directly in intensive care unit (ICU). The aim of this study is to examine the utility of the Samu-Smur with regard to such direct admission (DA).

PATIENTS AND METHODS

This retrospective study was performed by the Samu of Paris. Patient details were gathered from three reports: namely hospitalization, transport and regulation reports. These were analysed to decide whether the admission diagnostic was exact, whether the patient's condition was serious, whether the prehospital treatment justified direct admission into an ICU and whether the management was coherent.

RESULTS

In 1997, 409 (31%) cases were studied among the 1,350 admitted patients in ICU. Three groups of patients were classified according to admission to surgical (n = 54), medical (n = 180), cardiological ICU (n = 175). The prehospital diagnosis was confirmed by the hospitalization report in 91% of patients in the all three groups. The patient's condition was found to the serious in all cases. Justification of the treatment was respectively found in 96, 88 and 84% of patients. The coherence of management was confirmed in 94, 96 and 89%.

DISCUSSION

This study has shown that Samu-Smur management lead to justified DA in ICU for all patients in the study. Prospective studies are needed to show the advantages of this strategy in term of speed of management and outcome.

Traumatic brain injury

The decrease in mortality and improved outcome for patients with severe traumatic brain injury over the past 25 years can be attributed to the approach of "squeezing oxygenated blood through a swollen brain". Quantification of cerebral perfusion by monitoring of intracranial pressure and treatment of cerebral hypoperfusion decrease secondary injury. Before the patient reaches hospital, an organised trauma system that allows rapid resuscitation and transport directly to an experienced trauma centre significantly lowers mortality and morbidity. Only the education of medical personnel and the institution of trauma hospital systems can achieve further improvements in outcome for patients with traumatic brain injuries.

The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Trauma systems

Published case series and cohort comparison studies of patients treated in regions where planned trauma systems are in place compared to regions without trauma systems, or before and after instituting a trauma system, conclude that mortality is reduced after major trauma in patients treated in a trauma system. For optimal care of neurotrauma, neurosurgeons should be involved in the planning and implementation of trauma systems and in support of a system once it is in place.

Emerging technology for vehicular safety and emergency response to roadway crashes

Emerging technology for vehicular safety and emergency response to roadway crashes is the topic of this article. Reduction in emergency medical services system notification time, improvements in vehicular safety, crash avoidance and protection, post-crash injury control, triage, national automatic crash notification systems, and technologic improvements in emergency diagnostics and treatment during the past year are discussed.

Trauma care regionalization: a process-outcome evaluation

BACKGROUND

Regionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients.

METHODS

This was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III).

RESULTS

A total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers.

CONCLUSION

This study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims

OBJECTIVE

Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system.

DESIGN

A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team.

SETTING

A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States.

SUBJECTS

Pediatric trauma victims identified as critically injured (designated as "trauma one") and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team.

INTERVENTIONS

A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as "trauma one") is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes.

OUTCOME MEASURES

Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation of z score.

RESULTS

Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 +/- 2 vs 21 +/- 4 minutes), operating room (63 +/- 16 vs 623 +/- 27 minutes) and total time in the ED (85 +/- 8 vs 821 +/- 9 minutes). Calculation of z score showed that survival for the control group was not different from the reference population (z = -0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102).

CONCLUSION

Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.