Differentiation in an inclusive trauma system: allocation of lower extremity fractures

Abstract

BackgroundImplementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system.MethodsThis is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands.ResultsOne thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1 = 417; L2 = 859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (> 1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2).ConclusionThe majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care.

Short-term outcome of isolated lateral malleolar fracture treatment is independent of hospital trauma volume or teaching status: a nationwide retrospective cohort study

“…Regarding the differences in the LOS, a multicenter analysis from the Netherlands demonstrated longer hospitalisation at HVCs for fractures of the lower extremities. This was attributed in particular to the severity of the trauma (which is probably also the cause in our study) and the accompanying injuries [ 32 ]. Jain et al showed a decreased LOS with higher surgeon case load for humerus fractures [ 33 ].…”

The evolution of trauma care in the Netherlands over 20 years

“…In 1999 the Netherlands implemented an inclusive trauma system, which organized the country in 11 trauma regions [9]. The goal of this inclusive system is to present all patients on a timely basis at the right hospital, with the centralisation of the most severely injured patients in level 1 centres [10][11][12][13][14][15][16][17][18][19][20][21][22][23]. The less severely injured patients are ideally treated at level 2 and level 3 centres.…”

“…This organizational change had a major impact on trauma care, as it did in most countries that implemented inclusive trauma systems [24,25]. The data presented in every time period is based on previous publications and where possible adjusted odd ratios presented in those publications were used [10][11][12][13][14][15][16][17][18][19][20][21][22][23]. Before centralisation (step 1) a regional mortality rate of 2.6% was documented, of which 40% died due to exsanguination.…”

Kompetenz, Kreativität und Kommunikation: Grundlagen zur Qualitätsverbesserung in der Traumatologie

“…Dass ein multidisziplinärer Ansatz bei komplexen Verletzungen häufig nur in einem überregionalen Zentrum gelingen kann, konnten Würdemann et al. zeigen [ 27 ]. Diese Behandlungsansätze haben bisher aber noch keine feste Implementierung in der Klinik.…”