Survival Benefit of Transfer to Tertiary Trauma Centers for Major Trauma Patients Initially Presenting to Nontertiary Trauma Centers

Abstract

Objectives: Recent evidence suggests a measurable reduction in mortality for patients transferred from a nontertiary trauma center (Level III or IV) to a Level I trauma center, but not for those transferred to a Level II trauma center. Whether this can be generalized to a predominantly rural region with fewer tertiary trauma care resources is uncertain. This study sought to evaluate mortality differences for patients initially presenting to nontertiary trauma centers in a predominantly rural region depending on transfer status.Methods: This was a retrospective cohort study of patients initially presenting to 104 nontertiary trauma centers in Oklahoma and meeting the state's criteria for major trauma. Patients dying within 1 hour of emergency department (ED) arrival at the nontertiary trauma center were excluded. The exposure variable of interest was admission status, which was categorized as either transfer to a tertiary (Level I or II) trauma center within 24 hours or admission to a nontertiary trauma center. Propensity scores were used to minimize the selection bias inherent in the decision to admit or transfer a patient for higher-level care. Multiple logistic regression was used to generate three propensity score models: probability of transfer to either a Level I or II, Level I only, and Level II only. Propensity scores were then included as a covariate in multivariable Cox regression models assessing outcome differences between admitted and transferred patients. The outcome of interest was 30-day mortality, defined as death at either the nontertiary trauma center or the tertiary trauma center within 30 days of arrival at the initial Level III ⁄ IV center's ED.Results: A total of 6,229 patients met study criteria, of whom 2,669 (43%) were transferred to tertiary trauma centers. Of those transferred, 1,422 patients (53%) were transferred to a Level I trauma center. Crude mortality was lower for patients transferred to tertiary trauma centers compared to those remaining at nontertiary trauma facilities (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.48 to 0.72). After adjusting for the propensity to be transferred, Injury Severity Score (ISS), presence of severe head injury, and age, transfer to a tertiary trauma center was associated with a significantly lower 30-day mortality (HR = 0.38; 95% CI = 0.30 to 0.50) compared to admission and treatment at a nontertiary trauma center. The observed survival benefit was similar for patients transferred to a Level I trauma center (HR = 0.36; 95% CI = 0.20 to 0.4) and those transferred to a Level II center (HR = 0.45; 95% CI = 0.33 to 0.61).Conclusions: This study suggests a survival benefit among patients initially presenting to nontertiary trauma centers who are subsequently transferred to tertiary trauma centers compared to those remaining in nontertiary trauma centers, even after adjusting for variables affecting the likelihood of transfer. Although this survival benefit was larger for patients treated at a Level I trauma center, Level II trauma...

The Association of Insurance Status and Race With Transfers of Patients With Traumatic Brain Injury Initially Evaluated at Level III and IV Trauma Centers

“…Regionalization of care to specialized institutions, capable of providing life saving interventions, allows TBI patients to capitalize on the above developments. [2][3][4][5] Timely inter-hospital transfers to level I and II trauma centers, after evaluation in the emergency department (ED) of lower level centers, have been associated with improved survival. [2][3][4][5] In this setting, the influence of non-medical factors in the decision to transfer TBI patients, initially seen in less specialized institutions, to higherlevel trauma centers remains an issue of debate.…”

Rural risk: Geographic disparities in trauma mortality

“…Injury treatment at designated trauma centers can reduce mortality from traumatic injury, [1][2][3][4] but the majority of US residents in rural areas do not have timely access to Level I or II trauma centers. 5 Geographic barriers to trauma care are more likely to impact racial minorities and people living in poverty, 6 paralleling established racial and socioeconomic disparities in trauma mortality.…”

Regionalisation of trauma care in England

“…Observational studies from the US have shown that quality of care is higher [8][9][10][11] and overall mortality is lower for severely injured patients at trauma centres with appropriate resuscitative, imaging, surgical and critical care facilities. [3][4][5][6][7] As a consequence, many countries across the developed world are now at various stages of developing trauma networks. [12][13][14] Common features of inclusive trauma networks include designation of specialist trauma centres, pre-hospital triage of severely injured patients 15 , agreed transfer protocols between network hospitals, and quality assurance programmes.…”

“…1,2 There is consistent evidence, particularly from the United States, that inclusive trauma systems with designated trauma centres reduce mortality for severely injured patients. [3][4][5][6][7] The American College of Surgeons launched an accreditation programme for trauma centres in 1987. Observational studies from the US have shown that quality of care is higher [8][9][10][11] and overall mortality is lower for severely injured patients at trauma centres with appropriate resuscitative, imaging, surgical and critical care facilities.…”