The association between level of trauma care and clinical outcome measures: A systematic review and meta-analysis

Abstract

BACKGROUND With implementation of trauma systems, a level of trauma care classification was introduced. Use of such a system has been linked to significant improvements in survival and other outcomes. OBJECTIVES The aim of this study was assessing the association between level of trauma care and fatal and nonfatal outcome measures for general and major trauma (MT) populations. METHODS A systematic literature search was conducted using six electronic databases up to December 18, 2019. Studies comparing mortality or nonfatal outcomes between different levels of trauma care in general and MT populations (preferably Injury Severity Score of >15) were included. Two independent reviewers performed selection of relevant studies, data extraction, and a quality assessment of included articles. With a random-effects meta-analysis, adjusted and unadjusted pooled effect sizes were calculated for level I versus non–level I trauma centers. RESULTS Twenty-two studies were included. Quality of the included studies was good; however, adjustment for comorbidity (32%) and interhospital transfer (38%) was performed less frequently. Nine (60%) of the 15 studies analyzing in-hospital mortality in general trauma populations reported a survival benefit for level I trauma centers. Level I trauma centers were not associated with higher mortality than non–level I trauma centers (adjusted odd ratio, 0.97; 95% confidence interval, 0.61–1.52). Of the 11 studies reporting in-hospital mortality in MT populations, 10 (91%) reported a survival benefit for level I trauma centers. Level I trauma centers were associated with lower mortality than non–level I trauma centers (adjusted odd ratio, 0.77; 95% confidence interval, 0.69–0.87). CONCLUSION The association between level of trauma care and in-hospital mortality is evident for MT populations; however, this does not hold for general trauma populations. Level I trauma centers produce improved survival in MT populations. This association could not be proven for nonfatal outcomes in general and MT populations because of inconsistencies in the body of evidence. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.

Primary admission and secondary transfer of trauma patients to Dutch level I and level II trauma centers: predictors and outcomes

“…The present study found no difference for in-hospital mortality in MT patients. This is not in accordance with findings by other studies [23]. A possible explanation is that while the trauma system in the Netherlands has been maturing, and along with public health in general, mortality rates have steadily been decreasing, also among MT patients.…”

“…The present study demonstrated similar in-hospital mortality for level I and level II TCs, and transfer patients. These findings were previously reported for general trauma populations [22,23]. Other studies did find a difference in mortality between level I and level II TCs [6,11,24].…”

“…Differences in clinical outcomes measures between level I and level II TCs have been studied in the past [22,23]. The present study demonstrated similar in-hospital mortality for level I and level II TCs, and transfer patients.…”

Trauma Prevalence and Resource Utilization During 4 COVID-19 “Surges”: A National Analysis of Trauma Patients From 92 Trauma Centers

“…However, trauma outcomes are likely multifactorial and complex and influenced by several factors beyond ISS including TC level, demographic factors, relative injury burden (singular injury vs. polytrauma), GCS, TBI status, and injury type and location. 41 , 42 , 43 , 44 , 45 …”

Dutch trauma system performance: Are injured patients treated at the right place?

“…A recent meta-analysis found an evident association between the level of trauma care and in-hospital mortality for major trauma patients. Unfortunately, this meta-analysis included only two European studies, which leaves the levels of undertriage in Europe relatively unattended [24] . Therefore, correct and early identification of severely injured patients in the field is of foremost importance in getting the ISS > 15 patients to the MTC the first time.…”