Trauma care regionalization: A process-outcome evaluation

Background: Regionalization of trauma care services in our region was initi ated in 1993 with the designation of four tertiary trauma centers. The proc ess continued in 1995 with the implementation of patient triage and transfe r protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma ce nters. In addition, during this period emergency medical personnel have bee n trained to assess and triage trauma victims within minimal prehospital ti me. 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 I njury 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 3 1, 1998. During this period, four distinct phases of trauma care regionaliz ation were defined: pre-regionalization (phase 0), initiation (phase I), in termediate (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 fr om 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 proporti on 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 sig nificant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortalit y for patients with fatal injuries (ISS greater than or equal to 50) was no t significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arr ival at the hospital decreased from 151 to 128 minutes (p < 0.001). The lat ter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 4 9 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 secon dary and tertiary centers showed a consistent decline (p < 0.001). In addit ion, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjust ing for injury severity and patient age, the primary factors contributing t o the reduced mortality were treatment at a tertiary center, reduced prehos pital 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 resu lts showed that tertiary trauma centers and reduced prehospital times are t he essential components of an efficient trauma care system.