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 evid ence that trauma system implementation has benefited rural populations. OBJ ECTIVE. TO evaluate risk-adjusted mortality in remote regions of Oregon bef ore and after implementation of a statewide trauma system. RESEARCH DESIGN. A retrospective cohort study assessing injury mortality th rough 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 lev el-4 trauma hospitals 3 years before and 3 years after trauma system implem entation. MEASURES. Interhospital transfer, hospital death, and demise within 30 days following hospital discharge. RESULTS. A total of 940 patients were analyzed. After trauma system impleme ntation, patients presenting to level-4 hospitals were more likely transfer red to level-2 facilities (P <0.001). Interhospital transfer times from lev el-3 hospitals lengthened significantly after system implementation (P <0.0 01). Overall mortality rates were higher in the postsystem period (8.3%) th an the presystem period (6.7%), but not significantly. Controlling for cova riates, no additional benefit to risk-adjusted mortality was associated wit h trauma system implementation. Additional deaths, occurring after trauma s ystem implementation, included head-injured patients transferred from rural hospitals to nonlevel-1 trauma center hospitals. CONCLUSIONS. Increased injury survival after Oregon trauma system implement ation, demonstrated in urban and statewide analyses, was not confirmed in r emote regions of the state. Efforts to improve trauma systems in rural area s should focus on the processes of care for head-injured patients transferr ed to higher designation trauma centers.