Level I Trauma Centers: More Is Not Necessarily Better.

The optimal number of level I trauma centers (L1TCs) in a region has not been elucidated. To begin addressing this, we compared mortalities for patients treated in counties or regions with 1 L1TC to those with >1 L1TC across Ohio. Ohio Trauma Registry data from 2010 to 2012 were analyzed. Patients with age ≥15 from counties/regions with L1TC were included. Region was defined as a L1TC containing county and its neighboring counties. Two analyses were performed. In the county analysis, counties containing 1 L1TC were compared with counties with multiple L1TCs. This comparison is repeated on a regional level for the regional analysis. Subgroup analyses were performed. 38,661 and 55,064 patients were in the county and regional analysis, respectively. Patients treated in counties or regions with multiple L1TCs were significantly younger (P < 0.001). Despite this, the mortality was similar for the two groups in the county analysis and significantly higher for regions with multiple L1TCs (P < 0.001). Multivariate logistic regression demonstrated that having multiple L1TC coverage in a region was an independent predictor for death (odds ratios: 1.17; 1.07-1.28; P = 0.001). Subgroup analyses showed that mortality in counties and regions with multiple L1TCs was not lower in any subgroups but was higher in patients with age ≥65 and patients with blunt injuries (P < 0.05). Having multiple L1TCs in a county was associated with increased mortality in certain patient subgroups. Having multiple L1TCs in a region was an independent predictor for death. These results should be considered carefully when designing future regionalized trauma networks. More L1TCs is not necessarily better.

Statewide Analysis Shows Collaborative Regional Trauma Network Reduces Regional Mortality.

A Regional Trauma Network (RTN), composed of one level I and several lower-level trauma centers (TCs) across multiple hospital systems, was established in 2010. This collaborative network used a unified triage protocol and a single transfer center. The impact of this RTN was assessed by evaluating regional mortality changes before and after RTN establishment. Patients in the state trauma registry aged 15 and older from 2006 to 2012 were analyzed; 2006 to 2009 and 2010 to 2012 were designated as pre-RTN and RTN periods, respectively. The region was defined as a county containing L1TC and its adjacent counties. Any counties bordering multiple L1TC-containing counties were excluded from analysis. Mortality was compared for all regions before and after RTN implementation. The following subgroups were also included a priori for the comparison: Injury Severity Score ≥15, age ≥65, and trauma mechanisms. 121,448 patients were analyzed; 66,977 and 54,471 patients were in the pre-RTN and RTN groups, respectively. Mean age was 58; 90 per cent had blunt injuries. The overall mortality was 4.9 per cent. Mortality comparisons over time for all regions are presented. The RTN region was the only region in the state that had mortality reduction in all patient subgroups. After adjusting for age, Injury Severity Score, level of TC that performed treatment, and trauma mechanism, RTN implementation was an independent predictor of survival (odds ratio: 0.876; 95% CI: 0.771-0.995, P = 0.04, c-statistic: 0.84). These findings suggest that regional collaboration and network-wide, uniform triage practices should be key components in the development of regionalized trauma networks.

Despite Trauma Center Closures, Trauma System Regionalization Reduces Mortality and Time to Definitive Care in Severely Injured Patients.

The Northern Ohio Trauma System (NOTS), consisting of multiple hospital systems, was established in 2010 to improve trauma outcomes. This study assessed its impact on mortality and time to definitive care, focusing especially on the severely injured patients. NOTS trauma registry was queried for all trauma activations from 2008 to 2013. The years between 2008-2009 and 2011-2013 were designated as pre- and post-NOTS, respectively. Data from 2010 was excluded as a transitional year. Two trauma centers (TCs) closed in 2010. Predetermined patient subgroups were analyzed. A total of 27,843 patients were examined. Mean age was 46 and 64 per cent were male. Median Injury Severity Score (ISS) was five, and 87 per cent sustained blunt injuries. Of these, 10,641 patients were pre-NOTS and 17,202 were post-NOTS. Comparing the two groups, mortality decreased from 5 to 4 per cent post-NOTS (P < 0.001); median time to definitive care increased by 12 minutes post-NOTS. Multivariate logistic regression showed that NOTS implementation was an independent predictor for survival (P = 0.008), whereas time to definitive care was not. Subgroup analyses demonstrated mortality reductions post-NOTS for all subgroups except patients with penetrating injuries, where mortality remained the same despite an increase in ISS. Patients with ISS ≥15 had a 23 per cent relative reduction in mortality, and their median time to definitive care decreased by 12 minutes. Implementation of a collaborative, regional trauma system was associated with mortality reduction and shortened time to definitive care in the severely injured patients. These findings highlight the importance of collaboration in the future development of regional trauma systems.

Performance of a regional trauma network: A state-wide analysis.

BACKGROUND: The Northern Ohio Trauma System (NOTS), established in 2010, is a collaborative regional trauma system composed of one level I and several lower-level trauma centers (TCs) across multiple hospital systems. Mortalities between counties in NOTS and other Ohio counties were compared to assess NOTS performance. METHODS: State trauma registry was analyzed for patients 15 years or older from 2006 to 2012. Mortality change over time was assessed by comparing all counties before and after NOTS establishment. Two analyses were done in the post-NOTS period: (1) a county analysis, comparing Cuyahoga County, the county containing NOTS level I TC (L1TC), with other counties containing L1TCs and (2) a regional analysis, comparing Cuyahoga and its adjacent counties (i.e., the NOTS region) with other L1TC containing regions. The following subgroups were included a priori: Injury Severity Score 15 or greater, age 65 years or older, and trauma mechanism. RESULTS: A total of 178,143 patients were analyzed. Cuyahoga was the only county that had a decrease in mortality for both the overall group and all subgroups over time (all p < 0.05). Both the county and regional analyses showed that the overall NOTS patients were 1 to 4 years older (p < 0.05), had similar or higher Injury Severity Score (p < 0.05), and were treated more often at lower-level TCs (p < 0.001). County analysis demonstrated that Cuyahoga County had approximately 1% lower mortality in geriatrics patients compared with non-NOTS counties. Regional analysis showed lower mortality in the NOTS region for the overall patient group, as well as geriatric and blunt injuries subgroups. CONCLUSIONS: Cuyahoga was the only county in Ohio that had significant mortality reduction for all patient groups over time. Trauma system regionalization was associated with greater utilization of lower-level TCs and lower patient mortality. These findings suggest that a collaborative regional trauma system may be more important than the number of L1TC in an area. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.