How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study.

OBJECTIVE: To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system. SETTING: ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million. PARTICIPANTS: 5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only. RESULTS: A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit. CONCLUSION: The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.

Sepsis and organ system failure are major determinants of post-intensive care unit mortality.

PURPOSE: The aim of the study was to investigate predictors of post-intensive care unit (ICU) in-hospital mortality with special emphasis on the impact of sepsis and organ system failure. METHODS: This study is a subanalysis of the database from the observational Sepsis Occurrence in Acutely Ill Patients study conducted in 198 ICUs in 24 European countries between May 1 and May 15, 2002. Potential predictors of post-ICU mortality were considered at 3 levels: admission status, procedures and therapy during the ICU stay, and status at ICU discharge. RESULTS: Of the 3147 patients included in the Sepsis Occurrence in Acutely Ill Patients study, 1729 (54.9%) were discharged to the general floor (study group) and 125 of these died (overall post-ICU hospital mortality rate, 4%); 26 (20.8%) died already the first day on the floor. Nonsurvivors were older, had higher incidence of hematologic cancer and cirrhosis, and greater Simplified Acute Physiology Score II and Sequential Organ Failure Assessment score on ICU admission; they were also more likely to have been admitted for medical reasons than survivors. In a multivariate forward stepwise logistic regression analysis, age, hematologic cancer, cirrhosis, simplified acute physiology score II on admission, medical admission, sepsis at any time during ICU stay, and organ dysfunction at ICU discharge were all independently associated with a greater risk of post-ICU death. CONCLUSIONS: This large international study identified not only age, medical admission, and preexisting comorbidities on ICU admission but also sepsis and organ system failure as important independent risk factors for in-hospital post-ICU death.