A Re-Evaluation of the Effect of Trauma Center Verification Level on the Early Risk of Death in Hemodynamically Unstable Patients

Abstract

BackgroundStudies show increased early and overall mortality at level II compared to level I trauma centers in hemodynamically unstable patients. We hypothesize there is no mortality difference between level I and level II centers applying more contemporary data. Study designUtilizing the 2017 Trauma Quality Program Participant Use File (TQP-PUF), we identified adult patients (age >14 years) who presented to an American College of Surgeons (ACS) verified level I or II center with hypotension (systolic blood pressure [SBP] < 90 mmHg). Logistic regression was performed to identify adjusted associations with mortality. ResultsA total of 7,264 patients met the inclusion criteria, of whom most were males ( 4,924 [67.8%]) with blunt trauma (5,924 [81.6%]) being predominated. Mean admission SBP was 73.2 (±13.0) mmHg. There were 1,097 (15.1%) deaths. Level I admissions (4,931 (67.9%]) were more likely male (3,389 [68.7%] vs. 1,535 [65.8]; p=0.012), non-white (3,119 [63.3%] vs. 1,664 [71.3%]; p<0.001), a victim of penetrating trauma (933 [18.9%] vs. 385 [16.5%]; p=0.015), and more severely injured (mean Injury Severity Score: 19.3 [±15] vs. 16.7 [±13.7]; p<0.001). Level II admissions (2,333 [32.1%]) were older (46.8 [±18.5] vs. 50.3 [±20.1] years; p<0.001) with more co-morbidities (mean Charlson Comorbidity Index: 1.43 [±2] vs. 1.77 [±2.2]; p<0.001). Adjusted mortality between level I and II admissions was similar (766 [15.5%] vs. 331 [14.2%]; p=0.918). Early hourly mortality also did not differ. ConclusionThere is no overall or hourly mortality discrepancy between ACS-verified level I and II centers for patients presenting with hypotension. This potentially relates to the use of more contemporary data gathered after implementation of updated verification requirements.

Evaluating associations between level of trauma care and outcomes of patients with specific severe injuries: A systematic review and meta-analysis

“…35,40,54 The majority (n = 32, 91%) were United States based, [21][22][23][25][26][27][28][29][30][32][33][34][35][36][37][38][39][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55] one study was conducted in France, 24 one in Israel, 40 and one study in Canada. 31 A total of 26 (74%) studies [22][23][24][25][26][27][29][30][31][32][34][35][36]…”

“…Of these 11 studies, nine studies (82%) 24,26,[30][31][32]36,43,48,51 compared Level I with Level II trauma centers. A total of 22 studies (65%) [21][22][23]25,[27][28][29][33][34][35][37][38][39]41,42,44,46,47,49,52,53 reported no difference in in-hospital mortality across different levels of trauma care (Table 1). Of these 22 studies, 17 studies (77%) 22,23,25,27,29,34,35,38,39,41,[44][45][46][47]49,52,55 compared Level I with Level II trauma centers.…”

“…A total of 22 studies (65%) [21][22][23]25,[27][28][29][33][34][35][37][38][39]41,42,44,46,47,49,52,53 reported no difference in in-hospital mortality across different levels of trauma care (Table 1). Of these 22 studies, 17 studies (77%) 22,23,25,27,29,34,35,38,39,41,[44][45][46][47]49,52,55 compared Level I with Level II trauma centers. One study found Level I trauma centers to be associated with higher in-hospital mortality rates compared with Level II.…”

“…Of 34 studies reporting in-hospital mortality, 22 studies (65%) [22][23][24][25][26][27][29][30][31][34][35][36][38][39][40][44][45][46][47]49,51,52 were included in the unadjusted meta-analysis on in-hospital mortality, comparing Level I and Level II trauma centers, comprising a total of 405,684 trauma patients (Fig. 2).…”

“…Adjusted meta-analysis on in-hospital mortality comparing Level I and Level II trauma centers, included 15 (44%) studies 23,25,26,[29][30][31]36,39,[43][44][45][46][47]51,52 (n = 135,861) with a pooled adjusted OR (95% CI) of 1.15 (1.06-1.25) (I 2 = 50%) (Fig. 2).…”