Outcome of femoral fractures care as a measure of trauma care between level I and level II trauma systems in Israel

Abstract

BackgroundOur hypothesis in this study was that the outcome of patients with femur fractures would be favorable in a level I trauma center (LITC).MethodsA prospective multicenter cohort study. 5 LITC and 6 regional (level II) trauma centers (RTCs) were enrolled to participate in the study. A total of 238 patients suffering from a femoral fracture were recruited to the study. 125 patients were treated in LITCs and 113 in RTCs. Data were extracted from the emergency medical services ambulances, emergency department records, patient hospitalization and discharge records, operating room records, and the national trauma registry (for LITCs). A study questionnaire was administered to all participating patients at discharge, 6 weeks and 6 months postoperatively. The following parameters were studied: mechanism of injury, time from injury to the hospital, Injury Severity Score, classification of femoral fracture, additional injuries, medical history, time to surgery, implant type, skill level of the surgical team, type of anesthesia, length of stay and intensive care unit (ICU) stay, postoperative and intraoperative complications and mortality.ResultsThere was a significant difference in the modality of patient transfer between the 2 study groups—with the LITC receiving more patients transported by helicopters or medical intensive care. Time to surgery from admission was shorter in the LITC. Length of stay, ICU stay, and mortality were similar. In the LITCs, 47% of the procedures were performed by residents without the supervision of an attending surgeon, and in the RTCs 79% of the procedures were performed with an senior orthopaedic surgeon. Intraoperative and immediate complication rates were similar among the 2 groups.ConclusionsA femoral shaft fracture can be successfully treated in an LITC and RTC in the state of Israel. Both research and policy implementation works are required. Also, a more detailed outcome analysis and triage criteria for emergency are desired.Level of evidenceII.

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

“…After removing duplicates, 4,151 records were screened on title and abstract, resulting in 122 potentially eligible studies. After full-text screening 32 studies were included 21–52 . Three additional studies were identified using reference chasing, 53–55 resulting in 35 included studies for the systematic review; 10 studies on traumatic brain injuries (TBIs), 22,26,29,30,33,45,49,50,53,54 six studies on thoracic injuries, 21,25,27,28,46,55 six studies on abdominal injuries, 34,35,38,47,48,52 three studies on spinal cord injuries, 23,37,41 five studies on lower-extremity injuries, 24,39,40,42,43 and five studies on hemodynamically unstable patients 31,36,44,51,54 …”

“…Most (n = 32, 91%) studies were retrospective cohorts, 21–34,36,37,39,41–53,55 three (9%) studies were prospective cohorts 35,40,54 . The majority (n = 32, 91%) were United States based, 21–23,25–30,32–39,41–55 one study was conducted in France, 24 one in Israel, 40 and one study in Canada 31 . A total of 26 (74%) studies 22–27,29–32,34–36,38–40,43–52 compared Level I with Level II trauma centers.…”

“…Of all 34 studies reporting in-hospital mortality, 21–49,51–55 11 studies (32%) 24,26,30–32,36,43,48,51,54,55 found Level I trauma centers are associated with lower in-hospital mortality versus non–Level I trauma centers (Table 1). Of these 11 studies, nine studies (82%) 24,26,30–32,36,43,48,51 compared Level I with Level II trauma centers.…”

“…Of these 22 studies, 17 studies (77%) 22,23,25,27,29,34,35,38,39,41,44–47,49,52,55 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 40 …”

“…Most (n = 32, 91%) studies were retrospective cohorts, [21][22][23][24][25][26][27][28][29][30][31][32][33][34]36,37,39,[41][42][43][44][45][46][47][48][49][50][51][52][53]55 three (9%) studies were prospective cohorts. 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]…”