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Quality of Care Within a Trauma Center Is not Altered by Injury Type

Shafi, Shahid MD, MPH; Ahn, Chul PhD; Parks, Jennifer MPH; Nathens, Avery B. MD, PhD; Cryer, Henry M. MD; Gentilello, Larry M. MD; Hemmila, Mark MD; Fildes, John J. MD

The Journal of Trauma: Injury, Infection, and Critical Care: March 2010 - Volume 68 - Issue 3 - p 716-720
doi: 10.1097/TA.0b013e3181a7bec0
Original Article
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Background: Previous studies have demonstrated variations in severity-adjusted mortality between trauma centers. However, it is not clear if outcomes vary by the type of injury being treated.

Methods: National Trauma Data Bank was used to identify patients 16 years or older with moderate to severe injuries (Abbreviated Injury score ≥3) treated at level I or II trauma centers (n = 127,439 patients, 105 centers). Observed-to-Expected mortality ratios (O/E ratios, 95% confidence interval [CI]) were calculated for each trauma center within each of the three injury types: blunt multisystem (two or more body regions; n = 27,980; crude mortality, 15%), penetrating torso (neck, chest, or abdomen; n = 9,486; crude mortality, 9%), and blunt single system (n = 89,973; crude mortality 5%). Multivariate logistic regression was used to adjust for age, gender, mechanism, transfer status, and injury severity (Glasgow Coma Scale, blood pressure). For each injury type, trauma centers' performance was ranked as high (O/E with 95% CI <1), low (O/E with 95% CI >1), or average performers (O/E overlapping 1).

Results: Almost three quarters of the trauma centers achieved the same performance rank in each of the three injury categories. There were 14 low-performing trauma centers in blunt multisystem injuries, six in penetrating torso injuries, and nine in the blunt single system injuries group. None of these centers achieved high performance in any other type of injury.

Conclusions: Risk-adjusted outcomes are consistent within trauma centers across different types of injuries, suggesting that quality improvement efforts should measure, analyze, and focus on hospital-wide systems of care, rather than on isolated quality domains related to specific types of injury.

From the Department of Surgery (S.S., J.P., L.M.G.), Division of Burns, Trauma and Surgical Critical Care, University of Texas Southwestern Medical School, Dallas, Texas; Department of Clinical Sciences (C.A.), University of Texas Southwestern Medical School; Department of Surgery (A.B.N.), University of Toronto, Toronto, Ontario, Canada; Department of Surgery (H.M.C.), The David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Department of Surgery (M.H.), University of Michigan, Ann Arbor, Michigan; and Department of Surgery (J.J.F.), University of Nevada School of Medicine, Las Vegas, Nevada.

Submitted for publication September 10, 2008.

Accepted for publication March 6, 2009.

Address for reprints: Shahid Shafi, MD, MPH, Department of Surgery, Division of Burns, Trauma and Surgical Critical Care, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Mail Code 9158, Dallas, TX 75390-9158; email: shahid.shafi@utsouthwestern.edu.

© 2010 Lippincott Williams & Wilkins, Inc.