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The mortality benefit of direct trauma center transport in a regional trauma system: A population-based analysis

Haas, Barbara MD; Stukel, Therese A. PhD; Gomez, David MD; Zagorski, Brandon MSc; De Mestral, Charles MD; Sharma, Sunjay V. MD; Rubenfeld, Gordon D. MD, MSc; Nathens, Avery B. MD, PhD, FACS

Journal of Trauma and Acute Care Surgery: June 2012 - Volume 72 - Issue 6 - p 1510–1517
doi: 10.1097/TA.0b013e318252510a

BACKGROUND By ensuring timely access to trauma center (TC) care, well-organized trauma systems have the potential to significantly reduce injury-related mortality. However, undertriage continues to be a significant problem in many regional trauma systems. Taking a novel, population-based approach, we estimated the potential detrimental impact of undertriage to a non-TC (NTC) within a regional system.

METHODS We performed a population-based, retrospective cohort study of TC effectiveness in a region with urban, suburban, and rural areas. Data were derived from administrative databases capturing all emergency department deaths and admissions in the region. Adult motor vehicle collision occupants presenting to any emergency department in the study region were included (2002–2010). Data were limited to patients with severe injury. The exposure of interest was initial triage destination (TC or NTC), regardless of later transfer to TC. Mortality was compared across groups, using an instrumental variable analysis to adjust for confounding.

RESULTS Among 6,341 motor vehicle collision occupants, 45% (n = 2,857) were triaged from the scene of injury to a TC. Among patients transported from the scene to a NTC, 57% (n = 2,003) were transferred to a TC within 24 hours of initial evaluation. Compared with patients triaged to a NTC, adjusted mortality was lower among patients triaged directly to a TC, both at 24 hours (odds ratio: 0.58, 95% confidence interval: 0.41–0.84) and at 48 hours (odds ratio: 0.68, 95% confidence interval: 0.48–0.96). A trend toward reduced mortality with TC triage was also observed at 7 and 30 days.

CONCLUSIONS Our data are population-based evidence of the early benefits of direct triage to TC. Although many surviving patients are later transferred to a TC, initial triage to a NTC is associated with at least a 30% increase in mortality in the first 48 hours after injury.

LEVEL OF EVIDENCE Therapeutic study, level IV.

Submitted: October 2, 2011, Revised: January 29, 2012, Accepted: February 1, 2012.

From the Department of Surgery (B.H., D.G., C.D.M., S.V.S., A.B.N.), University of Toronto; Institute for Clinical Evaluative Sciences (T.A.S., B.Z., G.D.R., A.B.N.); Department of Health Policy, Management and Evaluation (T.A.S.) University of Toronto; Department of Medicine (G.D.R.), University of Toronto; and Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital (A.B.N.), Toronto, Ontario, Canada.

Supported, in part, by funds from a Canada Research Chair Program (to A.B.N.), a Canadian Institutes of Health Research (CIHR) fellowship (to B.H.), and a CIHR Team Grant in Trauma System Development. In addition, this study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Presented, in part, at the 2011 Annual Meeting of the American Association for the Surgery of Trauma, Chicago, IL.

Address for reprints: Barbara Haas, MD, 30 Bond Street, Queen Wing, 3-074, Toronto, ON, Canada M5B 1W8; email:

© 2012 Lippincott Williams & Wilkins, Inc.