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American College of Surgeons Committee on Trauma verification level affects trauma center management of pelvic ring injuries and patient mortality

Oliphant, Bryant W. MD, MBA, MSc; Tignanelli, Christopher J. MD; Napolitano, Lena M. MD; Goulet, James A. MD; Hemmila, Mark R. MD

Journal of Trauma and Acute Care Surgery: January 2019 - Volume 86 - Issue 1 - p 1–10
doi: 10.1097/TA.0000000000002062
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BACKGROUND Pelvic ring fractures represent a complex injury that requires specific resources and clinical expertise for optimal trauma patient management. We examined the impact of treatment variability for this type of injury at Level I and II trauma centers on patient outcomes.

METHODS Trauma quality collaborative data (2011–2017) were analyzed. This includes data from 29 American College of Surgeons Committee on Trauma verified Level I and Level II trauma centers. Inclusion criteria were adult patients (≥16 years), Injury Severity Score of 5 or higher, blunt injury, and evidence of a partially stable or unstable pelvic ring fracture injury coding as classified using Abbreviated Injury Scale version 2005, with 2008 updates. Patients directly admitted, transferred out for definitive care, with penetrating trauma, or with no signs of life were excluded. Propensity score matching was used to create 1:1 matched cohorts of patients treated at Levels I or II trauma centers. Trauma center verification level was the exposure variable used to compare management strategies, resource utilization, and in-hospital mortality in univariate analysis.

RESULTS We selected 1,220 well-matched patients, from 1,768 total patients, using propensity score methods (610 Level I and 610 Level II cohort). There were no significant baseline characteristic differences noted between the groups. Patients with pelvic ring fractures treated at Level I trauma centers had significantly decreased mortality (7.7% vs. 11.6%, p = 0.02). Patients treated at Level II trauma centers were less likely to receive interventional angiography, undergo complicated definitive orthopedic operative treatment, and to be admitted to an intensive care unit.

CONCLUSION Admission with a partially stable or unstable pelvic ring injury to a Level I trauma center is associated with decreased mortality. Level II trauma centers had significantly less utilization of advanced treatment modalities. This variation in clinical practice highlights potential processes to emphasize in the appropriate treatment of these critically ill patients.

LEVEL OF EVIDENCE Economic/Decision, Level II.

From the Department of Orthopaedic Surgery (B.W.O., J.A.G.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (C.J.T.), University of Minnesota, Minneapolis; Department of Surgery (C.J.T.), North Memorial Health Hospital, Robbinsdale; Institute for Health Informatics (C.J.T.), University of Minnesota, Minneapolis, Minnesota; and Department of Surgery (L.M.N., M.R.H.), University of Michigan, Ann Arbor, Michigan.

This study will be presented at the 77th annual meeting of American Association for the Surgery of Trauma Meeting, September 26–29, 2018, in San Diego, CA.

Address for reprints: Bryant W. Oliphant, MD, Department of Orthopaedic Surgery, University of Michigan, North Campus Research Complex, 014-G016-11, 2800 Plymouth Rd., Ann Arbor, MI; email:

© 2019 Lippincott Williams & Wilkins, Inc.