High-level trauma care may limit disability
People treated for severe injuries at a specialized trauma center may survive with fewer disabilities than those at other hospitals, a study from Australia suggests.
The findings, researchers say, add to evidence that patients fare better when they’re treated under an organized trauma system - where hospitals, emergency services and state governments have coordinated plans for getting the right patients to the appropriate treatment.
So-called Level I trauma centers provide the most comprehensive care for traumatic injuries and have to meet certain requirements - like having a specific number of surgeons and other specialists on duty 24 hours a day.
Studies have found that for severely injured people, getting care at a Level I trauma center can cut the risk of dying by 25 percent.
But there’d been some question about whether that drop in death rates might mean more people are surviving with severe disabilities, according to Belinda J. Gabbe, the lead researcher on the study from Monash University in Melbourne.
“Our study shows that care at specialized trauma centers improves the chances of a better functional outcome—that is, less disability, which really strengthens the evidence for organized trauma systems,” Gabbe told Reuters Health in an email.
The study, reported in the Annals of Surgery, found that of nearly 5,000 seriously injured patients treated in the state of Victoria’s trauma system, those seen at a Level I center tended to be less severely disabled one year later.
The sample included people who’d been in a car or motorcycle accident or had suffered a fall with head, chest or spinal cord injuries.
Overall, 35 percent of patients had a “good” recovery—either back to their healthy selves or with some disruption to their daily activities and relationships.
The odds of a better recovery were 22 percent higher for patients treated at Level I centers versus similar patients at other hospitals.
Overall, patients’ outlook also got better over time—with generally lower levels of disability among patients treated in 2008-2009 versus 2006-2007.
Gabbe said it’s not clear why that is.
But, she added, it might be due to the “maturing” of the state’s trauma system.
In the U.S., about 45 million people live more than an hour away from a Level I or Level II trauma center (by ambulance or helicopter), according to the Centers for Disease Control and Prevention.
Like Victoria, where this study was done, some U.S. states have statewide trauma systems that aim to get the right patients to the right hospital as quickly as possible.
But there are also county-level systems.
“There are studies from San Diego, Los Angeles, Maryland and Milwaukee showing similar results” as the current one, said Dr. Raul Coimbra, who heads the division of trauma, surgical critical care and burns at the University of California, San Diego Health System.
So the new findings are “not novel,” according to Coimbra, who was not involved in the study.
But, he said in an email, “the findings provide additional support to the concept that organized, regionalized systems of care… are effective in decreasing death and disability, and provide high quality of care.”
Of course, not all hospitals can—or should—be trauma centers, Coimbra said. “In fact, only a few should,” he noted.
The goal then is to coordinate ambulance services, hospitals and local governments to get severely injured patients to the right medical center as fast as possible—and also to rehabilitation services for their injuries afterward.
“A significant amount of organization, investment and effort is necessary to provide timely transport of a trauma patient to the most appropriate facility capable of taking care of severely injured patients,” Coimbra told Reuters Health.
Right now, he said there are California counties with “some of the best regional (trauma) systems in the world.”
But California does not yet have a statewide system, Coimbra noted, and there are still areas of the state where people live far from any trauma center.
The cost of setting up a statewide system is a major obstacle, he said.
Gabbe agreed that expense has been an issue in general when it comes to setting up trauma systems. But their benefit is becoming clearer, she said.
“There is strong evidence that organized trauma systems save lives, and the evidence that they also reduce disability is growing,” Gabbe said. “They should be considered best practice for trauma care.”
SOURCE: Annals of Surgery, online April 13, 2012
Improved Functional Outcomes for Major Trauma Patients in a Regionalized, Inclusive Trauma System
Results: There were 4986 patients older than 18 years. In-hospital mortality decreased from 11.9% in 2006-2007 to 9.9% in 2008-2009. The follow-up rate at 12 months was 86% (n = 3824). Eighty percent reported functional limitations. Odds of better functional outcome increased in the 2007-2008 [adjusted odds ratio (AOR): 1.22; 95% CI: 1.05, 1.41] and 2008-2009 (AOR: 1.16; 95% CI: 1.01, 1.34) years compared with 2006-2007. Cases managed at major trauma services (MTS) achieved better functional outcome (AOR: 1.22; 95% CI: 1.03, 1.45). Female gender, older age, and lower levels of education demonstrated lower adjusted odds of better outcome.
Conclusions: Despite an annual decline in mortality, risk-adjusted functional outcomes improved over time, and cases managed at MTS (level-1 trauma centers) demonstrated better functional outcomes. The findings provide early evidence that this inclusive, regionalized trauma system is achieving its aims.
Gabbe, Belinda J. BPhysio (Hons); Biostat, Grad Dip MAppSc, PhD; Simpson, Pam M. BSc (Hons); Sutherland, Ann M. RN, RM; Dip, Grad Occ Environ Health; Wolfe, Rory BSc, PhD; Fitzgerald, Mark C. MBBS, FACEM, MRACMA; Judson, Rodney MBBS, FRACS, FRCS, FACS; Cameron, Peter A. MBBS, MD, FACEM
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