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Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis

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Abstract

Background

The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes.

Methods

We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria.

Results

We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65–0.80]) and helicopter transport (OR = 0.70 [0.55–0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4–7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44–1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [−0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68–0.85]). Quality of evidence was low or very low for mortality and healthcare utilization.

Conclusions

This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.

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Acknowledgements

The authors would like to thank Michèle Shemilt for her assistance with the search strategy.

Funding

This research is funded by the Fonds de Recherche du Québec—Santé (research career award, LM) and the Canadian Institutes of Health Research (Foundation Grant #353374 [LM], Canada Research Chair in Critical Care Neurology and Trauma [AFT]).

Author information

Authors and Affiliations

  1. Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada

    Lynne Moore, Pier-Alexandre Tardif, Teegwendé V. Porgo & Alexis F. Turgeon

  2. Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence - Soins intensifs (Trauma – Emergency – Critical Care Medicine), CHU de Québec – Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada

    Lynne Moore, Pier-Alexandre Tardif, Brice-Lionel Kuimi, Teegwendé V. Porgo & Alexis F. Turgeon

  3. Department of Surgery, University of the Health Sciences, Annapolis, MD, USA

    Howard Champion

  4. Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia

    Gerard O’Reilly & Peter Cameron

  5. Abdominal Center, Helsinki University hospital, Helsinki, Finland

    Ari Leppaniemi

  6. Trauma Service, Royal Children’s Hospital, Melbourne, Australia

    Cameron S. Palmer

  7. Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates

    Fikri M. Abu-Zidan

  8. School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

    Gerard O’Reilly, Peter Cameron & Belinda Gabbe

  9. Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway

    Christine Gaarder

  10. Department of Surgery, Dalhousie University, Halifax, NS, Canada

    Natalie Yanchar

  11. Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Canada

    Henry Thomas Stelfox

  12. Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, CA, USA

    Raul Coimbra

  13. Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, AB, Canada

    John Kortbeek

  14. Rick Hansen Institute, Vancouver, BC, Canada

    Vanessa K. Noonan

  15. Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands

    Amy Gunning & Luke Leenen

  16. Department of Emergency Medicine, University of Glasgow, Glasgow, UK

    Malcolm Gordon

  17. Seth G.S. Medical College and KEM Hospital, Mumbai, India

    Monty Khajanchi

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  1. Lynne Moore
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On behalf of the International Injury Care Improvement Initiative

Corresponding author

Correspondence to Lynne Moore.

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The authors declare that they have no conflict of interest.

Additional information

The International Injury Care Improvement Initiative (IICII) is a global effort of over 60 injury care experts, harnessing national capabilities in injury control from 30 countries in pursuit of our mission to reduce the global burden of injuries.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Online resource 1

MEDLINE research strategy via PubMed (DOCX 12 kb)

Online resource 2

Description of included studies (DOCX 85 kb)

Online resource 3

Methodological quality of studies using the Risk of Bias In Non-randomized Studies—of Interventions (ROBINS-I) assessment tool (PDF 90 kb)

Online resource 4

Funnel plots of odds ratio (OR, left) and mean differences (MD, right). Legend for online resource 4: The Y axis shows the standard errors (SE) of log OR (left) and MD (right) (TIFF 18 kb)

Online resource 5

Associations between trauma system components and clinically significant outcomes measured on a multiplicative (HR, OR, RR) or additive (DP, MD) scale from studies not included in meta-analyses and for which data were available to calculate summary measures. Legend for online resource 5: CI: confidence interval; benchmarking: a = complications, b = mechanical ventilation (days), c = hospital length of stay, d = intensive care unit length of stay, e = survival; DP: difference of proportions; HR: hazard ratio; interf. trans. prot.: interfacility transfer protocols; IRR: incidence rate ratio; MD: mean difference; OR: odds ratio; Pre-hos. maj.traum.def: pre-hospital major trauma definition; RR: relative risks; TC: trauma center. Measures in black are on a multiplicative scale (null value = 1), whereas measures in gray are on the additive scale (null value = 0) (PDF 180 kb)

Online resource 6

Sensitivity analysis restricted to studies of high methodological quality (TIFF 69 kb)

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Moore, L., Champion, H., Tardif, PA. et al. Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis. World J Surg 42, 1327–1339 (2018). https://doi.org/10.1007/s00268-017-4292-0

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