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Evolution of Patient Outcomes Over 14 Years in a Mature, Inclusive Canadian Trauma System



The introduction of trauma systems in many countries worldwide has been shown to improve injury survival. However, few data are available on the long-term evolution of outcomes other than mortality. The objective of this study was to describe trends in mortality, unplanned readmission, complications, and length of stay in a mature inclusive trauma system from 1999 to 2012.


This retrospective cohort study was based on the inclusive trauma system of Quebec, Canada. Data were drawn from the trauma registry linked to the hospital discharge database. Time trends were evaluated using generalized linear mixed models with a correction for hospital clusters and cohort effects.


Between 1999 and 2012, risk-adjusted mortality decreased from 5.8 to 4.2 % for all patients and from 14.9 to 13.1 % for major trauma (p < 0.0001). Mean LOS decreased from 9.5 days to 8.0 days for all patients and from 15.5 days to 11.5 days for major trauma (p < 0.0001). Unplanned readmission and complication rates remained stable over the observation period at around 6.6 and 11.6 % for all patients and 7.6 and 25.6 % for major trauma, respectively.


The results of this study suggest that there have been significant decreases in patient mortality and hospital length of stay in the inclusive trauma system of Québec over the last decade. Results also suggest that efforts should be made to reduce in-hospital complications and unplanned readmissions. Future research should attempt to identify determinants of observed decreases in mortality and LOS and assess whether similar improvements have occurred in functional outcomes.

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  1. The economic burden of injury in Canada.

  2. Major injury in Canada (2009) report.

  3. Jurkovich GJ, Mock C (1999) Systematic review of trauma system effectiveness based on registry comparisons. J Trauma 47:S46–S55

    Article  CAS  PubMed  Google Scholar 

  4. Mackenzie EJ, Rivara FP, Jurkovich GJ et al (2007) The National Study on Costs and Outcomes of Trauma. J Trauma Acute Care Surg 63:S54–S67 discussion S81–56

    Article  Google Scholar 

  5. Haas B, Stukel TA, Gomez D et al (2012) The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis. J Trauma Acute Care Surg 72:1510–1515 discussion 1515–1517

    Article  PubMed  Google Scholar 

  6. Utter GH, Maier RV, Rivara FP et al (2006) Inclusive trauma systems: do they improve triage or outcomes of the severely injured? J Trauma 60:529–535 discussion 535-537

    Article  PubMed  Google Scholar 

  7. McKee JL, Roberts DJ, van Wijngaarden-Stephens MH, et al (2014) The right treatment at the right time in the right place: a population-based, before-and-after study of outcomes associated with implementation of an all-inclusive trauma system in a large canadian province. Ann Surg

  8. Evans CC, Tallon JM, Bridge J et al (2013) An inventory of canadian trauma systems: opportunities for improving access to trauma care. CJEM 15:1–7

    PubMed  Google Scholar 

  9. Mann NC, Mackenzie E, Teitelbaum SD et al (2005) Trauma system structure and viability in the current healthcare environment: a state-by-state assessment. J Trauma 58:136–147

    Article  PubMed  Google Scholar 

  10. Mullins RJ, Veum-Stone J, Hedges JR et al (1996) Influence of a statewide trauma system on location of hospitalization and outcome of injured patients. J Trauma 40:536–545 discussion 545-536

    Article  CAS  PubMed  Google Scholar 

  11. Mann NC, Cahn RM, Mullins RJ et al (2001) Survival among injured geriatric patients during construction of a statewide trauma system. J Trauma 50:1111–1116

    Article  CAS  PubMed  Google Scholar 

  12. Liberman M, Mulder DS, Lavoie A et al (2004) Implementation of a trauma care system: evolution through evaluation. J Trauma 56:1330–1335

    Article  PubMed  Google Scholar 

  13. Cameron PA, Gabbe BJ, Cooper DJ et al (2008) A statewide system of trauma care in victoria: effect on patient survival. Med J Aust 189:546–550

    PubMed  Google Scholar 

  14. Nathens AB, Jurkovich GJ, Cummings P et al (2000) The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA 283:1990–1994

    Article  CAS  PubMed  Google Scholar 

  15. Moore L, Hanley JA, Turgeon AF et al (2010) Evaluation of the long-term trend in mortality from injury in a mature inclusive trauma system. World J Surg 34:2069–2075. doi:10.1007/s00268-010-0588-z

    Article  PubMed  Google Scholar 

  16. American College of Surgeons Committee on Trauma (2006) Resources for optimal care of the injured patient. American College of Surgeons, Chicago

    Google Scholar 

  17. Batomen BL, Moore L, Lavoie A, et al (2014) Access to an integrated trauma system: A population based-cohort study. J Trauma Acute care

  18. Kuimi BLB, Moore L, Cisse B, et al (2014) Determinants of access to an integrated trauma system: a population-based cohort study Ann Surg [Submitted]

  19. Abbreviated Injury Scale (AIS) (1990) AAM Publications, Illinois

  20. Moore L, Hanley JA, Turgeon AF et al (2010) A new method for evaluating trauma centre outcome performance: TRAM-adjusted mortality estimates. Ann Surg 251:952–958

    Article  PubMed  Google Scholar 

  21. Moore L, Lauzier F, Stelfox HT, et al (2014) Validation of Complications Selected by Consensus to Evaluate the Acute Phase of Adult Trauma Care: A Multicenter Cohort Study. Ann Surg [accepted]

  22. Moore L, Lauzier F, Stelfox HT et al (2014) Complications to evaluate adult trauma care: An expert consensus study. J Trauma Acute Care Surg 77:322–329 discussion 329–330

    Article  PubMed  Google Scholar 

  23. Moore L, Lavoie A, Turgeon AF et al (2009) The trauma risk adjustment model: a new model for evaluating trauma care. Ann Surg 249:1040–1046

    Article  PubMed  Google Scholar 

  24. Moore L, Stelfox HT, Turgeon AF et al (2014) Derivation and validation of a quality indicator for 30-day unplanned hospital readmission to evaluate trauma care. J Trauma Acute Care Surg 76:1310–1316

    Article  PubMed  Google Scholar 

  25. Stelfox HT, Turgeon AF et al (2014) Derivation and Validation of a quality indicator of acute care length of stay to evaluate trauma care. Ann Surg 260(6):1121–1127

    Article  PubMed  Google Scholar 

  26. Charlson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383

    Article  CAS  PubMed  Google Scholar 

  27. Moore L, Lavoie A, Le Sage N et al (2008) Using information on preexisting conditions to predict mortality from traumatic injury. Ann Emerg Med 52(356–364):e352

    Google Scholar 

  28. Moore L, Stelfox HT, Lauzier F et al (2014) Complications selected by consensus to evaluate the acute phase of adult trauma care: validation in a population-based cohort. Ann Surg (Accepted). Accessed 28 Aug 2014

  29. Elixhauser A, Steiner C, Harris DR et al (1998) Comorbidity measures for use with administrative data. Med Care 36:8–27

    Article  CAS  PubMed  Google Scholar 

  30. Daly L, Bourke GJ (2008) Interpretation and uses of medical statistics. Blackwell Science, Oxford

    Google Scholar 

  31. Moore L, Lavoie A, LeSage N et al (2005) Multiple imputation of the Glasgow Coma Score. J Trauma 59:698–704

    Article  PubMed  Google Scholar 

  32. Little RJ, Rubin DB (2002) Statistical analysis with missing data, 2nd edn. Wiley, New York

    Book  Google Scholar 

  33. Gabbe BJ, Lyons RA, Fitzgerald MC, et al (2014) Reduced Population Burden of Road Transport-Related Major Trauma After Introduction of an Inclusive Trauma System. Ann Surg

  34. Pracht EE, Langland-Orban B, Tepas JJ et al (2006) Analysis of trends in the florida trauma system (1991-2003): changes in mortality after establishment of new centers. Surgery 140:34–43

    Article  PubMed  Google Scholar 

  35. Tinkoff GH, Reed JF, Megargel R et al (2010) Delaware’s inclusive trauma system: impact on mortality. J Trauma 69:245–252

    Article  PubMed  Google Scholar 

  36. Estimates of Unit Costs for Patient Services for Canada.

  37. Moore L, Turgeon AF, Emond M et al (2011) Definition of mortality for trauma center performance evaluation: a comparative study. Crit Care Med 39:2246–2252

    Article  PubMed  Google Scholar 

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Conflict of interest


Financial support

Canadian Institutes of Health Research: New Investigator Award (HTS and LM) and research grant (LM; #110996); Fonds de la Recherche du Québec—Santé: clinician-scientist award (AFT). 2.

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Correspondence to Lynne Moore.

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Moore, L., Turgeon, A.F., Lauzier, F. et al. Evolution of Patient Outcomes Over 14 Years in a Mature, Inclusive Canadian Trauma System. World J Surg 39, 1397–1405 (2015).

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  • Readmission Rate
  • Major Trauma
  • Trauma Care
  • Glasgow Coma Scale Score
  • Abbreviate Injury Scale