Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis
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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.
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.
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.
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.
The authors would like to thank Michèle Shemilt for her assistance with the search strategy.
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]).
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 1.Levit K, Wier L, Stranges E et al (2009) HCUP facts and figures: statistics on hospital-based care in the United States 2007. Agency for Healthcare Research and Quality, RockvilleGoogle Scholar
- 5.Australian Institute of Health and Welfare (2012) The burden of disease and injury in Australia. http://www.aihw.gov.au/burden-of-disease/. Accessed 18 Apr 2016
- 6.World Health Organisation (2013) WHO global alliance for care of the injured. http://www.who.int/emergencycare/gaci/gaci_flyer_web.pdf?ua=1%5d. Accessed 11 May 2016
- 7.Mock C, Lormand J, Goosen J et al (2004) Guidelines for essential trauma care. http://apps.who.int/iris/bitstream/10665/42565/1/9241546409_eng.pdf. Accessed 10 Oct 2016
- 8.American College of Surgeons Committee on Trauma (2008) Regional trauma systems: optimal elements, integration, and assessment. Systems consultation guide. American College of Surgeons, ChicagoGoogle Scholar
- 9.Nathens AB, Ball JW, Burton RA et al (2008) Regional trauma systems: optimal elements, integration, and assessment systems consultation guide. In: Surgeons Cotaco (ed). Chicago: American College of SurgeonsGoogle Scholar
- 12.Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions, version 5.1.0 [updated March 2011]. The Cochrane Collaboration. Available from www.cochranehandbook.org
- 15.Lefebvre C, Manheimer E, Glanville J et al (2011) Searching for studies. In: Higgins J, Green S (eds) Cochrane handbook for systematic reviews of interventions. Cochrane Collaboration, LondonGoogle Scholar
- 16.Sterne J, Higgins J, Reeves B (2016) ROBINS-I: a tool for assessing risk of bias in non-randomized studies of interventions. http://www.riskofbias.info. Accessed 25 Mar 2016
- 18.Berkman ND, Lohr KN, Ansari M, et al (2008) Grading the strength of a body of evidence when assessing health care interventions for the effective health care program of the agency for healthcare research and quality: an update methods guide for effectiveness and comparative effectiveness reviews. Rockville: Agency for Healthcare Research and QualityGoogle Scholar
- 22.La Banque Mondiale (2014) Médecins (pour 1000 personnes). http://donnees.banquemondiale.org/indicateur/SH.MED.PHYS.ZS. Accessed 10 Sep 2015
- 28.Garner AA, Lee A, Weatherall A (2012) Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew—case identification rates and effect on the Sydney paediatric trauma system. Scand J Trauma Resusc Emerg Med 20:82CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Rios-Diaz AJ, Metcalfe D, Olufajo OA et al (2016) Geographic distribution of trauma burden, mortality, and services in the United States: Does availability correspond to patient need? J Am Coll Surg 223(764–773):e762Google Scholar
- 48.Delgado MK, Staudenmayer KL, Wang NE et al (2013) Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Ann Emerg Med 62(351–364):e319Google Scholar
- 50.Galvagno SM, Thomas S, Stephens C et al (2013) Helicopter emergency medical services for adults with major trauma. Cochrane Database Syst Rev 28(3):CD009228. doi: 10.1002/14651858.CD009228.pub2
- 51.Center for Disease Control and Prevention (2012) Guidelines for the field triage of injured patients. www.facs.org/~/media/files/quality%20programs/trauma/vrc%20resources/6_guidelines%20field%20triage%202011.ashx. Accessed 13 Apr 2017
- 57.WHO emergency and essential surgical care: WHO EESC Global database. http://www.who.int/surgery/eesc_database/en/. Accessed 27 Mar 2017
- 66.McKee JL, Roberts DJ, Van Wijngaarden-Stephens MH et al (2015) 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 261:558–564CrossRefPubMedGoogle Scholar
- 68.Crandall M, Sharp D, Wei X et al (2016) Effects of closure of an urban level I trauma centre on adjacent hospitals and local injury mortality: a retrospective, observational study. BMJ Open 6: 5 Article Number: e011700Google Scholar
- 72.Moore L, Stelfox H, Evans D et al (2016) Hospital and intensive care unit length of stay for injury admissions: a Pan-Canadian cohort study. Ann Surg. doi: 10.1097/SLA.0000000000002036