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Change in trauma level designation associated with improved patient survival

January 22, 2008

Death rates among patients admitted to a Colorado trauma center appeared to decrease after the center's designation was upgraded, according to a report in the January issue of Archives of Surgery, one of the JAMA/Archives journals.

Trauma centers are accredited through the American College of Surgeons, according to background information in the article. Level designations are based on factors such as surgeon and nurse availability, protocols and research. Level 1 is the highest level of trauma center and most studies report improvements in survival and outcomes for patients admitted to these centers as compared with lower-level centers and non-trauma centers, although some have found no difference between level 1 and level 2 centers.

The trauma center at Swedish Medical Center-a community hospital in Englewood, Colo.-was upgraded from level 2 to level 1 in 2002. Kristin Scarborough, B.S., and colleagues at the hospital studied all 17,413 trauma patients consecutively admitted to the trauma center between 1998 and 2007. The researchers compared death rates of the 9,511 patients admitted when the center was designated level 2 (Jan. 1, 1998, to Dec. 31, 2002) to those of the 7,902 patients admitted after the upgrade to level 1 (Jan. 1, 2003, to March 31, 2007).

After adjusting for several other factors-including age, sex, injury severity, low blood pressure on hospital admission, breathing rate and co-occurring illnesses-3.48 percent of patients admitted during level 2 designation died, compared with 2.5 percent of those admitted during level 1 designation. Among severely injured patients, 14.11 percent of those admitted during the level 2 designation died, compared with 8.99 percent of those admitted during level 1 designation.

"Patients admitted during a level 1 designation with a severe head, chest or abdominal or pelvic injury diagnosis had a significant decrease in mortality [death] (9.96 percent vs. 14.51 percent, 7.14 percent vs. 11.27 percent, and 6.76 percent vs. 17.05 percent, respectively), as did patients who developed acute respiratory distress syndrome during their hospital stay (9.51 percent vs. 26.87 percent)," the authors write.

The results suggest that modifying protocols to send trauma patients to the appropriate trauma facility may improve survival, the authors note. "The number of patients needed to be treated at a level 1 trauma center over a level 2 trauma center to save one life is as follows: overall, 70 patients; injury severity score of 15 or more [severely injured], 22 patients; head injury, 17 patients; chest injury, 20 patients; and abdominal or pelvic injury, eight patients," they write. "In addition, every fourth patient who developed acute respiratory distress syndrome may have been saved had the patient been triaged to a level 1 trauma center."

JAMA and Archives Journals