Population-based study of hospital trauma care in a rural state without a formal trauma system

Formalized systems of trauma care are believed to improve outcomes in an urban setting, but little is known of the applicability in a rural setting.

We conducted a population-based analysis of hospital survival after trauma comparing an American College of Surgeons-verified Level I trauma center (TC) with the pooled results of 13 small community hospitals (CH) in a rural state with no formal trauma system. All patients admitted to any hospital within the state of Vermont over a 5-year period (1995-1999) with a trauma discharge diagnosis were included. Elderly patients with isolated femur fractures were excluded from the database. International Classification of Diseases Injury Severity Scores (ICISSs) were calculated for each patient and used to control for injury severity in an omnibus logistic regression model that included age, ICISS, and hospital type (TC vs. CH) as predictors of survival. Patients who died were characterized on the basis of ICISS into "expected" (ICISS < 0.25), "indeterminate" (ICISS = 0.26-0.50), and "unexpected" (ICISS > 0.5).

In 16,354 trauma admissions over the 5-year period in the rural state of Vermont, 370 (2.2%) died. There were 5,964 (36%) admitted to TC. Patients admitted to TC were more injured (ICISS 0.94 vs. 0.96) and had a higher mortality (3.1% vs. 1.8). Overall, care at the CH provided an improved survival (odds ratio = 1.75, 95% confidence internal = 1.31-2.18, p = 0.000). However, in the more severely injured cohort of trauma patients (expected and indeterminate; n = 133), overall survival was higher in the TC (16% CH vs. 38% TC, p = 0.02, chi2). Because the TC was known to provide care equivalent to Major Trauma Outcome Study norms during this time period (Z = -0.03, M = 0.894), we believe this study confirms that trauma care throughout the state is in accordance with national norms.

In a rural state, without a statewide formal trauma system, survival after trauma is no worse at CH than TC when corrected for injury severity and age. Future expenditures of resources might better be concentrated in other areas such as discovery or prehospital care to further improve outcomes.