Study: Level I designation makes a big difference
Facility upgrades designation, mortality rates drop
When it comes to transferring seriously injured patients, there has not been a significant difference in how Level I and Level II trauma centers have traditionally been viewed, according to Sue Slone, MD, FACS, director of trauma surgery at Swedish Medical Center in Denver.
"People have always felt Is and IIs had fairly equivalent resources to take care of multi-injury patients," she asserts.
However, a new study comparing mortality rates at her facility before and after it was upgraded from a Level II trauma designation to a Level I indicates there may in fact be a significant difference — so significant, in fact, that Slone thinks there may be times when an ED manager should consider transferring a patient to a Level I facility instead of a Level II even if the Level II facility is closer.
Swedish Medical was upgraded from a Level II to a Level I in 2002. The researchers compared death rates of 9,511 patients admitted when the center was designated Level II (Jan. 1, 1998, to Dec. 31, 2002) to those of the 7,902 patients admitted after the upgrade to Level I (Jan. 1, 2003, to March 31, 2007). Here is what they found:
- 3.48% of all patients before upgrading died, while 2.5% of all patients after upgrading died;
- 14.11% of all severely injured patients before upgrading died, while only 8.99% of all severely injured patients after upgrading died;
- Patients admitted after the upgrading with a severe head, chest, abdominal, or pelvic injury diagnosis had a significant decrease in mortality (14.51% to 9.96%, 11.27% to 7.14%, and 17.05% to 6.76%, respectively), as did patients who developed acute respiratory distress syndrome during their hospital stay (26.87% to 9.51%).1
David Bar-Or, MD, FACEP, one of the article's authors and director of the Trauma Research Department at Swedish Medical Center, observes, "This data says that having patients triaged to a Level I trauma center can save lives."
The development of trauma levels I-V has helped ensure the most seriously injured patients go to the facilities with the greatest capabilities of treating them, says Slone, who also is one of the article's authors and has been involved in trauma for 35 years. "The only issue we found was there seems to be a misunderstanding about whether there was a big difference [in mortality rates] between Level I and II and what those differences were," she says. "It's very important in an urban area like Denver that we do all we can to make sure the highest level of multi-injury patients get to those hospitals that are best able to treat them."
'Apples and apples'
While some studies in the past have shown that Level I facilities had better survival rates than Level IIs, others have failed to show a significant difference, notes Slone. "These studies compared 'apples and oranges' — that is, different facilities with different unique characteristics," she says.
Bar-Or agrees. "This was a very unique opportunity for us to study the effect of the change [of trauma designation] in the same institution, because it could serve as its own 'control.' We did not have to worry about comparing apples and oranges."
What is the significance of the finding for ED managers? "In my mind, if a patient is deemed to be severely injured, there is no question they should be triaged to a Level I facility," Bar-Or says. "With patients who had specific injuries, like head, chest, abdominal, and pelvic injuries, we found that even if they did not appear to be very sick in the field, we could improve survival by triaging them to a Level I facility." Multiple injuries "are the ones where we can save lives," he emphasizes.
Slone agrees. "What your readers need to know is that there is improved mortality in going for the Level I facility," she says. "This is the information they need when they collect all the data, X-rays, and so forth, to say, 'If this makes a difference in their mortality, let's get a helicopter and fly them to a Level I.'"
In some cases, such a transfer would make sense even in the Level I facility is farther away, she adds. "We all talk about the 'golden hour,' but I don't know if our information is refined enough to say it's worth taking an hour to a Level I vs. a half-hour to a Level II," she says. "But if the ED manager knows the difference in mortality, every time they make that decision they should put all the different factors together and then they might say, 'You know, this might be worth 25 or 30 minutes.'"
Reference
- Scarborough K, Slone DS, Uribe P, et al. Reduced mortality at a community hospital trauma center: The impact of changing trauma level designation from II to I. Arch Surg 2008; 143:22-28.
Sources
For more information on transfers to trauma centers, contact:
- David Bar-Or, MD, FACEP, Director, Trauma Research Department, Swedish Medical Center, Denver. Phone: (303) 918-0344. Fax: (303) 788-4064.
- Sue Slone, MD, FACS, Director of Trauma Surgery, Swedish Medical Center, Denver. Phone: (303) 788-5000.
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