Higher center volume is significantly associated with lower mortality in trauma patients with shock |
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| Affiliation: | 1. Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA;2. Division of Trauma and Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA;1. Emergency Department, Centre Hospitalier Universitaire de Toulouse Hospital, Toulouse, France;2. EQUITY Team, CERPOP, INSERM, Toulouse, France;3. Centre de Recherche, CHU de Québec-Université Laval, Québec, QC G1J 1Z4, Canada;4. Epidemiology Department, Centre Hospitalier Universitaire de Toulouse Hospital, Toulouse, France;1. Department of Surgery, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, United States;2. Department of Neurosurgery, Emory University School of Medicine, United States;3. Center for Data Science, New York University, United States;1. Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte NC, USA;2. Morehouse School of Medicine, Atlanta, GA, USA;3. University of South Florida Morsani College of Medicine, Tampa, FL, USA;1. Trauma, Critical Care, and General Surgery Services, St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., St. Elizabeth Youngstown Hospital, Youngstown, OH 44501, United States;2. Trauma and Neuroscience Research Department, St. Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44501, United States;3. Department of Surgery, St Elizabeth Youngstown Hospital, 1044 Belmont Ave., Youngstown, OH 44501, United States |
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| Abstract: | IntroductionInjured patients presenting in shock are at high risk of mortality despite numerous efforts to improve resuscitation. Identifying differences in outcomes among centers for this population could yield insights to improve performance. We hypothesized that trauma centers treating higher volumes of patients in shock would have lower risk-adjusted mortality.MethodsWe queried the Pennsylvania Trauma Outcomes Study from 2016 to 2018 for injured patients ≥16 years of age at Level I&II trauma centers who had an initial systolic blood pressure (SBP) of <90 mmHg. We excluded patients with critical head injury (abbreviated injury score [AIS] head ≥5) and patients coming from centers with a shock patient volume of ≤10 for the study period. The primary exposure was tertile of center-level shock patient volume (low, medium, or high volume). We compared risk-adjusted mortality by tertile of volume using multivariable Cox proportional hazards model incorporating age, injury severity, mechanism, and physiology.ResultsOf 1,805 included patients at 29 centers, 915 (50.7%) died. The median annual shock trauma patient volume was 9 patients for low volume centers, medium 19.5, and high 37. Median ISS was higher at high volume compared to low volume centers (22 vs 18, p <0.001). Raw mortality was 54.9% at high volume centers, 46.7% for medium, and 42.9% for low. Time elapsed from arrival to emergency department (ED) to the operating room (OR) was lower at high volume than low volume centers (median 47 vs 78 min) p = 0.003. In adjusted analysis, hazard ratio for high volume centers (referenced to low volume) was 0.76 (95% CI 0.59–0.97, p = 0.030).ConclusionAfter adjusting for patient physiology and injury characteristics, center-level volume is significantly associated with mortality. Future studies should seek to identify key practices associated with improved outcomes in high-volume centers. Furthermore, shock patient volume should be considered when new trauma centers are opened. |
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