Survival Advantage in Trauma Centers: Expeditious Intervention or Experience?

Background: Trauma patients who receive care at designated trauma centers have a decreased risk of death, but the processes of care that lead to improved outcomes are unknown. We set out to examine the relationship between trauma center care, rapidity of assessment and intervention, and mortality among trauma patients with indications for immediate operative intervention. Study Design: Data were collected from a multicenter prospective cohort study of adult patients cared for in trauma centers (TC) and nondesignated centers (NTC). From this cohort, we identified patients with two patterns of injury: hypotensive penetrating trauma (PT) and blunt traumatic brain injury (TBI) with mass effect. Times from admission to relevant interventions were assessed, as were relative risks of in-hospital death in TC compared with NTC. Relative risks were adjusted for differences in case mix using propensity analysis. Results: Among 1,331 patients who met inclusion criteria, 23.5% died in hospital. Relative risk of death was 0.61 (95% CI, 0.43 to 0.86) among patients managed at TC compared with those admitted to NTC. This survival advantage was greatest among patients in the PT group managed at TC (relative risk: 0.43; 95% CI, 0.19 to 0.94). Relative risk of death at TC among patients in the TBI group was 0.72 (95% CI, 0.50 to 1.0). Within the first 24 hours of admission, however, there was no statistically significant difference between median times to radiographic assessment or operative intervention at TC as compared with other hospitals. Conclusions: Risk of death is considerably lower among patients requiring early operative intervention if they are treated at a designated Level I trauma center. These outcomes are not a result of more rapid assessment and intervention alone, and emphasize the complex factors that contribute to the survival benefit of trauma center care.