In states with relatively poor access to comprehensive trauma centers, more deaths occur before injured patients arrive at a hospital, according to new research presented at the American College of Surgeons Clinical Congress 2018 in Boston. The investigators believe that poor-access states could prevent thousands of prehospital deaths annually by shortening patient transport times, optimizing placement of trauma centers and improving the quality of prehospital care.
The research was conducted by a team at Brigham and Women’s Hospital in Boston under the direction of Adil H. Haider, MD, MPH, FACS. The team analyzed 1.95 million trauma deaths in U.S. adults (ages 15 and older) reported to the CDC between 1999 and 2016. The study was restricted to blunt and penetrating injuries and excluded trauma deaths due to drowning, burns and other causes.
The researchers compared the frequency of deaths occurring in-hospital with those occurring before hospital arrival. They also calculated the proportion of each state’s population with timely access to a Level I or Level II trauma center.
The team then developed a novel metric called the prehospital:in-hospital death (PH:IH) ratio, which is the number of prehospital trauma deaths divided by the number of in-hospital trauma deaths. States with a higher-than-average PH:IH ratio and age-adjusted mortality rate were classified as having a “high prehospital death burden.”
Overall, the largest percentage of trauma deaths occurred before hospital arrival (49%), compared with 42% of in-hospital deaths. (The remaining 9% were dead-on-arrival, nursing home, and hospice deaths, which the researchers excluded from analysis.) The national average PH:IH ratio was 1.18.
An association existed between states with a high prehospital death burden and a lower proportion of the state’s population with 1-hour access to a Level I or II trauma center, according to Zain G. Hashmi, MD, who helped conduct the study as a research fellow at Brigham and Women’s and is now a general surgery resident at Sinai Hospital, Baltimore. Only 63.2% of the population in high prehospital burden states had timely access to care versus 90.2% among the remaining states.
If all states had the same PH:IH ratio as did the states in the quartile with the best trauma center access, 7,601 prehospital trauma deaths could be prevented per year, the researchers estimated.
More than half of states have higher prehospital death burden
The 28 states identified as having a high prehospital death burden are Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nevada, New Mexico, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Texas, Utah, West Virginia, Wisconsin and Wyoming.
The reasons why these states have worse prehospital death burden are unknown but likely varied, Dr. Hashmi said.
Dr. Haider said two major themes emerged from this study. “First, there is tremendous potential for saving lives by improving prehospital care and access to trauma centers. Second, to undertake these improvements, we need high-quality, detailed data from the point of injury through recovery and rehabilitation,” he said. “That’s where we can make the greatest impact in saving lives and ensuring meaningful functional outcomes after injury.”