Lynne Moore1,2, Howard Champion3, Pier-Alexandre Tardif4,5, Brice-Lionel Kuimi5, Gerard O'Reilly6,7, Ari Leppaniemi8, Peter Cameron6,7, Cameron S Palmer9, Fikri M Abu-Zidan10, Belinda Gabbe7, Christine Gaarder11, Natalie Yanchar12, Henry Thomas Stelfox13, Raul Coimbra14, John Kortbeek15, Vanessa K Noonan16, Amy Gunning17, Malcolm Gordon18, Monty Khajanchi19, Teegwendé V Porgo4,5, Alexis F Turgeon4,5, Luke Leenen17. 1. Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada. lynne.moore@fmed.ulaval.ca. 2. Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada. lynne.moore@fmed.ulaval.ca. 3. Department of Surgery, University of the Health Sciences, Annapolis, MD, USA. 4. Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada. 5. Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada. 6. Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia. 7. School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. 8. Abdominal Center, Helsinki University hospital, Helsinki, Finland. 9. Trauma Service, Royal Children's Hospital, Melbourne, Australia. 10. Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates. 11. Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway. 12. Department of Surgery, Dalhousie University, Halifax, NS, Canada. 13. Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Canada. 14. Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, CA, USA. 15. Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, AB, Canada. 16. Rick Hansen Institute, Vancouver, BC, Canada. 17. Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. 18. Department of Emergency Medicine, University of Glasgow, Glasgow, UK. 19. Seth G.S. Medical College and KEM Hospital, Mumbai, India.
Abstract
BACKGROUND: The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. METHODS: We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. RESULTS: We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. CONCLUSIONS: This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.
BACKGROUND: The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. METHODS: We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. RESULTS: We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. CONCLUSIONS: This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.
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