Trauma center: Niveau 1 ou 2 ?

Patient Outcomes at Urban and Suburban Level I Versus Level II Trauma Centers.

Kaji AH et Al. Ann Emerg Med. 2017 Feb 23. pii: S0196-0644(17)30074-4

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Il est admis que la prise en charge des traumatisés dans des structures optimisées comme les trauma center de niveau 1 améliore la survie. Il semblerait que ceci mérite encore d'être encore discuté tout particulièrement en zone urbaine ou sub-urbaine et quand les équipes chirurgicales des TC de niveau 2 ont reçu une formation adaptée. Bien équipé ne signifie pas performance, les auteurs mettent en avant la qualité des équipes opérant dans le centre avant la disponibilité d'équipement spécialisé ne correspondant pas forcément aux besoins quotidiens. 

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STUDY OBJECTIVE:

Regionalized systems of trauma care and level verification are promulgated by the American College of Surgeons. Whether patient outcomes differ between the 2 highest verifications, Levels I and II, is unknown. In contrast to Level IIcenters, Level I centers are required to care for a minimum number of severely injured patients, have immediate availability of subspecialty services and equipment, and demonstrate research, substance abuse screening, and injury prevention. We compare risk-adjusted mortality outcomes at Levels I and II centers.

METHODS:

This was an analysis of data from the 2012 to 2014 Los Angeles County Trauma and Emergency Medical Information System. The system includes 14 trauma centers: 5 Level I and 9 Level II centers. Patients meeting criteria for transport to a trauma center are routed to the closest center, regardless of verification level. All adult patients (≥15 years) treated at any of the traumacenters were included. Outcomes of patients treated at Level I versus Level II centers were compared with 2 validated risk-adjusted models: Trauma Score-Injury Severity Score (TRISS) and the Haider model.

RESULTS:

Adult subjects (33,890) were treated at a Level I center; 29,724, at a Level II center. We found lower overall mortality at Level II centers compared with Level I, using TRISS (odds ratio 0.68; 95% confidence interval 0.59 to 0.78) and Haider (odds ratio 0.84; 95% confidence interval 0.73 to 0.97).

CONCLUSION:

In this cohort of patients treated at urban and suburban trauma centers, treatment at a Level II trauma center was associated with overall risk-adjusted reduced mortality relative to that at a Level I center. In the subset of penetrating trauma, no differences in mortality were found. Further study is warranted to determine optimal trauma system configuration and allocation of resources.