Access to a Canadian provincial integrated trauma system: A population-based cohort study
Introduction
Injuries represent one of the most important public health problems in the world [1]. In Canada, injuries are the leading cause of death during the first four decades of life [2]. Half of the deaths due to injuries occur at the site of the incident and it is estimated that the remaining 50% could be avoided if they had access to appropriate medical care [3]. Major injuries should be treated in a designated trauma centre (TC), certified by competent health authorities [3]. These TCs are acute care facilities which have a trauma team immediately available to assess patients and dispose of all the resources needed to provide appropriate and definitive care to these patients [2]. An integrated trauma system consists of a network of TCs that cover the whole health service territory and include service corridors with pre-hospital transport and inter-hospital transfer agreements [4].
The benefits of access to specialised trauma care on mortality and functional outcome following injury have been fairly well demonstrated [5], [6]. Several studies have evaluated access to level I or II TCs in health care systems with no formal trauma system or an exclusive system [7], [8], [9], [10]. However, data on access to TCs in an integrated, mature trauma system are lacking.
The aim of this study was to determine the proportion of access to TCs and identify its determinants in an integrated and mature trauma system, globally and among major trauma.
Section snippets
Setting and study design
The study was based on the integrated trauma system of the province of Québec. Québec has about 8 million inhabitants, making it the second most populous province in Canada [11]. The province has 110 acute care centres including 59 TCs [12]. The Québec trauma system was instated in 1992 and involves regionalised care from urban level I TCs to rural community hospitals including: 6 level I, 4 level II, 21 level III and 28 level IV TCs [13]. Designation levels are based on American College of
Results
The study population comprised 135,653 injury admissions. Over half of admissions were men, 40% were 65 years of age or older, almost one third had pre-existing conditions and almost one fifth were admitted for major trauma (Table 1). Globally, 75% of injury admissions were treated in a TC and access rose to 90% for patients with major trauma (n = 25,522). Access increased with increasing injury severity but decreased with age and was lower for patients with comorbidities (Table 1). Access was
Discussion
In this population-based cohort study, 90% of major trauma patients in a Canadian province with an integrated trauma system had access to TCs. The most important determinants of access to trauma care were the region of residence, injury mechanism, the number of trauma diagnoses, injury severity and age. In particular, access was low for patients in urban regions, elderly patients and women.
Previous studies have observed lower access to TCs than that observed in our study [8], [9]. For example,
Financial support
Canadian Institutes of Health Research: young investigator award [LM] and research grant [LM; no. 110996]; Fonds de la recherche du Québec—Santé: young investigator award [LM].
Conflicts of interest statement
The authors declare no financial interest.
Source of funding
This study was funded by the Canadian Institutes of Health Research (CIHR) and the Fonds de Recherche du Québec-Santé (FRQS).
References (36)
- et al.
Evaluating potential spatial access to trauma center care by severely injured patients
Health Place
(2013) - et al.
Gender-associated differences in access to trauma center care: a population-based analysis
Surgery
(2012) - et al.
Fifteen-year trauma system performance analysis demonstrates optimal coverage for most severely injured patients and identifies a vulnerable population
J Am Coll Surg
(2013) - et al.
Trauma patients: you can get them in, but you can’t get them out
Am J Surg
(2008) - et al.
Evaluation of care and surveillance of cardiovascular disease: can we trust medico-administrative hospital data?
Can J Cardiol
(2012) Injuries and violence: the fact
(2010)Trauma system: accreditation guidelines
(2011)- Société de l’assurance automobile Québec. Historique de la traumatologie à la SAAQ [March 14, 2013]. Available from...
- et al.
A national evaluation of the effect of trauma-center care on mortality
N Engl J Med
(2006) - et al.
The impact of trauma-center care on functional outcomes following major lower-limb trauma
J Bone Joint Surg Am
(2008)
Geographic distribution of severely injured patients: implications for trauma system development
J Trauma Acute Care Surg
A resource-based assessment of trauma care in the United States
J Trauma
Institutional and provider factors impeding access to trauma center care: an analysis of transfer practices in a regional trauma system
J Trauma Acute Care Surg
Definition of mortality for trauma center performance evaluation: a comparative study
Crit Care Med
The resources for optimal care of the injured patient: 2006
Rates, patterns, and determinants of unplanned readmission after traumatic injury: a multicenter cohort study
Ann Surg
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