Elsevier

Injury

Volume 46, Issue 4, April 2015, Pages 595-601
Injury

Access to a Canadian provincial integrated trauma system: A population-based cohort study

https://doi.org/10.1016/j.injury.2015.01.006Get rights and content

Abstract

Background

Access to specialised trauma care is an important measure of trauma system efficiency. However, few data are available on access to integrated trauma systems. We aimed to describe access to trauma centres (TCs) in an integrated Canadian trauma system and identify its determinants.

Methods

We conducted a population-based cohort study including all injured adults admitted to acute care hospitals in the province of Québec between 2006 and 2011. Proportions of injured patients transported directly or transferred to TCs were assessed. Determinants of access were identified through a modified Poisson regression model and a relative importance analysis was used to determine the contribution of each independent variable to predicting access.

Results

Of the 135,653 injury admissions selected, 75% were treated within the trauma system. Among 25,522 patients with major injuries [International Classification of diseases Injury Severity Score (ICISS < 0.85)], 90% had access to TCs. Access was higher for patients aged under 65, men and among patients living in more remote areas (p-value <0.001). The region of residence followed by injury mechanism, number of trauma diagnoses, injury severity and age were the most important determinants of access to trauma care.

Conclusions

In an integrated, mature trauma system, we observed high access to TCs. However, problems in access were observed for the elderly, women and in urban areas where there are many non-designated hospitals. Access to trauma care should be monitored as part of quality of care improvement activities and pre-hospital guidelines for trauma patients should be applied uniformly throughout the province.

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).

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