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The Impact of Changing Trauma Level Designation From II to I

Kristin Scarborough, BS; Denetta Sue Slone, MD; Phyllis Uribe, RN; Michael Craun, MD; Raphael Bar-Or, BS; David Bar-Or, MD

Arch Surg. 2008;143(1):22-27.

Objective  To determine if a change in trauma designation from level II (L2) to level I (L1) in the same institution reduces mortality.

Design, Setting, and Patients  A retrospective cohort study of all patients consecutively admitted to a community hospital trauma center.

Intervention  The upgrade to trauma L1 designation (January 1, 2003-March 31, 2007) (n = 7902) from trauma L2 designation (January 1, 1998-December 31, 2002) (n = 9511).

Main Outcome Measures  Adjusted overall mortality and adjusted mortality for severely injured patients, patients with complications, and patients with severe sites of injury.

Results  After adjusting for age, sex, Injury Severity Score, mechanism of injury, hypotension on admission, respirations, and comorbidities, there was a significant decrease in overall mortality during L1 designation compared with L2 designation (2.50% vs 3.48%; P = .001). Severely injured patients (Injury Severity Score of  15) admitted during an L1 trauma designation had a significant reduction in mortality compared with patients admitted during an L2 designation (8.99% vs 14.11%; P < .001). Patients admitted during an L1 designation with a severe head, chest, or abdominal or pelvic injury diagnosis had a significant decrease in mortality (9.96% vs 14.51% [P = .005], 7.14% vs 11.27% [P = .01], and 6.76% vs 17.05% [P = .002], respectively), as did patients who developed acute respiratory distress syndrome during their hospital stay (9.51% vs 26.87%; P = .02).

Conclusion  The significant reduction in mortality of trauma patients with severe or specific injuries after the change to a higher trauma level designation may justify direct triage of these patients to L1 facilities, when available.

Author Affiliations: Trauma Research Department (Ms Scarborough, Mr Bar-Or, and Dr Bar-Or), Trauma Services (Drs Slone and Craun and Ms Uribe), and Emergency Department (Dr Bar-Or), Swedish Medical Center, Englewood, Colorado.

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