Abstract
Background
Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. The aim of this study was to compare the effects of transport to trauma centers on survival outcomes in different age groups among severe trauma patients in Korea.
Methods
Cross-sectional study using Korean national emergency medical service (EMS) based severe trauma registry in 2018–2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age < 19), working age (age 19–65), and elderly (age > 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting of age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted.
Results
Overall, total of 10,511 patients were included in the study, and the number of patients in each age group were 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality from were 0.76 (95% CI, 0.43–1.32) in pediatrics, 0.78 (95% CI, 0.68–0.90) in working age, 0.71(95% CI, 0.60–0.85) in elderly, respectively. In subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group.
Conclusion
We found out trauma centers showed better clinical outcomes for adult and elderly groups, excluding the pediatric group than non-trauma centers. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.
Keywords: Age, Trauma Center, Mortality
Graphical Abstract
INTRODUCTION
Severe trauma poses significant disease burden globally. According to WHO Global Health Observatory, about 6 million deaths were occurred from trauma in 2018.1 Additionally, overall economic burden from injury due to the medical treatments and lost productivity in 2000 was more than $400 billion.2 Many developed countries are making various efforts to reduce the disease burden of trauma patients, and trauma centers are a key factor among them.3
Previous studies suggest that there is a significant difference in mortality between trauma centers and non-trauma centers.4,5 A study conducted in United States revealed that the in-hospital mortality rate was lower at trauma centers than non-trauma centers (7.6% vs. 9.5%).4 A study using dataset from National Trauma Data Bank found out that adult traumatic patients with brain injuries with Injury Severity Score over 15 treated in level 1 trauma centers designated by American College of Surgeons had significantly lower mortality rates than patients treated in level 2 trauma centers (adjusted odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09–1.20).6 Studies about trauma centers conducted in other countries such as United Kingdom, Australia7 and Japan8 showed similar results.
Although trauma centers can deliver overall benefits to trauma patients, the effectiveness of trauma centers can vary depending on patients’ characteristics. Age is one of the most important factor for clinical outcomes of severe trauma patients,9,10 and it can also affect the magnitude of the effect of trauma center. In pediatrics, there can be a meaningful difference in pathophysiology after trauma injury due to the distinctive underlying anatomy. This led to establishment of pediatric trauma centers in United States which consists of pediatric specialists with variety of specialties,11 and the survival rates were shown to be better in pediatric trauma centers for pediatric and adolescent patients,12,13 as well as the functional outcomes.14 The similar issue could be adopted to elderly patients as well,15 since the underlying diseases and complex features observed on geriatric patients can alter the outcomes from traumatic injuries. Generalized deconditioning from chronic illnesses, loss of visual acuity, gait instability, and cognitive impairments are some of major cause which induce trauma in geriatric populations, and trauma itself can increase probability for another future injury in these patients.16
The fact that the treatment effects of trauma centers can vary according to age means that individualized treatment methods may be required according to age groups. This approach should be more emphasized considering the disease burden of severe trauma. In order to determine whether such an approach is necessary, it is essential to first analyze whether the current trauma center treatment method produces an effective outcome for each age group, and through this, it would be possible to presume whether more specialized treatment is needed for each age group.
There are some studies that analyzed the effectiveness of treatment in trauma centers in specific pediatric and elderly groups.17,18,19 However, the results were based on the data where the trauma care systems were well-established, and there may be differences in results in countries where the development of trauma systems is relatively delayed or ongoing.
In Korea, the designation of regional trauma centers began in 2012 with the purpose of effectively responding to patients with severe trauma. Although the disease burden from trauma in Korea has been known to incur severe socio-economic costs, trauma systems yet require further development and research.20
The aim of this study was to compare the effects of general trauma centers (refers to a trauma center in Korea which does not distinguish between pediatrics and adults) on outcomes of severe trauma patients according to age group (pediatrics, working age, and elderly).
METHODS
Study design & setting
This was a community-based observational study using a nationwide trauma registry in Korea. Korea has 51.3 million inhabitants living in an area of 100,210 km2. The prehospital emergency medical service (EMS) system in Korea is exclusively managed by the National Fire Agency (NFA) and the regional fire headquarters of 17 provinces. All prehospital trauma patients are managed by emergency medical technicians (EMTs) (equivalent to intermediate level EMT in the United States) or nurses. In 2012, the NFA adopted the US CDC (United States Centers for Disease Control and Prevention) field triage decision scheme to evaluate trauma patients21 and developed an EMS severe trauma in-depth registry. EMS providers evaluate whether patients meet trauma center transport criteria in the field triage decision scheme. If patients meet the trauma center transportation criteria, the EMS transport protocol recommends taking the patient to a nearby regional trauma center, but this is not mandatory.22 Regional trauma centers in Korea are designated by the Ministry of Health and Welfare and evaluated annually for performance and quality, and a total of 13 of them were in operation in 2019.
Data source
We used the Korean Nationwide Severe Trauma Registry, which captures all cases of EMS-treated severe injury throughout the country. This registry was established by collaboration with NFA and Korea Disease Control and Prevention Agency (KDCA) in purpose to collect and monitor incidence and outcomes of severe injury and multicasualty injury patients. Approximately 700 medical institutions are participating in data collection. Data collection for the registry started in 2013 and is still ongoing, and data from 2018 to 2019 are publicly available and accessible.
In this study, patient data was collected from 399 emergency medical centers, among which 11 trauma centers were operated as of 2018 and 13 as of 2019 to collect data. All emergency medical institutions designated by the Ministry of Health and Welfare were included. Trauma centers not opened before July 1st, 2019 were not included in the study.
The registry includes EMS-treated severe trauma, which is defined as patients who met trauma center transport criteria in the field triage decision scheme. Based on the EMS severe trauma in-depth registry which includes all criteria of field decision scheme, EMS-treated severe trauma patients were primarily identified. In addition, physiologic criteria (hypotension [systolic blood pressure ≤ 90 mmHg], abnormal respiration rate [< 10 or > 29 respirations/min], or abnormal mental status [nonalert response according to the AVPU (Alert, Voice, Pain, Unresponsive) scale]) was also assessed by ambulance runsheet which includes vital signs. If patients met physiologic criteria using vital signs, those patients were also identified as EMS-treated severe trauma. Medical record reviewers from the KDCA extracted data regarding the diagnosis, Abbreviated Injury Scale (AIS) scores, hospital management, and clinical outcomes for all identified cases transported to emergency medical centers. Nine medical record review experts composed of healthcare information managers were trained in conducting medical record reviews. To ensure the quality of the medical record review process, a quality management committee of emergency physicians, epidemiologists, statistical experts, and medical record review experts analyzed the data each month while providing feedback to each medical record reviewer.22
Study population
EMS-treated severe trauma patient who visited emergency department (ED) between January 2018 to December 2019 and whose Injury Severity Score (ISS) above or equal to 16 were included. We excluded EMS-treated severe trauma patients whose ISS was below 16. We also excluded patients with traumatic cardiac arrest at scene or death-on-arrival in ED. Patients with missing information on injury severity score, or survival outcomes were also excluded.
Variables
Hospital level (Trauma center or non-trauma center) were collected. Age was classified into 3 groups. Patients with age under 19 were classified into ‘pediatric’ group, those with age from 19 to 65 were classified into ‘working age’ group, and those with age from 65 were classified into ‘elderly’ group. Elixhauser Comorbidity Index23,24,25 was used for evaluation of each patient’s comorbidities. Elixhauser Comorbidity Index is an index developed in 199826 to evaluate severity through comorbidities of patents consisting of 30 disease items. The weighting and adjustment of items for the index were performed in 2009. Sex, location of injury, mechanism of injury, intention of injury, vital status at EMS arrival (systolic blood pressure, consciousness status, respiratory rate), EMS management (Basic airway management, Advanced airway management, Oxygen supply, Spinal mobilization restriction, Hemorrhage control, IV line insertion), EMS time interval (response time, scene time, transport time, total prehospital time), ISS, hospital management (intensive care unit [ICU] admission, transfusion within 24 hours, operation, embolization, embolization within 24 hours), hospital length of stay, mortality at ED, and Glasgow Outcome Scale (GOS) at discharge were also collected.
Main outcomes
The primary outcome of study was in-hospital mortality. For patients who were transported to another hospital from the ED of the first hospital visited, in-hospital mortality were evaluated at discharge from the second hospital visited.
Statistical analysis
For the descriptive statistics of risk factors, χ2 tests were used for categorical variables and Wilcoxon rank sum tests were used for continuous variables.
Stratified analyses were conducted according to age group. To determine the association between trauma center and outcomes of severe patients, we constructed a logistic regression model and assessed the crude and adjusted ORs and 95% CIs. Adjustment for the models were conducted in 2 ways. In model 1, Trauma and Injury Severity Score (TRISS) was adjusted. The TRISS is a combination index based on the Revised Trauma Score (RTS), ISS, and patient age, offering a standard approach for evaluating trauma outcomes.27 We utilized the Major Trauma Outcome Study database-derived coefficients from 1995 (Probability of Survival = 1/[1 + eb], Blunt: b = 0.4499 − [0.0835 × ISS] + [0.8085 × RTS] – [1.7430 × Age Index]; Penetrating: b = −2.5355 − [0.0651 × ISS] + [0.9934 × RTS] – [1.1360 × Age Index]).27 In model 2, we adjusted for age (1-year interval), sex, Elixhauser Comorbidity Index, mechanism of injury, RTS, and ISS. Elixhauser Comorbidity index was not adjusted for pediatric group, since Elixhauser Comorbidity Score was less than or equal to zero in 99% of the group. The area under the curve (AUC) was calculated for each logistic regression model in each age group for the representation of statistical power.
We calculated the standardized mortality ratio (SMR) of trauma center and non-trauma center for each age group. The expected death was computed based on TRISS score which estimates probability of survival for trauma patients.
Because traumatic brain injury accounts for a large portion of severe trauma and has a critical effect on survival, disability and disease burden,28,29 we also investigated the different effect of trauma center for traumatic brain injury patients by age group as a subgroup analysis. Traumatic brain injury was defined as patients with abbreviated injury score of head were higher or equal to 3.
All analysis were conducted using SAS software, version 9.4. Statistical values were defined significant if P value were less than 0.05.
Ethics statement
The study complied with the Declaration of Helsinki, and its protocol was approved by the Institutional Review Board (IRB) of the study hospital with a waiver of informed consent (IRB No. 30-2019-72).
RESULTS
Demographic findings
Among 66,934 EMS-transported trauma patients, 10,511 patients were included. Patients with trauma cardiac arrest or death on arrival (n = 7,336), injury severity score less than 16 (n = 49,016) patients, those with unknown outcomes (n = 53) were excluded (Fig. 1).
Fig. 1. Patient flow.
Among 10,511 patients, 488 patients were ‘pediatric’ group, 6,812 patients were classified as ‘working age’ group, and 3,211 patients were classified as ‘elderly’ group. Demographics of each age groups are shown on Table 1. Mean age of each age group was 14.0, 47.6, 75.5 for pediatric, working age, elderly group, respectively. The proportion of male sex of whole group was 7,808 (74.3%). The percentage of transport to trauma centers for each age groups were 49.4%, 42.7%, 33.0% for pediatric, working age, elderly group, respectively. Traffic accident was most common mechanism of injury for all age groups, followed by falls. Mortality at discharge for each age groups was 23.6%, 17.6%, 18.0% for pediatric, working age, elderly group, respectively.
Table 1. Demographic characteristics of study population by age group.
| Variables | Total | Pediatric (0–18 yr) | Working age (19–65 yr) | Elderly (66– yr) | |
|---|---|---|---|---|---|
| Total | 10,511 | 488 | 6,812 | 3,211 | |
| Trauma center | 4,211 (40.1) | 241 (49.4) | 2,910 (42.7) | 1,060 (33.0) | |
| Age, yr | 54.5 ± 19.2 | 14.0 ± 4.8 | 47.6 ± 13.2 | 75.5 ± 6.5 | |
| Male | 7,808 (74.3) | 330 (67.6) | 5,408 (79.4) | 2,070 (64.5) | |
| Elixhauser comorbidity score | |||||
| < 0 | 240 (2.3) | 24 (4.9) | 167 (2.5) | 49 (1.5) | |
| 0 | 9,239 (87.9) | 458 (93.9) | 6,177 (90.7) | 2,604 (81.1) | |
| 1–4 | 369 (3.5) | 2 (0.4) | 146 (2.1) | 221 (6.9) | |
| > 5 | 663 (6.3) | 4 (0.8) | 322 (4.7) | 337 (10.5) | |
| Urbanization level of location of injury | |||||
| Metropolitan | 4,979 (47.4) | 266 (54.5) | 3,327 (48.8) | 1,386 (43.2) | |
| Urban | 3,778 (35.9) | 181 (37.1) | 2,466 (36.2) | 1,131 (35.2) | |
| Rural | 1,754 (16.7) | 41 (8.4) | 1,019 (15.0) | 694 (21.6) | |
| Mechanism of injury | |||||
| Traffic accident | 6,103 (58.1) | 328 (67.2) | 3,828 (56.2) | 1,947 (60.6) | |
| Fall | 3,800 (36.2) | 153 (31.4) | 2,464 (36.2) | 1,183 (36.8) | |
| Other | 608 (5.8) | 7 (1.4) | 520 (7.6) | 81 (2.5) | |
| Intention of injury | |||||
| Unintentional | 9,692 (92.2) | 414 (84.8) | 6,179 (90.7) | 3,099 (96.5) | |
| Intentional | 384 (3.7) | 52 (10.7) | 300 (4.4) | 32 (1.0) | |
| Unknown | 150 (1.4) | 2 (0.4) | 144 (2.1) | 4 (0.1) | |
| Injury Severity Score | |||||
| 16–25 | 6,440 (61.3) | 318 (65.2) | 4,241 (62.3) | 1,881 (58.6) | |
| 26–75 | 4,071 (38.7) | 170 (34.8) | 2,571 (37.7) | 1,330 (41.4) | |
| Injury Severity Score, median (IQR) | 22 (17–26) | 22 (17–27) | 22 (17–27) | 22 (17–26) | |
| Vital status at EMS arrival | |||||
| Non-alert | 6,518 (62.0) | 329 (67.4) | 4,061 (59.6) | 2,128 (66.3) | |
| SBP < 90 mmHg | 1,332 (12.7) | 74 (15.2) | 949 (13.9) | 309 (9.6) | |
| RR < 10 or RR > 29 | 420 (4.0) | 32 (6.6) | 288 (4.2) | 100 (3.1) | |
| EMS management | |||||
| Basic airway management | 6,709 (63.8) | 348 (71.3) | 4,375 (64.2) | 1,986 (61.8) | |
| Advanced airway management | 64 (0.6) | 3 (0.6) | 47 (0.7) | 14 (0.4) | |
| O2 supply | 6,783 (64.5) | 338 (69.3) | 4,401 (64.6) | 2,044 (63.7) | |
| Spinal mobilization restriction | 9,277 (88.3) | 460 (94.3) | 6,083 (89.3) | 2,734 (85.1) | |
| Hemorrhage control | 6,735 (64.1) | 294 (60.2) | 4,433 (65.1) | 2,008 (62.5) | |
| IV line insertion | 3,171 (30.2) | 162 (33.2) | 2,244 (32.9) | 765 (23.8) | |
| EMS time interval | |||||
| Response time | 7 (5–10) | 6 (5–9) | 7 (5–11) | 7 (5–10) | |
| Scene time | 7 (5–10) | 6 (4–8) | 7 (5–10) | 7 (5–9) | |
| Transport time | 12 (7–23) | 10 (6–16) | 13 (7–23) | 13 (7–25) | |
| Total prehospital time | 29 (20–44) | 24 (18–32) | 30 (20–45) | 29 (20–44) | |
| Hospital management | |||||
| ICU admission | 7,384 (70.3) | 366 (75.0) | 4,857 (71.3) | 2,161 (67.3) | |
| Transfusion within 24 hr | 4,393 (41.8) | 196 (40.2) | 2,859 (42.0) | 1,338 (41.7) | |
| Operation | 5,621 (53.5) | 267 (54.7) | 4,003 (58.8) | 1,351 (42.1) | |
| Operation within 24 hr | 3,601 (34.3) | 154 (31.6) | 2,568 (37.7) | 879 (27.4) | |
| Embolization | 751 (7.1) | 48 (9.8) | 502 (7.4) | 201 (6.3) | |
| Embolization within 24 hr | 704 (6.7) | 46 (9.4) | 469 (6.9) | 189 (5.9) | |
| Hospital length of stay (days) | 22.9 (8.9–45.1) | 21.4 (10.7–43.4) | 24.8 (11.1–45.8) | 19.2 (4.4–43.0) | |
| ED mortality | 444 (4.2) | 13 (2.7) | 228 (3.3) | 203 (6.3) | |
| GOS at discharge | |||||
| Death | 2,483 (23.6) | 86 (17.6) | 1,228 (18.0) | 1,169 (36.4) | |
| Neurovegetative state | 135 (1.3) | 7 (1.4) | 74 (1.1) | 54 (1.7) | |
| Severe disability | 1,895 (18.0) | 57 (11.7) | 1,179 (17.3) | 659 (20.5) | |
| Moderate disability | 2,992 (28.5) | 145 (29.7) | 2,126 (31.2) | 721 (22.5) | |
| Good recovery | 3,006 (28.6) | 193 (39.5) | 2,205 (32.4) | 608 (18.9) | |
Values are presented as number (%) or mean ± standard deviation.
IQR = interquartile range, EMS = emergency medical service, SBP = systolic blood pressure, RR = respiratory rate, O2 = oxygen, IV = intravenous, ICU = intensive care unit, ED = emergency department, GOS = Glasgow Outcome Scale.
Table 2 shows the demographic data of each age group depending whether the patient was transported to trauma center or not. Proportion of higher ISS was higher for patients transported to trauma centers in all age groups, and mortality was lower for patients transported to trauma centers in all age groups (Table 2).
Table 2. Demographic characteristics of study population by age group and trauma center care.
| Variables | Pediatric (0–18 yr) | Working age (19–65 yr) | Elderly (66– yr) | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Non-trauma center | Trauma center | P | Non-trauma center | Trauma center | P | Non-trauma center | Trauma center | P | ||
| Total | 247 | 241 | 3,902 | 2,910 | 2,151 | 1,060 | ||||
| Age, yr | 14.2 (4.7) | 13.7 (5.0) | 0.177 | 48.0 (13.1) | 46.9 (13.2) | 0.001 | 75.7 (6.7) | 75.1 (6.3) | 0.054 | |
| Male | 174 (70.4) | 156 (64.7) | 0.177 | 3,090 (79.2) | 2,318 (79.7) | 0.638 | 1,375 (63.9) | 695 (65.6) | 0.361 | |
| Elixhauser comorbidity score | 0.304 | 0.565 | 0.735 | |||||||
| < 0 | 10 (4.0) | 14 (5.8) | 89 (2.3) | 78 (2.7) | 36 (1.7) | 13 (1.2) | ||||
| 0 | 234 (94.7) | 224 (92.9) | 3,550 (91.0) | 2,627 (90.3) | 1,746 (81.2) | 858 (80.9) | ||||
| 1–4 | 2 (0.8) | 0 (0.0) | 86 (2.2) | 60 (2.1) | 144 (6.7) | 77 (7.3) | ||||
| > 5 | 1 (0.4) | 3 (1.2) | 177 (4.5) | 145 (5.0) | 225 (10.5) | 112 (10.6) | ||||
| Urbanization level of location of injury | 0.009 | < 0.001 | < 0.001 | |||||||
| Metropolitan | 120 (48.6) | 146 (60.6) | 1,792 (45.9) | 1,535 (52.7) | 868 (40.4) | 518 (48.9) | ||||
| Urban | 108 (43.7) | 73 (30.3) | 1,547 (39.6) | 919 (31.6) | 824 (38.3) | 307 (29.0) | ||||
| Rural | 19 (7.7) | 22 (9.1) | 563 (14.4) | 456 (15.7) | 459 (21.3) | 235 (22.2) | ||||
| Mechanism of injury | 0.353 | < 0.001 | < 0.001 | |||||||
| Traffic accident | 163 (66.0) | 167 (69.3) | 2,141 (54.9) | 1,707 (58.7) | 1,259 (58.5) | 710 (67.0) | ||||
| Fall | 78 (31.6) | 72 (29.9) | 1,475 (37.8) | 929 (31.9) | 833 (38.7) | 313 (29.5) | ||||
| Other | 6 (2.4) | 2 (0.8) | 286 (7.3) | 274 (9.4) | 59 (2.7) | 37 (3.5) | ||||
| Intention of injury | 0.538 | 0.239 | 0.845 | |||||||
| Unintentional | 206 (83.4) | 208 (86.3) | 3,549 (91.0) | 2,630 (90.4) | 2,074 (96.4) | 1,025 (96.7) | ||||
| Intentional | 31 (12.6) | 21 (8.7) | 167 (4.3) | 133 (4.6) | 22 (1.0) | 10 (0.9) | ||||
| Unknown | 1 (0.4) | 1 (0.4) | 72 (1.8) | 72 (2.5) | 2 (0.1) | 2 (0.2) | ||||
| Injury Severity Score | 0.115 | < 0.001 | < 0.001 | |||||||
| 16–25 | 162 (65.6) | 156 (64.7) | 2,545 (65.2) | 1,696 (58.3) | 1,338 (62.2) | 543 (51.2) | ||||
| 26–75 | 85 (34.4) | 85 (35.3) | 1,357 (34.8) | 1,214 (41.7) | 813 (37.8) | 517 (48.8) | ||||
| Injury Severity Score, median (IQR) | 21 (17–26) | 22 (17–27) | 0.088 | 22 (17–26) | 22 (17–29) | < 0.001 | 21 (17–25) | 24 (18–29) | < 0.001 | |
| Vital status at EMS arrival | ||||||||||
| Non–alert | 172 (69.6) | 157 (65.1) | 0.290 | 2,503 (64.1) | 1,558 (53.5) | < 0.001 | 1,459 (67.8) | 669 (63.1) | 0.008 | |
| SBP < 90 mmHg | 31 (12.6) | 43 (17.8) | 0.103 | 486 (12.5) | 463 (15.9) | < 0.001 | 171 (7.9) | 138 (13.0) | < 0.001 | |
| RR < 10 or RR > 29 | 14 (5.7) | 18 (7.5) | 0.422 | 173 (4.4) | 115 (4.0) | 0.328 | 70 (3.3) | 30 (2.8) | 0.515 | |
| EMS management | ||||||||||
| Basic airway management | 186 (75.3) | 162 (67.2) | 0.048 | 2,450 (62.8) | 1,925 (66.2) | 0.004 | 1,296 (60.3) | 690 (65.1) | 0.008 | |
| Advanced airway management | 0 (0.0) | 3 (1.2) | 0.120 | 22 (0.6) | 25 (0.9) | 0.145 | 11 (0.5) | 3 (0.3) | 0.570 | |
| O2 supply | 159 (64.4) | 179 (74.3) | 0.018 | 2,302 (59.0) | 2,099 (72.1) | < 0.001 | 1,264 (58.8) | 780 (73.6) | < 0.001 | |
| Spinal mobilization restriction | 233 (94.3) | 227 (94.2) | 0.947 | 3,449 (88.4) | 2,634 (90.5) | 0.005 | 1,780 (82.8) | 954 (90.0) | < 0.001 | |
| Hemorrhage control | 145 (58.7) | 149 (61.8) | 0.481 | 2,475 (63.4) | 1,958 (67.3) | 0.001 | 1,307 (60.8) | 701 (66.1) | 0.003 | |
| IV line insertion | 73 (29.6) | 89 (36.9) | 0.084 | 1,046 (26.8) | 1,198 (41.2) | < 0.001 | 418 (19.4) | 347 (32.7) | < 0.001 | |
| EMS time interval | ||||||||||
| Response time | 6 (5–9) | 6 (5–9) | 0.389 | 7 (5–10) | 8 (5–11) | < 0.001 | 7 (5–10) | 7 (5–11) | 0.974 | |
| Scene time | 6 (4–8) | 6 (4–9) | 0.148 | 7 (5–10) | 8 (5–11) | < 0.001 | 7 (5–9) | 7 (5–10) | 0.010 | |
| Transport time | 8 (5–13) | 13 (7–20) | < 0.001 | 10 (5–19) | 16 (9–28) | < 0.001 | 11 (6–22) | 18 (9–31) | < 0.001 | |
| Total prehospital time | 21 (16–28) | 27 (20–36) | < 0.001 | 26 (19–39) | 35 (25–50) | < 0.001 | 27 (19–40) | 36 (23–51) | < 0.001 | |
| Hospital management | ||||||||||
| ICU admission | 149 (60.3) | 217 (90.0) | < 0.001 | 2,221 (56.9) | 2,636 (90.6) | < 0.001 | 1,217 (56.6) | 944 (89.1) | < 0.001 | |
| Transfusion within 24 hr | 88 (35.6) | 108 (44.8) | 0.048 | 1,457 (37.3) | 1,402 (48.2) | < 0.001 | 778 (36.2) | 560 (52.8) | < 0.001 | |
| Operation | 112 (45.3) | 155 (64.3) | < 0.001 | 1,833 (47.0) | 2,170 (74.6) | < 0.001 | 747 (34.7) | 604 (57.0) | < 0.001 | |
| Operation within 24 hr | 69 (27.9) | 85 (35.3) | 0.081 | 1,192 (30.5) | 1,376 (47.3) | < 0.001 | 495 (23.0) | 384 (36.2) | < 0.001 | |
| Embolization | 15 (6.1) | 33 (13.7) | 0.005 | 192 (4.9) | 310 (10.7) | < 0.001 | 88 (4.1) | 113 (10.7) | < 0.001 | |
| Embolization within 24 hr | 14 (5.7) | 32 (13.3) | 0.004 | 175 (4.5) | 294 (10.1) | < 0.001 | 79 (3.7) | 110 (10.4) | < 0.001 | |
| Hospital length of stay [days] | 26.0 (10.9–42.5) | 19.8 (10.6–43.9) | 0.332 | 24.7 (9.8–48.7) | 24.9 (12.0–43.9) | 0.790 | 18.6 (4.1–42.7) | 20.2 (5.0–43.6) | 0.167 | |
| ED mortality | 8 (3.2) | 5 (2.1) | 0.425 | 185 (4.7) | 43 (1.5) | < 0.001 | 171 (7.9) | 32 (3.0) | < 0.001 | |
| GOS at discharge | < 0.001 | < 0.001 | < 0.001 | |||||||
| Death | 44 (17.8) | 42 (17.4) | 759 (19.5) | 469 (16.1) | 809 (37.6) | 360 (34.0) | ||||
| Neurovegetative state | 6 (2.4) | 1 (0.4) | 59 (1.5) | 15 (0.5) | 39 (1.8) | 15 (1.4) | ||||
| Severe disability | 44 (17.8) | 13 (5.4) | 795 (20.4) | 384 (13.2) | 447 (20.8) | 212 (20.0) | ||||
| Moderate disability | 67 (27.1) | 78 (32.4) | 1,033 (26.5) | 1,093 (37.6) | 425 (19.8) | 296 (27.9) | ||||
| Good recovery | 86 (34.8) | 107 (44.4) | 1,256 (32.2) | 949 (32.6) | 431 (20.0) | 177 (16.7) | ||||
Values are presented as number (%) or mean ± standard deviation.
IQR = interquartile range, EMS = emergency medical service, SBP = systolic blood pressure, RR = respiratory rate, O2 = oxygen, IV = intravenous, ICU = intensive care unit, ED = emergency department, GOS = Glasgow Outcome Scale.
Main outcomes
Table 3 represents primary outcomes, where in-hospital mortalities and their differences depending on the age groups are shown. In-hospital mortality in non-trauma center are set as reference value for each age groups. In model 1, there was no significant difference in mortality in pediatric group (OR, 0.77; 95% CI, 0.45–1.32), where there was significant difference in working age group (OR, 0.76; 95% CI, 0.66–0.87) and elderly group (OR, 0.68; 95% CI, 0.57–0.81). In model 2, there was also no significant difference in mortality in pediatric group (OR, 0.76; 95% CI, 0.44–1.33), where there was significant difference in working age group (OR, 0.78; 95% CI, 0.68–0.90) and elderly group (OR, 0.71; 95% CI, 0.60–0.85). The AUC for each logistic regression model in each age group is represented in Supplementary Table 1.
Table 3. Multivariable logistic regression analysis for in-hospital mortality among study population.
| Age group | No. of outcome/No. (%) | Unadjusted odds ratio (95% CI) | Adjusted odds ratio (95% CI) | ||
|---|---|---|---|---|---|
| Model 1 | Model 2 | ||||
| Pediatric | |||||
| Non-trauma center | 44/247 (17.8) | Reference | Reference | Reference | |
| Trauma center | 42/241 (17.4) | 0.97 (0.61–1.55) | 0.77 (0.45–1.32) | 0.76 (0.44–1.33) | |
| Working age | |||||
| Non-trauma center | 759/3,902 (19.5) | Reference | Reference | Reference | |
| Trauma center | 469/2,910 (16.1) | 0.80 (0.70–0.90) | 0.76 (0.66–0.87) | 0.78 (0.68–0.90) | |
| Elderly | |||||
| Non-trauma center | 809/2,151 (37.6) | Reference | Reference | Reference | |
| Trauma center | 360/1,060 (34.0) | 0.85 (0.73–1.00) | 0.68 (0.57–0.81) | 0.71 (0.60–0.85) | |
Model 1, adjusted for TRISS.
Model 2, adjusted for age, sex, comorbidity, mechanism of injury, revised trauma score, and injury severity score. Because Elixhauser comorbidity score was less than or equal to zero in 488 (99%) of pediatric patients, comorbidity was not adjusted in model 2 for pediatric patients.
CI = confidence interval, TRISS = Trauma Injury Severity Score.
SMR
The SMR of trauma center for each age group are descripted in Table 4. In pediatric patients who were transported to non-trauma center, the SMR (95% CI) was 1.52 (1.10–2.00), which was not significantly different from the SMR of pediatric patients who visited trauma center (SMR [95% CI] 1.17 [0.84–1.55]). For working age group, the SMR of patients who visited non-trauma center was significantly higher than patients who visited trauma center (SMR [95% CI] 1.06 [0.99–1.14] for non-trauma center and 0.85 [0.79–0.94] for trauma center). For elderly group, the SMR of patients who visited non-trauma center was significantly higher than patients who visited trauma center (SMR [95% CI] 1.29 [1.20–1.38] for non-trauma center and 1.02 [0.91–1.12] for trauma center).
Table 4. Standardized mortality ratio by trauma center care among study population.
| Age group | Center | Total | Observed deaths | Expected deaths | SMR (95% CI) |
|---|---|---|---|---|---|
| Pediatric | Non-trauma center | 247 | 44 | 29 | 1.52 (1.10–2.00) |
| Trauma center | 241 | 42 | 36 | 1.17 (0.84–1.55) | |
| Working age | Non-trauma center | 3,902 | 759 | 715 | 1.06 (0.99–1.14) |
| Trauma center | 2,910 | 469 | 543 | 0.86 (0.79–0.94) | |
| Elderly | Non-trauma center | 2,151 | 809 | 629 | 1.29 (1.20–1.38) |
| Trauma center | 1,060 | 360 | 354 | 1.02 (0.91–1.12) |
SMR = standardized mortality ratio, CI = confidence interval.
Subgroup analysis
The same analysis was done for subgroup who had traumatic brain injury, and the results are descripted in Table 5. In model 1, there was no significant difference in mortality in pediatric group (OR, 1.10; 95% CI, 0.59–2.04). There was significant difference in working age group (OR, 0.84; 95% CI, 0.71–0.99) and elderly group (OR, 0.69; 95% CI, 0.57–9.84). In model 2, there was no significant difference in mortality in pediatric group (OR, 1.18; 95% CI, 0.61–2.28) and working age group (OR, 0.89; 95% CI, 0.75–1.05). However, there was significant difference in elderly group (OR, 0.73; 95% CI, 0.60–0.90).
Table 5. Multivariable logistic regression analysis for in-hospital mortality among patients with traumatic brain injury.
| Age group | No. of outcome/No. (%) | Unadjusted odds ratio (95% CI) | Adjusted odds ratio (95% CI) | ||
|---|---|---|---|---|---|
| Model 1 | Model 2 | ||||
| Pediatric | |||||
| Non-trauma center | 32/180 (17.8) | Reference | Reference | Reference | |
| Trauma center | 33/145 (22.8) | 1.36 (0.79–2.35) | 1.10 (0.59–2.04) | 1.18 (0.61–2.28) | |
| Working age | |||||
| Non-trauma center | 571/2,625 (21.8) | Reference | Reference | Reference | |
| Trauma center | 347/1,603 (21.6) | 0.99 (0.86–1.16) | 0.84 (0.71–0.99) | 0.89 (0.75–1.05) | |
| Elderly | |||||
| Non-trauma center | 690/1,693 (40.8) | Reference | Reference | Reference | |
| Trauma center | 301/777 (38.7) | 0.92 (0.77–1.09) | 0.69 (0.57–0.84) | 0.73 (0.60–0.90) | |
Model 1, adjusted for TRISS.
Model 2, adjusted for age, sex, comorbidity, mechanism of injury, revised trauma score, and injury severity score. Because Elixhauser comorbidity score was less than or equal to zero in 488 (99%) of pediatric patients, comorbidity was not adjusted in model 2 for pediatric patients.
CI = confidence interval, TRISS = Trauma Injury Severity Score.
DISCUSSION
Using a nationwide, community-based observational study of EMS-treated severe trauma patients over 2-year period, we were able to analyze the effects of general trauma centers on outcomes of severe trauma patients according to age group for patients with severe trauma in Korea. We found that transfer to trauma center significantly lowered the mortality rate in the working age, elderly group, however no such effect was evident for pediatric group. These findings were consistent in analysis using logistic regression or standard mortality ratio. Similar results were also shown for those with traumatic brain injury.
The effectiveness of transport to trauma center was well-known from previous studies,4,5 and studies in Korea have also shown that transport to trauma center can make better outcomes.30,31,32 However, our study suggested that the transportation to the trauma center after severe trauma may not be significantly effective for pediatric populations. It is well validated that pediatric trauma centers improved clinical and functional outcomes for pediatric patients with traumatic injuries.12,14 As for in Republic of Korea, however, the distinguishment between adult and pediatric trauma center does not exist, which means that the care of pediatric trauma patients is also implemented on general trauma centers. Even though there was a study which advocated that trauma centers for adults show comparable and acceptable outcomes for pediatric patients as well,33 the results of studies may vary depending on the personnel, equipment, and settings of individual trauma centers.
Emergency Medical Service Act in Korea sets out the requirements and establishment rules for trauma centers in Republic of Korea. These statements provides conditions required for trauma centers such as rooms and devices for resuscitations, medical faculty (surgery and emergency medicine parts, especially), beds for patients. However, there is no provision in this law that there must be a specialist in pediatrics or pediatric surgery. In order to provide professional medical treatment for pediatric population, it would be necessary to improve the relevant laws. As for United States, pediatric surgeons, physicians certified in pediatric critical care and emergency medicine and the related educations are key components for establishing a pediatric trauma center, and these would be important factors contributing to improved survival rates.34
The similar arguments could be done in patients with traumatic brain injuries. Traumatic brain injuries are key injury site in severe trauma and account for a large portion of the global disease burden.35 It is also the leading cause of death in trauma patients in Korea,36 and it was also found in domestic research that head injuries accounted for the largest portion of traumatic injuries in children.37 Traumatic brain injuries for pediatric patients differ in several characteristics compared to those for adult patients, since they composes potential for developments and are related to different mechanism of injuries and metabolisms.38 In terms of treatment, the guidelines for pediatric severe traumatic brain injury contains information such as monitoring, various methods for intracranial pressure control, sedatives, and seizure prevention,39 and these contents are also thought to be different from those in adults in details. In this context, cooperation with a pediatric specialist should be important accordingly, and therefore, it is considered essential to place them in trauma centers.
Pediatric trauma center is required to enhance the survival rate for pediatric population specifically. However, since the financial burden required to establish pediatric trauma center is substantial and there may be inadequate reimbursements,40 it is not easy to operate it sufficiently in Korea in reality. Thus, developing the capacity to respond to pediatric patients with severe trauma by related trainings and educations would be helpful,41 and placing physicians with specialties at pediatrics, pediatric surgery, and pediatric critical care would be essential. Additionally, it is also necessary to improve the triage of pediatric patients with severe trauma in the ED, since the physiologic response for pediatric patients can defer from those of adults, and the current criteria for determining and transferring severe trauma is targeted to adults. Pediatric Trauma Score is scoring system comparable to RTS in adults, and this might be needed to be introduced for more accurate evaluation of severity of trauma.42 Prehospital care for pediatric patients should be revised as well, since a previous study suggest that 1st responder treatment such as endotracheal intubation, intravenous access is suboptimal for pediatric patients with trauma compared to adults.43 The decision whether to undergo surgery or not may also depend on whether the medical staff is specialized in pediatric surgery,44,45 and this would also emphasize the importance of specialist in pediatrics and pediatric surgery.
This study has several advantages compared to previous studies. First, there was few previous studies in Korea which emphasized importance of management in pediatric trauma. Second, this was a nation-wide study, and we were able to collect large national data based on the registries of patients. This meant the data was collected from multiple hospital distributed nation-wide, and this process would mitigate the vias which can arise from the difference of system each hospital owns. Third, the data set was composed of medical records of a patient from EMS to ED, ward or ICU, and discharge, which enabled us to analyze relationships between various variables and parameters for all participants, as well as the adjustment for characteristics which can effect result of the analysis.
This study has several limitations. First, the results would not be generalized to world-wide population, due to the lack of pediatric trauma center in Korea and different systems of medical transportation. Additionally, although Korea’s preventable death rate for patients with severe trauma has recently been on a downward trend, it is known that the rates are still higher in Korea compared to other developed countries with organized systems for trauma care,46 and this suggests that the trauma treatment system in Korea has areas to be improved compared to the internationally standardized system. Second, this was a retrospective cross-sectional study. Data in different periods and additional, prospective study would be essential to get more precise results. Third, the numbers in each age group is heterogenous, especially for pediatric group. Compared to adult group, there is more than 10-fold difference between two groups, and this would effect statistical significancy in each age groups. Fourth, even though this study proved efficacy of transportation to trauma center for working age and elderly group compared to pediatric group, whether there is a benefit from a cost-effectiveness point of view is controversial. It is known that trauma center can increase medical expenses and this increases as the time goes, despite the benefit from the trauma-related preventable deaths.47 The issue whether the establishment of pediatric trauma center would decrease the economical burden should be discussed additionally.
In conclusion, trauma centers are more effective for patients in adult and elderly groups, excluding the pediatric group than non-trauma centers, showing better clinical outcomes. A further study would be needed to analyze in a larger pediatric population and to observe whether the introduction of additional resources, education, etc. can improve the treatment outcomes of severe trauma patients in various age groups.
Footnotes
Funding: This study was supported by the National Fire Agency of Korea and Korea Disease Control and Prevention Agency (2020-2021).
Disclosure: The authors have no potential conflicts of interest to disclose.
- Conceptualization: Song KJ, Hong KJ.
- Data curation: Park JH, Kim TH, Lee SGW.
- Formal analysis: Park JH.
- Funding acquisition: Song KJ.
- Resources: Song KJ.
- Supervision: Song KJ, Hong KJ, Kim TH.
- Writing - original draft: Kim HR.
- Writing - review & editing: Song KJ, Park JH, Lee SGW.
SUPPLEMENTARY MATERIAL
Statistical power for each logistic regression model
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Associated Data
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Supplementary Materials
Statistical power for each logistic regression model