How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study

Abstract

Objective: To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system.

Setting: ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million.

Participants: 5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only.

Results: A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit.

Conclusion: The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.

Keywords: Trauma management; clinical governance; neurosurgery; quality In health care.

Figure 1

Simplified map of the Emilia Romagna region. The territory is divided into three SIATs and the central location of the three corresponding trauma centres level I (hubs) is reported. The population of each SIAT and each district referring to the level II trauma centre (spoke hospital) are described. The location and characteristics (neurosurgical versus nonsurgical) of the Level II trauma centres (spoke) are reported. SIAT, Integrated System for Trauma.

Figure 2

Patient distribution, by age, in the level I TC, the level II TC, with or without neurosurgery. Data are expressed as absolute values (A) as well as in percentage (B). TC, trauma centre.

Figure 3

Comparison of 30-day observed to expected mortality (OE ratios with 95% confidence intervals, CI) of patients affected by predominant TBI and patients affected by multiple injuries including TBI, among (1) the level I TC (Cesena) in the SIAT (Romagna) with no other neurosurgical hospitals (NSHs); (2) the level I TC (Bologna Maggiore and Parma) in the SIATs (Emilia) with neurosurgical hospitals other than the level I TC; and (3) the level II TC (Ferrara, Modena Baggiovara, Reggio Emilia) in the SIATs (Emilia) with NSHs other than the level I TC. NSHs, neurosurgical hospitals; OE, observed to expected; SIAT, Integrated System for Trauma; TBI, traumatic brain injury.