Organised trauma systems and designated trauma centres for improving outcomes in injured patients

Abstract

Rationale: Trauma systems have become the standard of care in high-income countries, but remain uncommon in low- and middle-income countries. High-quality evidence of effectiveness is needed to advocate for the development of trauma systems in low- and middle-income countries, where the burden of injury is highest.

Objectives: To assess the benefits and harms of organised trauma systems and designated trauma centres compared with usual care in injured patients.

Search methods: We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP on 16 December 2023. We also searched grey literature, checked reference lists of included studies, and contacted the authors of relevant studies.

Eligibility criteria: We included randomised controlled trials, non-randomised trials, controlled before-after studies, and interrupted time series studies comparing organised trauma systems or designated trauma centres with usual care. We planned to include patients who had had major trauma (i.e. Injury Severity Score greater than 15), but made a post-hoc decision to include patients regardless of injury severity. Studies were considered for inclusion regardless of date, language, or publication status.

Outcomes: The critical outcomes were patient outcomes (such as mortality, survival, and recovery), and adverse effects. Important outcomes were utilisation and access to trauma care services, quality of care provided, equity, and knowledge about trauma care services. Studies only reported patient outcomes (mortality, survival); there were no reports on adverse effects, utilisation and access to services, quality of care, equity, and knowledge about trauma care services.

Risk of bias: We used the Cochrane RoB 1 tool and guidance from the Cochrane Effective Practice and Organisation of Care (EPOC) group to evaluate individual studies.

Synthesis methods: Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. We could not perform a meta-analysis due to substantial clinical heterogeneity across studies. We re-analysed data from individual studies so they could be presented in a standardised format as relative effect, change in level, and change in slope. We summarised findings using a narrative synthesis.

Included studies: There were four interrupted time series studies (157,111 participants). Two studies (131,220 participants) compared organised trauma systems to usual care and two studies (25,891 participants) compared designated trauma centres to usual care. Two studies were conducted in the US, one in the UK, and one in Norway.

Synthesis of results: It is very uncertain whether organised trauma systems reduce mortality compared to usual care because the certainty of the evidence was very low (2 studies, 131,220 participants). One study (20,357 participants, follow-up 6 years) reported reduced mortality with an organised trauma system intervention and a relative effect of -30% (change in level -2.02, 95% confidence interval (CI) -3.17 to -0.86; change in slope -0.10, 95% CI -0.53 to 0.33). A second study (110,863 participants, follow-up 9 years) reported improved survival with intervention and a relative effect of 14% (change in level 0.13, 95% CI -0.50 to 0.76; an increase of 0.13 survival cases per quarter; change in slope 0.08, 95% CI 0.01 to 0.15). No studies reported data on adverse effects, utilisation and access to trauma care services, quality of care provided, equity, or knowledge about trauma care services. It is very uncertain whether designated trauma centres reduce mortality compared to usual care because the certainty of the evidence was very low (2 studies, 25,891 participants). One study (7247 participants) reported a decrease in mortality for all patients (relative effect -42%; change in level -3.60, 95% CI -11.26 to 4.07; change in slope -0.51, 95% CI -2.26 to 1.23), patients with Injury Severity Score 15 to 24 (relative effect -44%; change in level -8.80, 95% CI -29.61 to 12.00; change in slope -0.96, 95% CI -5.69 to 3.77), and patients with Injury Severity Score greater than 24 (relative effect -55%; change in level -17.87, 95% CI -47.12 to 11.37; change in slope -1.90, 95% CI -8.55 to 4.75). A second study (18,644 participants, follow-up 11 years) reported reduced mortality for adults (relative effect -67%; change in level -17.52, 95% CI -42.27 to 7.23; change in slope -2.09, 95% CI -6.22 to 2.04) and children (relative effect -84%; change in level -18.56, 95% CI -30.11 to -7.01; change in slope -1.12, 95% CI -3.04 to 0.80). No studies reported data on adverse effects, utilisation and access to trauma care services, quality of care provided, equity, or knowledge about trauma care services.

Authors' conclusions: The available evidence is currently insufficient to quantify the implications and impact of organised trauma systems and designated trauma centres on clinical practice. This is primarily due to a lack of studies with high methodological rigour for assessing the effects of clinical interventions, as well as the absence of reporting on important outcomes for determining their effectiveness. Future research could provide evidence by utilising observational studies with high methodological rigour when randomised trials are not feasible; and focus on collecting important outcomes such as the utilisation, access, and quality of care provided, and knowledge about trauma care services.

Funding: This Cochrane review had no dedicated funding.

Registration: Protocol available via doi.org/10.1002/14651858.CD012500.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.