BMJ No 7119 Volume 315
Papers Saturday 22 November 1997
Effectiveness of a regional trauma system in reducing mortality from major trauma: before and after study
Jon Nicholl, Janette Turner
See Editorial by Yates, p 1321
Abstract
Objective: To assess the effect of the development of an experimental trauma centre and regional trauma system on the survival of patients with major trauma.Design: Controlled before and after study examining outcomes between 1990 and 1993, spanning the introduction of the system in 1991-2.
Setting: Trauma centre in North Staffordshire Royal Infirmary and five associated district general hospitals in the North West Midlands regional trauma system, and two control regions in Lancashire and Humberside.
Subjects: All trauma patients taken by the ambulance services serving the regions or arriving other than by ambulance with injury severity scores >15, whether or not they had vital signs on arrival at hospital.
Main outcome measures: Survival rates standardised for age, severity of injury, and revised trauma score.
Results: In 1990, 33% of major trauma patients in the experimental region were taken to the trauma centre, and by 1993 this had risen to only 39%. Crude death rates changed by the same amount in the control regions (46.5% in 1990-1 to 44.4% in 1992-3) as in the experimental region (44.8% to 41.3%). After standardisation, the estimated change in the probability of dying in the experimental region compared with the control regions was -0.8% per year (95% confidence interval -3.6% to 2.2%); for out of hours care, the change was 1.6% per year (-2.3% to 5.6%), and, for multiply injured patients, the change was -1.6% (-6.1% to 2.6%).
Conclusion: Any reductions in mortality from regionalising major trauma care in shire areas of England would probably be modest compared with reports from the United States.
Introduction
A working party of the Royal College of Surgeons of England found "significant deficiencies in the management of seriously injured patients," most notably that up to 33% of the deaths of 514 patients with major trauma admitted to hospitals' accident and emergency departments could have been avoided.(1) It recommended that accident and emergency services for the care of major trauma patients in Britain should be reorganised so that such patients would be transferred to regional trauma centres conceived along the lines of the American model,(2) which was widely reported as reducing avoidable trauma deaths, particularly for patients with multiple injuries.(3-6) In this model a number of key elements were identified by the American College of Surgeons - such as 24 hour reception in emergency departments by senior staff, all key specialties in the treatment of trauma care on the same site, a high volume of seriously injured patients (about 10-20 a week), and a system to ensure that seriously injured patients would be treated in the trauma centre.(2)
In order to assess whether this concept would transfer cost effectively into the British setting, the Department of Health funded the establishment and evaluation of an experimental regional trauma system in the North West Midlands region based around the North Staffordshire Royal Infirmary. The nascent regional system covered an area of about 6000 km2 with a catchment population of 1.8 million and was served by five other district general hospitals' accident and emergency departments and three ambulance services (see table 1).
| Table 1 - Summary of services and facilities for trauma care in North West Midland region, provided with experimental regional trauma system, and in two control regions | |||
|---|---|---|---|
| Characteristics | Experimental region | Control regions | |
| Lancashire | Humberside | ||
| Approximate area (km2) | 5,500 | 2,500 | 3,500 |
| Size of catchment population (millions) | 1.8 | 1.3 | 0.9 |
| No of ambulance services | 3 | 1 | 1 |
| No of district general hospitals with accident and emergency departments: | 6 | 5 | 3 |
| With neurosurgery on site | 1 | 1 | 1 |
| With cardiothoracic surgery on site | 1 | 1 | 0 |
| Range of new attendances at accident and emergency (thousands per year) | 20-90 | 30-70 | 40-80 |
This paper concentrates on the benefits from the system in terms of survival from major trauma. Detailed results on other patient groups, avoidable deaths, outcomes for survivors, and costs will be reported elsewhere.
Methods
Design
We examined changes in outcomes for trauma patients before and
after the development of the trauma system. In order to control for
secular trends over the four years studied, from January 1990 to
December 1993, we compared changes in the experimental region with
changes in two control regions - Lancashire and Humberside - which were
similar to the North West Midlands region at the start of the study,
before the development of the trauma system. Both control regions had a
single central hospital which, like the North Staffordshire Royal
Infirmary, had an accident and emergency department of good practice,
with neurosurgery on site, to which patients with head injuries were
referred from within the region, but neither had cardiothoracic surgery
(see table 1).
We obtained approval for our observational study from the appropriate ethics committees. The design and progress of the study were overseen by an advisory group convened by the Department of Health.
Inclusion criteria
We included all patients who had an injury severity
score(7) of >15, indicating major trauma, and who were
brought directly to accident and emergency departments in the regions
by any means other than ambulance services from outside the regional
systems (whether or not they were recorded as dead on arrival).
Outcomes
The development of the trauma system was monitored by measuring
changes in the processes of care in the experimental region and control
regions. All patients were followed up to assess survival at six months
after the trauma. Deaths were assessed from the records of all
hospitals in the United Kingdom to which patients were admitted or
transferred, and from coroner's lists in the study regions.
Details recorded
We obtained information from ambulance service records, accident
and emergency records, inpatient notes and hospital administrative
databases, and coroner's records. A full description of all injuries
sustained and their codes on the abbreviated injury scale(8)
was made from accident and emergency records, inpatient notes, and
necropsy reports. The abbreviated injury scale indicates threat to life
and ranges from 1 to 6 (non-survivable injury). Injury mechanism was
classified as blunt or penetrating. The injury descriptions were coded
with the 1990 abbreviated injury scale dictionary.(8) Injury
severity scores(7) were calculated by summing the squares of
scores on the abbreviated injury scale of the most severe injuries in
up to three body regions. Injury severity scores range from 1 to 75
(non-survivable injuries).
All injuries from the regions were coded by four researchers, with advice from a fifth (JT) for difficult cases. The injury coders attended several one-day training sessions on coding injuries, organised with the help of the coordinator of the major trauma outcome study, that were designed to ensure, as far as possible, consistency in scoring between the researchers. Agreement between researchers was assessed during the study.
Statistical methods
We compared trends in death rates over the study period in the
experimental region and control regions after adjustment for case mix.
We made the adjustment by "indirect standardisation," calculating
expected numbers of deaths in each year in the three regions and
comparing these with observed numbers to calculate standardised
mortality ratios.
For the indirect standardisation, we used three different methods: using strata derived from age, injury severity scores, and revised trauma scores (which are based on the Glasgow coma score, respiratory rate, and systolic blood pressure); using the TRISS method(9); or using the death rates observed within the study for all data combined. Patients with injury severity scores of 75 (of whom 0/129 survived) or revised trauma scores of 0 (1/283 survived) could not contribute to examining differences in survival and were excluded from comparisons of standardised mortality ratios.
For the TRISS method, we calculated expected numbers of deaths using the British norms for blunt injuries from the major trauma outcome study(10) and American rates for the few cases of penetrating injury (British norms were not available). When using the TRISS method, we also had to exclude patients with missing age (n=5) or missing revised trauma scores (n=873/2229) from comparisons of standardised mortality ratios.
To calculate standardised mortality ratios based on internally derived standard death rates, we used strata defined by three categories of injury severity scores (16-24, 25-40, and 41-74), two age groups (0-64 and 65 and over), and five categories of revised trauma scores (0-5.79, 5.97-6.82, 6.90-7.55, 7.84, and missing). We estimated differences in trends between regions by fitting equivalent logistic regression models to the proportions of deaths, using injury severity scores, age group (0-44, 45-64, 65-74, or 75 and over), and revised trauma scores (including a missing data category) as covariates. The same models were also fitted without revised trauma scores, as has been recommended(11) in order to examine the robustness of the estimate obtained by including the "missing" category for revised trauma scores.
Results
Development of the trauma system
The main developments in the trauma system were at the trauma
centre. Briefly, these were the appointment of four new consultants to
provide 24 hour cover by consultants, 12 nursing staff for accident and
emergency, and 12 nursing staff for the intensive care unit; the start
of the West Midlands helicopter ambulance service during 1991; and one
further consultant and the development of the current "trauma team"
model in 1992. Training in advanced trauma life support,(12)
nursing teams for the reception of seriously injured patients, and
paramedic training also developed from mid-1991.
Numbers of patients with major trauma
During the four year study the trauma centre was the primary
receiving hospital for 416 patients with major trauma, and other
hospitals in the experimental region received 727 major trauma patients
(table 2). There were 1,002 major trauma patients during the study in
Lancashire and 501 in Humberside. In this period the total number of
major trauma patients seen in the experimental region declined by about
20%, from 319 in 1990 to 251 in 1993. This decline closely reflected
the 28% reduction in the number of deaths in road traffic accidents
and "serious" injuries recorded in police statistics (Stats19) for
the experimental region.
| Table 2 - No of patients with major trauma patients (injury severity score >15) recorded in North West Midland region, provided with experimental regional trauma system, and in two control regions | ||||
|---|---|---|---|---|
| Year | ||||
| 1990 | 1991 | 1992 | 1993 | |
| Experimental region | ||||
| Trauma centre (North Staffordshire Royal Infirmary) | 108 | 98 | 112 | 98 |
| District general hospitals | 211 | 172 | 191 | 153 |
| Total | 319 | 270 | 303 | 251 |
| Control regions | ||||
| Lancashire | 253 | 269 | 247 | 233 |
| Humberside | 117 | 120 | 157 | 107 |
| Total | 370 | 389 | 404 | 340 |
Processes of care
In the trauma centre's accident and emergency department the
proportion of major trauma patients attended first by a consultant rose
from 28% in 1990 to 70% in 1993 (table 4), whereas this never
exceeded 24% in other hospitals in the experimental region or in the
control regions. There was also a small increase in the proportion of
patients admitted to the intensive care unit, but no change in the
length of time from arrival in accident and emergency to an operation
for those who had an operation within 24 hours.
Deaths from major trauma
Using a multiple logistic regression model including age, injury
severity scores, and revised trauma scores, we estimated that the
annual change from 1990 in the probability of dying in the experimental
region compared with the control regions was -0.8% (95% confidence
interval -3.6% to 2.2%) for all major trauma patients, 1.6%
(-2.3% to 5.6%) for patients seen out of hours, and -1.6%
(-6.1% to 2.6%) for patients with multiple injuries. Using the
model including only age and injury severity scores, we estimated that
the relative annual change in the probability of dying in the
experimental region for all major trauma patients was -0.2%
(-2.9% to 2.7%).
In a unique prospective experimental study, carried out by
an independent research team, we investigated whether funding a good
accident and emergency department in order to provide facilities for a
regional trauma centre and encouraging the development of a trauma
system could improve survival from major trauma. The processes of care
did change in several ways, but there was no evidence of any
significant improvement in the chance of major trauma patients
surviving compared with control regions. Several questions are raised
by these findings: are they reliable, and if they are, why do they
differ from indicative results from the United States, and how
generalisable are they?
Reliability The control areas in this study were selected because they were similar
in size and characteristics to the experimental area at the start of
the period of evaluation and could therefore be expected to be subject
to the same influences. This means that, at the outset, each control
region also included a central hospital with a large, high quality
accident and emergency department. However, we have not compared the
outcomes of patients treated in these hospitals but trends in the
outcomes of all major trauma occurring in the regions they help serve.
These comparisons of regional trends were made more reliable by
ensuring that there were as few pre-existing differences as possible.
The question of whether the "before" and "after" phases clearly
represent periods before and after the development of a central trauma
system is less clear. At the start of the study period, in January
1990, some efforts had already been made at the North Staffordshire
Royal Infirmary to involve the surrounding hospitals in an integrated
approach to managing major trauma in the region. Equally, at the end of
the study in December 1993, developments were still taking place.
Nevertheless, substantial investment and change did not take place
until mid-1991, when staffing and resources in the accident and
emergency department and intensive care unit were increased, and these
developments were completed during 1992. Thus the study does clearly
span a period of rapid change in the resources available for the care
of patients with serious injuries.
With regard to the accuracy of our data, in 1993 the internal
audit at the North Staffordshire Royal Infirmary recorded 123 major
trauma patients being taken directly to the hospital, but we identified
only 98. This difference arose principally because of differences in
assigning scores on the abbreviated injury scale and differences in
inclusion criteria. For example, we included only those patients
brought in directly by the three ambulance services included in the
study, or indirectly from the satellite hospitals in the experimental
region. The methods we used for scoring patients' injuries produced
better agreement between the researchers who coded injuries than has
previously been reported in Britain(13) (agreement on injury
severity scores 41% versus 28%,(13) disagreement
on injury severity scores >15 17.5% versus
19-24%(13)) and were applied consistently by the same
researchers over the four years of the study in order to minimise bias
in the comparisons.
The power of our study to detect a relative decline of four deaths per
100 major trauma patients admitted with vital signs to the trauma
centre per year was only 50%, and this raises the question of how much
reliance can be put on the finding of no significant effect. The
results, however, are consistent with the facts that there has been no
relative decline in the case fatality rate among casualties from road
traffic accidents in the experimental region compared with the control
regions(14); there were only small changes in the processes
of care; and the small effect detected was not specific to or different
in those groups in which it would have been expected to be
greatest - patients seen out of hours, and multiply injured patients.
Generalisability However, it is generally accepted that such systems can reduce
mortality. We suggest that there are two broad groups of reasons why we
could find no evidence of effectiveness in our study. Firstly, the
trauma system in the North West Midlands region did not develop into a
comprehensive regionalised system. Thus, for example, by the end of our
study, the objective of "getting the right patient to the right
hospital at the right time"(22) had not been achieved.
Secondly, trauma epidemiology is so different in kind and volume in
Britain compared with the United States that there is no reason to
expect that American solutions should translate directly to Britain.
For example, penetrating injuries cause less than 5% of major trauma
in Britain(10) but typically cause over 20% of cases in the
United States,(16) and in the whole of the North West
Midlands region there were only six major trauma patients taken to
hospitals each week.
The benefits from developing regional trauma systems in shire areas of
England are probably modest, therefore, compared with reports from the
United States. However, we evaluated only one model of regional trauma
care, in only one setting, and that system was not fully developed.
Thus, greater benefits might be found with trauma systems in other
environments, such as metropolitan conurbations, or if greater
integration in the whole process of trauma care could be achieved.
Nevertheless, our results cast some doubt on the benefits of adopting a
national policy of regionalising trauma care along the lines of the
American model.
Contributing authors: Brian Williams, John Brazier (study
design); Sylvia Bickley, Patricia Myers, Neil Beeby, Marita Lunn (data
collection); Simon Dixon (health economics).
We are grateful to the staff at the North Staffordshire
Royal Infirmary, who cooperated so wholeheartedly: Professor J
Templeton, Mr D McGeehan, Dr P Morrison, Dr P Oakley, Mr I Phair, Mr M
Prescott, Professor A Redmond, Miss A Cook, Mr S Davies, and Mrs D
Griffiths. We are grateful for the help and cooperation of the accident
and emergency consultants at the other hospitals in the trauma system
and comparator regions: Mr S Al-Atrakchi, Mr J Bache, Mr T George, Mr N
Goel, Mr S Goode, Dr J Gosnold, Mr P Grout, Mr N Harrop, Mr M Hockey,
Mr M James, Mr A Kumar, Mr A Leaman, Mr A Lester, Mr M McColl, Dr R
McGlone, and Mr F O'Dwyer. We also thank the coroners offices in each
of the three regions for their help and support.
Funding: This work was undertaken by the Medical Care Research
Unit, which is supported by the Department of Health. The views
expressed here are those of the authors and not necessarily those of
the department.
(Accepted 21 October 1997)
Medical Care Research Unit,
Correspondence to: Professor Jon
Nicholl
References
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management of patients with major injuries. London, RCS, 1988.
2 American College of Surgeons Committee on Trauma.
Resources for optimal care of the injured patient.
Chicago: American College of Surgeons, 1990.
3 Cales R H. Trauma mortality in Orange County: The effect of
implementation of a regional trauma system. Ann Emergency
Med 1984;13:1-10.
4 Lowe D K, Gately H L, Goss R, Frey C L, Peterson C G. Patterns of
death, complication and error in the management of motor vehicle
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J Trauma 1983;23(6):503-7.
5 Shackford S R, Hollingsworth-Fridlund P, Cooper G F, Eastman AB.
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assessed by concurrent audit before and after the institution of a
trauma system: a preliminary report. J Trauma
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6 Guss D A, Meyer F T, Neuman T S, Baxt W G, Dunford J V, Griffith
L D, et al. The impact of a regionalised trauma system on trauma care in
San Diego County. Ann Emergency Med 1989;18:1141-5.
7 Baker S P, O'Neill B, Haddon W, Long W B. The injury severity
score: a method for describing patients with multiple injuries and
evaluating emergency care. J Trauma 1974;14:187-96.
8 Association for the Advancement of Automotive Medicine.
The abbreviated injury scale. 1990 revision. Des
Plaines: Association for the Advancement of Automotive Medicine, 1990.
9 Boyd C R, Tolson M A, Copes W S. Evaluating trauma care: the
TRISS method. J Trauma 1987;27:370-8.
10 Yates D W, Woodford M, Hollis S. Preliminary analysis of the
care of injured patients in 33 British hospitals: first report of the
United Kingdom major trauma outcome study. BMJ
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11 Bull J P, Dickson G R. Injury scoring by TRISS and ISS/age.
Injury 1991;21(2):127-31.
12 Myers R A. Advanced trauma life support course editorial.
J R Soc Med 1990;83:281-2.
13 Zoltie N, deDombal F T. The hit and miss of ISS and TRISS.
BMJ 1993;307:906-9.
14 Nicholl J P, Turner J, Dixon S. The cost-effectiveness of
the regional trauma system in the North West Midlands.
Sheffield: Medical Care Research Unit, University of Sheffield, 1995.
15 Rutledge R, Messick J, Baker C C, Rhyne S, Butts J, Meyer A, et
al. Multivariate population-based analysis of the association of county
trauma centers with per capita county trauma death rates. J
Trauma 1992;33(1):29-38.
16 Cales R H, Trunkey D D. Preventable trauma deaths: a review of
trauma care systems development. JAMA 1985;254:1058.
17 Cambell S, Wattans G, Kreis D. Preventable deaths in a
self-designated trauma system. Am Surg 1989;55:478-86.
18 Cayten E, Stahl W, Ararwal N, Murphy J. Analyses of preventable
deaths by mechanism of injury in 13,500 trauma admissions. Ann
Surg 1991;214(4):510-20.
19 Roy P D. The value of trauma centres: a methodological review.
Can J Surg 1987;30:17-22.
20 Kane G, Wheeler N C, Cook S, Englehardt R, Pavey B, Green K, et
al. Impact of the Los Angeles County trauma system on the survival of
seriously injured patients. J Trauma 1992;32:576-83.
21 Mullins R J, Veun-Stone J, Hedges J R, Zimmer-Gembeck M J, Mann
N C, Southard P A, et al. Influence of a statewide trauma system on
location of hospitalization and outcome of injured patients. J
Trauma 1996;40:536-45.
22 Redmond A, Johnstone S, Maryosh J, Templeton J. A trauma centre
in the UK. Ann R Coll Surg Engl 1993;75:317-20.
The proportion of major trauma patients in the experimental region
who were taken directly to the trauma centre increased from 34% in
1990 to 39% in 1993, from a widening catchment area (table 3).
H
*Abbreviated injury scale = 5.
Table 3 - Percentage of patients with major trauma
transported directly to the central hospital in North West Midland
region, provided with experimental regional trauma system, and in two
control regions, Lancashire and Humberside Types of patient Year
1990 1991 1992 1993
All major trauma patients Experimental
region 34 36 37 39
Control
regions 42 40 46 43
Patients with multiple injuries Experimental
region 26 34 40 41
Control
regions 44 42 50 45
Patients seen out of hours Experimental
region 34 36 38 42
Control
regions 45 40 49 49
Patients with severe head injuries* Experimental
region 41 38 31 46
Control
regions 37 44 43 35 Table 4 - Changes in processes of care for patients with
major trauma seen in the trauma centre in North West Midland region,
provided with experimental regional trauma system
Process Year
1990 1991 1992 1993
Percentage of
patients: First
attended by consultant in accident and
emergency 28 49 71 70
Ever attended by consultant in accident and
emergency 36 53 77 79
Admitted to intensive care
unit 43 56 55 54
Median (interquartile range) time to operation for patients sent to
theatre within 24 hours (hours) 2.9
(1.8-7.5)3.5
(1.7-6.7)2.7
(1.3-9.7)3.3
(2.3-8.9)
During the study, 493 (43%) of the 1143 major trauma patients in
the experimental region died, while 683 (45%) of the 1503 patients in
the control regions died. There was little evidence of any difference
between the experimental region and the control regions in changes in
mortality. Between 1990-1 and 1992-3 the crude death rate from major
trauma declined from 44.8% to 41.3% in the experimental region and by
a similar amount, from 46.5% to 44.4%, in the control regions. There
was also no difference when we excluded cases with unknown age or
injury severity scores, or with injury severity scores of 75 or revised
trauma scores of 0 (table 5).
Table 5 - Numbers (percentages) of deaths of patients
with major trauma in North West Midland region, provided with
experimental regional trauma system, and in two control regions before
the establishment of the Stoke regional trauma centre (1990-1) and
after establishment of the centre (1992-3)
Injury severity score Experimental
region Control regions
Before (1990-1) After
(1992-3) Before (1990-1) After (1992-3)
Patients aged <65 years
16-24 11/193
(5.7) 11/171 (6.4) 16/229
(7.0) 12/214 (5.6) 25-40 62/151
(41.1) 55/158
(34.8) 78/204
(38.2) 73/205 (35.6) 41-74 27/35
(77.1) 23/30
(76.7) 24/33
(72.7) 23/34 (67.6) Patients aged
65 years and over 16-24 8/45
(17.8) 18/51
(35.3) 17/58
(29.3) 30/81 (37.0) 25-40 57/66
(86.4) 49/68
(72.1) 74/87
(85.1) 57/73 (78.1) 41-74 12/12
(100) 10/12
(83.3) 8/9
(88.9) 9/10 (90.0) Total 177/502
(35.3 (95% CI 31.1 to 39.5)) 166/490 (33.9 (95%
CI 29.7 to 38.1)) 217/620 (35.0 (95%
CI 31.2 to 38.8)) 204/617 (33.1 (95% CI 29.4 to
36.8)) Excluded cases Unknown age or injury
severity
score 0 0 1/4
(25.0) 2/3 (66.7) Injury severity
score=75 27/27 (100) 14/14
(100) 44/44 (100) 42/42
(100) Revised trauma score=0 60/60
(100) 49/50 (98.0) 91/91
(100) 82/82 (100) All cases 264/589
(44.8 (95% CI 40.8 to 48.8)) 229/554 (41.3 (95%
CI 37.2 to 45.4)) 353/759 (46.5 (95%
CI 42.0 to 50.0)) 330/744 (44.4 (95% CI 40.8 to
48.0))
Standardised mortality ratios
Standardised mortality ratios - calculated by means of TRISS or
internally derived standards based on age, injury severity scores, and
the revised trauma scores - showed no evidence of relative improvement
in the experimental region during the four year study (fig 1). For
patients admitted to accident and emergency departments out of hours
(20 00 to 07 59) and for patients with multiple injuries, there was
also no evidence that standardised mortality ratios improved in the
experimental region relative to the controls (figs 2).
Discussion
A randomised study was not possible, of course, but it is
widely accepted that a controlled before and after study such as we
have undertaken is the next best approach.
Fig 1: Standardised mortality ratios for all patients
with major trauma in North West Midland region, provided with
experimental regional trauma system, and in two control regions: (a)
calculated by means of internally derived standards, and (b) calculated
by means of TRISS with results of the British major trauma outcome
study(10) as the standard. 
Fig 2: Standardised mortality ratios for patients
with major trauma (calculated by means of internally derived standards)
in North West Midland region, provided with experimental regional
trauma system, and in two control regions: (a) patients seen out of
hours, and (b) patients with multiple injuries.
These results are in sharp contrast to reports from the
United States, where it has been reported that major trauma patients
can receive better care in regions with trauma systems than in regions
without(15) and that avoidable deaths can be substantially
reduced after the introduction of trauma
centres.(3-6, 16-18) However, most of the earlier studies
examined avoidable death rates in uncontrolled case series or used
historical controls. When before and after comparisons were made there
were usually no controls to take account of changes in external
factors. With a few exceptions, no attempt has been made to blind
assessors of avoidable deaths to the hospital (or region, or period) in
which the patients were treated. These deficiencies in early studies
have been well documented.(19) More recent before and after
studies, which have attempted to overcome these problems, have shown
mixed results. Evaluation of the Los Angeles trauma system, based on
1424 major trauma patients (injury severity scores g15), did not find
a significant improvement in survival,(20) and a study
including 8221 patients with injury severity scores g15 in Oregon
found an improvement of only marginal significance.(21)
Key Messages
In an experimental regional trauma system in the North West
Midlands region the trauma centre was provided with 24 hour cover by
consultants in accident and emergency and additional resources for
intensive care We assessed the effect of the regional trauma system on the
survival of patients with major trauma There was little evidence of the development of an integrated
trauma system, and the proportion of patients taken directly to the
trauma centre increased only for those with multiple injuries There was no reliable or consistent evidence that these
developments improved patients' chance of survival from major trauma
in the region Possible benefits from regionalising trauma care in shire
areas of England are probably modest compared with claims from the
United States
Conflict of interest: None.
University of
Sheffield,
Regent Court,
30 Regent Street,
Sheffield, S1 4DA
Jon Nicholl, director MCRU
Janette Turner,
research fellow
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