Objective: Formalized systems of trauma care are believed to improve outcom
es in an urban setting, but little is known of the applicability in a rural
setting.
Methods: We conducted a population-based analysis of hospital survival afte
r trauma comparing an American College of Surgeons-verified Level I trauma
center (TC) with the pooled results of 13 small community hospitals (CH) in
a rural state with no formal trauma system. All patients admitted to any h
ospital within the state of Vermont over a 5-year period (1995-1999) with a
trauma discharge diagnosis were included. Elderly patients with isolated f
emur fractures were excluded from the database. International Classificatio
n of Diseases Injury Severity Scores (ICISSs) were calculated for each pati
ent and used to control for injury severity in an omnibus logistic regressi
on model that included age, ICISS, and hospital type (TC vs. CH) as predict
ors of survival. Patients who died were characterized on the basis of ICISS
into "expected" (ICISS < 0.25), "indeterminate" (ICISS = 0.26-0.50), and "
unexpected" (ICISS > 0.5),
Results: In 16,354 trauma admissions over the 5-year period in the rural st
ate of Vermont, 370 (2.2%) died. There were 5,964 (36%) admitted to TC, Pat
ients admitted to TC were more injured (ICISS 0.94 vs. 0.96) and had a high
er mortality (3.1% vs. 1.8), Overall, care at the CH provided an improved s
urvival (odds ratio = 1.75, 95% confidence internal = 1.31-2.18, p = 0.000)
, However, in the more severely injured cohort of trauma patients (expected
and indeterminate; n = 133), overall survival was higher in the TC (16% CH
vs. 38% TC,p = 0.02, chi (2)). Because the TC was known to provide care eq
uivalent to Major Trauma Outcome Study norms during this time period (Z = -
0.03, M = 0.894), we believe this study confirms that trauma care throughou
t the state is in accordance with national norms.
Conclusion: In a rural state, without a statewide formal trauma system, sur
vival after trauma is no worse at CH than TC when corrected for injury seve
rity and age. Future expenditures of resources might better be concentrated
in other areas such as discovery or prehospital care to further improve ou
tcomes.