Inclusive trauma systems: Do they improve triage or outcomes of the severely injured?

Background. Trauma systems decrease injury-related mortality, but not all systems have the same configuration. In some systems, nearly all acute care hospitals participate to the extent that their resources allow (inclusive systems), whereas in others, relatively few high-level centers participate (exclusive systems). We postulate that inclusive systems assure that severely injured patients are more likely to be triaged to a level I or II regional trauma center, and this greater degree of participation would lead to lower mortality. Methods: We used administrative discharge data for 2001 in 24 states with formal systems, and we included all urgently hospitalized adults with an Injury Severity Score >= 16. We categorized states by trauma system configuration ("exclusive", "more inclusive", "most inclusive") based on the proportion of all hospitals designated as a Level I through V trauma center (0-13%, 14-37%, 38-100%, respectively). We compared the rates of triage to a regional trauma center and inpatient death in inclusive states relative to exclusive states, while adjusting for patient- and state-level factors. Results: Out of 61,496 patients, 40,706 (66.2%) were hospitalized at regional trauma centers. Inpatient mortality was 14.7%. After adjusting for patient age, primary payer status, and system maturity, the odds of triage to a regional trauma center were similar in inclusive and exclusive systems. After adjusting for primary payer status, mechanism of injury, and system maturity, the odds of death were similar in more inclusive and exclusive systems (odds ratio, 0.93; 95% confidence interval, 0.80-1.08) but were significantly lower in the most inclusive systems (odds ratio, 0.77; 95% confidence interval, 0.60-0.99). Conclusions: Severely injured trauma patients have greater inpatient survival in inclusive trauma systems even though they are no more likely to be hospitalized at a regional trauma center. Consideration should be given to continuing implementation of systems with an inclusive configuration, especially in light of other theoretical benefits of these systems, such as better dispersing of trauma care resources in the event of natural disasters or terrorist events.