Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system

BACKGROUND. Injury mortality in rural regions remains high with little evidence that trauma system implementation has benefited rural populations. OBJECTIVE. TO evaluate risk-adjusted mortality in remote regions of Oregon before and after implementation of a statewide trauma system. RESEARCH DESIGN. A retrospective cohort study assessing injury mortality through 30 days after hospital discharge. SETTING. Nine rural Oregon hospitals serving counties with populations < 18 persons per square mile. SUBJECTS. Severely injured patients presenting to four level-3 and five level-4 trauma hospitals 3 years before and 3 years after trauma system implementation. MEASURES. Interhospital transfer, hospital death, and demise within 30 days following hospital discharge. RESULTS. A total of 940 patients were analyzed. After trauma system implementation, patients presenting to level-4 hospitals were more likely transferred to level-2 facilities (P <0.001). Interhospital transfer times from level-3 hospitals lengthened significantly after system implementation (P <0.001). Overall mortality rates were higher in the postsystem period (8.3%) than the presystem period (6.7%), but not significantly. Controlling for covariates, no additional benefit to risk-adjusted mortality was associated with trauma system implementation. Additional deaths, occurring after trauma system implementation, included head-injured patients transferred from rural hospitals to nonlevel-1 trauma center hospitals. CONCLUSIONS. Increased injury survival after Oregon trauma system implementation, demonstrated in urban and statewide analyses, was not confirmed in remote regions of the state. Efforts to improve trauma systems in rural areas should focus on the processes of care for head-injured patients transferred to higher designation trauma centers.