title: Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system.
abstract: 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.
  
  
  METHODS
  A retrospective cohort study assessing injury mortality through 30 days after hospital discharge.
  
  
  METHODS
  Nine rural Oregon hospitals serving counties with populations <18 persons per square mile.
  
  
  METHODS
  Severely injured patients presenting to four level-3 and five level-4 trauma hospitals 3 years before and 3 years after trauma system implementation.
  
  
  METHODS
  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.
authors.affiliation: Department of Emergency Medicine, Univeristy of Utah, School of Medicine, Salt Lake City 84108-9161, USA. clay.mann@hsc.utah.edu
authors.forename: N
authors.initials: N
authors.lastname: Clay Mann
authors.forename: R J
authors.initials: RJ
authors.lastname: Mullins
authors.forename: J R
authors.initials: JR
authors.lastname: Hedges
authors.forename: D
authors.initials: D
authors.lastname: Rowland
authors.forename: M
authors.initials: M
authors.lastname: Arthur
authors.forename: A D
authors.initials: AD
authors.lastname: Zechnich
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D016555:Matched-Pair Analysis; D015999:Multivariate Analysis; D009922:Oregon / Q000453:epidemiology; D010360:Patient Transfer / Q000458:organization & administration*; D015397:Program Evaluation; D012041:Regional Medical Programs; D012189:Retrospective Studies; D020379:Risk Adjustment; D019035:Rural Health Services / Q000458:organization & administration*; D015996:Survival Rate; D014193:Trauma Centers / Q000458:organization & administration*; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000401:mortality*