title: The evolution of trauma care at a level I trauma center.
abstract: BACKGROUND
  My colleagues and I compared trauma patient demographics and outcomes between two time periods in the last 10 years in our Level I trauma center to evaluate the impact of the marked evolution in trauma care and determine additional opportunities for improvement.
  
  
  METHODS
  Our trauma registry was queried for adult trauma patients admitted from 1991 to 1993 (EARLY) and 1999 to 2001 (LATE). The EARLY period predated creation and maturation of a dedicated trauma service and Level I trauma center verification. Continuous data were compared using Student's t-test, and categorical data using chi-square.
  
  
  RESULTS
  Increased transfers of severely injured patients from regional hospitals, combined with fewer admissions for "observation," resulted in fewer, but sicker, patients admitted in the LATE period. Patients were considerably older in the LATE period and mortality was higher. Despite higher acuity of patients, hospital and ICU lengths of stay were shorter in the LATE period. Nonoperative management of solid organ injuries was more common in the LATE period, but the overall operative volume was similar. Nonsurvivors in the LATE period had higher Injury Severity Scores and were older compared with the EARLY period. Mortality attributable to blunt CNS injury was higher, and that attributed to late sepsis and multiple organ failure was lower in the LATE period.
  
  
  CONCLUSIONS
  Over the past decade, more older, severely injured patients have been admitted to our Level I trauma center. Overall mortality among these higher acuity patients has increased, with a marked shift in attributable mortality to CNS injury and away from late sepsis and multiple organ failure. This highlights the need for continued efforts to identify optimal management strategies for severe brain injury. Additional areas for improvement include enhancement of our regional trauma network and injury prevention initiatives.
authors.affiliation: Division of Trauma and Surgical Critical Care, Rhode Island Hospital and Brown Medical School, Providence, RI 02903, USA.
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: David T
authors.initials: DT
authors.lastname: Harrington
authors.forename: Sarah D
authors.initials: SD
authors.lastname: Majercik
authors.forename: Jayne
authors.initials: J
authors.lastname: Starring
authors.forename: William G
authors.initials: WG
authors.lastname: Cioffi
mesh_terms: D000328:Adult; D000367:Age Factors; D001930:Brain Injuries / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D009102:Multiple Organ Failure / Q000453:epidemiology; D010360:Patient Transfer / Q000706:statistics & numerical data; D012042:Registries; D012237:Rhode Island; D012720:Severity of Illness Index; D014193:Trauma Centers / Q000458:organization & administration / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000401:mortality; D014949:Wounds, Nonpenetrating / Q000453:epidemiology; D014950:Wounds, Penetrating / Q000453:epidemiology