title: Directness of transport of major trauma patients to a level I trauma center: a propensity-adjusted survival analysis of the impact on short-term mortality.
abstract: BACKGROUND
  Whether severely injured patients should be transported directly to tertiary trauma centers, bypassing closer nontertiary facilities, or be transported first to nearby, less-specialized facilities for immediate care and stabilization has been studied with mixed findings. Differences in study locale, case mix, and variation in the structure and level of maturation of the trauma system may explain some of the discrepancy in findings. In addition, risk adjustment strategies used in these studies did not take into account prehospital baseline characteristics as well as time since injury.
  
  
  METHODS
  This was a retrospective cohort study of 1,998 patients treated at a Level I trauma center between January 1, 2006, and December 31, 2007. Propensity-adjusted survival analyses were used to compare short-term mortality outcomes in transferred versus directly transported major trauma patients.
  
  
  RESULTS
  A total of 1,398 patients were transported directly to the Level I trauma center and 600 patients were transferred from lower level facilities. After adjusting for the propensity to be transported directly, age, injury severity score, severe head injury, emergency medical service or emergency department intubation, comorbid conditions, and time to definitive Level I trauma care, the 2-week mortality risk in transferred patients was almost three-fold that of patients transported directly to a Level I trauma center (hazard ratio, 2.7; 95% confidence interval, 1.31-5.6).
  
  
  CONCLUSIONS
  Transferred patients in a predominantly rural region are at an increased risk of short-term mortality. This suggests that severely injured patients should be transported directly to tertiary trauma centers. For patients requiring immediate stabilization at nontertiary facilities, this should be performed promptly without unnecessary delays.
authors.affiliation: Oklahoma State Department of Health, Trauma Division, Oklahoma City, Oklahoma 73117, USA. tabithag@health.ok.gov
authors.forename: Tabitha
authors.initials: T
authors.lastname: Garwe
authors.forename: Linda D
authors.initials: LD
authors.lastname: Cowan
authors.forename: Barbara R
authors.initials: BR
authors.lastname: Neas
authors.forename: John C
authors.initials: JC
authors.lastname: Sacra
authors.forename: Roxie M
authors.initials: RM
authors.lastname: Albrecht
mesh_terms: D000293:Adolescent; D000328:Adult; D006259:Craniocerebral Trauma / Q000453:epidemiology / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009825:Oklahoma / Q000453:epidemiology; D010360:Patient Transfer / Q000458:organization & administration*; D057216:Propensity Score; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014187:Transportation of Patients / Q000458:organization & administration*; D014193:Trauma Centers / Q000706:statistics & numerical data*; D055815:Young Adult