title: The right treatment at the right time in the right place: a population-based, before-and-after study of outcomes associated with implementation of an all-inclusive trauma system in a large Canadian province.
abstract: OBJECTIVE
  To evaluate the implementation of an all-inclusive philosophy of trauma care in a large Canadian province.
  
  
  BACKGROUND
  Challenges to regionalized trauma care may occur where transport distances to level I trauma centers are substantial and few level I centers exist. In 2008, we modified our predominantly regionalized model to an all-inclusive one with the hopes of increasing the role of level III trauma centers.
  
  
  METHODS
  We conducted a population-based, before-and-after study of patient admission and transfer practices and outcomes associated with implementation of an all-inclusive provincial trauma system using multivariable Poisson and linear regression and Cox proportional hazard models.
  
  
  RESULTS
  In total, 21,772 major trauma patients were included. Implementation of the all-inclusive model of trauma care was associated with a decline in transfers directly to level I trauma centers [risk ratio (RR) = 0.91; 95% confidence interval (CI): 0.88-0.94; P < 0.001] and an increase in transfers from level III to level I centers (RR = 1.10; 95% CI: 1.00-1.21; P = 0.04). These changes in trauma care occurred in conjunction with a 12% reduction in the hazard of mortality (hazard ratio = 0.88; 95% CI: 0.84-0.98; P = 0.003) and a decrease in mean trauma patient hospital length of stay by 1 day (95% CI: 1.02-1.11; P = 0.02) after adjustment for differences in case mix.
  
  
  CONCLUSIONS
  In this study, introduction of an all-inclusive provincial trauma system was associated with an increased number of injured patients cared for in their local systems and improved trauma patient mortality and hospital length of stay.
authors.affiliation: *Alberta Center for Injury Control and Research, Edmonton †Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Canada ‡Department of Community Health Sciences (Division of Epidemiology), University of Calgary, Calgary, Canada §Department of Surgery, University of Alberta Hospital, Edmonton, Canada ¶Division of Critical Care, University of Alberta Hospital, Edmonton, Canada ‖Regional Trauma Services, University of Alberta Hospital, Edmonton, Canada **Stollery Children's Hospital, Edmonton, Canada ††Queen Elizabeth II Regional Hospital, Grand Prairie, Canada ‡‡Chinook Regional Hospital, Lethbridge, Canada §§Royal Alexandra Hospital, Edmonton, Canada ¶¶Medicine Hat Regional Hospital, Medicine Hat ‖‖Red Deer Regional Hospital, Red Deer, Canada; and ***Alberta Children's Hospital, Calgary, Canada †††Regional Trauma Services, Foothills Medical Centre, Calgary, Canada.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Mckee
authors.forename: Derek J
authors.initials: DJ
authors.lastname: Roberts
authors.forename: Mary H
authors.initials: MH
authors.lastname: van Wijngaarden-Stephens
authors.forename: Christine
authors.initials: C
authors.lastname: Vis
authors.forename: He
authors.initials: H
authors.lastname: Gao
authors.forename: Kathy L
authors.initials: KL
authors.lastname: Belton
authors.forename: Don
authors.initials: D
authors.lastname: Voaklander
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
authors.forename: Ioana
authors.initials: I
authors.lastname: Bratu
authors.forename: Geoffrey C
authors.initials: GC
authors.lastname: Ibbotson
authors.forename: Kevin
authors.initials: K
authors.lastname: Martin
authors.forename: Paul
authors.initials: P
authors.lastname: Engels
authors.forename: Damian
authors.initials: D
authors.lastname: Paton-Gay
authors.forename: Paul
authors.initials: P
authors.lastname: Parks
authors.forename: Lyle
authors.initials: L
authors.lastname: Thomas
authors.forename: Jonathan
authors.initials: J
authors.lastname: Guilfoyle
authors.forename: John B
authors.initials: JB
authors.lastname: Kortbeek
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Kirkpatrick
mesh_terms: D000416:Alberta; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D017063:Outcome Assessment, Health Care; D010343:Patient Admission / Q000706:statistics & numerical data*; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012042:Registries; D014193:Trauma Centers / Q000458:organization & administration*; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000628:therapy*