title: Impact of trauma centre designation level on outcomes following hemorrhagic shock: a multicentre cohort study.
abstract: BACKGROUND
  Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these occur within 2 h of injury. There is currently a lack of evidence regarding the trajectories of patients in hemorrhagic shock and the potential benefit of level I/II care for these patients. We aimed to compare mortality across trauma centre designation levels for patients in hemorrhagic shock. Secondary objectives were to compare surgical delays, complications and hospital length of stay (LOS).
  
  
  METHODS
  We performed a retrospective cohort study based on a Canadian inclusive trauma system (1999-2012), including adults with systolic blood pressure (SBP) < 90 mm Hg on arrival who required urgent surgical care (< 6 h). Logistic regression was used to examine the influence of trauma centre designation level on risk-adjusted surgical delays, mortality and complications. Linear regression was used to examine LOS.
  
  
  RESULTS
  Compared with level I centres, adjusted odds ratios (and 95% confidence intervals [CI]) of mortality for level III and IV centres were 1.71 (1.03-2.85) and 2.25 (1.08-4.73), respectively. Surgical delays did not vary across designation levels, but mean LOS and complications were lower in level II-IV centres than level I centres.
  
  
  CONCLUSIONS
  Level I/II centres may offer a survival advantage over level III/IV centres for patients requiring emergency intervention for hemorrhagic shock. Further research with larger sample sizes is required to confirm these results and to identify optimal transport time thresholds for bypassing level III/IV centres in favour of level I/II centres.
authors.affiliation: From the Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, CHU de Québec, Université Laval Research Centre, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Social and Preventive Medicine, Université Laval, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Sugery, McGill University, Montreal, Que., (Razek); and the Department of Surgery, Université Laval, Québec, Que. (Clément).
authors.forename: Philippe
authors.initials: P
authors.lastname: Dufresne
authors.affiliation: From the Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, CHU de Québec, Université Laval Research Centre, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Social and Preventive Medicine, Université Laval, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Sugery, McGill University, Montreal, Que., (Razek); and the Department of Surgery, Université Laval, Québec, Que. (Clément).
authors.forename: Lynne
authors.initials: L
authors.lastname: Moore
authors.affiliation: From the Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, CHU de Québec, Université Laval Research Centre, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Social and Preventive Medicine, Université Laval, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Sugery, McGill University, Montreal, Que., (Razek); and the Department of Surgery, Université Laval, Québec, Que. (Clément).
authors.forename: Pier-Alexandre
authors.initials: PA
authors.lastname: Tardif
authors.affiliation: From the Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, CHU de Québec, Université Laval Research Centre, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Social and Preventive Medicine, Université Laval, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Sugery, McGill University, Montreal, Que., (Razek); and the Department of Surgery, Université Laval, Québec, Que. (Clément).
authors.forename: Tarek
authors.initials: T
authors.lastname: Razek
authors.affiliation: From the Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, CHU de Québec, Université Laval Research Centre, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Social and Preventive Medicine, Université Laval, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Sugery, McGill University, Montreal, Que., (Razek); and the Department of Surgery, Université Laval, Québec, Que. (Clément).
authors.forename: Madiba
authors.initials: M
authors.lastname: Omar
authors.affiliation: From the Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, CHU de Québec, Université Laval Research Centre, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Social and Preventive Medicine, Université Laval, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Sugery, McGill University, Montreal, Que., (Razek); and the Department of Surgery, Université Laval, Québec, Que. (Clément).
authors.forename: Amélie
authors.initials: A
authors.lastname: Boutin
authors.affiliation: From the Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, CHU de Québec, Université Laval Research Centre, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Social and Preventive Medicine, Université Laval, Québec, Que., (Dufresne, Moore, Tardif, Omar, Boutin); the Department of Sugery, McGill University, Montreal, Que., (Razek); and the Department of Surgery, Université Laval, Québec, Que. (Clément).
authors.forename: Julien
authors.initials: J
authors.lastname: Clément
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D011792:Quebec / Q000453:epidemiology; D012042:Registries / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012771:Shock, Hemorrhagic / Q000150:complications / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D013997:Time Factors; D014193:Trauma Centers / Q000706:statistics & numerical data*; D055815:Young Adult