Trauma Center Outcomes After Transition From Level 2 to Level 1: A National Trauma Data Bank Analysis

J Surg Res. 2021 Aug:264:499-509. doi: 10.1016/j.jss.2021.03.021. Epub 2021 Apr 13.


Background: Previous US-based studies have shown that a trauma center designation of level 1 is associated with improved patient outcomes. However, most studies are cross-sectional, focus on volume-related issues and are direct comparisons between levels. This study investigates the change in patient characteristics when individual trauma centers transition from level 2 to level 1 and whether the patients have similar outcomes during the initial period of the transition.

Study design: We performed a retrospective cohort study that analyzed hospital and patient records included in the National Trauma Data Bank from 2007 to 2016. Patient characteristics were compared before and after their hospitals transitioned their trauma level. Mortality; complications including acute kidney injury, acute respiratory distress syndrome, cardiac arrest with CPR, deep surgical site infection, deep vein thrombosis, extremity compartment syndrome, surgical site infection, osteomyelitis, pulmonary embolism, and so on; ICU admission; ventilation use; unplanned returns to the OR; unplanned ICU transfers; unplanned intubations; and lengths of stay were obtained following propensity score matching, comparing posttransition years with the last pretransition year.

Results: Sixteen trauma centers transitioned from level 2 to level 1 between 2007 and 2016. One was excluded due to missing data. After transition, patient characteristics showed differences in the distribution of race, comorbidities, insurance status, injury severity scores, injury mechanisms, and injury type. After propensity score matching, patients treated in a trauma center after transition from level 2 to 1 required significantly fewer ICU admissions and had lower complication rates. However, significantly more unplanned intubations, unplanned returns to the OR, unplanned ICU transfers, ventilation use, surgical site infections, pneumonia, and urinary tract infections and higher mortality were reported after the transition.

Conclusions: Trauma centers that transitioned from level 2 to level 1 had lower overall complications, with fewer patients requiring ICU admission. However, higher mortality and more surgical site infections, pneumonia, urinary tract infections, unplanned intubations, and unplanned ICU transfers were reported after the transition. These findings may have significant implications in the planning of trauma systems for administrators and healthcare leaders.

MeSH terms

  • Accreditation / standards
  • Adult
  • Aged
  • Databases, Factual / statistics & numerical data
  • Female
  • Hospital Mortality
  • Hospitals, High-Volume / standards
  • Hospitals, High-Volume / statistics & numerical data*
  • Humans
  • Injury Severity Score
  • Intensive Care Units / statistics & numerical data
  • Male
  • Middle Aged
  • Operating Rooms / statistics & numerical data
  • Postoperative Complications / epidemiology*
  • Postoperative Complications / etiology
  • Retrospective Studies
  • Surgical Procedures, Operative / adverse effects*
  • Surgical Procedures, Operative / statistics & numerical data
  • Trauma Centers / organization & administration
  • Trauma Centers / standards
  • Trauma Centers / statistics & numerical data*
  • United States / epidemiology
  • Wounds and Injuries / complications
  • Wounds and Injuries / diagnosis
  • Wounds and Injuries / mortality
  • Wounds and Injuries / surgery*