A trauma network with centralized and local health care structures: Evaluating the effectiveness of the first certified Trauma Network of the German Society of Trauma Surgery

BACKGROUND: Trauma is a global burden of disease and one of the main causes of death worldwide. Therefore, many countries around the world have implemented a wide range of different initiatives to minimize mortality rates after trauma. One of these initiatives is the bundling of treatment expertise in trauma centers and the establishment of trauma networks. Germany has a decentralized system of trauma care medical centers. Severely injured patients ought to receive adequate treatment in both level I and level II centers. This study investigated the effectiveness of a decentralized network and the question whether level I and level II centers have comparable patient outcome. MATERIALS AND METHODS: In 2009, the first trauma network DGU(®) in Germany was certified in the rural area of Eastern Bavaria. All patients admitted to the 25 participating hospitals were prospectively included in this network in the framework of a study sponsored by the German Federal Ministry of Education and Research between March 2012 and February 2014. 2 hospitals were level I centers (maximal care centers), 8 hospitals were level II centers, and 15 hospitals were level III centers. The criterion for study inclusion was an injury severity score (ISS) ≥ 16 for patients´ primarily admitted to a level I or a level II center. Exclusion criteria were transferal to another hospital within 48 h, an unknown revised injury severity classification II score (RISC II), or primary admittance to a level III center (n = 52). 875 patients were included in the study. Univariate analyses were used regarding the preclinical and clinical parameters, the primary endpoint mortality rate, and the secondary endpoints length of stay, organ failure, and neurological outcome (GOS). The primary endpoint was additionally evaluated by means of multivariable analysis. RESULTS: Indices for injury severity (GCS, AIS(Head), ISS, and NISS) as well as the predicted probability of death (RISC II) were higher in level I centers than in level II centers. No significant differences were found between the mortality rate of the unadjusted analysis [level I: 21.6% (CI: 16.5, 27.9), level II: 18.1% (CI: 14.4, 22.5), p = 0.28] and that of the adjusted analysis [level I SMR: 0.94 (CI: 0.72, 1.21), level II SMR: 1.18 (CI 0.95, 1.48) SMR: expected vs. calculated mortality rate according to RISC II]. Multivariable analysis showed a survival advantage of patients admitted to a level I center with a probability of death of 13% (RISC II). The number need to treat was 10 patients. DISCUSSION: This study showed that a rural trauma network with centralized and local structures may achieve equivalent results with regard to mortality rates to those obtained in level I and level II centers. These results were furthered by a certain preclinical centralization (24/7 air rescue) of patients. The study also showed a survival advantage of patients admitted to a level I center with a probability of death of 13%. Preclinical and initial clinical evaluation with regard to probable mortality rates should be further improved to identify patients who would benefit from admittance to a level I center.