Association Between Trauma Center Level and Outcomes of Adult Patients with Motorcycle Crash–Related Injuries in the United States

Abstract

Background

Motorcycle crash–related injury mechanism is a criterion in the Centers for Disease Control and Prevention field triage guidelines of injured patients, with a recommendation to transport affected patients to a trauma center need not be the highest level.

Objective

This study examines the evidence behind this recommendation because severe injuries can result from motorcycle crashes and patients can benefit from treatment at higher-level trauma centers.

Methods

This retrospective cohort study used the National Trauma Data Bank 2015 dataset. We conducted descriptive analyses (univariate and bivariate) followed by adjusted multivariate analysis to examine the association between trauma center designation levels and survival to hospital discharge.

Results

A total of 28,821 patients with motorcycle injuries were included. Most patients were men (n = 25,361; 88%) and aged between 16 and 64 years (n = 26,989; 93.6%). Survival rates were higher in level II (n = 10,658; 95.3%) and III (n = 2,129; 95.5%) trauma centers compared to level I centers (n = 14,498; 94.6%). After adjusting for confounders, decreased survival to hospital discharge was noted for patients treated at level III trauma centers compared to those at level I centers (odds ratio 0.543; 95% confidence interval 0.390–0.729). No difference in survival was noted between level I and II centers.

Conclusions

Patients with motorcycle crash–related injuries treated at higher-level trauma center (I or II) had increased survival. This warrants a re-evaluation and adjustment of the field triage criterion for such patients. Examining the evidence behind field triage guidelines in trauma systems is needed for improved patient outcomes.

Introduction

Motorcycle crash–related injury constitutes a significant cause of mortality and morbidity, along with a substantial financial burden worldwide. In the United States, motorcycle crash incidence is 68% higher than that for other automobiles, with a 28 times higher fatality rate, and accounting for up to 14% of all automobile crash fatalities (1). When compared with car crashes, patients involved in motorcycle crashes have higher injury prevalence (3×), injury severity (10×), mortality (5×), and medical costs (6×) (2).

The American College of Surgeons (ACS) designates trauma centers into four levels (level I or highest to level IV or lowest). The trauma center level is assigned based on trauma volume, resources, and educational and research commitment (3). Similarly, state designation of trauma center level is also used in the United States for trauma centers. Trauma center designation and higher trauma center levels have been previously associated with improved outcomes (4). The overall mortality rate was previously reported to be 25% lower for patients with traumatic injuries when treated at a trauma center compared to a non–trauma center (5). This difference in outcomes was more pronounced for patients with severe injuries based on stratification using the Abbreviated Injury Scale (5). Moreover, the treatment of trauma patients at level I trauma centers was also significantly associated with both lower mortality and lower severe disability at discharge compared to those treated at level II trauma centers (3).

Prehospital field triage criteria are used to guide prehospital providers to identify patients with severe traumatic injuries and to transport them to appropriate receiving facilities, mainly trauma centers (4). However, criteria for trauma patients’ referral to trauma center levels are still vague and lack sufficient validity (3).

Several prehospital parameters, such as training level and total number of emergency medicine technician (EMT) personnel, response, scene, and transport times, have been found to be significantly associated with mortality rates in trauma patients (6). The Centers for Disease Control and Prevention (CDC) guidelines for field triage of injured patients use the mechanism of injury of “motorcycles > 20 mph” as criterion in step 3 for recommending transport to a trauma center need not be the highest trauma level (7). Patients with motorcycle crash–related injuries are, however, more likely to be severely injured and might benefit from treatment at higher-level trauma centers. This study examines the association between trauma center level and outcomes of patients with motorcycle crash-related injuries in an attempt to provide a more evidence-based recommendation for prehospital field triage in this patient population.