Regionalization of Trauma Care by Operative Experience: Does the Volume of Emergent Laparotomy Matter?

INTRODUCTION: The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients.

METHODS: We performed a (2017) analysis of the Trauma Quality Improvement Program (TQIP) database. We included adult (age ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: HV (high volume) ≥25 cases/year; MV (medium volume) 13-24 cases/year; LV (low volume) ≤12 cases/year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality.

RESULTS: A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean age was 40±17y, abdomen AIS was 3[2-4], and ISS was 26[17-35]. For ACS Level I centers: 50% were HV, 29% MV, and 21% LV. For ACS Level II centers: 7% were HV, 23% MV, and 70% LV. For ACS Level III centers: 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. HV blunt centers had a significantly lower time to laparotomy (72[41-144] minutes) vs. MV (81[49-145]) and LV (94[56-158]) centers (p<0.001). The same trend was observed for HV penetrating trauma centers (35[24-52] minutes) vs. MV (46[33-63]) and LV (51[38-69]) centers (p<0.001).

CONCLUSION: Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience.

LEVEL OF EVIDENCE: Level III PrognosticPrognostic.