Extending Trauma Quality Improvement beyond Trauma Centers: Hospital Variation in Outcomes among Nontrauma Hospitals

Peter C. Jenkins, Lava Timsina, Patrick Murphy, Christopher Tignanelli, Daniel N. Holena, Mark R. Hemmila, Craig Newgard

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Objective:The American College of Surgeons (ACS) conducts a robust quality improvement program for ACS-verified trauma centers, yet many injured patients receive care at non-accredited facilities. This study tested for variation in outcomes across non-trauma hospitals and characterized hospitals associated with increased mortality.Summary Background Data:The study included state trauma registry data of 37,670 patients treated between January 1, 2013, and December 31, 2015. Clinical data were supplemented with data from the American Hospital Association and US Department of Agriculture, allowing comparisons among 100 nontrauma hospitals.Methods:Using Bayesian techniques, risk-adjusted and reliability-adjusted rates of mortality and interfacility transfer, as well as Emergency Departments length-of-stay (ED-LOS) among patients transferred from EDs were calculated for each hospital. Subgroup analyses were performed for patients ages >55 years and those with decreased Glasgow coma scores (GCS). Multiple imputation was used to address missing data.Results:Mortality varied 3-fold (0.9%-3.1%); interfacility transfer rates varied 46-fold (2.1%-95.6%); and mean ED-LOS varied 3-fold (81-231 minutes). Hospitals that were high and low statistical outliers were identified for each outcome, and subgroup analyses demonstrated comparable hospital variation. Metropolitan hospitals were associated increased mortality [odds ratio (OR) 1.7, P = 0.004], decreased likelihood of interfacility transfer (OR 0.7, P ≤ 0.001), and increased ED-LOS (coef. 0.1, P ≤ 0.001) when compared with nonmetropolitan hospitals and risk-adjusted.Conclusions:Wide variation in trauma outcomes exists across nontrauma hospitals. Efforts to improve trauma quality should include engagement of nontrauma hospitals to reduce variation in outcomes of injured patients treated at those facilities.

Original languageEnglish (US)
Pages (from-to)406-413
Number of pages8
JournalAnnals of surgery
Issue number2
StatePublished - Feb 1 2022

Bibliographical note

Funding Information:
Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002529 and the Indiana State Department of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Indiana State Department of Health.

Publisher Copyright:
© 2022 Lippincott Williams and Wilkins. All rights reserved.


  • hospital variation
  • mortality
  • outcomes
  • quality
  • system
  • trauma

PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't


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