A Re-Evaluation of the Effect of Trauma Center Verification Level on the Early Risk of Death in Hemodynamically Unstable Patients

Background Studies show increased early and overall mortality at level II compared to level I trauma centers in hemodynamically unstable patients. We hypothesize there is no mortality difference between level I and level II centers applying more contemporary data. Study design Utilizing the 2017 Trauma Quality Program Participant Use File (TQP-PUF), we identified adult patients (age >14 years) who presented to an American College of Surgeons (ACS) verified level I or II center with hypotension (systolic blood pressure [SBP] < 90 mmHg). Logistic regression was performed to identify adjusted associations with mortality. Results A total of 7,264 patients met the inclusion criteria, of whom most were males (4,924 [67.8%]) with blunt trauma (5,924 [81.696]) being predominated. Mean admission SBP was 73.2 (+/- 13.0) mmHg. There were 1,097 (15.1%) deaths. Level I admissions (4,93[(67.9%]) were more likely male (3,389 [68.7%] vs. 1,535 [65.8]; p=0.012), non-white (3,119 [63.3%] vs. 1,664 [71.3%]; p<0.001), a victim of penetrating trauma (933 [18.9%] vs. 385 [16.5%]; p=0.015), and more severely injured (mean Injury Severity Score: 19.3[+/- 15] vs. 16.7 [+/- 13.7]; p<0.001). Level II admissions (2,333 [32.1%]) were older (46.8[+/- 18.5]vs. 50.3[+/- 20.1] years; p<0.001) with more co-morbidities (mean Charlson Comorbidity Index: 1.43 [+/- 2] vs. 1.77 [+/- 2.2]; p<0.001). Adjusted mortality between level I and II admissions was similar (766 [15.5%] vs. 331 [14.2%]; p=0.918). Early hourly mortality also did not differ. Conclusion There is no overall or hourly mortality discrepancy between ACS-verified level I and II centers for patients presenting with hypotension. This potentially relates to the use of more contemporary data gathered after implementation of updated verification requirements.