Injury trends and mortality in adult patients with major trauma in New South Wales

To the Editor: It is pleasing to see Curtis and colleagues report injury trends and mortality across New South Wales,1 but the data are old and precede major changes to the NSW trauma system. We are concerned that the conclusions of this study will be misapplied by policymakers, leading to unnecessary out-of-area transport of injured patients.

The authors concluded that there is a survival benefit when definitive care occurs at a “level 1” major trauma centre (MTC) rather than at a regional trauma centre (RTC).1 Unfortunately, the definitions they used for trauma centre designation are not those used by NSW Health for service planning.2 According to the NSW Health definition, there were nine MTCs and two RTCs during the study period, in contrast to eight level 1 and three level 3 hospitals defined in the study. Adding to the ambiguity, NSW Health designated two hospitals as RTCs in 20013 and three in 2004,4 with no documented dates for any of these changes. Further, the authors did not mention that Wollongong Hospital did not enter data into the NSW Trauma Registry until 2004.5 These points contradict the statement that “there were no changes in trauma centre designation or data collection resources during the study period”1 and place significant limitations on interpreting the results.

The conclusion that mortality is decreasing is not supported by the data. If 2003 is excluded, the mortality has been static in the years 2004–2007, and was the same as Victoria with two MTCs,6 and similar to outcomes in the United States.7 This negates any argument to force patients to be transported considerable distances to access trauma care, especially given that the Ambulance Service of NSW “Protocol T1” for prehospital management of major trauma performs poorly, with sensitivity for serious injury of 63% and an overtriage rate of 77%.8 The incidence of severe neurotrauma has a major impact on overall outcomes, and no casemix data were provided to confirm comparability between centres.

Finally, data did not include patients with an injury severity score < 15 — the bulk of trauma patients. However, it is essential to examine treatment and outcomes for all trauma patients — owing to the lack of specificity of the ambulance bypass tool as well as the impact of trauma bypass on the ambulance service’s ability to respond to non-trauma patients needing time-critical care. Much better, region-specific data are needed to determine what services trauma patients need and where best to provide them to optimise patient outcomes.