Prehospital transportation decisions for patients sustaining major trauma in road traffic crashes: a comparison between US and Sweden
In 2012, road traffic crashes (RTC) accounted for almost a quarter of injury deaths in the world. The World Health Organization (WHO) estimated that in 2013 RTC killed 1.25 million people. Therefore, RTC became the tenth leading cause of death in the world, and the leading cause of death among children and young people below the age of 45. The present study was therefore designed to assess proportions and characteristics of patients sustaining minor and major trauma in RTC and transported to either a trauma center (TC) or a non-trauma center (non-TC) in the US and Sweden and to compare results from the countries. The aim was to evaluate what the prehospital transportation decisions on the scene of accident were and to understand the purposes for the decision in both countries. Currently in Sweden, there exists no trauma care system similar to the system established in the US. However, University Hospitals in Sweden provide a high level of care comparable to TCs in US. Thus, a comparison between Sweden and US, with a well established trauma care system, may contribute to establish major trauma destination policies in Sweden.
The data were selected from the National Automotive Sampling System - Crashworthiness Data System (NASS-CDS) and Swedish TRaffic Accident Data Acquisition (STRADA) database for US and Sweden, respectively. The data from RTC that occurred from 2010 to 2015 were analysed. For the given years there were a total of 45,075 patients from RTC reported by the police in US and 39,733 patients reported by police and hospitals in Sweden. However, not all cases were analysed. Patients
below age 18, patients with missing value for Injury Severity Score (ISS) and patients for which transport to hospital was not provided or was unknown, were excluded from analysis. Thus, the final sample consisted of 10 289 patients and 31 415 patients for US and Sweden, respectively.
An analysis of the patient characteristics sustaining major trauma in comparison with patients sustaining minor trauma (ISS < 15) and an analysis of major trauma patients transported to a TC versus non-TC was conducted. The variables that were analysed for both countries were sex, age and location of road RTC (rural or urban area). In addition, an analysis of race and BMI level was conducted for the US. Due to lack of data, the analysis of race and BMI for Sweden was not possible.
The proportions of patients sustaining minor trauma and transported to TC were 55.7% and 19.1% in US and Sweden, respectively. The proportions of patients sustaining major trauma and transported to TC were 87.6% in US and 31.9% in Sweden. The proportion of patients sustaining minor trauma and major trauma, and the proportions of patients sustaining major trauma transported to TC and non-TC, for each country and between both countries were analysed. Chi-square tests were performed to find statistically significant differences. Proportions of patients aged > 55, proportions of males, and proportions of patients involved in RTC in urban environment differed with
statistical significance (P < 0.05) between the two countries.
The conducted study reveals that in Sweden many RTC patients with severe injury are transported to hospital with a lower level of care. This may be caused by undertriage or by lack of formal designated trauma care system and major trauma destination policies in Sweden. The opposite situation is presented in US, where observed results indicate low undertriage but at the price of high overtriage which may be linked to the field triage protocol where it is stated that "When in doubt, transport to a trauma center".
This study offers a unique insight into the rate of prehospital transportation decisions for major RTC and points out the large differences between US and Sweden.