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Comparison of trauma care structures, processes and outcomes between the English National Health Service and Quebec, Canada

Samy Bouderba, Fiona Lecky, Kahina Soltana, Xavier Neveu, Dhushy Surendra Kumar, Omar Bouamra, Timothy J. Coats, Pier-Alexandre Tardif, Amina Belcaid, Catherine Gonthier and Lynne Moore
CAN J SURG January 18, 2023 66 (1) E32-E41; DOI: https://doi.org/10.1503/cjs.001822
Samy Bouderba
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Fiona Lecky
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Kahina Soltana
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Xavier Neveu
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Dhushy Surendra Kumar
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Omar Bouamra
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Timothy J. Coats
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Pier-Alexandre Tardif
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Amina Belcaid
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Catherine Gonthier
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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Lynne Moore
From the Department of Social and Preventive Medicine, Université Laval, Québec, Que. (Bouderba, Soltana, Tardif, Moore); the Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de recherche du CHU de Quebec – Université Laval, Hôpital de l’Enfant-Jésus, Québec, Que. (Bouderba, Soltana, Neveu, Tardif, Moore); the Department of Emergency Medicine, University of Sheffield, Sheffield, UK (Lecky); the Trauma Audit and Research Network, Salford, UK (Kumar); the Department of Biology, Medicine and Health, Trauma Audit and Research Network, Manchester, UK (Bouamra); the Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (Coats); and the Institut national d’excellence en santé et en services sociaux, Québec, Que. (Belcaid, Gonthier)
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    Fig. 1

    Flow diagram showing selection of patients from Quebec and the English National Health Service (NHS).

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    Table 1

    Trauma system components and benchmarking activities in Quebec and the English National Health Service*

    Component/activityQuebecNHS
    Trauma system component
    Trauma centres10 MTCs (5 level I [3 adult centres and 2 pediatric centres], 5 level II, 21 level III, 28 level IV)27 MTCs, 154 trauma units
    No. of MTCs per 100 000 population0.1250.05
    No. of MTCs per 1000 km20.0060.111
    Designation/accreditationInstitut national d’excellence en santé et services sociaux; mandatoryStrategic Health Authorities; mandatory
    Prehospital triageUniform, validated tool (adapted from American College of Surgeons Committee on Trauma)Varies across regions
    Bypass to MTC60 min60 min
    Highest level of prehospital careLevel II. Basic Life SupportLevel IV. Advanced Life Support On-Scene, Physician Field Care
    Prehospital intubationNoneTracheal intubation
    Surgical airway
    Nontracheal intubation intervention: pharyngeal tube, supraglottic airway device, airway positioning
    Prehospital transportationGround; fixed-wing aircraftGround; fixed-wing aircraft; helicopter
    Trauma team leaderIn 1 level I hospitalAll MTCs
    Benchmarking activities
    Process indicators13Tranexamic acid, rapid sequence intubation, rehabilitation prescription
    Risk-adjusted outcomesDeath, readmission, complications, hospital length of stayDeath
    FeedbackConfidential audit and feedback reportsPublicly available reports, dashboards, best practice tariffs, alerts (2 SDs), alarms (3 SDs)
    AccountabilityMandatory quality-improvement report; linked to accreditationPay-for-performance indicators
    FrequencyAccreditation cycles (about 3 yr)4 mo (reports), 3 mo (dashboard)
    • MTC = major trauma centre; NHS = English National Health Service; SD = standard deviation.

    • ↵* Sources: The Trauma Audit & Research Network (https://www.tarn.ac.uk/) and the Trauma Care Continuum, Institut national d’excellence en santé et services sociaux (https://www.inesss. qc.ca/thematiques/sante/traumatologie/continuum-de-services-en-traumatologie-cst.html).

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    Table 2

    Characteristics of patients with major trauma in Quebec and the English National Health Service, 2014/15 to 2016/17

    CharacteristicNo. (%) of patients
    Quebec
    n = 6484
    NHS
    n = 36 337
    Age, yr
     16–441778 (27.4)12 993 (35.7)
     45–54761 (11.7)5006 (13.8)
     55–641075 (16.6)4678 (12.9)
     65–751152 (17.8)5157 (14.2)
     ≥ 761718 (26.5)8503 (23.4)
    Male sex4542 (70.0)25 266 (69.5)
    Modified Charlson Comorbidity Index score
     04026 (62.1)19 835 (54.6)
     1–51216 (18.7)12 376 (34.0)
     6–10447 (6.9)3213 (8.8)
     ≥ 11795 (12.3)913 (2.5)
    Mechanism of injury
     Motor vehicle2200 (33.9)12 942 (35.6)
     Low fall1404 (21.6)12 406 (34.1)
     High fall1854 (28.6)7188 (19.8)
     Stabbing, shooting227 (3.5)1099 (3.0)
     Other799 (12.3)2702 (7.4)
    Body region of most severe injury
     Head3549 (54.7)20 301 (55.9)
     Thorax1564 (24.1)8655 (23.8)
     Abdomen232 (3.6)1097 (3.0)
     Spine718 (11.1)2627 (7.2)
     Extremity390 (6.0)3494 (9.6)
     Other31 (0.5)163 (0.4)
    Injury Severity Scale score
     12–161612 (24.9)9821 (27.0)
     17–242082 (32.1)9773 (26.9)
     25–392552 (39.4)14 885 (41.0)
     ≥ 40238 (3.7)1858 (5.11)
    Maximum Abbreviated Injury Scale score
     32484 (38.3)7976 (21.9)
     41758 (27.1)13 567 (37.3)
     5–62242 (34.6)14 794 (40.7)
    Glasgow Coma Scale score
     3–81140 (17.6)5561 (15.3)
     9–12462 (7.1)2879 (7.9)
     13–154882 (75.3)27 897 (76.8)
    Systolic blood pressure, mm Hg
     ≥ 906263 (96.6)34 609 (95.2)
     < 90221 (3.4)1728 (4.8)
     Transfer3363 (51.9)14 166 (39.0)
    • NHS = English National Health Service.

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    Table 3

    Comparison of median time to major trauma centre and median time in the emergency department

    VariableMedian (IQR)p value
    QuebecNHS
    Overall
    Time to MTC, h2.7 (1.0–6.2)1.6 (1.2–2.2)< 0.001
     Transfer6.0 (4.0–9.3)2.5 (1.5–4.9)< 0.001
     No transfer1.0 (0.7–1.5)1.5 (1.1–1.9)< 0.001
    Time in ED6.4 (3.1–16.1)4.0 (2.8–6.1)< 0.001
    Head injury
    Time to MTC2.9 (1.0–5.9)1.5 (1.1–1.2)< 0.001
     Transfer5.3 (3.6–8.3)2.9 (1.5–5.0)< 0.001
     No transfer0.9 (0.7–1.4)1.4 (1.1–1.8)< 0.001
    Time in ED5.8 (2.8–15.8)4.0 (2.6–5.9)< 0.001
    Thoracoabdominal injury
    Time to MTC1.9 (0.9–6.2)1.6 (1.2–2.2)< 0.001
     Transfer6.6 (4.6–10.7)2.6 (1.7–5.1)< 0.001
     No transfer1.0 (0.7–1.5)1.6 (1.2–2.0)< 0.001
    Time in ED6.7 (3.1–16.1)4.1 (3.0–6.1)< 0.001
    Spine injury
    Time to MTC4.4 (1.4–8.4)1.7 (1.3–2.3)< 0.001
     Transfer7.0 (4.9–11.9)2.0 (1.4–4.1)< 0.001
     No transfer1.2 (0.9–1.9)1.7 (1.3–2.2)< 0.001
    Time in ED9.0 (4.7–18.7)4.7 (3.4–6.9)< 0.001
    Extremity injury
    Time to MTC1.9 (0.9–5.9)1.7 (1.3–2.3)0.009
     Transfer5.9 (4.1–7.7)2.0 (1.5–4.4)< 0.001
     No transfer1.0 (0.7–1.7)1.6 (1.2–2.1)< 0.001
    Time in ED5.5 (3.2–12.4)4.1 (3.1–6.1)< 0.001
    • ED = emergency department; IQR = interquartile range; MTC = major trauma centre; NHS = English National Health Service.

    • View popup
    Table 4

    Odds of death and hazard ratios for hospital and intensive care unit length of stay*

    Region of injury; subgroupDeath, adjusted OR† (95% CI)†Adjusted HR† (95% CI)‡
    Hospital LOSICU LOS
    Overall1.16 (1.02–1.33)1.09 (0.98–1.21)1.00 (0.90–1.11)
    Head
     Overall1.28 (1.09–1.51)0.99 (0.85–1.16)1.01 (0.89–1.16)
     Age < 65 yr1.35 (1.06–1.73)0.90 (0.70–1.16)0.96 (0.83–1.11)
     Age ≥ 65 yr1.27 (1.04–1.57)0.91 (0.80–1.04)1.02 (0.86–1.22)
    Thoracoabdominal
     Overall0.69 (0.52–0.90)1.17 (1.06–1.29)1.01 (0.87–1.18)
     Age < 65 yr0.67 (0.44–1.00)1.23 (1.09–1.40)1.03 (0.87–1.22)
     Age ≥ 65 yr0.69 (0.48–0.99)1.17 (1.00–1.37)0.99 (0.78–1.25)
    Spine
     Overall1.30 (0.71–2.35)1.23 (0.97–1.56)1.36 (1.07–1.71)
     Age < 65 yr1.27 (0.36–4.50)1.64 (1.04–2.58)1.45 (1.07–1.96)
     Age ≥ 65 yr1.31 (0.66–2.60)1.16 (0.90–1.49)1.26 (0.83–1.92)
    Extremities
     Overall1.77 (1.00–3.12)1.07 (0.90–1.28)0.80 (0.64–0.99)
     Age < 65 yr1.37 (0.39–4.83)1.35 (1.06–1.71)0.80 (0.62–1.04)
     Age ≥ 65 yr2.03 (1.06–3.88)0.93 (0.69–1.27)0.67 (0.43–1.05)
    • CI = confidence interval; HR = hazard ratio; ICU = intensive care unit; LOS = length of stay; OR = odds ratio; NHS = English National Health Service.

    • ↵* Reference is NHS.

    • ↵† Adjusted for the following variables in a propensity score: age, sex, modified Charlson Comorbidity Index score, body region of worst injury, maximum Abbreviated Injury Scale score, Glasgow Coma Scale score, systolic blood pressure, mechanism of injury and transfer.

    • ↵‡ Where the hazard of discharge is modelled so that HRs greater than 1 indicate shorter LOS in Quebec than in the NHS (reference).

    • View popup
    Table 5

    Odds of death and hazard ratios for hospital and intensive care unit length of stay in sensitivity analysis*

    VariableDeath, adjusted OR† (95% CI)Adjusted HR† (95% CI)‡
    Hospital LOSICU LOS
    All patients1.16 (1.02–1.33)1.09 (0.98–1.21)1.00 (0.90–1.11)
    Complete data observations1.18 (0.99–1.40)1.06 (0.94–1.19)0.96 (0.85–1.08)
    Only level I hospitals in Quebec1.16 (0.97–1.39)1.01 (0.86–1.19)0.91 (0.78–1.06)
    Without adjustment for comorbidities1.21 (0.98–1.38)1.10 (0.99–1.23)1.01 (0.90–1.13)
    Patients aged < 85 yr1.18 (1.00–1.36)1.11 (0.99–1.25)0.98 (0.88–1.10)
    30-d in-hospital mortality1.10 (0.96–1.27)——
    7-d mortality1.10 (0.94–1.29)——
    72-h mortality1.15 (0.95–1.38)——
    24-h mortality1.04 (0.83–1.30)——
    Deaths excluded—1.29 (1.11–1.50)1.12 (0.96–1.32)
    Transfer to another acute care hospital excluded—1.35 (1.19–1.55)—
    • CI = confidence interval; ICU = intensive care unit; HR = hazard ratio; LOS = length of stay; OR = odds ratio; NHS = English National Health Service.

    • ↵* Reference is NHS.

    • ↵† Adjusted for the following variables in a propensity score: age, sex, modified Charlson Comorbidity Index score, body region of worst injury, maximum Abbreviated Injury Scale score, Glasgow Coma Scale score, systolic blood pressure, mechanism of injury and transfer.

    • ↵‡ Where the hazard of discharge is modelled so that HRs greater than 1 indicate shorter LOS in Quebec than in the NHS (reference).

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Canadian Journal of Surgery: 66 (1)
CAN J SURG
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Comparison of trauma care structures, processes and outcomes between the English National Health Service and Quebec, Canada
Samy Bouderba, Fiona Lecky, Kahina Soltana, Xavier Neveu, Dhushy Surendra Kumar, Omar Bouamra, Timothy J. Coats, Pier-Alexandre Tardif, Amina Belcaid, Catherine Gonthier, Lynne Moore
CAN J SURG Jan 2023, 66 (1) E32-E41; DOI: 10.1503/cjs.001822

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Comparison of trauma care structures, processes and outcomes between the English National Health Service and Quebec, Canada
Samy Bouderba, Fiona Lecky, Kahina Soltana, Xavier Neveu, Dhushy Surendra Kumar, Omar Bouamra, Timothy J. Coats, Pier-Alexandre Tardif, Amina Belcaid, Catherine Gonthier, Lynne Moore
CAN J SURG Jan 2023, 66 (1) E32-E41; DOI: 10.1503/cjs.001822
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