Right patient to the right place: the impact of a 6-year regional trauma center-led prehospital trauma education program on patient outcomes

doi:10.21203/rs.3.rs-3812105/v1

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Right patient to the right place: the impact of a 6-year regional trauma center-led prehospital trauma education program on patient outcomes

https://doi.org/10.21203/rs.3.rs-3812105/v1

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Background: In regional trauma systems, emergency medical service (EMS) providers render an important function by performing prehospital triage for severely injured patients and transporting them to regional trauma centers. Since 2016, a regional trauma center has been providing trauma surgeon-provided prehospital medical guidance for EMS providers through a trauma hotline to guide field triage, treatment, and transport. This study analyzedthe effects and clinical outcomes of a regional trauma center-led performance improvement program that followed closed-loop principles for EMS providers.

Methods: Data from the regional trauma center databases (2016–2021) were collected, and patients with trauma with an Injury Severity Score (ISS) >15 in the Gyeonggi province who were injured, regardless of whether they visited the trauma center directly or not, were included. After adjusting for severity and baseline demographics through propensity score matching, clinical outcomes were analyzed using logistic regression, and the results were expressed as relative risks with 95% confidence intervals (95% CIs).

Results: We included 3017 patients from the 6-year study period. Correct triage and undertriage were performed in 2528 and 489 patients, respectively. Prehospital medical directions and feedback were provided 432 times (32.1%) in 2016 and increased to 1505 times (96.8%) in 2021 (z=11.342, p<0.001). The undertriage rate decreased from 32.7% (n=55/168) to 6.3% (n=52/820) (z=−13.689, p<0.001), and the overall mortality decreased from 21.4% to 10% (z=−5.96, p<0.001). After propensity score matching, 484 correctly triaged and 484 undertriaged patients were identified for subgroup analyses. The in-hospital mortality of undertriaged and correctly triaged patients was 20.5% (n=99) and 12.6% (n=61), respectively. The relative risk (95% CI)for undertriaged over correctly-triaged patients regardingin-hospital mortality, length of intensive care unit (ICU) stay, and mechanical ventilation duration was 1.78 (1.26–2.52, p=0.001), 1.01 (1.00–1.02, p=0.052; mean ± standard deviation [SD] 12.2±20.2 vs. 10.0±13.5), and 1.01 (1.00–1.02, p=0.048, mean ± SD 7.2±17.9 vs. 5.2±10.9), respectively.

Conclusion: Undertriage was associated with increased in-hospital mortality, length of ICU stay, and mechanical ventilation duration. The closed-loop communication program for EMS providers improved the undertriage rate. Specifically, in the early stages of regional trauma-system development, the trauma center-led trauma hotline feedback and case-based education programs can be effective models to facilitate prehospital patient triage and centralization of patients with severe trauma to trauma centers.

undertriage

prehospital

performance improvement

regional trauma system

EMS provider education

Worldwide, trauma is the leading cause of more deaths than human immunodeficiency virus infection, malaria, and tuberculosis [1, 2]. A National Health Insurance Corporation Study in Korea showed that injuries, including trauma, incurred the greatest socioeconomic cost, with most of the costs derived from future income losses due to premature deaths [3] as trauma-related mortality occurs in a relatively younger age group than in other disease groups [4]. In the Republic of Korea, trauma is the third leading cause of death and the leading cause of death among individuals younger than 45 years [5]. In 1999, the preventable trauma death rate (PTDR) in South Korea was 50.4%, which decreased to 39.6% in 2006 [4, 5]. Recognizing the problem of a high PTDR, the Korean government has promoted a government-led trauma center project since 2010 [4, 6]. Furthermore, a total of 17 Regional Trauma Centers have been designated nationwide and opened sequentially since 2014 [4, 6], and the PTDR has gradually decreased from 30.5% to 19.9% from 2015 to 2017, respectively [7]. Countries that have introduced the regional trauma system early have reduced the preventable mortality from 25% to 10% [8, 9].

Nonetheless, in the regional trauma system, it is important that emergency medical service (EMS) providers correctly perform onsite triage of severely injured patients and transport them directly to the regional trauma centers [6, 10, 11]. However, correct triage of patients with severe trauma in the prehospital stage proves difficult, and their treatment experience depends on the accuracy of trauma triage [12-15]. Therefore, to improve trauma triage, a regional trauma center-led training program for EMS providers, remote medical guidance by experienced trauma staff, and new triage criteria for trauma patients have been proposed [16-22]. However, EMS providers lack awareness regarding the Korean trauma center, which has been operational since 2014, and there has been no specialized training for paramedics on the triage of patients with severe trauma or the selection of transfer hospitals. Therefore, in the Korean trauma system, patients with severe trauma are often not transported to regional trauma centers [6].

Thus, a program that provides education and appropriate onsite medical guidance to EMS providers regarding field triage, treatment, and transport is necessary to ensure that patients with severe trauma can be quickly transported to the trauma center. As our regional trauma center has been implementing the trauma center-led trauma hotline feedback and case-based education programs to guide the field triage, treatment, and transport by EMS providers, this study was conducted to analyze the effects of regional trauma center-led EMS provider programs introduced in 2016 on the clinical outcomes.

Current status of study population and trauma medical resources in the region

The Gyeonggi Province has an area of 10,187 km², which is slightly smaller than that of San Diego County, USA (11,720 km²; Figure 1), with a population of 14 million as of 2023, of which 10.38 million (74%) and 3.62 million (26%) live in the southern and northern Gyeonggi Provinces (5,910 km² and 4,265 km²), respectively. The Gyeonggi province has 57 emergency medical facilities, including five regional emergency medical centers and one trauma center each in the southern and northern Gyeonggi provinces. This trauma center in the southern Gyeonggi Province is in a catchment area, the only Level I trauma center in the province and the final referral institution for patients with severe trauma (Figure 1). In 2021, 3100 people visited the Trauma Center in southern Gyeonggi Province, of which 39% (n = 1200) had an Injury Severity Score (ISS) >15. We retrospectively reviewed the case data of all adult patients with trauma (age ≥ 19 years) with an ISS > 15 who were registered in the Korean Trauma Data Bank (KTDB) between March 2016 and February 2021 at the Southern Gyeonggi Trauma Center.

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Definition and analysis of undertriage

Undertriage can be defined in several ways. Despite several limitations, in general, an ISS > 15 defines severely injured and undertriaged patients if trauma team activation was not performed, whereas overtriage is defined as the direct transfer of a patient with an ISS < 15 to a trauma center [15]. In the current study, an ISS > 15 was defined as a severe injury. In South Korea, which initiated the government-led trauma system policy, the trauma team is operated only at the designated trauma center. As this institution independently operates the trauma bay, direct transfer to the trauma center automatically activates the trauma team [4, 6]. Therefore, in this study, an ISS > 15 in the Gyeonggi Province constituted a severe injury, and if the patient was not directly transported to the trauma center, the case was defined as undertriaged and analyzed accordingly in this study.

EMS provider education and feedback programs

Since 2016, our regional trauma center has provided remote medical guidance for EMS providers. Trauma surgeons implemented a 24-hour trauma hotline and remotely evaluated the mechanisms of injuries, vital signs, and treatment (MIVT) provided by EMS providers at the scene of the accident. Immediately after transporting the patient, EMS providers can report triage, treatment, and transport to the trauma surgeon and trauma team leader and receive real-time feedback simultaneously. Through feedback programs, field triage, first aid, airway management, hemostasis, splinting, and severity are briefly taught, and errors are corrected immediately (Figure 2). Hotline-based guidance is increasing annually. In addition, the trauma center is implementing a training program for EMS providers. The primary courses were field triage, patient transport, initial field management, case-based feedback and discussion, and hands-on procedures (Table 1). Education was conducted online or offline, depending on the circumstances. In addition, there are regular and ad hoc training programs for EMS providers.

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Covariates and Outcomes

Data from the trauma database of the Southern Gyeonggi Province Trauma Center from 2016 to 2021 were analyzed. The extracted data included basic demographics, the abbreviated injury scale (AIS), ISS, vital signs prehospital and on arrival at the hospital, mechanism of injury, comorbidities, transfusions, transport, admission route, and prehospital medical direction. Patients with trauma whose dead-on-arrival (DOA) and ISS classifications could not be calculated, or those who visited a hospital outside the Gyeonggi province, were excluded. The primary outcome was the undertriage rate, and the secondary outcomes were in-hospital mortality, length of hospital stay, length of intensive care unit (ICU) stay, and duration of mechanical ventilation.

Statistical analyses

After the normality test using the Kolmogorov–Smirnov test, continuous variables were compared between the two groups using the Mann–Whitney U or Student’s t-test, and the data were presented as medians and interquartile ranges. Categorical variations were analyzed using the chi-squared or Fisher’s exact test. A trend analysis was conducted on the effects of education led by regional trauma centers and pre-hospital medical directions. Trauma patients with an ISS > 15 who were injured in the Gyeonggi province and who did or did not visit the trauma center directly were included in an analysis after adjustment for severity and baseline demographics through propensity score matching (PSM) using logistic regression. A 1:1 nearest neighbor matching was performed without replacement with a caliper of 0.2. Absolute standardized mean differences were calculated to evaluate balance, and variables were considered appropriately balanced if < 0.25. Clinical outcomes were analyzed using logistic regression after propensity score matching, and the results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). For all statistical analyses, SPSS version 23.0 (IBM Corp., Armonk, NY, USA) was used, and for propensity score matching, the MatchIt package for R software version 4.02 was used. Results were considered statistically significant at p < 0.05.

From March 2016 to February 2022, 16,527 patients were registered with the KTDB in the southern Gyeonggi Province. A total of 7262 adult patients with trauma (age ≥ 19 years) visited the Southern Gyeonggi Trauma Center. After excluding those whose ISS could not be calculated and patients who were DOA, there were 6792 patients, of whom 3017 patients had an ISS > 15. The 2528 correctly triaged patients visited the trauma center, whereas 489 undertriaged patients did not visit the center (Figure 3). Prehospital medical direction and feedback, which were conducted 432 times in 2016, increased to 1505 times in 2021. During the study period, 5500 prehospital medical directions and feedback sessions were conducted (Figure 2) along with 43 education sessions, including regular and ad hoc programs and international trauma symposiums (Table 1).

Undertriaged patients had a higher mean age (59.4 vs 50.6) and higher comorbidity rates (60.3% vs. 42.7%, p < 0.001) (Table 2). In the undertriage group, the proportion of females was higher than that of males (31.5% vs. 21.0%, p < 0.001), and the mean Glasgow Coma Scale (GCS) score was high (12.8 vs 11.9, p < 0.001). The mean ISS (24.8 vs 26.7, p < 0.001) of patients with undertriage was lower, and the blood product amount of all types of transfusions for 4 or 24 h after arrival at the hospital was lower than that of those with correct triage. There were no statistical differences between the two groups in terms of systolic blood pressure, pulse rate, or injury mechanisms. From 2016 to 2021, the undertriage rate decreased from 32.7% (n = 55/168) to 6.3% (n = 52/820) (z = -13.689, p < 0.001) (Figure 4).

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<kindly insert Table 2. here>

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Primary and secondary outcomes

To analyze the primary outcome (undertriage), logistic regression analysis was performed using the year 2016 as a reference. PSM was performed to adjust for demographic variables and the severity of the study population. Standardized mean differences were calculated to evaluate balance, and all variables were appropriately balanced (Figure 5). The OR (95% CI) of undertriage in 2021 was 0.14 (0.09-0.21; Figure 6A). For secondary outcome analysis, logistic regression analysis was performed to calculate the relative risk (95% CI). The in-hospital mortality in the adjusted cohort was 20.5% (n = 99) for undertriage vs. 12.6% (n = 61) for correct triage (Figure 6B). The relative risk for in-hospital mortality in undertriage patients was 1.78 (95% CI, 1.26–2.52; p = 0.001). The mean (standard deviation [SD]) and relative risk (95% CI) of ICU length of stay for undertriage compared to correct triage was 12.2 ± 20.2 vs. 10.0 ± 13.5 (1.01 [1.00–1.02], p = 0.052), and the duration of mechanical ventilation was 7.2 ± 17.9 for undertriage vs. 5.2 ± 10.9 for correct triage (1.01 [1.00–1.02], p = 0.048) (Figure 6B).

<kindly insert Figure 5. here>

<kindly insert Figure 6. here>

This study showed that undertriage was associated with increased in-hospital mortality, length of stay in the ICU, and duration of mechanical ventilation. Moreover, the closed-loop communication program for EMS providers improved the undertriage rate.

Appropriate treatment at the right time and place is important to improve the survival rate of patients with severe trauma [27]. Haas et al. reported that non-trauma center transport in patients with severe trauma increased early mortality by 30% [10]. The American College of Surgeons Committee on Trauma (ACS-COT) recommends an undertriage rate target of 5% or less in the regional trauma system [27, 28]. Although there may be differences by country or region, the subject of initial trauma triage is the EMS provider, which is the same in South Korea [4, 29]. Therefore, undertriage is determined by hospital selection based on the initial triage by the EMS provider [29]. However, the triage of patients with trauma is difficult, and areas with well-developed trauma systems have high undertriage rates [13, 15]. General physicians, including emergency physicians, report that triage accuracy is low if the experience with patients with severe trauma is insufficient [14]. Therefore, to reduce the undertriage of patients with severe trauma, various educational programs, medical guidance programs, mobile application developments, and revisions of the field triage scheme have been attempted for EMS providers, nurses, and physicians who perform field triage [16-22, 24, 26, 30]. In this region, after the opening of a government-led designated trauma center in 2016, a regional trauma center-led program that educates and provides medical guidance to EMS providers was initiated.

The selection of hospitals for transporting patients with trauma by EMS providers is influenced by various factors such as geographical proximity to hospitals, preference of patients and families, experience of paramedics, and level of the regional trauma system [22, 29, 31]. In Korea, in which the government-led regional trauma center establishment project was started in 2012, there were differences in preventable mortality according to the triage and transport of patients with trauma between regions and between cities and rural areas in 2023. Lokerman et al. reported that the undertriage rate could be improved as a result of developing and distributing a mobile application that reflected the Field Triage criteria of the Dutch centers [26]. The trauma center officially started operations in 2016 and introduced a trauma hotline. As regional EMS providers have not received systematic training and medical guidance on the field triage of patients with trauma from a trauma center, a trauma hotline was operated with the aim of providing medical guidance to EMS providers and centralizing patients with severe trauma to the regional trauma center. Trauma surgeons carried a 24-hour trauma hotline, remotely evaluated the MIVT provided by EMS providers at the scene of the accident, and provided medical advice on field triage, treatment, and transportation. Immediately after transporting the patient, EMS providers can report triage, treatment, and transport to the trauma surgeon and trauma team leader and receive feedback simultaneously. Prehospital medical direction and feedback were conducted 432 times in 2016, and increased to 1505 times in 2021, and was conducted a total of 5541 times during the study period. The institutional undertriage rate decreased from 32.7% in 2016 to 6.3% in 2021.

According to the ACS-COT, the criteria for distinguishing between level 1 and level 2 trauma centers are resources, trauma volume, and educational commitment [32]. Level I trauma centers maintain in-house availability of resuscitation, operative procedures, and critical care, in which attending trauma surgeons participate 24 hours a day, hospitalize more than 240 patients with trauma with ISS ≥ 16 annually, and perform trauma education, training, and research. In implementing the regional trauma system, it is important to improve the ability of EMS providers to perform prehospital triage of patients with trauma [29, 33]. The Korean Fire Agency partially supports the triage of patients with trauma and medical guidance through general or emergency physicians; however, the accuracy of triage by medical staff who do not have much experience with patients with severe trauma may not be high [14]. Chiu et al. reported that field triage training for EMS providers can improve triage accuracy; the authors have been operating a trauma education program for local EMS providers since 2017. We provided various educational programs based on cases of severe trauma triaged and treated by EMS providers. In all training sessions, the trauma hotline was introduced, and information was provided to communicate with the trauma surgeon 24 hours a day about field triage, medical direction, and transport for patients suspected of severe trauma.

Performance improvement programs based on the closed-loop principle have been widely adopted to improve trauma management quality [34-38]. Huh et al. reported improvements in in-hospital outcomes such as the preventable trauma death rate after implementing the performance improvement and patient safety program based on the closed-loop principle at a new regional trauma center [34]. Hietbrink et al. studied the Netherlands’ Trauma System and reported that the OR for mortality in level I trauma centers decreased to 0.54 as the number of correct triage procedures increased [39]. To increase the correct triage rate, the EMS providers’ education and feedback program implemented by this regional trauma center enables communication between regional trauma centers and EMS providers, according to the closed-loop principle. Undertriage rate decreased from 32.7% in 2016 to 6.3% in 2021 (OR 0.17, 95% CI, 0.09–0.29), and the in-hospital mortality of the correct-triage group was 0.56 times that of the undertriage group (OR, 0.56; 95% CI, 0.39–0.79).

Our study had several limitations. First, because EMS providers move in and out frequently, it was not possible to identify the percentage of all EMS providers in the Gyeonggi Province who experienced training and feedback. Therefore, it was not possible to analyze the effects of education and feedback quantitatively. Second, in the southern Gyeonggi Province, the regional trauma system is still developing, and data sharing between the trauma center and fire department is not being performed currently. Therefore, patients with severe trauma visiting our center did not accurately represent the occurrence of severe trauma in the region, and those who did not visit our center were not included in this study. Third, this study may have a selection bias owing to its nature of being a single-institution retrospective study. Therefore, a multicenter study is required to verify these results. However, since the establishment of the regional trauma center, improvements in the PTDR and the development of the regional trauma system have been quantitatively confirmed [40]. Therefore, the authors believe that this study serves as evidence that the regional trauma center-led performance improvement program contributed to the improvement of the undertriage rate and development of the regional trauma system. Lastly, the method of retrospectively evaluating triage accuracy based on the AIS and ISS at regional trauma centers may underestimate the actual severity because it does not reflect the physiological, anatomical, or mechanism of injury criteria of the field triage scheme proposed by the Center for Disease Control (CDC) and others [12, 23, 24]. However, for the convenience of trauma research and quality management of trauma treatment, the method of evaluating the accuracy of triage based on the ISS is widely adopted [12, 25, 26].

In conclusion, we believe that the closed-loop communication program for EMS providers, which considers the maturity of the regional trauma system, contributed to an improvement in the undertriage rate. Specifically, trauma center-led trauma hotline feedback and case-based education programs are suggested as models that can be helpful for pre-hospital patient triage and centralization of patients with severe trauma to trauma centers in the early stages of the regional trauma system development.

95% CI: 95% confidence interval

ACS-COT: The American College of Surgeons Committee on Trauma

AIS: abbreviated injury scale

CDC: Center for Disease Control

DOA: dead-on arrival

EMS: emergency medical service

FFP: fresh frozen plasma

GCS: Glasgow Coma Scale

ICU: intensive care unit

ISS: Injury Severity Score

KTDB: Korean Trauma Data Bank

MIVT: mechanisms of injuries, vital signs, and treatment

OR: odds ratio

PR: pulse rate

PRBC: packed red blood cells

PSM: propensity score matching

PTDR: preventable trauma death rate

SBP: systolic blood pressure

SD: standard deviation

Ethics approval and consent to participate

This study was approved by the Institutional Review Board (IRB) of Ajou University Hospital (IRB No. AJOUIRBDB-2023-322) and performed in accordance with the provisions of the Declaration of Helsinki. The need for obtaining informed consent was waived by IRB of Ajou University Hospital because of the observational nature of the study.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable

Authors’ contributions

DC and HJ conceived the study and designed the trial. DC, YH, BH, and KJ contributed to article search, data extraction, and quality assessment of studies. SK, SS supervised data collection and management. DC performed data analyses and manuscript writing. HJ reviewed the article independently and made minor revisions after consultation with DC. All the authors read and gave the final approval of the version to be submitted and contributed substantially to its revision. The manuscript, including related data, figures, and tables, has not been previously published. All authors read and approved the final manuscript.

Acknowledgements

We would like to thank Editage (www.editage.co.kr) for editing and reviewing this manuscript for English language.

Author details

¹Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea, ²Regional Trauma Center of Southern Gyeonggi Province, Ajou University School of Medicine, Suwon, Republic of Korea

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Table 1. Regional trauma center-led performance improvement programs for EMS providers

Program types	Year	Number of sessions	Number of participants
Prehospital medical direction and feedback program	2016–2021	5541*	11082**
Regular education program
-Annual International Trauma Conference	2016–2021	5
-Regional EMS provider education program	2017–2021	25	786
Non regular education program
-119 EMS provider education in the regional fire service academy (lecture)	2017	1
-Heli-EMS education course (lecture)	2018, 2019	2
-Conference for the establishment of a regional trauma system with the National Fire Agency (discussion, case review)	2021	1
-Fire Agency Cooperation Conference	2018	2	61
-EMS provider course for infants and toddler (lecture)	2019	1
-Field triage and treatment course of emergency patients (lecture, hands on practice)	2021	2	76
-Training course of standard field skill guideline for EMS provider (lecture, case discussion)	2021	1
-Trauma Saver Judge	2019-2021	3

*A total of 5541 direct admissions and feedback through the trauma bay were received after prehospital hotline calls.

**EMS dispatch comprises a team of at least 2–3 EMS providers.

Table 2. General characteristics of the study population and propensity score matched population

	Original population		p	Adjusted population		p
	Correct_triage	Undertriage		Correct_triage	Undertriage
	(n=2528)	(n=489)		(n=484)	(n=484)
Age, years	50.6 ± 17.0	59.4 ± 17.7	< 0.001	58.7 ± 17.9	59.2 ± 17.5	0.682
19–64	1993 (78.8 %)	297 (60.7 %)	< 0.001	298 (61.6 %)	297 (61.4 %)	1.000
64	535 (21.2 %)	192 (39.3 %)	< 0.001	186 (38.4 %)	187 (38.6 %)	1.000
Sex			< 0.001			0.449
Male	1997 (79.0 %)	335 (68.5 %)		323 (66.7 %)	335 (69.2 %)
Female	531 (21.0 %)	154 (31.5 %)		161 (33.3 %)	149 (30.8 %)
Comorbidity	1079 (42.7 %)	295 (60.3 %)	< 0.001	248 (51.2 %)	290 (59.9 %)	0.008
ISS	26.7 ± 10.0	24.8 ± 9.8	< 0.001	25.4 ± 9.3	24.9 ± 9.8	0.427
16–30	1860 (73.6 %)	412 (84.3 %)	< 0.001	377 (77.9 %)	407 (84.1 %)	0.018
30	668 (26.4 %)	77 (15.7 %)	< 0.001	107 (22.1 %)	77 (15.9 %)	0.018
Injury mechanism			0.209			1.000
Blunt	2434 (96.3 %)	477 (97.5 %)		473 (97.7 %)	472 (97.5 %)
Penetrating	94 (3.7 %)	12 (2.5 %)		11 (2.3 %)	12 (2.5 %)
Hospital value on arrival
AVPU scale			< 0.001			< 0.001
- Alert	1127 (44.6 %)	239 (48.9 %)		208 (43.0 %)	235 (48.6 %)
- Verbal response	615 (24.3 %)	76 (15.5 %)		134 (27.7 %)	76 (15.7 %)
- Painful response	507 (20.1 %)	99 (20.2 %)		102 (21.1 %)	99 (20.5 %)
- Unresponsive	279 (11.0 %)	75 (15.3 %)		40 (8.3 %)	74 (15.3 %)
SBP (mmHg)	134.7 ± 29.0	135.7 ± 33.4	0.6	136.4 ± 28.1	135.6 ± 33.3	0.722
PR (min^-1)	90.8 ± 22.2	89.1 ± 21.0	0.15	88.3 ± 21.8	89.1 ± 21.0	0.587
GCS	11.9 ± 4.1	12.8 ± 3.4	< 0.001	12.1 ± 3.8	12.8 ± 3.4	0.006
Transfusion (unit)
PRBC_4h	2.6 ± 5.6	1.7 ± 4.1	< 0.001	2.2 ± 4.7	1.7 ± 4.2	0.083
FFP_4h	1.8 ± 4.3	1.1 ± 3.1	< 0.001	1.4 ± 3.6	1.1 ± 3.1	0.159
Platlet_4h	0.2 ± 1.2	0.2 ± 1.2	0.361	0.2 ± 1.5	0.2 ± 1.1	0.885
PRBC_24h	4.0 ± 8.4	2.6 ± 5.7	< 0.001	3.7 ± 7.0	2.6 ± 5.7	0.013
FFP_24h	3.4 ± 7.7	2.5 ± 5.5	0.001	3.1 ± 6.8	2.5 ± 5.5	0.132
Platlet_24h	1.3 ± 3.9	1.2 ± 3.8	0.76	1.5 ± 3.9	1.2 ± 3.8	0.315

ISS, Injury Severity Score; SBP, systolic blood pressure; PR, pulse rate; GCS, Glasgow Coma Scale; PRBC, packed red blood cells; FFP, fresh frozen plasma

No competing interests reported.

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Right patient to the right place: the impact of a 6-year regional trauma center-led prehospital trauma education program on patient outcomes

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