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Introduction: Defining major trauma (MT) with an Injury Severity Score (ISS) > 15 has limitations. This threshold is used for concentrating MT care in networks with multiple levels of trauma care. Objective: This study aims to identify subgroups of severely injured patients benefiting on in-hospital mortality and non-fatal clinical outcome measures in an optimal level of trauma care. Methods: A multicentre retrospective cohort study on data of the Dutch National Trauma Registry, region South West, from January 1, 2015 until December 31, 2019 was conducted. Patients ≥ 16 years admitted within 48 h after trauma transported with (H)EMS to a level I trauma centre (TC) or a non-level I trauma facility with a Maximum Abbreviated Injury Scale (MAIS) ≥ 3 were included. Patients with burns or patients of ≥ 65 years with an isolated hip fracture were excluded. Logistic regression models were used for comparing level I with non-level I. Subgroup analysis were done for MT patients (ISS > 15) and non-MT patients (ISS 9–14). Results: A total of 7,493 records were included. In-hospital mortality of patients admitted to a non-level I trauma facility did not differ significantly from patients admitted to the level I TC (adjusted Odds Ratio (OR): 0.94; 95% confidence interval (CI) 0.68–1.30). This was also applicable for MT patients (OR: 1.06; 95% CI 0.73–1.53) and non-MT patients (OR: 1.30; 95% CI (0.56–3.03). Hospital and ICU LOS were significantly shorter for patients admitted to a non-level I trauma facilities, and patients admitted to a non-level I trauma facility were more likely to be discharged home. Findings were confirmed for MT and non-MT patients, per injured body region. Conclusion: All levels of trauma care performed equally on in-hospital mortality among severely injured patients (MAIS ≥ 3), although patients admitted to the level I TC were more severely injured. Subgroups of patients

Background: Severe traumatic brain injury (TBI) is associated with a high mortality rate and those that survive commonly have permanent disability. While there is a broad consensus that appropriate prehospital treatment is crucial for a favorable neurological outcome, evidence to support currently applied treatment strategies is scarce. In particular, the relationship between prehospital treatments and patient outcomes is unclear. The BRAIN-PROTECT study therefore aims to identify prehospital treatment strategies associated with beneficial or detrimental outcomes. Here, we present the study protocol. Study Protocol: BRAIN-PROTECT is the acronym for BRAin INjury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma. It is a prospective observational study on the prehospital treatment of patients with suspected severe TBI in the Netherlands. Prehospital epidemiology, interventions, medication strategies, and nonmedical factors that may affect outcome are studied. Multivariable regression based modeling will be used to identify confounder-adjusted relationships between these factors and patient outcomes, including mortality at 30 days (primary outcome) or mortality and functional neurological outcome at 1 year (secondary outcomes). Patients in whom severe TBI is suspected during prehospital treatment (Glasgow Coma Scale score 8 in combination with a trauma mechanism or clinical findings suggestive of head injury) are identified by all four helicopter emergency medical services (HEMS) in the Netherlands. Patients are prospectively followed up in 9 participating trauma centers for up to one year. The manuscript reports in detail the objectives, setting, study design, patient inclusion, and data collection process. Ethical and juridical aspects, statistical considerations, as well as limitations of the study design are discussed. Discussion: Current prehospital treatment of patients with suspected severe TBI is based on marginal evidence, and op