Impact of trauma center accreditation in Canada

The introduction of trauma systems in many countries over the last fifty years has led to important reductions in injury mortality and disability. Essential to the development of a trauma system is the designation of trauma centers, which are acute care hospitals where resources are prioritized to ensure that injured patients receive appropriate and timely care.In North America, states or provinces are responsible for determining the optimal number of trauma centers in their jurisdictions, based on available resources and anticipated volume of trauma patients. Many injury organizations provide guidelines for optimal trauma care, which has led to the development of an external peer review process called accreditation or verification. This process aims to verify the capacity of a trauma center to deliver appropriate trauma care. Accreditation processes generally require centers to submit a prereview questionnaire and to complete an on-site visit by an experienced peer review team in trauma care. In Canada, accreditation is voluntary, except in the province of Quebec where it is mandatory.Although accreditation has become a common practice, evidence of its effectiveness on patient outcomes is lacking. Proponents of accreditation argue that it enhances stakeholder engagement, strengthens collaboration through elements of the continuum of care and improves adherence to evidence-based protocols, all of which improve patient outcomes. Criticisms of accreditation include the mobilization of resources, and the possibility that improvements in care are only transitory.In the first manuscript of this thesis, I present a systematic review of the literature on the impact of trauma center accreditation on adherence to evidence-based clinical processes of care and patient outcomes, including in-hospital mortality, complications and hospital length of stay. This review highlighted some key findings. First, available studies have serious methodological limitations, including the lack of robust controls and competing-risk issues. Second, mixed and inconsistent results between accreditation and studied outcomes were found. Third, all available studies were conducted in the United States, limiting the generalizability of observed associations. Therefore, the actual state of knowledge adds little guidance to inform hospitals’ decision to seek accreditation.Disregarding the competing risk of in-hospital mortality when assessing the impact of accreditation on hospital length of stay was one of the primary issues identified in the review. The second manuscript of this thesis is a methodological study, which describes novel approaches to estimate the impact of hospital interventions on in-hospital length of stay while considering the competing risk of in-hospital mortality.The third and fourth manuscripts present estimates of the impact of accreditation in mandatory (Quebec) and voluntary (British Columbia) settings, respectively. In both studies, I conducted an interrupted time series analysis to assess the effect of the first or subsequent accreditation cycles on in-hospital mortality, complications and hospital length of stay.Overall, results suggest that in a mandatory context, accreditation is mostly beneficial for centers experiencing decreases in performance during the months preceding the visit. In a voluntary context, the impact of accreditation seems to be sustained after the first cycle and temporary for subsequent accreditation cycles. However, results did not support a universally beneficial impact of accreditation on studied outcomes, partly because some measured estimates were imprecise.In conclusion, the collective findings presented in this work fill a gap in the literature regarding trauma center accreditation, particularly the important methodological limitations of existent observational work and its focus on the United States context. Further work evaluating other outcomes such as staff recruitment and retention is needed

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