Highlight
- Hospitals with high blunt intestinal injury (BInI) trauma volume demonstrate significantly shorter times to surgical intervention than low-volume centers.
- High BInI volume hospitals have a 42% lower risk of post-injury sepsis compared to low-volume centers, suggesting improved clinical outcomes.
- Volume of blunt trauma and overall trauma admissions similarly correlate with reduced surgical delay, reinforcing the role of institutional experience and resources.
Study Background
Blunt intestinal injury (BInI) resulting from trauma is a diagnostic challenge even among experienced trauma providers. Full-thickness perforations of the ileum, jejunum, or colon are rare but carry high morbidity and mortality if management is delayed. Timely surgical intervention is critical to prevent complications such as sepsis and death. However, diagnostic difficulty often leads to treatment delays, raising concerns about variability in care depending on hospital capabilities and experience. This study addresses the influence of hospital trauma volume on time to surgical intervention and patient outcomes in blunt intestinal injuries, an area with limited prior data despite its important clinical implications.
Study Design
This retrospective cohort study utilized the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database from 2017 to 2020. Inclusion criteria were adult trauma patients (aged ≥18 years) with documented full-thickness perforations of the ileum, jejunum, or colon due to blunt trauma. Hospitals were stratified into low, medium, and high volume based on annual BInI case counts.
The primary exposure was hospital blunt intestinal injury trauma volume. Primary outcomes included time to surgery (with >24 hours considered delayed) and key clinical outcomes such as mortality and post-injury sepsis.
Multivariable logistic regression models adjusted for demographics, comorbidities, injury severity, and other confounders. Sensitivity analyses were conducted by stratifying hospitals according to their blunt trauma and total trauma admission volumes to validate findings.
Key Findings
Out of over 4 million trauma admissions, 3,954 patients met discharge criteria with BInI: 1,397 in low-volume, 1,373 in medium-volume, and 1,184 in high-volume hospitals. The mean time to surgical intervention was significantly reduced in high-volume centers (15 ± 45 hours) compared to low-volume hospitals (18 ± 46 hours, P < 0.001).
On adjusted analyses, patients treated in high BInI volume hospitals had significantly lower odds of delayed surgery (adjusted odds ratio [aOR] for delayed surgery 0.68; 95% CI 0.53–0.88). Furthermore, these patients had a 42% reduced risk of post-injury sepsis (aOR 0.58; 95% CI 0.37–0.91). Mortality trends also favored higher-volume centers though were not explicitly detailed.
Sensitivity analyses confirmed similar protective associations for high blunt trauma volume (aOR 0.65; 95% CI 0.51–0.84) and total trauma volume (aOR 0.66; 95% CI 0.51–0.85) hospital classifications, supporting a volume-outcome relationship beyond just the injury-specific subset.
Expert Commentary
These findings align with prior trauma literature demonstrating improved outcomes at higher-volume centers, which typically have greater clinical expertise, multidisciplinary trauma teams, advanced diagnostic capabilities, and infrastructure geared towards rapid intervention.
The delay in diagnosing blunt intestinal injury is well-known due to nonspecific presentations and limitations of imaging, and such delays compound morbidity risks. Facilities managing a larger case volume likely benefit from streamlined protocols and clinical acumen that expedite diagnosis and surgery.
Limitations of the study include its observational nature and reliance on registry coding accuracy. Residual confounding by unmeasured variables such as patient socioeconomic factors, timing of hospital presentation, or specific surgeon expertise cannot be excluded. Additionally, data on exact diagnostic modalities and decision-making processes were unavailable.
However, the robust sample size and national scope lend substantial weight to the conclusions. Future research might evaluate targeted interventions at lower-volume centers, telemedicine support, and early transfer protocols to bridge gaps in care.
Conclusion
This study reveals a clear association between hospital trauma volume and time to surgical management in blunt intestinal injury, with high-volume centers achieving earlier surgery and lower sepsis rates. These results emphasize the importance of experienced trauma care environments and resource preparedness in managing this rare but complex injury. Ensuring access to high-volume trauma centers or enhancing capabilities at lower-volume hospitals may improve outcomes for these patients. Policymakers and trauma system architects should consider these findings when optimizing regional trauma care networks and referral pathways.
Funding and Clinical Trials
This study was conducted using a publicly available ACS-TQIP database and did not report external funding or clinical trial registration data.
References
1. Arda Y et al. Rare and Tricky: The Relationship Between Hospital Trauma Volume and Delay in Surgical Intervention in Blunt Intestinal Injury. Ann Surg. 2025 Dec 11;284(1):12-19. PMID: 41373107.
2. Clarke JR, Trooskin SZ, Implantation of clinical protocols in trauma care: volume-outcome relationships and implications. J Trauma. 2002;53(5 Suppl):S15-22.
3. Demetriades D, et al. The effect of trauma center designation and volume on outcome in severe trauma. J Trauma. 2001;51(4):676-80.
4. Stassen NA, et al. Blunt bowel and mesenteric injuries: don’t miss the diagnosis. J Trauma Acute Care Surg. 2012;72(3):555-66.
