Trauma systems and timing of patient transfer: are we improving?

The regionalization of trauma services is based on the premise that injured persons presenting to nontertiary facilities will be stabilized and rapidly transported to a more definitive center. Although trauma systems seem to improve outcomes for urban patients, this same benefit has not been shown for rural patients. There are many factors associated with the decision to transfer injured patients to a regional trauma center, including referral hospital and patient age, for example. The purpose of this study is to examine factors that influence the timing of transfer of trauma patients and specifically to determine if establishing specific trauma systems has led to any changes in transfer timing over time.

The trauma registry at the University of Wisconsin was queried for all patients admitted between July 1, 1999, and June 30, 2005. Patients were included in this study if they had been transferred to the university hospital after evaluation at an outside hospital. The registry variables that were abstracted were age, referring hospital, emergency department (ED) time at referring hospital, injury severity score (ISS), the presence of a head injury, performance of a head computed tomography (CT), mode of transport, and the date of ED evaluation.

There were 1656 patients with ISS higher than 9 transferred during the period. The mean ED time was 153 +/- 82 minutes. Emergency department time was significantly shorter for those with ISS higher than 25 and for those transported by helicopter. Four hundred ninety-two (30%) patients had a head CT performed at the outside hospital, of which 221 (44%) were repeated at the trauma center. The mean ED time for those in whom a CT was performed was significantly longer than those without CT (179 +/- 81 vs 142 +/- 84 minutes). The ED times were slightly longer for level III hospitals (158 +/- 82 minutes) than for level IV hospitals (137 +/- 74 minutes). Emergency department times were longer for older patients. The times in the ED showed an upward, but not statistically significant, trend. After controlling for all other variables, ED times were not significantly different over the period studied.

Development of a statewide trauma system and outreach education has not significantly affected transfer times from nontrauma centers in our system. Outreach educational efforts should focus on systematic trauma evaluation, prompt transfer, and limitation of nontherapeutic testing.