title: Surgical trauma referrals from rural level III hospitals: should our community colleagues be doing more, or less?
abstract: BACKGROUND
  Rural citizens die more frequently because of trauma than their urban counterparts. Skill maintenance is a potential issue among rural surgeons because of infrequent exposure to severely injured patients. The primary goal was to evaluate the outcomes of multiple injuries patients who required a laparotomy after referral from level III trauma centers.
  
  
  METHODS
  All severely injured patients (injury severity score >12) referred to a level I trauma center from level III hospitals, during a 48-month period were evaluated. Comparisons between referrals (level III and IV) as well as survivors and nonsurvivors used standard statistical methodology.
  
  
  RESULTS
  One thousand two hundred and thirty patients (35%) were transferred from level III (33%) and level IV (67%) centers (43% underwent an operative procedure). Only 13% required a laparotomy, whereas 87% needed procedures from other subspecialists. Referred patients had a mean injury severity score of 28, length of stay of 28 days, and mortality rate of 26%. More patients arrived hemodynamically unstable from level IV (55%) versus level III (35%) hospitals (p < 0.05). Nonsurvivors from level III centers were more likely to transfer via aircraft (100%) than from level IV hospitals (55%) (p < 0.05). Most (91%) definitive general surgery procedures could have been completed by surgeons at level III centers; however, 90% also had multisystem injuries requiring treatment by other subspecialists.
  
  
  CONCLUSIONS
  Most severely injured patient referrals from level III and IV trauma centers in Western Canada are appropriate. The lack of consistent subspecialty coverage mandates most transfers from level III hospitals. This data will be used to engage rural Alberta physicians in an educational outreach program.
authors: Department of Surgery, Grady Memorial Hospital, Atlanta, Georgia, USA. ball.chad@gmail.com
authors: Chad G
authors: CG
authors: Ball
authors: Francis R
authors: FR
authors: Sutherland
authors: Elijah
authors: E
authors: Dixon
authors: David V
authors: DV
authors: Feliciano
authors: Indraneel
authors: I
authors: Datta
authors: Ravi R
authors: RR
authors: Rajani
authors: Scott
authors: S
authors: Hannay
authors: Anthony
authors: A
authors: Gomes
authors: Andrew W
authors: AW
authors: Kirkpatrick
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006780:Hospitals, Rural / Q000458:organization & administration*; D006801:Humans; D007813:Laparotomy / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000401:mortality / Q000601:surgery*; D012017:Referral and Consultation / Q000458:organization & administration*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014193:Trauma Centers / Q000706:statistics & numerical data*; D055815:Young Adult