The Victorian major trauma transfer study.
OBJECTIVE
To comprehensively examine the inter-hospital transfer of major trauma patients-including the reason for transfer, duration, escorts, interventions and unexpected events.


METHODS
This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form.


RESULTS
A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min. Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%). Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p<0.001). Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p<0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p<0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p<0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p=0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p=0.001).


CONCLUSIONS
Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.
Zalstein
Salomon
S
Emergency Department, Bendigo Health, Bendigo Hospital, PO Box 126, Bendigo, Victoria 3552, Australia. solzalstein@bendigohealth.org.au
Danne
Peter
P
Taylor
David
D
Cameron
Peter
P
McLellan
Susan
S
Fitzgerald
Mark
M
Kossmann
Thomas
T
Patrick
Ian
I
Walker
Tony
T
Crameri
Joe
J
Bailey
Michael
M
Magilton
Gay
G
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000552:Ambulances / Q000458:organization & administration / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D004282:Documentation / Q000592:standards; D004632:Emergency Medical Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D004634:Emergency Medical Technicians; D004638:Emergency Treatment / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D006753:Hospital Records; D006801:Humans; D007223:Infant; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009740:Nursing Staff; D010360:Patient Transfer / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000458:organization & administration / Q000706:statistics & numerical data; D019035:Rural Health Services; D013997:Time Factors; D014187:Transportation of Patients / Q000458:organization & administration / Q000592:standards; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D019037:Urban Health Services; D014739:Victoria; D000078329:Workforce; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*; D055815:Young Adult