title: Exploring the characteristics of high-performing hospitals that influence trauma triage and transfer.
abstract: BACKGROUND
  Many trauma patients might be first cared for at nondesignated centers before transfer to a trauma center. Limited research has investigated determinants of timely triage and transfer to identify those amenable to quality improvement. This study explored factors influencing timely triage and transfer in a regional trauma system.
  
  
  METHODS
  Centers (n = 15) with both long and short transfer times (emergency department length of stay before transfer) in Ontario were identified using a regional trauma registry. Physicians and nurses in these centers were interviewed with a view to determining factors that either impeded or enabled rapid decisions regarding the need for transfer to a trauma center. A grounded theory approach and constant comparative technique were used to collect and analyze data.
  
  
  RESULTS
  Nineteen physicians and eight nurses participated. Clinician level (experience, training, personality, fear of judgment, nursing role), institutional level (guidelines, continuing education, trauma infrastructure, human resources) and system-level (bed availability, referral center, air transport, communication with trauma centers) factors influenced timely decision making. Participants offered several recommendations to improve care. These included guidelines for transfer, a "no refusal" policy at trauma centers, improved air transport and referral center services, as well as further regionalization. Additional features of hospitals with shorter transfer times included coaching of new staff, team meetings, leadership engagement, sharing of performance data, and minimum work hours for physicians.
  
  
  CONCLUSIONS
  Numerous interacting factors that may influence trauma triage and transfer were identified. These findings can be used by policy makers, health care managers, and clinicians in emergency departments or trauma centers to evaluate and improve trauma triage and transfer, or plan new services. The findings can also be used by researchers to examine the relevance of these factors in other settings or to implement and evaluate the impact of interventions informed by recommendations generated here.
authors.affiliation: From the Toronto General Research Institute (A.R.G.), University Health Network; and Division of General Surgery (A.B.N.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
authors.forename: Anna R
authors.initials: AR
authors.lastname: Gagliardi
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D003657:Decision Making; D006801:Humans; D007407:Interviews as Topic; D009864:Ontario; D010360:Patient Transfer / Q000592:standards*; D036301:Qualitative Research; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014218:Triage / Q000592:standards*