title: Effect of an organizational change in a prehospital trauma care protocol and trauma transport directive in a large urban city: a before and after study.
abstract: BACKGROUND
  Trauma systems and regionalized trauma care have been shown to improve outcome in severely injured trauma patients. The aim of this study was to evaluate the implementation of a prehospital trauma care protocol and transport directive, and to determine its effects on the number of primary admissions and secondary trauma transfers in a large Scandinavian city.
  
  
  METHODS
  We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County; patients > 15 years of age with an Injury Severity Score (ISS) > 15 transported to any emergency care hospitals in the Stockholm area were included for the years 2006 and 2008. We also included secondary transferred patients to the regional trauma center during 2006, 2008, and 2013.
  
  
  RESULTS
  A total of 693 primarily admitted trauma patients were included for the years 2006 and 2008. For the years 2006, 2008 and 2013, we included 114 secondarily transported trauma patients. The number of primary patient transports to the trauma center increased during the years by 20.2%, (p < 0.001); patients primarily transported to the trauma center had a significantly higher Injury Severity Score in 2008 than in 2006, and the number of patients transported secondarily to the trauma center in 2006 was higher compared to 2008 and to 2013 (p < 0.001, all 3 years).
  
  
  CONCLUSIONS
  Our data indicate that implementation of a prehospital trauma care protocol may have an effect on transportation of severely injured trauma patients. A decrease in secondarily transported trauma patients to the regional trauma center was noted after 1 year and persisted at 7 years after the organizational change. Patients primarily admitted to the trauma center after the change had more severe injuries than patients transported to other emergency hospitals in the area even if 20 % of patients were not admitted primarily to a trauma center. This does not imply that the transport directives or the criteria were not followed but rather reveals the difficulties and uncertainties of field triage.
  
  
  CONCLUSIONS
  With the introduction of a prehospital trauma transport directive in a large urban city, an increase in patients transported to the regional trauma center and a decrease in secondary transfers were detected, but a considerable number of severely injured patients were still transported to local hospitals.
authors.affiliation: Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE-118 83, Sweden. rebecka.rubenson.wahlin@ki.se.|Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, SE-118 83, Sweden. rebecka.rubenson.wahlin@ki.se.
authors.forename: Rebecka
authors.initials: R
authors.lastname: Rubenson Wahlin
authors.affiliation: Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE-118 83, Sweden.
authors.forename: Sari
authors.initials: S
authors.lastname: Ponzer
authors.affiliation: Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, FI-00029 HUS, Finland.
authors.forename: Markus B
authors.initials: MB
authors.lastname: Skrifvars
authors.affiliation: Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE-118 83, Sweden.|Field of Prehospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, Stavanger, NO, 4036, Norway.
authors.forename: Hans Morten
authors.initials: HM
authors.lastname: Lossius
authors.affiliation: Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, SE-118 83, Sweden.|Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, FI-00029 HUS, Finland.
authors.forename: Maaret
authors.initials: M
authors.lastname: Castrén
mesh_terms: D000328:Adult; D000368:Aged; D003422:Critical Care; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009936:Organizational Innovation; D012189:Retrospective Studies; D013548:Sweden; D014187:Transportation of Patients / Q000458:organization & administration*; D014505:Urban Population; D014947:Wounds and Injuries / Q000628:therapy*