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Scoop and Run to the Trauma Center or Stay and Play at the Local Hospital: Hospital Transfer's Effect on Mortality

Nirula, Ram MD, MPH, FACS; Maier, Ronald MD; Moore, Ernest MD; Sperry, Jason MD, MPH; Gentilello, Larry MD

Journal of Trauma-Injury Infection & Critical Care: September 2010 - Volume 69 - Issue 3 - pp 595-601
doi: 10.1097/TA.0b013e3181ee6e32
Original Article

Background: Triage attempts to ensure that severely injured patients are transported to a high-level trauma facility to reduce mortality. However, some patients are triaged to the nearest medical facility before transport to a final destination trauma center (TC). We sought to analyze whether initial triage of critically injured patients to a nontrauma center (NTC) is associated with increased mortality.

Methods: The Glue Grant Trauma Database of severely injured patients was analyzed. Mortality risk for patients who had an intermediate stop at another facility was compared with patients triaged directly from the scene to the TC. Patient demographics, time from injury to TC arrival, resuscitation volume, transfusions, head injury, initial systolic blood pressure, co-morbidities, and injury severity were included as confounders in a multivariate logistic regression model.

Results: There were 1,112 patients of whom 318 (29%) were initially triaged to an NTC. After adjusting for confounders, this was associated with an increase in prehospital crystalloids (4.2 L vs. 1.4 L, p < 0.05) and a 12-fold increase in blood transfusions (60% vs. 5%, p < 0.001). Age, injury severity score, Acute Physiology and Chronic Health Evaluation II score, and time from injury to TC arrival were independent predictors of mortality. The odds of death were 3.8 times greater (95% CI, 1.6–9.0) when patients were initially triaged to a nontrauma facility.

Conclusions: Triaging severely injured patients to hospitals that are incapable of providing definitive care is associated with increased mortality. Attempts at initial stabilization at an NTC may be harmful. These findings are consistent with a need for continued expansion of regional trauma systems.

From the Section of Burns/Trauma/Critical Care (R.N.), Department of Surgery, University of Utah, Salt Lake City, Utah; Department of Surgery (R.M.), University of Washington, Harborview Medical Center, Seattle; Department of Surgery (E.M.), Denver Health Medical Center, Denver, Colorado; Division of General Surgery and Trauma (J.S.), Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Department of Surgery (L.G.), UT Southwestern Medical Center, Dallas, Texas.

Submitted for publication April 14, 2009.

Accepted for publication June 23, 2010.

Presented at the 67th Annual Meeting of the American Association for the Surgery of Trauma, September 24–27, 2008, Maui, Hawaii.

Address for reprints: Raminder Nirula, MD, MPH, University of Utah, 30 North 1900 East, SOM, Room No. 3A328G, Salt Lake City, UT 84132; email: r.nirula@hsc.utah.edu.

© 2010 Lippincott Williams & Wilkins, Inc.