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Multiregion Trauma Center Follow-Up Protocol for Transferred Trauma Patients

Moran, Mary E. PhD; Moore, Deanah AAS; Krizo, Jessica PhD; Keefe, Judy MSM-HC, BSN; Houck, Olivia C MPH; Rossler, Danielle N. BSN; George, Richard L. MD, MPH

Author Information
doi: 10.1097/JTN.0000000000000643
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American College of Surgeons (ACS) Committee on Trauma (ACS-COT)-verified trauma centers participate in performance improvement. This process is a mechanism for continuous improvement for the care of the injured patient (ACS-COT, 2014). When a patient transfer occurs within a single hospital system, patient data are available for review between transferring and receiving facilities. But when patients are transferred outside of the hospital system, access to secondary encounter information may not always be available, compromising performance improvement (Bradley et al., 2017; Colson et al., 2020; Coniglio et al., 2018; Pidgeon, 2015). To address this, the ACS requires Level I trauma centers to send feedback to referring institutions (Rae & Bulger, 2015).

The Injury Severity Score (ISS) is the gold standard for evaluating injury severity and is commonly utilized in case reviews (Shi et al., 2019). Without final patient injuries and ISS, transfer facilities cannot complete a comprehensive case review (Lecky et al., 2014). Trauma transfers often occur before all injuries can be identified, leading to artificially low ISSs. The value in linking pre- and posttransfer data for more accurately assessing patient outcomes has been documented (Coniglio et al., 2018). However, a process for sharing posttransfer outcomes with the referring facility requires a level of coordination between facilities that often does not exist (Holena et al., 2020).

Currently, no systematic protocol is defined to allow injuries identified posttransfer to be entered into the trauma registry separately (Lecky et al., 2014). Data integrity is critical to accurately calculate the ISS (Deng et al., 2016; Huang et al., 2019; Javali et al., 2019; Lovely et al., 2018; Shi et al., 2019). To allow for loop closure and assist in performance improvement, receiving facilities need to provide additional new follow-up diagnoses to the transferring facilities. However, if these revised diagnoses are entered in the registry at the transferring facility, the ISS would reflect the completed workup rather than the workup conducted prior to transfer. It is important that the ISS created for the completed workup is created as a secondary field. There is minimal literature regarding protocols that have provided consistent patient follow-up for patients transferred to external health care systems. One approach that can promote process improvement for transferred trauma patients is a standardized follow-up feedback process (Byrnes et al., 2010). Software-based solutions to feedback limitations that included automated letters had early success (Colson et al., 2020). To our knowledge, there is no published literature on the regional implementation of standardized reports between facilities.


  1. Collaboration with multiple regional trauma systems can develop and implement a feedback protocol.
  2. Utilizing a template can result in standardized follow-up information for transferred patients.
  3. Injury Severity Scores from transferring facilities can assist in performance improvement.


The purpose of this project was to create a standardized ISS follow-up feedback protocol for transferred trauma patients within a multiregional trauma network comprising several health systems.



This project was a multiregion effort of ACS-accredited trauma centers that used one of two trauma registry software systems to develop and implement a protocol for feedback for transferred trauma patients. The project included three regional trauma systems within a Midwestern state that included Level I, II, and III trauma centers within each region. There were seven Adult Level I, one Pediatric Level I, four Adult Level II, four Pediatric Level II, and nine Adult Level III trauma centers that participated. A workgroup was created with representation of each regional trauma system to design the protocol. The group comprised a trauma medical director, a trauma program manager, three regional data managers, and a trauma research expert.


The workgroup identified the use of standardized follow-up feedback letters as a viable mechanism for loop closure. Trauma vendors were consulted to ensure standardization across regions. Trauma registry fields were identified to populate the ISS follow-up feedback letter (Figure 1). In addition, a transferring facility diagnosis table was built into the registry to enter the final diagnoses. The transferring facility diagnosis table collected International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), ICD-10-CM Description, and Abbreviated Injury Score (AIS) code assigned by the transferring facility. Finally, a standardized ISS follow-up feedback letter template was provided to participating trauma centers.

Figure 1.:
Follow-up feedback letter template. AIS = Abbreviated Injury Score; DOB = date of birth; Dx = diagnosis; ICD-10 =International Classification of Diseases, Tenth Revision; OR = operating room.

Injury Diagnosis Known Data Element

A new field, Injury Diagnosis Known, was developed to assist both referring and receiving facilities with their performance improvement process. This field provides all injury diagnoses and the source of the diagnosis (referring, receiving, or autopsy). This field is utilized in the ISS follow-up feedback letter.

ISS Follow-Up Feedback Letter

The data extracted from the registry auto-populates the ISS follow-up feedback letter template, including injury data, data source, and final ISS. Per the ISS follow-up feedback protocol, the transferring facility auto-populates the letter and sends it to the transferring facility to enter the injury information into the additional transferring facility diagnosis table.

Transferring Facility Diagnosis Table

The transferring facility diagnosis table was created to allow the transferring facility to add any diagnoses identified at the receiving facility to the registry. This process allows the transferring facility to collect, compare, and analyze the patient's final diagnosis and ISS.


Project Impact

This project was widely accepted among participants. Anecdotal feedback revealed several benefits related to the ISS follow-up feedback protocol from both the transferring and receiving facilities. The time needed to prepare letters was reduced with the template. Prior to implementation, there were concerns regarding increased workloads. So autofill capabilities were included in the transferring facility diagnosis table for the information provided in the feedback letter to address these concerns. In addition, ISS was automatically calculated with AIS autofilled from the feedback letter. These data collection automations helped minimize additional workload to the trauma center staff.

Unintended Consequences

The use of multiple trauma registry vendors within the three regional trauma systems led to a complication within the project. One region successfully developed the registry fields and follow-up letter template. Other regions, working with a separate trauma registry vendor, could not support the development of additional fields without incurring significant costs. Ultimately, these facilities were unable to incorporate the additional diagnosis table but did participate by including the remaining information in their existing follow-up feedback.


This multiregion project allows transferring trauma centers to receive standardized and timely feedback, including updated injury diagnoses, which allows for the calculation of an updated ISS. This process is critical to the improvement processes at the transferring facility (Huang et al., 2019; Javali et al., 2019; Lovely et al., 2018). Anecdotal reports suggest the ISS follow-up feedback protocol has been successful and has not been overly burdensome to hospital staff.

The goal of this project was to communicate patient injury details from the receiving facility to the transferring facility. Additional injuries were able to be identified at the transferring facility on the basis of the standardized follow-up letters. Transferring this information allows for performance improvement at transferring trauma centers. Systematic evaluation of transfers in the performance improvement process allows transferring facilities to evaluate institutional guidelines and protocols (Rae & Bulger, 2015) as a standard component in improving patient care.


The goal of this project was to communicate patient injury details from the receiving facility to the transferring facility. An automated letter from receiving facility was used to create an updated ISS for transferring facilities. Challenges included software variances and workload concerns. Next steps include further evaluation of the protocol with the goal of implementation at the state level.


Member Trauma Centers of Northeast Ohio Regional Trauma Network (NORTN), Northern Ohio Trauma System (NOTS), and Northwest Ohio Regional Trauma Registry (NORTR) made substantial conceptual contributions to the project.


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Feedback; Injury Severity Score; Patient Transfer; Performance Improvement; Referral; Trauma Center; Trauma Registry

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