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Direct Transport to Tertiary Trauma Centers versus Transfer from Lower Level Facilities: Impact on Mortality and Morbidity among Patients with Major Trauma

Sampalis, John S. PhD; Denis, Ronald MD; Frechette, Pierre MD; Brown, Rea MD; Fleiszer, David MD; Mulder, David MD

The Journal of Trauma: Injury, Infection, and Critical Care: August 1997 - Volume 43 - Issue 2 - p 288-296

Background  The purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals.

Methods  The data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly.

Results  The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures.

The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003).

Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay (transfer, 2.0 days; direct, 0.95 days; p = 0.001).

Conclusion  The results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential.

From the Montreal General Hospital (J.S.S., R.B., D.F., D.M.), the Sacre-Coeur Hospital (R.D.), and the Enfant-Jesus Hospital (P.F.), Montreal, Quebec, Canada.

This study was supported by the National Health Research Development Programme of Canada. J.S.S. was supported by the Medical Research Council of Canada.

Presented at the 56th Annual Meeting of the American Association for the Surgery of Trauma, September 19-21, 1996, Houston, Texas.

Address for reprints: John S. Sampalis, PhD, Department of Surgery and Division of Clinical Epidemiology, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.

© Williams & Wilkins 1997. All Rights Reserved.