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The Effect of Interfacility Transfer on Outcome in an Urban Trauma System

Nathens, Avery B. MD, PhD, MPH; Maier, Ronald V. MD; Brundage, Susan I. MD, MPH; Jurkovich, Gregory J. MD; Grossman, David C. MD, MPH

The Journal of Trauma: Injury, Infection, and Critical Care: September 2003 - Volume 55 - Issue 3 - p 444-449
doi: 10.1097/01.TA.0000047809.64699.59

Background  Transporting all trauma patients to regional trauma centers is inefficient; however, the bypass of nearer, nondesignated hospitals in deference to regional trauma centers decreases mortality in the severely injured. One approach to improving efficiency is to allow the initial assessment of selected patients at lower level (Level III/IV) designated centers. We set out to evaluate whether patients initially assessed at these centers and then transferred to a Level I facility were adversely affected by delays to definitive care.

Methods  This is a retrospective cohort study in which the primary exposure being evaluated is initial assessment at a Level III or IV trauma center before transport to a Level I center in an urban setting. The outcomes in this transfer cohort were compared with outcomes in patients transported directly from the scene to a Level I center (direct cohort). The outcomes of interest were mortality, length of stay, and hospital charges. Multivariate analyses were used to adjust for differences in baseline characteristics across these two cohorts.

Results  Crude length of stay was comparable, whereas mortality was lower and charges were 40% higher in the transfer cohort (n = 281) compared with the direct cohort (n = 4,439). After adjusting for confounders, mortality and length of stay were similar and total charges were significantly greater in the transferred patients.

Conclusion  Interfacility transfers in a mature urban trauma system do not appear to impact on clinical outcome. However, transfer patients use significantly greater resources as measured by hospital charges. This effect is likely because of the nature of their injuries or, alternatively, delays in reaching definitive care.

From the Division of General and Trauma Surgery, Harborview Medical Center (A.B.N., G.J.J.), Department of Surgery (A.B.N., G.J.J.) and Harborview Injury Prevention and Research Center (A.B.N., R.V.M., G.J.J., D.C.G.), University of Washington, Seattle, Washington, and Department of Surgery, Baylor College of Medicine (S.I.B.), Houston, Texas.

Submitted for publication May 22, 2002.

Accepted for publication October 28, 2002.

Supported by grant R49/CCR002570 from the Centers for Disease Control and Prevention.

Address for reprints: Avery B. Nathens, MD, Harborview Medical Center, Box 359796, 325 Ninth Avenue, Seattle, WA 98104-2499; email:

© 2003 Lippincott Williams & Wilkins, Inc.