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Impact of Interhospital Transfer on Outcomes for Trauma Patients: A Systematic Review

Hill, Andrea D. MSc; Fowler, Robert A. MD, MSc; Nathens, Avery B. MD, PhD

The Journal of Trauma: Injury, Infection, and Critical Care: December 2011 - Volume 71 - Issue 6 - p 1885-1901
doi: 10.1097/TA.0b013e31823ac642
Review Article

Background: Evidence suggests that there may be an association between transfer status (direct admission or interhospital transfer) and outcomes in trauma patients. The purpose of this study was to systematically review the current evidence of the association between transfer status and outcomes for patients.

Methods: Systematic search of Medline and EMBASE databases to identify eligible control trials or observational studies that examined the impact of transfer status on trauma patient outcomes. Data were extracted on study design, quality, participants, outcomes, and risk estimates reported. Pooled odds ratio based on data from retrieved studies was calculated using a random effect model.

Results: Thirty-six observational studies were identified. There were no significant differences in length of stay (LOS) between transfer and direct admissions although costs were marginally higher for transferred patients, (relative increase, 1.09; 95% confidence interval, 1.08–1.09). We found no significant association between transfer status (transfer vs. direct) and in-hospital mortality (pooled odds ratio, 1.06; 95% confidence interval, 0.90–1.25); however, heterogeneity of the studies was high (I 2 = 82%).

Conclusion: Available evidence suggests there is no difference in mortality between transfer and direct admissions. However, the significant heterogeneity across studies precludes deriving any definitive conclusions regarding the impact of interhospital transfer on mortality after major trauma. Moreover, most studies excluded patients dying at outlying hospitals, which may underestimate the association of transfer status with mortality. Prospective studies that address the limitations of the current evidence, including use of population-based trauma registries, are warranted to establish whether the process of interhospital transfer to higher level care when compared with direct admission to a trauma center negatively impacts clinical outcomes for trauma patients.

From the Department of Health Policy (A.D.H.), Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, Department of Medicine and Department of Critical Care Medicine (R.A.F.), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery (A.B.N.), University of Toronto, Toronto, Ontario; and The Keenan Research Centre in the Li Ka Shing Knowledge (A.B.N.), Institute of St. Michaels Hospital, Toronto, Ontario, Canada.

Submitted for publication August 20, 2010.

Accepted for publication September 30, 2011.

Supported by a Doctoral Fellowship from Canadian Institute for Health Research (to A.D.H.), an Ontario Ministry of Health and Long-term Care Clinician Scientist Award and a Heart and Stroke Foundation Phase II Clinician Scientist Award (to R.A.F.), and Canada Research Chair in System of Trauma Care (to A.B.N.).

Address for reprints: Andrea D. Hill, MSc, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, Canada; email:

Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.