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Institutional and provider factors impeding access to trauma center care: An analysis of transfer practices in a regional trauma system

Gomez, David MD, PhD; Haas, Barbara MD, PhD; de Mestral, Charles MD; Sharma, Sunjay MD; Hsiao, Marvin MD; Zagorski, Brandon MS; Rubenfeld, Gordon MD, MSc; Ray, Joel G. MD, MSc; Nathens, Avery B. MD, PhD

Journal of Trauma and Acute Care Surgery: November 2012 - Volume 73 - Issue 5 - p 1288–1293
doi: 10.1097/TA.0b013e318265cec2

BACKGROUND More than a third of patients with severe injury who receive initial care at nontrauma centers (NTCs) are not transferred to trauma center care. In those who are transferred, significant delays have been described. The availability of specialists, imaging modalities, or critical care resources might significantly affect transfer practices.

METHODS We undertook a population-based retrospective cohort study of adult patients with severe injury who were transported from the scene to an NTC. NTCs were characterized based on the availability of general and orthopedic surgeons, computed tomographic scanners, intensive care units, and emergency department staffing. NTCs that had all of the resources were characterized as resource rich, while those with none were characterized as resource limited. We evaluated the relationships between NTC resources and the likelihood and timeliness of interfacility transfer through the use of hierarchical regression modeling.

RESULTS We identified 15,906 patients with severe injury across 192 NTCs (22% were resource limited, 57% were resource intermediate, and 21% were resource rich). Patients at resource rich centers, as compared with those at resource limited centers, were less likely to be transferred (27% vs. 50%, p < 0.001). This association persisted after adjustment for confounders (odds ratio, 0.66; 95% confidence interval, 0.47–0.92). Among patients who were transferred, median emergency department length of stay (ED-LOS) was 3.5 hours (interquartile range, 1.7–4.6 hours). However, ED-LOS varied significantly because resource rich centers had a greater proportion of patients experiencing prolonged ED-LOS when compared with resource limited centers (31% vs. 15%, p < 0.001). This association also persisted on multivariable analysis (odds ratio, 2.02; 95% confidence interval, 1.19–3.43).

CONCLUSION Severely injured patients who received initial care in resource rich NTCs were less likely to be transferred to a trauma center compared with resource limited NTCs. Significant delays in the transfer process were identified. However, patients transferred from resource rich centers were more likely to experience prolonged ED-LOS compared with resource limited NTCs.

LEVEL OF EVIDENCE Epidemiologic study, level II.

From the Division of General Surgery (D.G., B.H., C.D., M.H., A.B.N.), Department of Surgery, and Sunnybrook Health Sciences Centre (G.R.), Department of Medicine, University of Toronto, Toronto; Keenan Research Centre (D.G., B.H., C.D., S.S., M.H., J.R., A.B.N.), Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto; Institute for Clinical Evaluative Sciences (B.Z., J.R., A.B.N.), Toronto, Ontario, Canada.

Submitted: January 8, 2012, Revised: June 16, 2012, Accepted: June 19, 2012, Published online: August 23, 2012.

This study was presented in part as a poster at the 70th Annual Meeting of theAmerican Association for the Surgery of Trauma, Chicago, Illinois, on September 2011.

Reprints will not be available

Author correspondence: David Gomez, MD, 30 Bond St, Queen Wing 3-076, Toronto, Ontario, Canada, M5B1W8; email:

© 2012 Lippincott Williams & Wilkins, Inc.