The influence of inter-hospital transfers on mortality in severely injured patients

Abstract

Purpose The importance of treating severely injured patients in higher-level trauma centers is undisputable. However, it is uncertain whether severely injured patients that were initially transported to a lower-level trauma center (i.e., undertriage) benefit from being transferred to a higher-level trauma center. Methods This observational study included all severely injured patients (i.e., Injury Severity Score ≥ 16) that were initially transported to a lower-level trauma center within eight ambulance regions. The exposure of interest was whether a patient was transferred to a higher-level trauma center. Primary outcomes were 24-h and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed to evaluate the association between transfer status and mortality. Results We included 165,404 trauma patients that were transported with high priority to a trauma center, of which 3932 patients were severely injured. 1065 (27.1%) patients were transported to a lower-level trauma center of which 322 (30.2%) were transferred to a higher-level trauma center. Transferring undertriaged patients to a higher-level trauma center was significantly associated with reduced 24-h (relative risk [RR] 0.26, 95%-CI 0.10–0.68) and 30-day mortality (RR 0.65, 0.46–0.92). Similar results were observed in patients with critical injuries (24-h: RR 0.35, 0.16–0.77; 30-day: RR 0.55, 0.37–0.80) and patients with traumatic brain injury (24-h: RR 0.31, 0.11–0.83; 30-day: RR 0.66, 0.46–0.96). Conclusions A minority of the undertriaged patients are transferred to a higher-level trauma center. An inter-hospital transfer appears to be safe and may improve the survival of severely injured patients initially transported to a lower-level trauma center.

Accuracy of Prehospital Triage of Adult Patients With Traumatic Injuries Following Implementation of a Trauma Triage Intervention

“…29 Also, the intervention was associated with improved chances of survival for patients, as we found a significant decrease of death within the first days of admission. Further research in which interhospital transfers are taken into account, as these are known to affect chances of survival, 30 is needed to determine definite triage rates and draw conclusions regarding the association of the intervention with mortality.…”

“…29 Also, the intervention was associated with improved chances of survival for patients, as we found a significant decrease of death within the first days of admission. Further research in which interhospital transfers are taken into account, as these are known to affect chances of survival, 30 is needed to determine definite triage rates and draw conclusions regarding the association of the intervention with mortality. b The TT app advised transport to a higher-level trauma center when the calculated probability was greater than the chosen threshold or when the EMS professional selected that higher-level trauma care was indicated.…”

Review article: Emergency medical services transfer of severe traumatic brain injured patients to a neuroscience centre: A systematic review

“…The seven reviewed studies had a combined total of 53 365 patients (Table 1). Two were undertaken in the US, 1,11 two in the Netherlands, 8,16 one in England, 17 one in Sweden 18 and the last in Taiwan. 19 Two were prospective observational studies, four were retrospective observational studies and the last was a feasibility study for a randomised control trial (RCT).…”

“…The earliest was completed in 2010, 19 the most recent in 2023. 16 Study periods ranged from 1 to 6 years. They each assessed mortality as an outcome, but non-measured mortality over a consistent period (Table 2).…”

“…16 The study including paediatric cases enrolled 1065 patients and did not separate the outcomes between adults (≥18, n = 1037) from paediatrics (<18; n = 28). 16 As the paediatric population represented less than 3% of all patients, the paper was included. Across the studies, the median age ranged from 48 to 69.5 years.…”