Association of Outcomes with Time to Transfer among Trauma Patients

Trauma systems are designed to achieve the best outcomes for injured patients by establishing triage procedures to assign patients to appropriate levels of care, defining patterns for transport both prehospital and interhospital, and educating caregivers to recognize actual and potentially life-threatening injuries that exceed the treatment capabilities of local resources and require transfer for definite care. Particularly in rural trauma centers, long delays in transferring patients to higher levels of care are deemed undesirable and are associated with inferior outcomes; however, when stabilization is achieved at the local care level, time to transfer has not been shown to have an impact on survival. An Injury Severity Score (ISS) is a strong predictor of mortality. By statute, the trauma system in the state of Illinois defines a 2-hour transfer window in ensure timely transfer of patients and provision of definitive care. However, according to researchers, transfer criteria are not well described and there have been observed deviations from this requirement. A retrospective review study was conducted recently to evaluate compliance with the 2-hour transfer rule and to characterize patient profiles of severity and outcomes, stratified by compliance. The researchers also sought to characterize severity profiles for patients transferred at <2 and >2 hours, and determine whether compliance or noncompliance with the 2-hour rule had any effect on patient outcome. Study results were reported in Archives of Surgery [2010;145(12):1171-1175]. The primary outcome measures were time to transfer, ISS score, mortality and time to operating room at the second facility; the variables were then stratified by time to transfer. Data were gathered from the Illinois State Trauma Registry (ISTR) from 1999 to 2003 on trauma patients who underwent interfacility transfer and those who did not. The ISTR includes data from 64 trauma centers at 62 hospitals in Illinois. The current study utilized data on 3 groups of patients: all trauma patients; patients transferred to another facility on the same day of injury at >2 hours; and patients transferred within 2 hours of arrival after injury. There were 22,447 interfacility transfers during the study period; however, data about time to transfer was available in 50% to 60% of cases per year. Overall transfer rate was 10.4%; 20% of the transfers occurred with 2 hours. Median transfer time over the study period was 2 hours 21 minutes. For all years in the study period, the ISS was higher for all transferred patients and significantly higher for patients transferred within 2 hours. Among patients transferred within 2 hours, the proportion of patients who underwent surgery on the day of transfer was higher compared with all trauma patients who underwent surgery at any time during hospitalization and patients transferred on the same day of injury >2 hours of arrival after injury. For any year in the study period, the most commonly transferred patients were those with head injuries or orthopedic injuries. Craniotomies and craniectomies were more common among patients transferred within 2 hours; however, <50% of those procedures occurred on the day of transfer. Compared with the total trauma cohort, orthopedic, vascular, abdominal, and thoracic procedures were not more common among the cohort of patients transferred within 2 hours. In comparison with all trauma patients or with other same-day transfers, the proportion of self-pay patients was greater among those transferred within the first 2 hours. Also, unadjusted mortality was higher each year for patients who were transferred within 2 hours; those transferred after the first 2 hours had mortality rates similar to the cohort that included all trauma patients. In summary, the researchers noted that there was poor compliance with the 2-hour transfer mandate, but the most severely injured patients were identified and transferred within the mandated time. “Of greater note may be the nature of transfers from level I to level II centers that appear to be predicated on factors unrelated to injury severity and associated with a perceived reluctance to treat locally. Regulation of transfer indication, rather than time to transfer, may be more beneficial to the system as a whole,” the authors commented.