Regional Relationships and Transfer of Patient Care

Jordan A. Weinberg

Loring W. Rue III

Ideally, any patient sustaining a significant injury would be promptly transported to a hospital capable of providing immediate and comprehensive trauma care. In reality, however, patients are often taken to facilities that have neither the expertise nor resources to manage complex or life-threatening injuries. As an example, in the Birmingham, Alabama region (population 1.2 million), before the development of a regional trauma system, 60% of patients meeting physiologically unstable trauma triage criteria of the American College of Surgeons were being transported to hospitals that lacked any organized trauma response.¹ The development of regional trauma systems, both in Alabama and across the nation, has helped to improve field triage, whereby critically injured patients may be transported directly to designated trauma centers, possibly bypassing closer nontrauma hospitals. There are still circumstances, however, where patients will arrive at facilities incapable of providing definitive treatment. This may be intentional, owing to logistic concerns regarding weather or transport time (particularly in rural scenarios), or unintentional, as a result of field undertriage or arrival of the patient by private vehicle. Interhospital transfer of such patients to centers with the capability of rendering definitive care is therefore necessary, and the benefit of the efficient handling of such transfers is obvious. In this chapter, the process of interhospital transfer is reviewed, both within the context of well-developed trauma systems and outside of such systems. The impact of the US federal regulations as outlined in the Emergency Medical Treatment and Labor Act (EMTALA) on the interhospital transfer of trauma patients is also discussed.

REGIONAL RELATIONSHIPS

Before the development of trauma centers, victims of injury were generally transported to the closest hospital to the scene. Over time, specific hospitals (most commonly university hospitals) developed expertise and dedicated resources to trauma, realizing the development of the “trauma center.” Formal designation of hospitals as trauma centers was spearheaded by the American College of Surgeons Committee on Trauma (ACSCOT), as outlined in the guideline, Optimal Hospital Resources for the Care of the Seriously Injured, published in 1976.² Despite the development of trauma centers, patients were still being transported to nondesignated hospitals, necessitating interhospital transfer to a trauma center when the patient’s injuries overwhelmed the capabilities of the nondesignated hospital. Protocols for interhospital transfer, however, were uncommon, making for an onerous and inefficient process. This reflected the need for improved interhospital cooperation within a region to better deliver injured patients to appropriate facilities in a timely manner.

The concept of the regional trauma system then evolved, whereby the varying facilities within a defined geographic region would form a hospital network to provide care
for patients injured within that region. Fundamental to this concept is the classification of hospitals within a region according to their level of expertise and available resources for the care of the injured patient. ACSCOT established well-defined trauma center designations, from Level I centers, which act as the region’s lead hospital for the system, through Level IV centers, which can provide initial evaluation and resuscitation of injured patients, but will generally require transfer of most patients to higher level centers (see Table 1).

The evidence concerning the effectiveness of trauma systems is largely retrospective, but is becoming increasingly robust. Mann et al. performed a systematic review of the literature in 1999 and concluded that a 15% to 20% decrease in mortality is observed following the implementation of a regional trauma system.³ Subsequently, Nathens et al. observed an 8% motor vehicle crash mortality reduction following trauma system implementation.⁴ They also noted a lag effect; that is, the mortality reduction was not realized until 10 years following system implementation. Utter et al. recently analyzed survival according to the extent of hospital participation within a trauma system and found that survival was greater in more “inclusive” systems although patients were no more likely to be hospitalized at a regional trauma center.⁵

TABLE 1 DESCRIPTION OF AMERICAN COLLEGE OF SURGEONS TRAUMA CENTER LEVELS

Trauma Center Level	Description
I	▪	Full range of specialists and equipment available 24 hr/d
	▪	Minimum annual volume of patients
	▪	Leader in trauma education and injury prevention
	▪	Conducts trauma-related research
II	▪	May exist to supplement Level I center in population-dense area, or may serve as lead trauma center in relatively less population-dense region
	▪	24 hr/d availability of all specialties and equipment
III	▪	Capability to initially manage majority of injured patients
	▪	Continuous surgical coverage
	▪	Maintains transfer agreements with Level I and/or II centers for patients whose needs exceed resources of Level III facility
IV	▪	24 hr/d emergency department coverage
	▪	Specialty coverage may or may not be available
	▪	Provides initial evaluation and resuscitation, but most patients will require transfer to higher level center
Adapted from Committee on Trauma, American College of Surgeons. Resources for optimal care of the injured patient 2006. Chicago: American College of Surgeons; 2006.

Coordination of field triage is a fundamental aspect of a trauma system, and is typically centrally directed. An example of such a system is the Birmingham Regional Emergency Medical Services System, the trauma system for North Central Alabama. Its Trauma Communications Center (TCC) serves as the coordinating command center for prehospital personnel. The TCC tracks the trauma capacity of all participating hospitals in real time, using a computer-linked modem system, with the goal of avoiding situations where a particular facility may be overwhelmed with a surge of incoming patients. Prehospital personnel arrive at the scene and determine, with guidance from the TCC, whether the injured patient should be entered into the trauma system based on well-developed criteria (primary triage). These criteria are generally based on physiologic/clinical parameters, mechanism of injury, and anatomic factors (e.g., penetrating injury to torso). Secondary triage is then performed, in conjunction with the TCC, whereby the severity of injury, geographic concerns, and hospital capacities are taken into account. The secondary triage status then determines the hospital destination (i.e., closest Level III center vs. regional Level I center).

INTERHOSPITAL TRANSFER

Whether in the setting of a mature statewide trauma system, with well-developed field triage protocols, or in the setting where no system exists, it is inevitable that patients will be transported initially to centers incapable of providing definitive care, owing to lack of hospital resources and/or specialist expertise. Interhospital transfer to a facility with the required capabilities must then be initiated. Patient outcomes benefit when this process is efficient and well coordinated.

Determining the Need for Patient Transfer

It is fundamental that doctors caring for trauma patients be well aware of their own capabilities and limitations, as well as those of their institution. This allows for the early determination of those patients who may be cared for in the local hospital versus those who require transfer to a higher level of care. In general, patients who exhibit signs of shock or progressive neurologic deterioration require the highest level of care and should be considered for timely transfer. While stable patients with blunt abdominal trauma and documented solid organ injury may be candidates for nonoperative management, such management should be supervised by a surgeon in a facility with the capability for immediate operative intervention, should nonoperative
management fail. It is inappropriate for such patients to be treated expectantly at facilities that are not prepared for this scenario. Early transfer of such patients is optimal. Patients with certain specific injuries or combinations of injuries are also likely to benefit from early transfer to a higher level of care, as outlined in Table 2.

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