PA-PSRS has received reports illustrating problems involving transfers to trauma centers, including at least one report suggesting that the emergency department of an acute care hospital did not have a working transfer agreement with any trauma center accredited by the Pennsylvania Trauma System Foundation. PA-PSRS invited Juliet Geiger, RN, MSN, to comment on this issue.
In 1985, Pennsylvania became the eighth state in the country to develop a trauma system. The goal of a trauma system is to reduce the burden of injury to individuals and society through “a group of related injury-oriented facilities, personnel, and organizational entities operating in an organized coordinated manner, typically within a defined geographic area.”1 The spectrum of activities needed to achieve this goal covers all phases of care from the prevention of injury, to primary care within the hospital environment, to care in the rehabilitation setting.
In 2002, the U.S. Health Resources and Services Administration published a report titled “A 2002 National Assessment of State Trauma System Development, Emergency Medical Services Resources, and Disaster Readiness for Mass Casualty Events.”2 In this publication, all states were reviewed according to criteria established by West et al.3 and later expanded upon by Bazzoli in 1995,4 which define the components of the ideal trauma system. These criteria are as follows:
Legal authority to designate trauma centers
Formal process for designating trauma centers
Use of American College of Surgeons (ACS) standards for trauma center designation
On-site verification of compliance with trauma center standards
Number of trauma centers limited based on community need
Pre-hospital triage criteria allowing for bypass of non-designated hospitals
Processes to monitor trauma system outcomes
The above components recognize the key parts of a system that need to be in place, but the components vary in how they interconnect and function within a given state.
In Pennsylvania, the Pennsylvania Trauma Systems Foundation (PTSF) is the accrediting body for trauma centers. This accreditation process is accomplished through the development of standards for the operation of trauma centers in Pennsylvania, adopting, at minimum, the current guidelines for trauma centers as defined by ACS. Then, PTSF evaluates the Pennsylvania hospital that is applying for accreditation to determine if the applicant hospital meets the Standards for Trauma Center Accreditation.5
Oversight of prehospital emergency medical services (EMS) is under the auspices of the Pennsylvania Department of Health Bureau of Emergency Medical Services. The bureau deals with care of the trauma patient at the scene of the injury and prior to arrival to a hospital. The component of the West criteria requiring “pre-hospital triage criteria allowing for bypass of nondesignated hospitals” is also under the jurisdiction of the bureau.
Importance of Transferring Trauma Patients to Accredited Trauma Centers
As part of the statewide protocols developed by the Department of Health, EMS personnel are required to transport trauma patients to the appropriate facility based on an algorithm of care that ensures that only mild injures are treated at community hospitals, and actual or potentially moderate to severe injuries are treated at accredited trauma centers.6 Research has proven that mortality rates are significantly lower when trauma patients are treated in trauma centers.7
Although algorithms are in place for EMS personnel to bypass community hospitals in favor of trauma centers for patients meeting selected criteria, often patients who arrive to the hospital with seemingly “mild” trauma (e.g., a single extremity fracture after a fall from standing position) are found to have more extensive injury upon diagnostic review then what was apparent upon initial assessment by the EMS provider in the field. This is particularly true when it comes to pediatric or geriatric patients. Both groups of patients require special diagnostic considerations due to cognition and physiology. Additionally, the elderly patient often presents with a cadre of coexisting medical conditions. A typical scenario encountered by a hospital emergency department is the elderly patient who falls, hits his or her head, and is taking Coumadin. Upon admission, a computed tomography scan of the brain may be negative, but a later scan may show bleeding. Complicating the neurologic assessment are factors such as dementia and brain atrophy. For this reason, many trauma centers identify age greater than 65 coupled with use of Coumadin as an automatic indication for consultation with the trauma team. Likewise, multiple broken ribs in a young person may not be fatal, but the same injury pattern in an elderly patient with limited pulmonary reserves can lead to pneumonia and rapid cardiopulmonary deterioration when coupled with pre-existing coronary artery disease. The importance of quickly transferring these types of patients to a trauma center cannot be overemphasized (see the
In summary, community hospitals that establish transfer agreements with trauma centers can optimize care delivery of injured patients. Benefits to the patient from timely transfers to a trauma center are:
enhanced quality of care though a team approach to trauma care provided by educated trauma care providers who are available 24 hours/day in an environment dedicated to placing trauma patients as a top priority; and
expeditious care including timely diagnosis and timely response by subspecialists, all of whom are monitored by PTSF through the trauma center accreditation process.
Benefits to the hospital are:
cost savings to the community hospital by assuring that patients with potentially complex injuries are stabilized and rapidly transferred to trauma centers where they will receive appropriate and timely diagnostic studies and therapeutic procedures provided by competent trauma care providers;
and decreased potential for technical errors in patient management due to lack of utilization of evidence based trauma protocols.
American College of Surgeons (ACS) Committee on Trauma.
Resources for Optimal Care of the Injured Patient: 2006. Chicago (IL): ACS; 2006.
U.S. Department of Health and Human Services, Health Resources and Services Administration, Trauma-EMS Systems Program. A 2002 national assessment of state trauma system development, emergency medical services resources, and disaster readiness for mass casualty events. 2003 Aug.
West JG, Williams MJ, Trunkey DD, et al. Trauma systems. Current status—future challenges.
JAMA 1988 Jun 24;259(24):3597-600.
Bazzoli GJ, Madura KJ, Cooper GF, et al. Progress in the development of trauma systems in the United States. Results of a national survey.
JAMA 1995 Feb 1;273(5):395-401.
Pennsylvania Trauma System Foundation. Standards for trauma center accreditation [online]. 2007 [cited 2007 Jul 10]. Available from Internet:
MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality.
N Engl J Med 2006 Jan 26;354(4):366-78.
Examples from PA-PSRS Reports
Here is one example of a report submitted to PA-PSRS involving an elderly patient:
76-year-old female [emergency department (ED)] patient — diagnosis: Multiple trauma [patient] arrived in ED via ALS ambulance following trauma resulting from being dragged by car 30 feet and run over. Emergency medicine physician did not order blood work or radiology studies, stating “all that is necessary for transfer is a chest x-ray, Foley catheter, and NG tube.” Neighboring ED was called but refused to accept transfer. Further studies were then ordered.
The report suggests that the ED of an acute care hospital did not have a working transfer agreement with any Pennsylvania Trauma System Foundation trauma center. This is an example of not just a simple fall, but a patient at risk for multisystem injuries (based on mechanism of injury) who may have suffered a poor outcome through lack of laboratory studies being drawn to assess for signs of coagulopathy and internal bleeding. Furthermore, the absence of radiology films of the spine, chest, and pelvis would have placed this patient at risk for death or disability had there been potentially life-threatening conditions requiring stabilization prior to transfer. Had the hospital had a transfer agreement with a higher level trauma center, rapid communication could have occurred, prompting completion of appropriate diagnostic studies, which could have been communicated to the receiving facility prior to transfer. Receipt of all of this information would have expedited transfer of the patient, reduced redundancy of diagnostic studies by the receiving facility, and also assisted the trauma center in preparing the proper personnel and resources to meet the demands of the patient upon admission.
Here is another example of the reports submitted to PA-PSRS that center around system delays, which could have been due to lack of an established relationship with an accredited trauma center:
21-year-old male ED patient given discharge instructions to go to a neighboring trauma facility for care/evaluation without facilitation of transfer process.
These delays can be reduced through written agreements whereby the receiving trauma center educates the sending facility about expectations for diagnostic screening prior to transfer and about the protocol for who to call when a trauma patient requires transport. Such agreements can save countless hours of personnel time to arrange the trans-fer, and, most importantly, expedite care of the patient and provide optimum treatment at a facility with an organized process of trauma care delivery.