Level I and II trauma centers are regularly on the receiving end of what may be termed as “futile transfers.” These are patients who have sustained unsalvageable injuries and are initially seen at a lower level center. They are then transferred upstream where they succumb shortly (0-48 hours) after arrival.

As you might imagine, these patients can place a significant burden on resources at the Level I or II center. This is an even more acute situation given the large numbers of COVID patients who also require hospitalization and palliative care services these days.

The group at the University of Kansas sought to put some numbers on this phenomenon. They examined their own experience as one of two Level I trauma centers in the Kansas City metro area. They defined futile care as patients who died or were discharged to hospice care within 48 hours of arrival and who did not undergo operative, endoscopic, or interventional radiology procedures.

Here are the factoids:

• A total of 1,241 patients were transferred in during the two year study period
• Of these, 407 had stays of 48 hours or less, and 18 (1.5%) were deemed futile care according to their definition
• The futile care patients tended to be much older (75 vs 61 years) and were much more severely injured (ISS 21 vs 8)
• When transport and hospital charges were combined, the average total cost was $56,000
• Total cost to this hospital was $1.7 million, and this was extrapolated to an annual cost of 27 million for the entire US

The authors concluded that these futile transfers are a small yet costly patient population. They suggested that accurately identifying these patients and providing resources to help referral hospitals figure out how to care for them would be helpful.

My comments: This is a very straightforward descriptive paper that details a problem that every high level trauma center sees on a regular basis. Older patients, typically those with critical head injuries that are beyond treatment, are transferred to the “big house.” The families are frequently told that there are no local resources to provide the care needed, and that the higher level center is their only chance. 

The families then have unrealistic expectations, and are inconvenienced by the travel involved. Wouldn’t it be better to just tell the family that the injury is a really bad one, and provide palliative / hospice care in the local community? Unfortunately, it’s not that simple. Many small hospitals do not have providers who are well-versed in this type of care. Thus, the suggestion to provide resources (people? training?) is a sound one.

This abstract highlights a problem we all face but seldom publicize. Hopefully this one will get us talking. And acting.

Here are my questions for the authors and presenter:

1. What kind of resources do you think are needed to allow referral hospitals to care for these patients?
2. How will these hospitals know when care is futile? Will there be an expectation to work with the receiving center to help determine this?

I enjoyed this paper and can’t wait to hear the details!

Reference: Futile trauma transfers: an infrequent but costly component of regionalized trauma care. EAST 2021, paper 9.