Tag Archives: transfer

Impact Of Patient Imaging Prior To Transfer Out

The reality is that 90% of injuries are minor and can be treated at any hospital. A minority of patients actually have issues that require transfer to a higher-level trauma center. Physical examination can certainly help determine who some of those patients are. Think obvious open fracture or severe brain injury at a hospital without key specialists to care for them.

But not all injuries are that obvious. Imaging techniques are the next step to identifying injuries that would require transfer. The question is, how much imaging is appropriate?

A few hospitals are selective about it. But many proceed with a comprehensive battery of scans and x-rays. Some believe that their receiving trauma center expects it. And a few may be doing it for the money, unfortunately. So who is right?

There are three issues at play: time, accuracy, and radiation exposure. Let’s pick them apart.

Time. It takes time to get radiographic studies. Depending on the number obtained, it can take up to 90 minutes. A study looking at transfers from rural hospitals to a regional trauma center in Wisconsin found that the median time to transfer significantly in-creased from 67 to 140 minutes with the addition of even a single CT scan.

This issue appears to be even more of a problem in children. A group at Cincinnati Children’s Hospital studied the characteristics of children who experienced prolonged transfer times to a Level I pediatric trauma center. They reviewed 5 years of registry data, looking at time of injury to time of arrival at their center. The State of Ohio has a goal of a maximum 2-hour transfer time.

And here are the factoids:

  • 748 patients were included in the study, and the demographics were predictable (65%male, 97% blunt)
  • 25% were more severely injured (ISS > 15)
  • The majority of the patients (82%) arrived well after the 2-hour goal (7 hrs!!)
  • 79% of patients with high ISS and 47% of those with severe TBI arrived late (!!)
  • Transfer tardiness did not correlate with distance, and was only slightly improved when a helicopter was used
  • Significantly more CT scans were obtained in the late transfer group (49% vs 23%), and appeared to have no correlation with GCS or vital signs. There was, however, a significant correlation with private insurance.
  • Half of the children with scans arrived without results or had suboptimal imaging, resulting in repeat scans in about one third.

Accuracy and radiation exposure. These two factors are inextricably linked because inaccuracy begets additional imaging. As noted in the previous study, radiology results are frequently lacking, or the studies are not done well, as determined by the receiving center. This means that inaccurate results, or no results at all, are available after transfer. How much of a problem is this?

The Level I center at UC Davis looked at all incoming trauma transfers that had any CT imaging done prior. Of 370 patients, one quarter needed repeat scans. Most common were head scans (47%) and cervical spine (20%). The most common reasons for repetition were referring hospital scan not available (42%) (not sent, couldn’t open) and insufficient quality (20%). This resulted in significant additional radiation exposure, with 4% of patients receiving more than 10mSv!

Bottom line: Imaging prior to transfer definitely increases time to transfer and frequently results in repeat imaging and more radiation exposure. So why does it happen? Sometimes, it’s the mistaken belief that it will save time after transfer. Not the case. Or there is time left before the transport ambulance or helicopter arrives, so why not use it? Not a good reason, and it may delay the transfer team if they arrive early. Or the receiving trauma center “expects it.” Not if they’ve looked at any of these papers!

The best approach is to order only images that will guide your therapy. A chest x-ray on arrival or after intubation. A pelvic x-ray to determine if a binder should be applied. A CT of the abdomen to see if there are any injuries that can’t be taken care of at your hospital. As a general rule, once you have found an injury your hospital can’t treat, or have made the decision to transfer for any other reason, no additional imaging is indicated! 

References:

  • Consequences of increased use of computed tomography imaging for trauma patients in rural referring hospitals prior to transfer to a regional trauma centre. Injury 45:835-839, 2014.
  • Unnecessary imaging, not hospital distance, or transportation mode impacts delays in the transfer of injured children. Pediatric Emerg Care 26(7):481-486, 2010.
  • Rate and Reasons for Repeat CT Scanning in Transferred Trauma Patients. Am Surg 83(5):465-569, 2017.

Rural Trauma Team Development Course Impact On Trauma Transfers

The Rural Trauma Team Development Course (RTTDC) is yet another quality program developed by the American College of Surgeons (ACS). It is designed for all trauma professionals in rural areas including doctors, nurses, advanced practice providers, prehospital providers, and administrative support. The course is presented over the course of one day and covers a number of topics including:

  • Organizing a rural trauma team
  • Preparing rural hospitals to manage trauma patients
  • Identifying local resources and limitations
  • Resuscitation of trauma patients
  • Initiating early transfer
  • Developing a performance improvement process
  • Building relationships between rural hospitals and regional or state trauma systems

The trauma group at Vanderbilt compared a group of six non-trauma hospital in rural Tennessee who had participated in the RTTDC with six other rural hospitals matched for size, volume, and distance from the Level I center.

Here are the factoids:

  • A total of 130 RTTDC patients were compared with 123 from hospitals that had not participated
  • Overall demographics and number of imaging studies were the same
  • The call to transfer occurred 41 minutes sooner in the RTTDC hospitals
  • Length of stay in the referring ED was 61 minutes shorter in the RTTDC hospitals
  • Number of images obtained pre-transfer and mortality were unchanged

Bottom line: The numbers were small and the review was retrospective, but the results are nonetheless impressive. Granted, there was no decrease in mortality, but this is a relatively crude indicator, especially when small numbers are involved. But time to phone call and time spent in the referring ED were significantly shorter. Does anyone think that longer times to transfer are somehow good for patients?

Rural hospitals should consider attending RTTDC in order to improve the care of patients from their communities.

Reference: Rural trauma team development course de-creases time to transfer for trauma patients. J Trauma 81(4):632-637, 2016.

Do Children With Low Grade Solid Organ Injury Need To Transfer To A Pediatric Trauma Center?

Pediatric trauma centers have an excellent reputation when it comes to caring for children when compared to their adult counterparts. Overall mortality for major trauma is lower. Splenectomy rates and the use of angiography are less in children with solid organ injury. And because of this expertise, it is common for surrounding trauma centers of all levels transfer these patients to the nearest pediatric trauma center.

But is this always necessary? Many of these children have relatively minor injury, and the pediatric trauma centers can be few and far between unless you are on one of the coasts. Researchers at the University of Washington, Harborview, and Seattle Children’s looked at their experience with pediatric transfers (or lack thereof) with spleen injury.

They retrospectively looked at 15 years of transfer data. The Seattle hospitals are the catchment area for a huge geographic area in the northwest, and the state trauma system maintains detailed records on all transfers to a higher level of care. Patients 16 years or younger with low grade (I-III) spleen injury were included. In an effort to narrow the focus to relatively isolated spleen injury, patients were excluded if they had moderate injuries in other AIS body regions.

Here are the factoids:

  • During the study, over 54,000 patients were admitted to hospitals, but only 1,177 had isolated, low grade spleen injury
  • About 20% presented directly to a Level I or II trauma center, 30% presented to a lower level center and were transferred, and 50% stayed put at the lower level center they to which they presented
  • 40 patients (3%) underwent an abdominal operation presumably for their spleen, but there was no difference based on which hospital they presented to or whether they were transferred
  • The incidence of total splenectomy was not different among the three groups
  • Likewise, there was no difference in ICU admission or ICU length of stay
  • The only significant difference was that patients who were not transferred to a pediatric center usually spent an extra day in the hospital

Bottom line: Injured children tend to do well, regardless of where they are treated. This study is huge and retrospective, which can cause analysis problems. And even given the size, the total number eligible for the study was relatively small. But it is the best study to date that shows that it is possible to treat select low grade injuries at non-pediatric, non-high level trauma centers. However, before going down this path, it is extremely important to define specific “safe” injuries to manage, and to have an escape valve available in case the patient takes an unexpected turn.

When Is It Not An “Unplanned ICU Admission?”

All US trauma centers verified by the American College of Surgeons (ACS) must now subscribe to the ACS Trauma Quality Improvement Program (TQIP). This program allows each center to benchmark themselves against other trauma centers that are just like them (level, volume, acuity, etc).  Every quarter, TQIP members receive a report that details their performance in a number of key categories. The report slices and dices a large number of data points, and shows how they compare to those other trauma centers.

One of the more interesting portions of the TQIP report deals with risk-adjusted complications. The one I wrote about yesterday, the “ICU bounce back,” is officially called an “unplanned ICU admission.”

I’ve had several trauma centers ask me what constitutes an unplanned ICU admission. Is it any bounce back? What about patients who were never in the ICU?

This questions is particularly important to me because my own center’s TQIP report shows that we have a significant number of unplanned ICU admissions. But I know for a fact that they are not surprises. We have an inpatient trauma unit, with capabilities somewhere between the usual ward bed and an ICU bed. Patients can get telemetry, continuous oximetry, vital signs every 2 hours, and more. It functions as a kind of step-down unit, so we frequently admit patients who may require ICU admission at other hospitals.

Every once in a while, a patient who is receiving care in the trauma unit shows signs that they are going to need a true ICU level of care. In that case, we promptly move them to the ICU before they decompensate any further.

Is that situation an “unplanned ICU admission?” In my opinion, no. The patient received the highest level of care while outside the ICU, and ultimately a considered decision was made to move them. In my mind, this is a “planned ICU admission.”

Bottom line: There are two issues at play if your “unplanned ICU admissions” get flagged on your TQIP report. The first is determining if it was truly unplanned. If the Rapid Response Team (RRT) was called, then it was almost certainly unplanned. But if the patient was being monitored properly, showed signs that they would need an ICU level of care, and was preemptively transferred there, it was not. Similarly, if one of your surgical specialists wants the patient transferred (e.g. MAP goals), then that is also a planned admission.

The second factor is figuring out why the admissions are getting reported to TQIP as unplanned. This is usually a trauma registrar issue. They may be looking for any ward to ICU transfer, and classifying it as unplanned. Educate all your registrars on the nuances of what is planned and what isn’t.

If you are on the receiving end of a TQIP variance on unplanned ICU admissions, use the drill-down tool to identify the exact patient records involved. Review the involved medical records, paying close attention to vital signs, monitoring, and all decision making leading up to the time of the ICU transfer. If it isn’t truly unplanned, educate your registrars. But if it is, make sure that it was properly dealt with by your trauma performance improvement program.

Do I Have To Call My Trauma Team For Incoming Transfers?

I had a great question sent in by a reader last week:

Some trauma centers receive a number of transfers  from referring hospitals. Much of the time, a portion of the workup has already been done by that hospital. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?

And the answer is: sometimes. But probably not that often.

Think about it. The reason you should be activating your team is that you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.

There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.

  • Physiologic. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
  • Anatomic. Most simple anatomic criteria (e.g. long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
  • Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
  • Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.

Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.

However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team. 

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